1
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Gomez-Eslava B, Raasveld FV, Hoftiezer YAJ, McCarty JC, Daddario JL, Valerio IL, Heng M, Eberlin KR. Pain Sketches to Predict Pain following Primary Targeted Muscle Reinnervation in Amputees. Plast Reconstr Surg 2024; 153:1162-1171. [PMID: 37252909 PMCID: PMC10676444 DOI: 10.1097/prs.0000000000010762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Numeric scales are validated methods to report pain outcomes after targeted muscle reinnervation (TMR) but do not include the assessment of qualitative pain components. This study evaluates the application of pain sketches within a cohort of patients undergoing primary TMR and describes differences in pain progression according to early postoperative sketches. METHODS This study included 30 patients with major limb amputation and primary TMR. Patients' drawings were categorized into four categories of pain distribution [focal pain (FP), radiating pain (RP), diffuse pain (DP), or no pain (NP)] and interrater reliability was calculated. Second, pain outcomes were analyzed for each category. Pain scores were the primary outcome, and Patient-Reported Outcomes Measurement Information System (PROMIS) instruments were the secondary outcome. RESULTS The interrater reliability for the sketch categories was good (overall kappa coefficient of 0.8). The NP category reported a mean decrease in pain of 4.8 points, followed by the DP (2.5 points) and FP categories (2.0 points). The RP category reported a mean increase in pain of 0.5 points. For PROMIS Pain Interference and Pain Intensity, the DP category reported a mean decrease of 7.2 and 6.5 points, respectively, followed by the FP category (5.3 and 3.6 points). The RP category reported a mean increase of 2.0 points in PROMIS Pain Interference and a mean decrease of 1.4 points in PROMIS Pain Intensity. Secondary outcomes for the NP category were not reported. CONCLUSION Pain sketches demonstrated reliability in pain morphology assessment and might be an adjunctive tool for pain interpretation in this setting.
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Affiliation(s)
| | - Floris V Raasveld
- From the Hand and Arm Center, Department of Orthopaedic Surgery
- Department of Plastic, Reconstructive, and Hand Surgery, Erasmus Medical Center
| | - Yannick A J Hoftiezer
- From the Hand and Arm Center, Department of Orthopaedic Surgery
- Department of Plastic, Reconstructive, and Hand Surgery, Radboud University Medical Center
| | - Justin C McCarty
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Jenna L Daddario
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Ian L Valerio
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Marilyn Heng
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine
- Orthopaedic Trauma Service, Jackson Memorial Ryder Trauma Center
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard Medical School
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Caragher SP, Khouri KS, Raasveld FV, Winograd JM, Valerio IL, Gfrerer L, Eberlin KR. The Peripheral Nerve Surgeon's Role in the Management of Neuropathic Pain. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5005. [PMID: 37360238 PMCID: PMC10287132 DOI: 10.1097/gox.0000000000005005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/29/2023] [Indexed: 06/28/2023]
Abstract
Neuropathic pain (NP) underlies significant morbidity and disability worldwide. Although pharmacologic and functional therapies attempt to address this issue, they remain incompletely effective for many patients. Peripheral nerve surgeons have a range of techniques for intervening on NP. The aim of this review is to enable practitioners to identify patients with NP who might benefit from surgical intervention. The workup for NP includes patient history and specific physical examination maneuvers, as well as imaging and diagnostic nerve blocks. Once diagnosed, there is a range of options surgeons can utilize based on specific causes of NP. These techniques include nerve decompression, nerve reconstruction, nerve ablative techniques, and implantable nerve-modulating devices. In addition, there is an emerging role for preoperative involvement of peripheral nerve surgeons for cases known to carry a high risk of inducing postoperative NP. Lastly, we describe the ongoing work that will enable surgeons to expand their armamentarium to better serve patients with NP.
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Affiliation(s)
| | - Kimberly S. Khouri
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
| | - Floris V. Raasveld
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jonathan M. Winograd
- From the Harvard Medical School, Boston, Mass
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
| | - Ian L. Valerio
- From the Harvard Medical School, Boston, Mass
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
| | - Lisa Gfrerer
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, N.Y
| | - Kyle R. Eberlin
- From the Harvard Medical School, Boston, Mass
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
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3
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Macionis V. Chronic pain and local pain in usually painless conditions including neuroma may be due to compressive proximal neural lesion. FRONTIERS IN PAIN RESEARCH 2023; 4:1037376. [PMID: 36890855 PMCID: PMC9986610 DOI: 10.3389/fpain.2023.1037376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/12/2023] [Indexed: 02/22/2023] Open
Abstract
It has been unexplained why chronic pain does not invariably accompany chronic pain-prone disorders. This question-driven, hypothesis-based article suggests that the reason may be varying occurrence of concomitant peripheral compressive proximal neural lesion (cPNL), e.g., radiculopathy and entrapment plexopathies. Transition of acute to chronic pain may involve development or aggravation of cPNL. Nociceptive hypersensitivity induced and/or maintained by cPNL may be responsible for all types of general chronic pain as well as for pain in isolated tissue conditions that are usually painless, e.g., neuroma, scar, and Dupuytren's fibromatosis. Compressive PNL induces focal neuroinflammation, which can maintain dorsal root ganglion neuron (DRGn) hyperexcitability (i.e., peripheral sensitization) and thus fuel central sensitization (i.e., hyperexcitability of central nociceptive pathways) and a vicious cycle of chronic pain. DRGn hyperexcitability and cPNL may reciprocally maintain each other, because cPNL can result from reflexive myospasm-induced myofascial tension, muscle weakness, and consequent muscle imbalance- and/or pain-provoked compensatory overuse. Because of pain and motor fiber damage, cPNL can worsen the causative musculoskeletal dysfunction, which further accounts for the reciprocity between the latter two factors. Sensitization increases nerve vulnerability and thus catalyzes this cycle. Because of these mechanisms and relatively greater number of neurons involved, cPNL is more likely to maintain DRGn hyperexcitability in comparison to distal neural and non-neural lesions. Compressive PNL is associated with restricted neural mobility. Intermittent (dynamic) nature of cPNL may be essential in chronic pain, because healed (i.e., fibrotic) lesions are physiologically silent and, consequently, cannot provide nociceptive input. Not all patients may be equally susceptible to develop cPNL, because occurrence of cPNL may vary as vary patients' predisposition to musculoskeletal impairment. Sensitization is accompanied by pressure pain threshold decrease and consequent mechanical allodynia and hyperalgesia, which can cause unusual local pain via natural pressure exerted by space occupying lesions or by their examination. Worsening of local pain is similarly explainable. Neuroma pain may be due to cPNL-induced axonal mechanical sensitivity and hypersensitivity of the nociceptive nervi nervorum of the nerve trunk and its stump. Intermittence and symptomatic complexity of cPNL may be the cause of frequent misdiagnosis of chronic pain.
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4
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Avery EC, Augustine H, Sade S, Dengler J. Extradigital glomus tumour of the thigh causing 8 years of undiagnosed debilitating pain. BMJ Case Rep 2022; 15:e249869. [PMID: 36535730 PMCID: PMC9764623 DOI: 10.1136/bcr-2022-249869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
A woman in her mid-50s was referred to a plastic surgeon with an 8-year history of undiagnosed, localised severe, reproducible pain of the right thigh. Treatment with oral and topical analgesics, corticosteroids, acupuncture and physiotherapy did not provide symptom relief. She was referred to multiple specialists over the preceding 8 years including chronic pain physicians, physiatry, orthopaedic surgery and plastic surgery. Investigations including sonographic and MRI eventually revealed a non-specific soft tissue abnormality in the area of tenderness, which was excised en bloc. Histopathology revealed an extradigital glomus tumour. The patient's symptoms immediately and permanently resolved postexcision.Physicians seeing patients suffering from undiagnosed focal, reproducible pain should consider extradigital glomus tumours in their differential diagnosis. Workup for extradigital glomus tumour includes focused sonographic or MRI over the area of pain. Additionally, local injection of an anaesthetic agent can be used to assist with diagnosis.
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Affiliation(s)
- Emma Claire Avery
- Plastic, Reconstructive and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Haley Augustine
- Plastic, Reconstructive and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Shachar Sade
- Department of Pathology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jana Dengler
- Plastic, Reconstructive and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Plastic and Reconstructive Surgery, Tory Trauma Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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5
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Peters BR, Sikora Z, Timmins BH, Berli JU. “Nerve-Morbidity at the Radial Forearm Donor Site Following Gender-Affirming Phalloplasty”. J Plast Reconstr Aesthet Surg 2022; 75:3836-3844. [DOI: 10.1016/j.bjps.2022.06.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 04/17/2022] [Accepted: 06/05/2022] [Indexed: 11/28/2022]
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6
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Heary KO, Wong AWK, Lau SCL, Dengler J, Thompson MR, Crock LW, Novak CB, Philip BA, Mackinnon SE. Quality of Life and Psychosocial Factors as Predictors of Pain Relief Following Nerve Surgery. Hand (N Y) 2022; 17:193-199. [PMID: 32188297 PMCID: PMC8984711 DOI: 10.1177/1558944720911213] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Peripheral nerve injuries may result in pain, disability, and decreased quality of life (QoL). Pain is an incompletely understood experience and is associated with emotional and behavioral qualities. We hypothesized that pain following peripheral nerve surgery could be predicted by changes in emotions or QoL postoperatively. Methods: Using prospectively collected data, a retrospective study design was used to evaluate the relationships among pain, QoL, and psychosocial factors in patients who underwent peripheral nerve surgery. Patients completed questionnaires rating pain; impact of pain on QoL, sadness, depression, frustration, anger, and hopefulness before surgery; and each postoperative follow-up visit. Multilevel modeling was used to assess the concurrent and lagged relationships between pain and psychosocial factors. Results: Increased pain was concurrently associated with decreased hopefulness (P = .001) and increased the impact on QoL, sadness, depression, and anger (P < .001). In lagged analyses, the impact on QoL and anger prospectively predicted pain (P < .001 and P = .02, respectively). Pain predicted subsequent scores of QoL, sadness, depression, anger, and hopefulness (P < .01). Having an upper limb nerve injury and self-report of "no comment for childhood trauma" were predictors of postsurgical pain. Conclusion: Psychosocial measures and pain are reciprocally related among patients who underwent surgery for peripheral nerve injuries or compression. Our study provides evidence of the important relationships among psychosocial factors, pain, and outcome and identifies treatment targets following nerve surgery.
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Affiliation(s)
| | - Alex W. K. Wong
- Washington University School of
Medicine, St. Louis, MO, USA
| | | | | | | | - Lara W. Crock
- Washington University School of
Medicine, St. Louis, MO, USA
| | | | | | - Susan E. Mackinnon
- Washington University School of
Medicine, St. Louis, MO, USA,Susan E. Mackinnon, Division of Plastic and
Reconstructive Surgery, Department of Surgery, Washington University School of
Medicine, 660 S. Euclid Avenue, Campus Box 8238, St. Louis, MO 63110, USA.
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7
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Felder JM, Ducic I. Cross-Sectional Evaluation of the Economic Burden on Patients Seeking Surgical Treatment for Chronic Nerve Injuries. Ann Plast Surg 2022; 88:200-207. [PMID: 34176908 DOI: 10.1097/sap.0000000000002924] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Little emphasis has been paid toward characterizing the socioeconomic burdens experienced by patients seeking treatment for chronic nerve injuries. The aim of this study was to characterize the direct and indirect costs faced by patients with chronic nerve injuries and their attendant health care utilization. MATERIALS AND METHODS A cross-sectional survey was distributed to all patients (N = 767) from a single nerve surgeon's practice treated for chronic nerve injuries in the ambulatory setting between 2014 and 2020. Data collected included demographics, etiology, comorbidities, duration and severity of symptoms, history of prior medical and interventional treatments, work or school time lost due to injury or treatment, money spent on treatment, and health care utilization. RESULTS Of the 767 patients, 209 (27.2%) completed the survey. Average age was 48.8 (SD = 19.1) years, 68.9% female and 31.1% male. Patients with chronic nerve injury reported significant direct costs, indirect costs, and health care utilization associated with their nerve injury symptoms. Direct costs consisted of out-of-pocket spending (68.4% had spent >$1000 per year), physician specialists visits (71.3% had seen at least 4 specialists), and prior interventional procedures intended to address symptoms. Indirect costs included lost time from work or school (24.6% had missed more than 12 months). Health care utilization, represented by annual emergency room visits and hospitalizations related to nerve symptoms, was increased relative to the general population. Detailed statistics are presented in the manuscript. CONCLUSIONS Chronic nerve injuries may be associated with a notable socioeconomic burden to the patient, including missed work or school, frequent physician visits and procedures, hospital visits, and out-of-pocket costs. Interdisciplinary algorithms recognizing a role for surgical evaluation in patients with chronic neuropathic pain due to underlying nerve injuries would facilitate future research into whether timely surgical intervention may reduce this economic burden.
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Affiliation(s)
- John M Felder
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St Louis, St Louis, MO
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8
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Nguyen B, Parikh P, Singh R, Patel N, Noland S. Trends in Peripheral Nerve Surgery: Workforce, Reimbursement, and Procedural Rates. World Neurosurg 2022; 160:e180-e188. [PMID: 35077894 DOI: 10.1016/j.wneu.2021.12.111] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Brandon Nguyen
- Mayo Clinic Alix School of Medicine - Arizona Campus, 13400 E Shea Blvd., Scottsdale, AZ, 85259, USA
| | - Parth Parikh
- Mayo Clinic Alix School of Medicine - Arizona Campus, 13400 E Shea Blvd., Scottsdale, AZ, 85259, USA
| | - Rohin Singh
- Mayo Clinic Alix School of Medicine - Arizona Campus, 13400 E Shea Blvd., Scottsdale, AZ, 85259, USA
| | - Naresh Patel
- Department of Neurosurgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ, 85054, USA
| | - Shelley Noland
- Department of Plastic and Reconstructive Surgery and Peripheral Nerve Clinic; Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ, 85054, USA.
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Taylor SS, Noor N, Urits I, Paladini A, Sadhu MS, Gibb C, Carlson T, Myrcik D, Varrassi G, Viswanath O. Complex Regional Pain Syndrome: A Comprehensive Review. Pain Ther 2021; 10:875-892. [PMID: 34165690 PMCID: PMC8586273 DOI: 10.1007/s40122-021-00279-4] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/03/2021] [Indexed: 12/22/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a chronic pain condition often involving hyperalgesia and allodynia of the extremities. CRPS is divided into CRPS-I and CRPS-II. Type I occurs when there is no confirmed nerve injury. Type II is when there is known associated nerve injury. Female gender is a risk factor for developing CRPS. Other risk factors include fibromyalgia and rheumatoid arthritis. Unfortunately, the pathogenesis of CRPS is not yet clarified. Some studies have demonstrated different potential pathways. Neuropathic inflammation, specifically activation of peripheral nociceptors of C-fibers, has been shown to play a critical role in developing CRPS. The autonomic nervous system (ANS) is involved. Depending on whether it is acute or chronic CRPS, norepinephrine levels are either decreased or increased, respectively. Some studies have suggested the importance of genetics in developing CRPS. More consideration is being given to the role of psychological factors. Some association between a history of depression and/or post-traumatic stress disorder (PTSD) and the diagnosis of CRPS has been demonstrated. Treatment modalities available range from physical therapy, pharmacotherapy, and interventional techniques. Physical and occupational therapies include mirror therapy and graded motor imagery. Medical management with non-steroidal anti-inflammatory drugs (NSAIDs) has not shown significant improvement. There have been supporting findings in the use of short-course steroids, bisphosphonates, gabapentin, and ketamine. Antioxidant treatment has also shown some promise. Other pharmacotherapies include low-dose naltrexone and Botulinum toxin A (BTX-A). Sympathetic blocks are routinely used, even if their short- and long-term effects are not clear. Finally, spinal cord stimulation (SCS) has been used for decades. In conclusion, CRPS is a multifactorial condition that still requires further studying to better understand its pathogenesis, epidemiology, genetic involvement, psychological implications, and treatment options. Future studies are warranted to better understand this syndrome. This will provide an opportunity for better prevention, diagnosis, and treatment of CRPS.
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Affiliation(s)
- Samantha-Su Taylor
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Nazir Noor
- Department of Anesthesiology, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL, 33130, USA.
| | - Ivan Urits
- grid.492905.3Southcoast Physician Group Pain Medicine, Southcoast Health, North Dartmouth, MA USA ,grid.64337.350000 0001 0662 7451Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA USA
| | - Antonella Paladini
- grid.158820.60000 0004 1757 2611Department of MESVA, University of L’Aquila, 67100 L’Aquila, Italy
| | - Monica Sri Sadhu
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Clay Gibb
- grid.260024.2Midwestern University Chicago College of Osteopathic Medicine, Chicago, IL USA
| | - Tyler Carlson
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Dariusz Myrcik
- grid.411728.90000 0001 2198 0923Department of Internal Medicine, Medical University of Silesia, 42-600 Katowice, Bytom Poland
| | | | - Omar Viswanath
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA ,grid.64337.350000 0001 0662 7451Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA USA ,Valley Pain Consultants-Envision Physician Services, Phoenix, AZ USA ,grid.254748.80000 0004 1936 8876Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE USA
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Impact of Nerve Surgery on Opioid and Medication Use in Patients with Chronic Nerve Injuries. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3789. [PMID: 34513538 PMCID: PMC8423382 DOI: 10.1097/gox.0000000000003789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 06/30/2021] [Indexed: 11/26/2022]
Abstract
Introduction: Limited information is available regarding the ability of nerve surgery to affect medication use patterns in patients with chronic pain or neuropathy due to nerve injury. Methods: A retrospective survey was distributed to all operative patients (N = 767) from a single nerve surgeon’s practice between 2014 and 2020. Data collected included demographics, specifics of the injury and symptoms, medication and opioid use before surgery, and medication/opioid use following surgery. Results: Out of the 767 patients, 209 (27.2%) completed the survey. Average age was 48.8 (SD = 19.1) years; 68.9% female and 31.1% male. More than 50% of the patients took at least three medications. More than 50% of the patients after surgery did not need medication or had significant reduction; 54.1% of the patients took opioid medication daily, and 97.3% of patients reported that narcotic medications did not resolve their problem. Patients rated the effectiveness (Likert scale 0–10) of opioid medications in general at an average 3.25 ± 2.03. Of patients who took opioids regularly, 61.6% reported a negative effect of these medications on daily or professional activities. After surgery, more than 50% of the patients did not need opioids or had a significant reduction in opioid usage. Conclusions: Untreated nerve injuries lead to ongoing chronic pain, explaining why medications are mostly ineffective in eliminating symptoms. In this study, nerve surgery targeting the anatomical source of symptoms effectively reduced both opioid and nonopioid medication use.
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Hama S, Uemura T, Onode E, Yokoi T, Okada M, Takamatsu K, Nakamura H. Nerve capping treatment using a bioabsorbable nerve conduit with open or closed end for rat sciatic neuroma. Clin Neurol Neurosurg 2021; 209:106920. [PMID: 34500341 DOI: 10.1016/j.clineuro.2021.106920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/07/2021] [Accepted: 08/21/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND AIMS Nerve capping treatment using bioabsorbable nerve conduits has recently been introduced for painful amputation neuroma. However, no clinical or experimental data are available for comparing nerve conduits with open distal ends and closed distal ends. Here, we investigated the nerve conduit with open or closed distal ends as the superior capping device, using a commercially available polyglycolic acid (PGA) nerve conduit in a rat sciatic nerve amputation model. METHODS Ninety-one rats were assigned to three groups: no-capping (n = 30), capping the resected nerve stump with open ends (n = 31), and closed-end nerve conduits (n = 30). Twelve weeks after sciatic neurectomy, with or without capping, the evaluation of neuropathic pain using the autotomy score was performed. Stump neuromas with perineural scars and neuroinflammation were evaluated histologically. RESULTS The mean autotomy scores in the closed-end nerve conduit group were significantly lower than those in the no-capping group. However, the difference between the open-end nerve conduit and the closed-end nerve conduit groups was insignificant. Histologically, distal axonal fibers expanded radially and formed neuromas in the no-capping group while they were terminated within the PGA conduit in both capping groups. In particular, the closed-end version of the PGA nerve conduit blocked scarring from intruding through the open end and protected the nerve stump with less neuroinflammation. Nerve capping with the closed-end version of the PGA nerve conduit most effectively suppressed perineural neuroinflammation and scar formation around the resected nerve stump. INTERPRETATION Nerve capping with the PGA nerve conduit, particularly those with closed ends, after rat sciatic neurectomy prevented amputation neuroma and relieved neuropathic pain.
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Affiliation(s)
- Shunpei Hama
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takuya Uemura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan; Department of Orthopaedic Surgery, Osaka General Hospital of West Japan Railway Company, Osaka, Japan.
| | - Ema Onode
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takuya Yokoi
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan; Department of Orthopaedic Surgery, Seikeikai Hospital, Osaka, Japan
| | - Mitsuhiro Okada
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kiyohito Takamatsu
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan; Department of Orthopaedic Surgery, Yodogawa Christian Hospital, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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12
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Aino M, Oka S, Haruguchi K, Aino M, Hashimura S, Kurosawa K. Comparison of spinal column alignment and autonomic nervous activity using the intersegmental tenderness test in the segment above. J Phys Ther Sci 2021; 33:570-575. [PMID: 34393365 PMCID: PMC8332640 DOI: 10.1589/jpts.33.570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/10/2021] [Indexed: 11/24/2022] Open
Abstract
[Purpose] The thoracolumbar supraspinous intersegmental tenderness test (ITT) in the
segment above was performed to compare spinal alignment and autonomic activity in the
presence or absence of pain. [Participants and Methods] Thirty young males were grouped
into Th1–4 (Cardiopulmonary visceral nerves), Th5–9 (Large visceral nerve), and Th10–12
(Small visceral nerve) by ITT for the presence of pain. Measurements of the spinal
alignment and autonomic function were performed. [Results] Those with ITT pain had a
significantly lower range of motion in the sagittal plane at Th12, Th12–L1, and L2–3 and
in the frontal plane at Th1–2, Th4–5, Th6–7, and L3–4 than those in the no pain group. On
autonomic function tests, the pain group had significantly lower Total Power, LF (Low
Frequency), and CVRR (Coefficient of variation of R-R interval). [Conclusion] In ITT,
patients with pain at Th5–9 have a mixture of reduced sagittal tilt angle and autonomic
hypofunction of the adjacent upper and lower thoracic to lumbar vertebrae.
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Affiliation(s)
- Masaki Aino
- Japan Systemic Fascia Neuro-Pain Approach Association: 1-13-24 Kashii Ekimae, Higashi-ku, Fukuoka-shi, Fukuoka 813-0013, Japan
| | - Shinichiro Oka
- Department of Physical Therapy, School of Health Sciences at Fukuoka, International University of Health and Welfare, Japan
| | | | - Mayumi Aino
- Department of Rehabilitation, Kitakyushu Koga Hospital, Japan
| | - Shun Hashimura
- Department of Rehabilitation, Kitakyushu Koga Hospital, Japan
| | - Kazuo Kurosawa
- Department of Physical Therapy, School of Health Sciences at Odawara, International University of Health and Welfare, Japan
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13
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Nirenberg M. Complex Regional Pain Syndrome: The Importance of Early Diagnosis. Orthop Nurs 2021; 40:204-208. [PMID: 34397974 DOI: 10.1097/nor.0000000000000769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a potentially life-altering, neuropathic pain condition that often affects an extremity in response to surgery or even minor trauma. The pain is often disproportionate to the injury sustained or the surgical procedure performed-and it has been described as excruciating and unbearable. CRPS can result in irreversible, disabling changes in the affected limb. In some cases it has resulted in amputation or severe psychological issues. However, CRPS outcomes are generally more successful with early detection and treatment. This article presents an overview of CRPS and discusses the critical role nurses can play in recognizing the condition early, assisting with treatment, and providing psychological support.
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Affiliation(s)
- Michael Nirenberg
- Michael Nirenberg, DPM , Clinical and Forensic Podiatrist, Friendly Foot Care, PC, Crown Point, IN
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14
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Dibbs RP, Ali K, Sarrami SM, Koshy JC. Revision Peripheral Nerve Surgery of the Upper Extremity. Semin Plast Surg 2021; 35:119-129. [PMID: 34121947 DOI: 10.1055/s-0041-1727290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Peripheral nerve injuries of the upper extremity can result from a wide array of etiologies, with the two most common being compression neuropathy and traumatic injuries. These types of injuries are common and can be psychologically, functionally, and financially devastating to the patient. A detailed preoperative evaluation is imperative for appropriate management. Traumatic injuries can typically be treated with local burial techniques, targeted muscle reinnervation, and regenerative peripheral nerve interfaces. Median nerve compression is frequently managed with complete release of the antebrachial fascia/transverse carpal ligament and/or use of flap coverage such as the hypothenar fat pad flap and local muscle flaps. Ulnar nerve compression is commonly managed via submuscular transposition, subcutaneous transposition, neurolysis, and nerve wrapping. In this review, we discuss the preoperative evaluation, surgical techniques, and advantages and disadvantages of each treatment modality for patients with compressive and traumatic upper extremity nerve injuries.
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Affiliation(s)
- Rami P Dibbs
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Texas
| | - Kausar Ali
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Texas
| | - Shayan M Sarrami
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Texas
| | - John C Koshy
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Texas
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15
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Felder JM, Ducic I. Chronic Nerve Injuries and Delays in Surgical Treatment Negatively Impact Patient-reported Quality of Life. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3570. [PMID: 34036022 PMCID: PMC8140770 DOI: 10.1097/gox.0000000000003570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 03/15/2021] [Indexed: 11/25/2022]
Abstract
Little emphasis has been paid to characterize quality of life (QoL) burdens experienced by patients seeking surgical treatment for nerve injuries and neuropathic pain. METHODS A cross-sectional survey was distributed to all patients (N = 767) from a single nerve surgeon's practice between 2014 and 2019. Data collected included demographics, specifics of the injury and symptoms, time to referral, and effects of the injury, surgery, and timing of surgery on QoL. RESULTS Of the 767 patients, 209 (27.2%) completed the survey. Average age was 48.8 years; 68.9% of patients were women and 31.1% men. At presentation, 68% had experienced symptoms for more than 1 year; 86.1% reported severity as being profound; 97.6% reported QoL was at least moderately negatively impacted by nerve injury; 70% felt they should have been referred earlier for surgical evaluation; 51.2% were not told that nerve surgery was an option for their problem; 83.1% felt that earlier referral would have improved their QoL. After surgery, symptoms were significantly mitigated in 55.5% of the patients, moderately mitigated in 21.5%. Patients reported QoL was significantly (59.8%) or at least moderately (76.6%) improved by nerve surgery. CONCLUSIONS The majority of patients reported that nerve injuries imparted a moderate to severe impact on QoL, and that surgical treatment improved QoL. Most patients felt that earlier referral for surgical intervention would have led to better outcome and positively impacted QoL. Interdisciplinary treatment algorithms, including a role for surgical intervention, may be helpful in facilitating timely diagnosis, referral, and thus improved outcomes.
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Affiliation(s)
- John M. Felder
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, Mo
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16
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Hong T, Wood I, Hunter DA, Yan Y, Mackinnon SE, Wood MD, Moore AM. Neuroma Management: Capping Nerve Injuries With an Acellular Nerve Allograft Can Limit Axon Regeneration. Hand (N Y) 2021; 16:157-163. [PMID: 31137979 PMCID: PMC8041431 DOI: 10.1177/1558944719849115] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Management of painful neuromas continues to challenge clinicians. Controlling axon growth to prevent neuroma has gained considerable traction. A logical extension of this idea is to therefore develop an approach to control and arrest axon growth. Given the limits in axonal regeneration across acellular nerve allografts (ANAs), these constructs could provide a means to reliably terminate axon regeneration from an injured nerve. The purpose of this study was to determine if attaching an ANA to an injured nerve could provide a means to control and limit axon regeneration in a predictable manner. Methods: Twenty (20) adult rats received a sciatic nerve transection, where only the proximal nerve was repaired using an ANA of variable length (0.5, 2.5, and 5.0 cm) or left unrepaired (control). The nerves were harvested 5 weeks post-operatively for gross and histomorphometric analysis. The extent of myelinated axons in regenerated tissue was quantified. Results: At 5 weeks, limited axon regeneration within the ANAs was observed. All lengths of ANAs lead to reduced myelinated axon numbers in the most terminal tissue region compared to untreated injured nerve (P = .002). Additionally, ANA length 2.5 cm or greater did not contain any axons at the most terminal tissue region. Conclusions: This study demonstrates a proof of concept that ANAs attached to the proximal end of an injured nerve can limit axon growth in a controlled manner. Furthermore, the extent of axon growth from the injured nerve into the ANA is dependent on the ANA length.
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Affiliation(s)
- Thomas Hong
- Washington University School of Medicine, St. Louis, MO, USA
| | - Ian Wood
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - Ying Yan
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - Matthew D. Wood
- Washington University School of Medicine, St. Louis, MO, USA
| | - Amy M. Moore
- Washington University School of Medicine, St. Louis, MO, USA,Amy M. Moore, Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8238, St. Louis, MO 63110, USA.
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17
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Smith DW. An Unusual Case of Periosteal Glomus Tumor at the Metacarpal Base Presenting as Type II CRPS: Case Report. Hand (N Y) 2021; 16:NP1-NP4. [PMID: 31984818 PMCID: PMC7818035 DOI: 10.1177/1558944719895618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: An unusual case involving a middle-aged male with a 9-year history of presumptive chronic regional pain syndrome (CRPS) and ulnar neuropathy was referred for failure in treatment. Methods: On presentation, the patient was requesting an amputation of his arm. However, work-up uncovered a periosteal extra-digital glomus tumor on the base of the small finger metacarpal. Results: Surgical excision of the lesion resulted in rapid resolution of his pain and normal hand function was ultimately restored. Conclusions: Glomus tumors account for up to 5% of all soft tissue tumors of the upper extremity, occurring most frequently within or adjacent to the nail bed. Time from onset of symptoms to correct diagnosis may not be established for many years, especially with atypical tumor locations. Although glomus tumors have been widely reported, atypical locations of these tumors should be included in the differential diagnosis for patients with unusual chronic pain or neuropathy. Furthermore, when evaluating a chronic pain patient, our findings support the opinion that assignment of the diagnosis of CRPS should only be a diagnosis of exclusion.
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Affiliation(s)
- Dean W. Smith
- The University of Texas Health Science Center
at Houston, USA,Dean W. Smith, Department of Orthopaedic Surgery,
The University of Texas Health Science Center at Houston, 6400 Fannin, Suite 1700,
Houston, TX 77030, USA.
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18
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Morgan R, Elliot I, Banala V, Dy C, Harris B, Ouellette EA. Pain Relief after Surgical Decompression of the Distal Brachial Plexus. J Brachial Plex Peripher Nerve Inj 2020; 15:e22-e32. [PMID: 33082844 PMCID: PMC7567639 DOI: 10.1055/s-0040-1716718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 07/26/2020] [Indexed: 11/24/2022] Open
Abstract
Background
Brachial plexopathy causes pain and loss of function in the affected extremity. Entrapment of the brachial plexus terminal branches within the surrounding connective tissue, or medial brachial fascial compartment, may manifest in debilitating symptoms. Open fasciotomy and external neurolysis of the neurovascular bundle in the medial brachial fascial compartment were performed as a surgical treatment for pain and functional decline in the upper extremity. The aim of this study was to evaluate pain outcomes after surgery in patients diagnosed with brachial plexopathy.
Methods
We identified 21 patients who met inclusion criteria. Documents dated between 2005 and 2019 were reviewed from electronic medical records. Chart review was conducted to collect data on visual analog scale (VAS) for pain, Semmes-Weinstein monofilament test (SWMT), and Medical Research Council (MRC) scale for muscle strength. Pre- and postoperative data was obtained. A paired sample
t
-test was used to determine statistical significance of pain outcomes.
Results
Pain severity in the affected arm was significantly reduced after surgery (pre: 6.4 ± 2.5; post: 2.0 ± 2.5;
p
< 0.01). Additionally, there was an increased response to SWMT after the procedure. More patients achieved an MRC rating score ≥3 and ≥4 in elbow flexion after surgery. This may be indicative of improved sensory and motor function.
Conclusion
Open fasciotomy and external neurolysis at the medial brachial fascial compartment is an effective treatment for pain when nerve continuity is preserved. These benefits were evident in patients with a prolonged duration elapsed since injury onset.
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Affiliation(s)
- Richard Morgan
- Department of Physical Medicine & Rehabilitation, Larkin Community Hospital, Miami, Florida, United States
| | - Iain Elliot
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington, United States
| | - Vibhu Banala
- Department of Orthopedic Surgery, Montefiore Medical Center, Bronx, New York, United States
| | - Christopher Dy
- Department of Orthopedic Surgery, Washington University, School of Medicine, St. Louis, Missouri, United States
| | - Briana Harris
- Department of Orthopedic Surgery, Miami Orthopedics and Sports Medicine Institute, Baptist Health Medical Group South Florida, Miami, Florida, United States
| | - Elizabeth Anne Ouellette
- Department of Orthopedic Surgery, Miami Orthopedics and Sports Medicine Institute, Baptist Health Medical Group South Florida, Miami, Florida, United States
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19
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de Ru JA, M Thomeer HGX, Tijink BM, van Doormaal TPC. Neurocap Use for the Treatment of Iatrogenic Neuropathic Pain: Preliminary Operative Results in 3 Patients. EAR, NOSE & THROAT JOURNAL 2020; 100:830S-834S. [PMID: 32192381 DOI: 10.1177/0145561320912048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Painful neuromas are a devastating condition that is notoriously difficult to treat. The large number of techniques that have been attempted suggest that no one technique is superior. Neuromas often occur in the extremities, but iatrogenically caused pain in the head and neck area has also been described. This article describes 3 consecutive patients diagnosed with traumatic neuroma who underwent transection of the causative nerve, followed by capping of the nerve stump with a Neurocap. With a follow-up of 7 to 24 months, our results show a marked reduction in the pain scores of all 3 patients. The preliminary results indicate that this technique might be a viable treatment option for patients with a suspected neuroma in the head and neck area.
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Affiliation(s)
- J Alexander de Ru
- Department of Otolaryngology, Head & Neck Surgery, 8124Central Military Hospital Utrecht, the Netherlands.,Department of Otolaryngology, Head & Neck Surgery, 8124University Medical Center Utrecht, the Netherlands
| | - Hans G X M Thomeer
- Department of Otolaryngology, Head & Neck Surgery, 8124University Medical Center Utrecht, the Netherlands
| | - Bernard M Tijink
- Department of Head and Neck Surgical Oncology, 8124University Medical Center Utrecht, the Netherlands
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20
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Abstract
Injury typically results in the development of neuropathic pain, but the pain normally decreases and disappears in paralleled with wound healing. The pain results from cells resident at, and recruited to, the injury site releasing pro-inflammatory cytokines and other mediators leading to the development of pro-inflammatory environment and causing nociceptive neurons to develop chronic ectopic electrical activity, which underlies neuropathic pain. The pain decreases as some of the cells that induce pro-inflammation, changing their phenotype leading to the blocking the release of pro-inflammatory mediators while releasing anti-inflammatory mediators, and blocking nociceptive neuron chronic spontaneous electrical activity. Often, despite apparent wound healing, the neuropathic pain becomes chronic. This raises the question of how chronic pain can be eliminated. While many of the cells and mediators contributing to the development and maintenance of neuropathic pain are known, a better understanding is required of how the injury site environment can be controlled to permanently eliminate the pro-inflammatory environment and silence the chronically electrically active nociceptive neurons. This paper examines how methods that can promote the transition of the pro-inflammatory injury site to an anti-inflammatory state, by changing the composition of local cell types, modifying the activity of pro- and anti-inflammatory receptors, inducing the release of anti-inflammatory mediators, and silencing the chronically electrically active nociceptive neurons. It also examines the hypothesis that factors released from platelet-rich plasma applied to chronic pain sites can permanently eliminate chronic inflammation and its associated chronic pain.
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Affiliation(s)
- Damien P Kuffler
- Institute of Neurobiology, Medical Sciences Campus, University of Puerto Rico, 201 Blvd. del Valle, San Juan, PR, 00901, USA.
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21
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Bjørklund G, Chirumbolo S, Dadar M, Pen JJ, Doşa MD, Pivina L, Semenova Y, Aaseth J. Insights on Nutrients as Analgesics in Chronic Pain. Curr Med Chem 2019; 27:6407-6423. [PMID: 31309880 DOI: 10.2174/0929867326666190712172015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/26/2019] [Accepted: 07/01/2019] [Indexed: 02/07/2023]
Abstract
Many serious inflammatory disorders and nutrient deficiencies induce chronic pain, and anti-inflammatory diets have been applied successfully to modify the inflammatory symptoms causing chronic pain. Numerous scientific data and clinical investigations have demonstrated that long-term inflammation could lead to an inappropriate or exaggerated sensibility to pain. In addition, some Non-steroidal Anti-inflammatory Drugs (NSAID), which directly act on the many enzymes involved in pain and inflammation, including cyclooxygenases, are used to dampen the algesic signal to the central nervous system, reducing the responses of soft C-fibers to pain stimuli. On the other hand, there are a few reports from both health authorities and physicians, reporting that decreased transmission of pain signals can be achieved and improved, depending on the patient's dietary habit. Many nutrients, as well as a suitable level of exercise (resistance training), are the best methods for improving the total mitochondrial capacity in muscle cells, which can lead to a reduction in sensitivity to pain, particularly by lowering the inflammatory signaling to C-fibers. According to the current literature, it could be proposed that chronic pain results from the changed ratio of neuropeptides, hormones, and poor nutritional status, often related to an underlying inflammatory disorder. The current review also evaluates the effective role of nutrition-related interventions on the severity of chronic pain. This review pointed out that nutritional interventions can have a positive effect on pain experience through the indirect inhibitory effect on prostaglandin E2 and attenuation of mitochondrial dysfunction caused by ischemia/reperfusion in skeletal muscle, improving the intracellular antioxidant defense system. These data highlight the need for more nutrition studies where chronic pain is the primary outcome, using accurate interventions. To date, no nutritional recommendation for chronic pain has been officially proposed. Therefore, the goal of this article is to explore pain management and pain modulation, searching for a mode of nutrition efficient in reducing pain.
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Affiliation(s)
- Geir Bjørklund
- Council for Nutritional and Environmental Medicine (CONEM), Mo i Rana, Norway
| | - Salvatore Chirumbolo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy,CONEM Scientific Secretary, Verona, Italy
| | - Maryam Dadar
- Razi Vaccine and Serum Research Institute, Agricultural Research, Education and Extension Organization (AREEO), Karaj, Iran
| | - Joeri J Pen
- Diabetes Clinic, Department of Internal Medicine, UZ Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium,Department of Nutrition, UZ Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Monica Daniela Doşa
- Department of Pharmacology, Faculty of Medicine, Ovidius University, Constanta, Romania
| | - Lyudmila Pivina
- Semey Medical University, Semey, Kazakhstan,CONEM Kazakhstan Environmental Health and Safety Research Group, Semey Medical University, Semey, Kazakhstan
| | - Yulia Semenova
- Semey Medical University, Semey, Kazakhstan,CONEM Kazakhstan Environmental Health and Safety Research Group, Semey Medical University, Semey, Kazakhstan
| | - Jan Aaseth
- Research Department, Innlandet Hospital Trust, Brumunddal, Norway,Faculty of Health and Social Science, Inland Norway University of Applied Sciences, Elverum, Norway
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22
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Affiliation(s)
- R Mark Richardson
- Center for the Neural Basis of Cognition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Epilepsy and Movement Disorders Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Taylor J Abel
- Center for the Neural Basis of Cognition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Pediatric Epilepsy Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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