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Background and Aims: Neurolytic splanchnic nerve block (NSNB) is practised in intractable abdominal pain secondary to intra-abdominal malignancies. This review evaluated the efficacy of NSNB. Methods: PubMed, Embase, Scopus, and Cochrane databases were searched for articles published from January 2001 to October 2023. Two independent reviewers extracted the data from the included studies. The quality of randomised controlled trials (RCTs) was assessed using the revised Cochrane risk-of-bias tool (RoB 2), and the Newcastle–Ottawa scale was used for cohort studies. Results: Fourteen articles (4 RCTs, 3 non-randomised prospective, and 7 retrospectives) were included. Ten articles were quantitatively assessed and demonstrated significant pain relief at 1 week (standardised mean difference (SMD): 3.46 [2.09, 4.83], P < 0.001, I2 = 95%), 2 weeks (SMD: 4.45 [2.61, 6.29], P < 0.001, I2 = 95%), 4 weeks (SMD: 3.35 [2.23, 4.47], P < 0.001, I2 = 97%), 8 weeks (SMD: 3.7 [2.71, 4.7], P < 0.001, I2 = 86%), 12 weeks (SMD: 4.01 [2.66, 5.36], P < 0.001, I2 = 95%), and 24 weeks (SMD: 2.54 [1.71,3.37], P < 0.001, I2 = 84%). Daily narcotic consumption and quality of life (QOL) significantly improved post neurolysis, but survival rates showed controversial results. Significant heterogeneity was reported, and sub-group analysis revealed a moderate level of variability [I2 = 47.3%] pertaining to study design as a source of heterogeneity. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Pro GDT recommendation for the primary objective was 'high' for the analysis of RCTs and 'very low' evidence quality for observational studies. Only transient minor complications were reported. Conclusion: NSNB appears to be an efficacious technique that provides substantial pain relief, reduces opioid consumption, and ameliorates QOL. [ABSTRACT FROM AUTHOR]

Shoulder disorders occasionally cause intractable pain. Central sensitization (CS) may be involved in such pain. Identifying risk factors associated with CS is crucial for effective pain control. This study aimed to determine the effects of shoulder osteoarthritis and rotator cuff tears (RCT) on CS and associated factors. This study included patients evaluated for CS using the Central Sensitization Inventory (CSI) before surgery for shoulder osteoarthritis, RCT, or cuff tear arthropathy. Patients with a CSI score of 40 or higher were defined as having CS. The relationships between glenohumeral osteoarthritis (GHOA), RCT size, and CS were statistically analyzed. Multiple regression analysis was performed to examine the factors affecting CSI scores. Subjects included 167 patients: 131 patients had RCT without GHOA, 23 had GHOA with RCT, and 13 had GHOA without RCT. The GHOA group had a significantly higher CSI score (27.5 [10.8–40.5] vs. 18.0 [10.0–27.5]) and CS prevalence (27.8% vs. 8.4%) than the RCT without GHOA group. There was no significant correlation between RCT size and CSI scores. Multiple regression analysis showed that female sex, severe pain, and long pain duration were associated with higher CSI scores. Considering the risk factors for CS might be helpful in shoulder treatment. [ABSTRACT FROM AUTHOR]

Severe and persistent pain of cancer and noncancer origin in pediatric patients can pose significant challenge to manage. The application of Radiofrequency ablation in Pediatric patients for pain management is not well reported in the literature. Here, we present pediatric cases where pulsed radiofrequency (PRF) treatment of the Lumbosacral plexus was done for pain relief. [ABSTRACT FROM AUTHOR]

Background: Although opioids are used first line for cancer pain and commonly for complex noncancer pain, there are risks associated with their use and not effective for all types of pain. There's a need to identify and develop clinical practice guidelines for nonopioids for the treatment of refractory pain. Methods: Our study collected information from national clinical practice guidelines for ketamine, lidocaine, and dexmedetomidine with the aim to identify consensus among the different practices. Results: Fifteen institutions nationally participated in the study and only nine of those institutions had guidelines and were permitted by their health system to share them. Of the institutions that participated, 44% had guidelines for ketamine and lidocaine, and only two institutions (22%) had guidelines for ketamine, lidocaine, and dexmedetomidine for refractory pain. There were variations in restriction of the level of care and prescribers, dosing, and determination of efficacy. There were trends of consensus in monitoring for side effects. Conclusion: This study serves as a starting point for a snapshot of the use of ketamine, lidocaine, and dexmedetomidine for refractory pain, but further studies and increased participation of institutions are needed to develop consensus clinical practice guidelines. [ABSTRACT FROM AUTHOR]

Background and Aims: Neurolytic splanchnic nerve block (NSNB) is practised in intractable abdominal pain secondary to intra-abdominal malignancies. This review evaluated the efficacy of NSNB. Methods: PubMed, Embase, Scopus, and Cochrane databases were searched for articles published from January 2001 to October 2023. Two independent reviewers extracted the data from the included studies. The quality of randomised controlled trials (RCTs) was assessed using the revised Cochrane risk-of-bias tool (RoB 2), and the Newcastle–Ottawa scale was used for cohort studies. Results: Fourteen articles (4 RCTs, 3 non-randomised prospective, and 7 retrospectives) were included. Ten articles were quantitatively assessed and demonstrated significant pain relief at 1 week (standardised mean difference (SMD): 3.46 [2.09, 4.83], P < 0.001, I2 = 95%), 2 weeks (SMD: 4.45 [2.61, 6.29], P < 0.001, I2 = 95%), 4 weeks (SMD: 3.35 [2.23, 4.47], P < 0.001, I2 = 97%), 8 weeks (SMD: 3.7 [2.71, 4.7], P < 0.001, I2 = 86%), 12 weeks (SMD: 4.01 [2.66, 5.36], P < 0.001, I2 = 95%), and 24 weeks (SMD: 2.54 [1.71,3.37], P < 0.001, I2 = 84%). Daily narcotic consumption and quality of life (QOL) significantly improved post neurolysis, but survival rates showed controversial results. Significant heterogeneity was reported, and sub-group analysis revealed a moderate level of variability [I2 = 47.3%] pertaining to study design as a source of heterogeneity. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Pro GDT recommendation for the primary objective was 'high' for the analysis of RCTs and 'very low' evidence quality for observational studies. Only transient minor complications were reported. Conclusion: NSNB appears to be an efficacious technique that provides substantial pain relief, reduces opioid consumption, and ameliorates QOL.

Purpose: The cingulate gyrus is a potential surgical area to treat tumours, psychiatric diseases, intractable pain and vascular malformations. The aim of the study was to define the topographic anatomy and arterial supply of the cingulate gyrus located on the medial surface of the cerebral hemisphere. Methods: We studied thirty-six hemispheres, each hemisected in the midsagittal plane. The vertical thickness of the cingulate gyrus was measured at the anterior commissure (AC), posterior commissure (PC), and genu levels of the corpus callosum. The branches of the anterior and posterior cerebral arteries supplying each zone were noted separately. The arterial pathways were transformed to digital data in AutoCAD to identify the condensation and reduction areas. Results: The mean AC-PC distance was 27.17 ± 1.63 mm. The thinnest region was the genu level of the corpus callosum (10.29 mm). The superior internal parietal artery (SIPA), inferior internal parietal artery (IIPA) and pericallosal artery (PrCA) supplied all zones of the cingulate gyrus. The anterior zone received the greatest supply. The arterial condensation and reduction areas on both sides of cingulate gyrus and its x, y, and z coordinates specified. Conclusions: The target cingulotomy (TC) area was determined for anterior cingulotomy. The properties of the TC area are that the thinnest region of the cingulate gyrus is supplied relatively less than other areas and is close to the anterior cingulotomy areas in the literature. The arterial reduction area (ARA) was found to be suitable for corpus callosotomy in terms of avoiding haemorrhage. [ABSTRACT FROM AUTHOR]

Objective: Neuropathic pain management involves both pharmacological and non-pharmacological interventions. Despite this, no prior research has demonstrated the efficacy of court-type Thai traditional massage (CTTM) for neuropathic pain relief. This study aimed to investigate the potential benefits of CTTM in alleviating neuropathic pain. Materials and Methods: A preliminary single-blind randomized controlled trial was conducted on 28 participants with peripheral neuropathic pain, who were equally assigned to 2 groups. Both groups received standard drug treatment; however, the intervention group additionally received CTTM and hot herbal compression, while the active control group only received HHC. The adjuvant treatments were administered twice weekly for 4 weeks (V1-V8). A follow-up was conducted 4 weeks posttreatment (V9). Outcome measures were assessed at V1, V4, V8, and V9 using a numerical rating scale and the Thai versions of the Neuropathic Pain Symptom Inventory, the Brief Pain Inventory, and the EQ‑5D‑5L health questionnaire. Results: The data revealed that the intervention and active control groups had statistically significant differences in their pain intensity scores (P

Multiple influences prevent recovery from pain. Our viewpoint is that non-conscious emotional memory images (EMIs) triggers outdated stress responses contributing to the intractability of pain. In this perspectives article we explore the concept that EMIs contribute to the persistence of pain. We contend that psychophysiological “stress” responses, resulting from first-time, novel and unprecedented pernicious or adverse events form EMIs within very short time frames (split-second learning). Subsequently, these EMIs are re-triggered in daily living, “re-playing” stress responses. We postulate that EMIs continually “raise the alarm” to socio-ecological stimuli by re-triggering the HPA-axis and amplifying neural input associated with threat, fear, anxiety, and pain, creating a debilitating state of psychophysiological dis-ease. We position the EMI within a philosophical debate on the nature and locus of memory and explain how the EMI, irrespective of whether it is a “thing” or a metaphor, can create a basis of understanding for the client to grasp. We describe a therapeutic approach (Split-Second Unlearning) to “clear” EMIs and the “stickiness” of pain and help people embark on a healing journey. This involves surveillance of clients for micro-expression(s) signifying an in-the-moment stress response, representative of the presence of an EMI, and encouraging the client to become a curious observer within/of their own experience. This helps the client detach their EMI from its stress response. We contend that this occurs rapidly without the need to get bogged down in a whole-life narrative. We advocate further exploration of our EMI model of dis-ease in the context of intractable pain.

This case series assesses the benefits of intracutaneous injection of botulinum toxin A (BTX-A) for the treatment of intractable pain of supraorbital postherpetic neuralgia (PHN) not responding to oral drug therapy. Three patients experiencing intractable pain of supraorbital PHN, which was not responding satisfactorily to oral pregabalin and oral amitriptyline therapy, were managed with the intracutaneous injection of BTX-A in the affected dermatomes. Postinjection during each visit at 2, 4, 6, 8, 10, and 16 weeks, the Numeric Rating Scale pain score of the patients was assessed (0: painless; 10: maximum pain). There was a significant reduction in the severity of pain after BTX-A injection, and subsequently, the oral medications were significantly reduced thereafter. Hence, BTX significantly decreases the severity of intractable pain in supraorbital PHN patients.

Objectives: The use of off‐label pharmacotherapies for neuropathic pain (NP) is growing relating to the many unmet needs of patients. However, clinical guidelines fail to address it, and the available evidence is sparse and fragmented. We arranged a formal expert consensus to address this controversial issue and provide some guidance on judicious use. Methods: A two‐round standard Delphi survey that involved pain clinic specialists with experience in the research and management of NP was done over an ad hoc 40‐item questionnaire prepared by the authors. Consensus on each statement was defined as at least either 80% endorsement or rejection after the second round. Results: Forty‐three and thirty‐seven panelists participated in the first and second round, respectively. Consensus was reached in 34 out of 40 statements. Endorsed alternatives for unresponsive patients include non‐gabapentinoid antiepileptics (oxcarbazepine and eslicarbazepine), venlafaxine, intravenous lidocaine (when doses can be optimized), and some vaporized cannabinoids (under appropriate surveillance). In addition, lacosamide, low‐dose naltrexone, propofol, or ketamine could prove beneficial if subjected to more research. Other options were rejected, and there was controversy about the usefulness of topical preparations. Discussion: For patients who do not respond to standard NP treatments, some other viable pharmacological options can be attempted before advancing to other therapeutic stages. This may help patients who are reluctant to or have some contraindication for interventional therapies. [ABSTRACT FROM AUTHOR]

Background: In March 2020, Pain Management Services were obliged to cease face-to-face consultations. This abrupt change, in line with recommendations from the British Pain Society, aimed to protect patients and staff and allowed resource re-allocation. Pain services were obliged to switch to remote consultations using Video Tele-Conferencing Technology (VTC) and Remote Consultations (RC) either through telephone or video calls using a variety of media and software applications. Little is known about the patient experience of remotely delivered pain care especially when alternatives are removed. The aim of this work was to understand the patient experience of this necessary switch regarding pain self-management interventions during the initial stages of the COVID-19 pandemic. Methods: A mixed-methods evaluation of the patient experience from three pain self-management interventions, taking place in a large community-based pain rehabilitation service along the South Coast of England, was performed. Experience-Based Design (EBD) methods were used to map patient experience at touch points through two interventions that were delivered in a structured format. Semi-structured recorded interviews were transcribed and analysed using thematic analysis for the third. Findings: Fifty-eight patients took part covering the scope of the service. In general, educational and psychological sessions were well received, with physical rehabilitation components being less easy to convey remotely. Attrition rates were high for the pain management programme. Group pain education worked particularly well in an online format with hope being the predominant emotion experienced. Clear limitations were technical failures and the lack of ability to form relationships in a virtual world. Conclusions: Remote digitalised interventions were acceptable to most patients. Attention should be paid to access and improving social aspects of delivery when considering such interventions. Physiotherapy may require more face-to-face necessitating a hybrid model and needs further investigation. EBD proved a highly suitable approach. [ABSTRACT FROM AUTHOR]

Background: Methadone was introduced in 2013 for the treatment of intractable cancer pain in Japan and is indicated for patients receiving opioid doses ≧60 mg/day as an oral morphine equivalent. Low-dose (≦10 mg/day) add-on methadone to prior opioids has been reported from European countries to successfully relieve various types of intractable cancer pain; however, there are few reports of such use in Japan. The aim of this study was to analyze more than a hundred cases with low-dose add-on methadone to treat intractable pain in Japanese cancer patients., Methods: All cases in which 5 or 10 mg/day of methadone was added to prior opioids by the Palliative Care Team or Division of Palliative Medicine in our hospital during the period between April 2016 and September 2023 were extracted and analyzed retrospectively on electrical medical charts., Results and Conclusions: A total of 102 cases were extracted with a male-to-female ratio of 60:42, and the age (mean ± SD) was 62.8 ± 14.7 years old. Methadone was introduced in an inpatient setting to 86 patients. The major pathologies that caused intractable pain were spinal metastases in 48, pelvis or pelvic floor lesions in 29 and pleural and/or chest wall lesions in 16. The most common mechanism of pain was the mixture of somatic and neuropathic components. The major opioids administered prior to methadone included tapentadol in 46 patients, hydromorphone in 36 and oxycodone in 19. The dose of the prior opioids [median, (interquartile range: IQR)] was 97, (62.8-167.3) (range: 15-1313) mg/day of oral morphine equivalent. Radiotherapy, chemotherapy and nerve blocks were performed as concomitant therapies in 48, 22 and 11 patients, respectively (with some overlap). The number of rescue doses [median (IQR)] was significantly decreased from three (two to five) on the day before methadone to one (zero to four) after seven days from methadone initiation. The side effects leading to discontinuation of methadone were drowsiness in three cases, nausea in three cases and dizziness in one case (with some overlap). Compared with complete switching from other opioids, low-dose add-on methadone can reduce the possibility of major dose discrepancies and can be quickly adjusted by combined opioid reduction/increase. Low-dose add-on methadone can be an effective and safe method for intractable cancer pain., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

Introduction. Complex regional pain syndrome (CRPS) is a debilitating disease with limited available treatment options. Spinal cord stimulation (SCS) is a universal option that promises to improve quality of life by reducing intractable neuropathic pain. The aim of this study was to describe the effectiveness and safety of SCS as a treatment for CRPS patients. Clinical rationale for the study. SCS as an invasive method has relatively recently been introduced to CRPS therapy. We hypothesised that by assessing the effectiveness and safety of SCS, we could justify its early use in the treatment of this debilitating condition. Material and methods. CRPS is a multifactorial and disabling disorder with complex aetiopathogenesis. The primary goals of CRPS treatment include pain relief, functional restoration, and psychological stabilisation. Early intervention is needed to achieve these objectives. In this study, we performed a retrospective evaluation of clinical outcomes in seven patients with severe, intractable CRPS treated by SCS. All patients underwent implantation of a non-rechargeable prime advanced MRI implantable pulse generator (IPG) (Medtronic, Minneapolis, MN, USA) between December 2017 and December 2020 using identical surgical and intraprocedural techniques. Results. From a total of 21 patients treated with SCS over the three years in question, seven (33%) were diagnosed with severe CRPS. The duration of chronic pain ranged between two and 12 years. In six cases (86%), an electrode was implanted in the thoracic segment. Good (partial pain reduction) or very good (complete pain relief) treatment results were observed in five patients (72%). In two cases (28%), two revision surgeries were performed for wound debridement. These hardware-related complications were primarily related to erosions located over implanted IPG's. Conclusions and clinical implications. SCS is the best alternative for patients with CRPS. It should be used immediately after the failure of conservative treatment. Despite the relatively high complication rate in our series, it is the best choice for pain reduction management in this select group of patients. [ABSTRACT FROM AUTHOR]

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 female 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.

Cordotomy consists in the discontinuation of the lateral spinothalamic tract (LST) in the anterolateral quadrant of the spinal cord, which aims to reduce the transference of nociceptive information in the dorsal horn of the gray matter of the spinal cord to the somatosensory cortex. The main indication is for patients with terminal cancer that have a low life expectancy. It improves the quality of life by relieving pain. The results are promising and the pain relief rate varies between 69 and 100%. Generally speaking, the complications are mostly temporary and not remarkable.

Background and Objectives: Interventional management of neuropathic pain (NP) is available to the patients who do not obtain satisfactory pain relief with pharmacotherapy. Evidence supporting this is sparse and fragmented. We attempted to summarize and critically appraise the existing data to identify strategies that yield the greatest benefit, guide clinicians, and identify areas that merit further investigation. Material and Methods: A two-round Delphi survey that involved pain clinic specialists with experience in the research and management of NP was done over an ad hoc 26-item questionnaire made by the authors. Consensus on each statement was defined as either at least 80% endorsement or rejection after the 2nd round. Results: Thirty-five and 29 panelists participated in the 1st and 2nd round, respectively. Consensus was reached in 20 out of 26 statements. There is sufficient basis to treat postherpetic neuralgias and complex regional pain syndromes with progressive levels of invasiveness and failed back surgery syndrome with neuromodulation. Radiculopathies and localized NP can be treated with peripheral blocks, neuromodulation, or pulsed radiofrequency. Non-ablative radiofrequency and non-paresthetic neuromodulation are efficacious and better tolerated than ablative and suprathreshold procedures. Conclusions: A graded approach, from least to most invasive interventions has the potential to improve outcomes in many patients with common refractory NP conditions. Preliminary promising data warrant further research on new indications, and technical advances might enhance the safety and efficacy of current and future therapies. [ABSTRACT FROM AUTHOR]

ABSTRACT 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.

Abstract Background This study is comparing thermal radiofrequency ablation (TRFA) of the thoracic dorsal root ganglia (TDRG) guided by Xper CT and fluoroscopy with the standard fluoroscopy. Methods This randomized clinical trial included 78 patients suffering from chronic refractory pain due to chest malignancies randomly allocated into one of two groups according to guidance of TRFA of TDRG. In CT guided group (n = 40) TRFA was done under integrated Xper CT-scan and fluoroscopy guidance, while it was done under fluoroscopy guidance only in standard group (n = 38). The primary outcome was pain intensity measured by visual analog scale (VAS) score, functional improvement and consumption of analgesics. The secondary outcome measures were patient global impression of changes (PGIC) and adverse effects. Results VAS scores decreased in the two groups compared to baseline values (p

Background: According to the World Health Organization analgesic ladder, cancer-related pain generally begins with pharmacotherapy in a stepwise approach. Nevertheless, some patients continue to experience poorly controlled pain despite medications, particularly when considering adverse effects and self-care quality. Percutaneous cervical cordotomy is an alternative interventional procedure for unremitting unilateral intractable cancer-related pain., Case Summary: The patient was diagnosed with lung cancer with destruction of the brachial plexus and ribs. For 2 mo, the patient experienced progressive severe weakness and pain in the right upper extremity. Notably, the pain intensity reached an extreme level, particularly when lying supine, even under heavy sedation. This heightened pain response posed a significant challenge; as a result, the patient was unable to undergo further evaluation through magnetic resonance imaging. Ultimately, he underwent percutaneous cervical cordotomy for symptom relief, resulting in complete resolution of right arm pain. After a 3-mo follow-up, the pain did not recur, and only a flurbiprofen local patch was required for mild scapular tightness., Conclusion: Cordotomy, under careful patient selection, appears to enhance the quality of life of patients with unilateral cancer-related pain., Competing Interests: Conflict-of-interest statement: The authors have no conflicts of interest to declare., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Epithelioid hemangioendothelioma (EHE) patients can experience severe pain. Nonsteroidal anti-inflammatory drugs, including ketorolac tromethamine, can effectively treat cancer-related pain, provide an opioid-sparing effect, and may be particularly effective for EHE pain. There are limited data describing prolonged (>5 days) continuous intravenous (IV) ketorolac infusion for cancer-related pain and no data on its use in EHE. Case Description: A 67-year-old woman with metastatic hepatic EHE suffered from chronic intractable pleuritic pain unresponsive to trials of nonopioid, opioid, adjuvant medications, and nonpharmacological interventions. In the hospital, continuous IV ketorolac infusion at 3.8 mg/hour (91.2 mg/day) effectively managed pain. With thorough monitoring, the patient was discharged on continuous IV ketorolac infusion at 3 mg/hour (72 mg/day). Infusion continued for 79 days without clinical or laboratory evidence of ketorolac toxicity. Conclusion: Ketorolac tromethamine as a long-term infusion is a potentially viable analgesic for patients with intractable EHE-related pain unresponsive to standard therapies. [ABSTRACT FROM AUTHOR]

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 sparing effect and can be used in metastatic cancer patients with intractable pain. This pilot project primarily aims to evaluate the effect of dexmedetomidine on pain treatment in patients with metastatic cancer. In addition, the work aims to determine its impact on anxiety and quality of communication of patients with their family members. Patients between 18 and 75 years, with metastatic cancer, who failed multiple pain treatments at home and admitted to the hospital for pain management were included. Patients were allocated randomly to Group A (who received morphine plus normal saline solution) or Group B (who received morphine plus dexmedetomidine) for pain management. The Visual Analogue Score (VAS) was used to assess pain intensity, a 5-point sedation scale was used to assess sedation level, and the Hamilton scale was used to assess anxiety. Results have shown that morphine consumption was reduced at different time points up to 48 h, p < 0.005 in both groups. There was a trend in decreasing pain scores after 36 h in both groups. All patients in Group A required rescue pain treatment; however, in Group B, this percentage was lower (67%). Communication was better in patients allocated to Group B than patients in Group A. To conclude, dexmedetomidine was safe and has exerted an opioid-sparing effect in patients with metastatic cancer with keeping their anxiety levels within an acceptable range. [ABSTRACT FROM AUTHOR]

Drug development for rare and intractable diseases has been challenging for decades due to the low prevalence and insufficient information on these diseases. Drug repositioning is increasingly being used as a promising option in drug development. We aimed to analyze the trend of drug repositioning and inter-disease drug repositionability among rare and intractable diseases. We created a list of rare and intractable diseases based on the designated diseases in Japan. Drug information extracted from clinical trial data were integrated with information of drug target genes, which represent the mechanism of drug action. We obtained 753 drugs and 551 drug target genes from 8307 clinical trials for 189 diseases or disease groups. Trend analysis of drug sharing between a disease pair revealed that 1676 drug repositioning events occurred in 4401 disease pairs. A score, Rgene, was invented to investigate the proportion of drug target genes shared between a disease pair. Annual changes of Rgene corresponded to the trend of drug repositioning and predicted drug repositioning events occurring within a year or two. Drug target gene-based analyses well visualized the drug repositioning landscape. This approach facilitates drug development for rare and intractable diseases. [ABSTRACT FROM AUTHOR]

Background and Objectives: Interventional management of neuropathic pain (NP) is available to the patients who do not obtain satisfactory pain relief with pharmacotherapy. Evidence supporting this is sparse and fragmented. We attempted to summarize and critically appraise the existing data to identify strategies that yield the greatest benefit, guide clinicians, and identify areas that merit further investigation. Material and Methods: A two-round Delphi survey that involved pain clinic specialists with experience in the research and management of NP was done over an ad hoc 26-item questionnaire made by the authors. Consensus on each statement was defined as either at least 80% endorsement or rejection after the 2nd round. Results: Thirty-five and 29 panelists participated in the 1st and 2nd round, respectively. Consensus was reached in 20 out of 26 statements. There is sufficient basis to treat postherpetic neuralgias and complex regional pain syndromes with progressive levels of invasiveness and failed back surgery syndrome with neuromodulation. Radiculopathies and localized NP can be treated with peripheral blocks, neuromodulation, or pulsed radiofrequency. Non-ablative radiofrequency and non-paresthetic neuromodulation are efficacious and better tolerated than ablative and suprathreshold procedures. Conclusions: A graded approach, from least to most invasive interventions has the potential to improve outcomes in many patients with common refractory NP conditions. Preliminary promising data warrant further research on new indications, and technical advances might enhance the safety and efficacy of current and future therapies.

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Background: This study is comparing thermal radiofrequency ablation (TRFA) of the thoracic dorsal root ganglia (TDRG) guided by Xper CT and fluoroscopy with the standard fluoroscopy. Methods: This randomized clinical trial included 78 patients suffering from chronic refractory pain due to chest malignancies randomly allocated into one of two groups according to guidance of TRFA of TDRG. In CT guided group (n = 40) TRFA was done under integrated Xper CT-scan and fluoroscopy guidance, while it was done under fluoroscopy guidance only in standard group (n = 38). The primary outcome was pain intensity measured by visual analog scale (VAS) score, functional improvement and consumption of analgesics. The secondary outcome measures were patient global impression of changes (PGIC) and adverse effects. Results: VAS scores decreased in the two groups compared to baseline values (p < 0.001) and were lower in CT guided group up to 12 weeks. Pregabalin and oxycodone consumption was higher in the standard group at 1, 4 and 12 weeks (p < 0.001). Functional improvement showed near significant difference between the two groups (P = 0.06 at week 1, 0.07 at week 4 respectively) while the difference was statistically significant at week 12 (P = 0.04). PGIC showed near significant difference only at week 1 (P = 0.07) while the per-patient adverse events were lower in CT guided group (p = 0.027). Conclusions: Integrated modality guidance with Xper CT-scan and fluoroscopy together with suprapedicular inferior transforaminal approach may improve efficacy and safety of TRFA of TDRG for the treatment of intractable chest pain in cancer patients. Trial registration: The study was retrospectively registered at clinicaltrials.gov on 04/22/2018 (Registration No.: NCT03533413). [ABSTRACT FROM AUTHOR]

Conservative therapy is often the first-line treatment for many symptoms of various disease processes, including pain. Nevertheless, if pharmacological or medical management fails for those patients with severe and chronic pain, a surgical strategy may be a reasonable option. First performed for psychiatric disorders, cingulotomy now has been recognized as a viable option for the management of pain. The authors review the literature on anterior cingulotomy for intractable pain to provide guidelines for management and expected outcomes.

Background: There is currently little evidence regarding the use of medical cannabis for the treatment of intractable pain. Literature published on the subject to date has yielded mixed results concerning the efficacy of medical cannabis and has been limited by study design and regulatory issues. Objective: The objective of this study was to determine if the use of medical cannabis affects the amount of opioids and benzodiazepines used by patients on a daily basis. Methods: This single-center, retrospective cohort study evaluated opioid and benzodiazepine doses over a 6-month time period for patients certified to use medical cannabis for intractable pain. All available daily milligram morphine equivalents (MMEs) and daily diazepam equivalents (DEs) were calculated at baseline and at 3 and 6 months. Results: A total of 77 patients were included in the final analysis. There was a statistically significant decrease in median MME from baseline to 3 months (-32.5 mg; P = 0.013) and 6 months (-39.1 mg; P = 0.001). Additionally, there was a non-statistically significant decrease in median DE at 3 months (-3.75 mg; P = 0.285) and no change in median DE from baseline to 6 months (-0 mg; P = 0.833). Conclusion and Relevance: Over the course of this 6-month retrospective study, patients using medical cannabis for intractable pain experienced a significant reduction in the number of MMEs available to use for pain control. No significant difference was noted in DE from baseline. Further prospective studies are warranted to confirm or deny the opioid-sparing effects of medical cannabis when used to treat intractable pain. [ABSTRACT FROM AUTHOR]

Bullous pemphigoid (BP) is an autoimmune blistering disorder that predominantly affects the elderly. Treatment regimens typically include topical and systemic immunosuppressive medications. Although effective, systemic corticosteroids are sometimes poorly tolerated in the elderly patient, contributing to the overall morbidity and mortality of BP. Dupilumab is a monoclonal antibody targeting interleukin 4 receptor alpha (IL4Ra), approved for the treatment of atopic dermatitis, as well as moderate to severe asthma and chronic rhinosinusitis with nasal polyposis. In recent reports, dupilumab has been successfully used off-label to treat a variety of pruritic disorders, including chronic spontaneous urticaria [1], anal and genital itch [2], allergic contact dermatitis [3], and prurigo nodularis [4, 5]. We report here a case of an elderly patient with refractory BP whose symptoms of pruritus and blistering became well-controlled with the addition of dupilumab to the treatment regimen. [ABSTRACT FROM AUTHOR]

Background: Up to 30% of patients with cancer continue to suffer from pain despite aggressive supportive care. The present study aimed to determine whether cordotomy can improve cancer pain refractory to interdisciplinary palliative care. Materials and Methods: In this randomized controlled trial, we recruited patients with refractory unilateral somatic pain, defined as a pain intensity (PI) ≥4, after more than three palliative care evaluations. Patients were randomized to percutaneous computed tomography‐guided cordotomy or continued interdisciplinary palliative care. The primary outcome was 33% improvement in PI at 1 week after cordotomy or study enrollment as measured by the Edmonton Symptom Assessment Scale. Results: Sixteen patients were enrolled (nine female, median age 58 years). Six of seven patients (85.7%) randomized to cordotomy experienced >33% reduction in PI (median preprocedure PI = 7, range 6–10; 1 week after cordotomy median PI = 1, range 0–6; p = .022). Zero of nine patients randomized to palliative care achieved a 33% reduction in PI. Seven patients (77.8%) randomized to palliative care elected to undergo cordotomy after 1 week. All of these patients experienced >33% reduction in PI (median preprocedure PI = 8, range 4–10; 1 week after cordotomy median PI = 0, range 0–1; p = .022). No patients were withdrawn from the study because of adverse effects of the intervention. Conclusion: These data support the use of cordotomy for pain refractory to optimal palliative care. The findings of this study justify a large‐scale randomized controlled trial of percutaneous cordotomy. Implications for Practice: This prospective clinical trial was designed to determine the improvement in pain intensity in patients randomized to either undergo cordotomy or comprehensive palliative care for medically refractory cancer pain. This study shows that cordotomy is effective in reducing pain for medically refractory cancer pain, and these results can be used to design a large‐scale comparative randomized controlled trial that could provide the evidence needed to include cordotomy as a treatment modality in the guidelines for cancer pain management. Can a cordotomy improve pain outcomes in optimally medically treated patients with refractory cancer pain? This article addresses the question. [ABSTRACT FROM AUTHOR]

Spinal cord stimulation (SCS) is both relatively safe and reversible. Although SCS is generally regarded as a last resort, some of these patients will undergo additional spinal surgery after the device has been implanted or after its removal. We present a descriptive study of subsequent spinal surgery after SCS implantation. A retrospective review of patients who had undergone percutaneous or paddle SCS lead placement at our institution from 2009 to 2016 was performed. Patients who had only undergone trials or who had not undergone spine surgery after SCS implantation were excluded. We identified 22 patients (5.7%) who had undergone spine surgery during the course of SCS treatment or after SCS removal, or both, of a total 383 patients who had undergone paddle and/or percutaneous SCS implantation. The most common additional spine interventions included lumbosacral decompression and fusion (n = 15; 42%). Of 36 surgeries, the most frequent indications for subsequent intervention were stenosis or restenosis (n = 16; 73%) and spine deformity (n = 6; 27%). The median EuroQol-5D index was 0.397 preoperatively and 0.678 postoperatively. To the best of our knowledge, the present study is the first to describe spine surgery in the setting of SCS implantation. Our results have indicated that spine surgery subsequent to, or concurrent with, SCS implantation appears to occur in few patients. Our study results suggest a modest improvement in quality of life outcomes. Therefore, clinicians should remember that patients might require further spine surgery despite the use of SCS implantation and, thus, might require reevaluation by the spine team. [ABSTRACT FROM AUTHOR]