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Casadei M, Miguel B, Rubione J, Fiore E, Mengelle D, Guerri-Guttenberg RA, Montaner A, Villar MJ, Constandil-Córdova L, Romero-Sandoval AE, Brumovsky PR. Mesenchymal Stem Cell Engagement Modulates Neuroma Microenviroment in Rats and Humans and Prevents Postamputation Pain. THE JOURNAL OF PAIN 2024; 25:104508. [PMID: 38484854 PMCID: PMC11283994 DOI: 10.1016/j.jpain.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 04/11/2024]
Abstract
Postamputation pain is currently managed unsatisfactorily with neuron-targeted pharmacological and interventional therapies. Non-neuronal pain mechanisms have emerged as crucial factors in the development and persistence of postamputation pain. Consequently, these mechanisms offer exciting prospects as innovative therapeutic targets. We examined the hypothesis that engaging mesenchymal stem cells (MSCs) would foster local neuroimmune interactions, leading to a potential reduction in postamputation pain. We utilized an ex vivo neuroma model from a phantom limb pain patient to uncover that the oligodeoxynucleotide IMT504 engaged human primary MSCs to promote an anti-inflammatory microenvironment. Reverse translation experiments recapitulated these effects. Thus, in an in vivo rat model, IMT504 exhibited strong efficacy in preventing autotomy (self-mutilation) behaviors. This effect was linked to a substantial accumulation of MSCs in the neuroma and associated dorsal root ganglia and the establishment of an anti-inflammatory phenotype in these compartments. Centrally, this intervention reduced glial reactivity in the dorsal horn spinal cord, demonstrating diminished nociceptive activity. Accordingly, the exogenous systemic administration of MSCs phenocopied the behavioral effects of IMT504. Our findings underscore the mechanistic relevance of MSCs and the translational therapeutic potential of IMT504 to engage non-neuronal cells for the prevention of postamputation pain. PERSPECTIVE: The present study suggests that IMT504-dependent recruitment of endogenous MSCs within severely injured nerves may prevent post-amputation pain by modifying the inflammatory scenario at relevant sites in the pain pathway. Reinforcing data in rat and human tissues supports the potential therapeutic value of IMT504 in patients suffering postamputation pain.
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Affiliation(s)
- Mailín Casadei
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | - Bernardo Miguel
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | - Julia Rubione
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | - Esteban Fiore
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | - Diego Mengelle
- Hospital Universitario Austral, Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | | | - Alejandro Montaner
- Instituto de Ciencia y Tecnología “César Milstein”, CONICET-Fundación Pablo Cassará, Buenos Aires, Argentina, C1440FFX
| | - Marcelo J. Villar
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | | | | | - Pablo R. Brumovsky
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
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Markewych AN, Suvar T, Swanson MA, Graca MJ, Lubenow TR, McCarthy RJ, Buvanendran A, Kurlander DE. Approaches to neuropathic amputation-related pain: narrative review of surgical, interventional, and medical treatments. Reg Anesth Pain Med 2024:rapm-2023-105089. [PMID: 38307612 DOI: 10.1136/rapm-2023-105089] [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: 10/12/2023] [Accepted: 12/26/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND/IMPORTANCE Neuropathic amputation-related pain can consist of phantom limb pain (PLP), residual limb pain (RLP), or a combination of both pathologies. Estimated of lifetime prevalence of pain and after amputation ranges between 8% and 72%. OBJECTIVE This narrative review aims to summarize the surgical and non-surgical treatment options for amputation-related neuropathic pain to aid in developing optimized multidisciplinary and multimodal treatment plans that leverage multidisciplinary care. EVIDENCE REVIEW A search of the English literature using the following keywords was performed: PLP, amputation pain, RLP. Abstract and full-text articles were evaluated for surgical treatments, medical management, regional anesthesia, peripheral block, neuromodulation, spinal cord stimulation, dorsal root ganglia, and peripheral nerve stimulation. FINDINGS The evidence supporting most if not all interventions for PLP are inconclusive and lack high certainty. Targeted muscle reinnervation and regional peripheral nerve interface are the leading surgical treatment options for reducing neuroma formation and reducing PLP. Non-surgical options include pharmaceutical therapy, regional interventional techniques and behavioral therapies that can benefit certain patients. There is a growing evidence that neuromodulation at the spinal cord or the dorsal root ganglia and/or peripheral nerves can be an adjuvant therapy for PLP. CONCLUSIONS Multimodal approaches combining pharmacotherapy, surgery and invasive neuromodulation procedures would appear to be the most promising strategy for preventive and treating PLP and RLP. Future efforts should focus on cross-disciplinary education to increase awareness of treatment options exploring best practices for preventing pain at the time of amputation and enhancing treatment of chronic postamputation pain.
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Affiliation(s)
| | - Tolga Suvar
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Marco A Swanson
- Department of Plastic & Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mateusz J Graca
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Timothy R Lubenow
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Robert J McCarthy
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Asokumar Buvanendran
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - David E Kurlander
- Department of Plastic & Reconstructive Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Vial B, Lieb M, Pysick H, Hettinger P, Rusy L, Hoben G. Challenges and Potential in Targeted Muscle Reinnervation in Pediatric Amputees. Pediatrics 2022; 149:184048. [PMID: 34966922 DOI: 10.1542/peds.2021-051010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2021] [Indexed: 11/24/2022] Open
Abstract
Targeted muscle reinnervation (TMR) is a powerful new tool in preventing and treating residual limb and phantom limb pain. In the adult population, TMR is rapidly becoming standard of care; however, there is a paucity of literature regarding indications and outcomes of TMR in the pediatric population. We present 2 cases of pediatric patients who sustained amputations and the relevant challenges associated with TMR in their cases. One is a 7-year-old patient who developed severe phantom and residual limb pain after a posttraumatic above-knee amputation. He failed pharmacologic measures and underwent TMR. He obtained complete relief of his symptoms and is continuing to do well 1.5 years postoperatively. The other is a 2-year-old boy with bilateral wrist and below-knee amputations as sequelae of sepsis. TMR was not performed because the patient never demonstrated evidence of phantom limb pain or symptomatic neuroma formation. We use these 2 cases to explore the challenges particular to pediatric patients when considering treatment with TMR, including capacity to report pain, risks of anesthesia, and cortical plasticity. These issues will be critical in determining how TMR will be applied to pediatric patients.
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Affiliation(s)
- Brian Vial
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Haley Pysick
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Patrick Hettinger
- Medical College of Wisconsin, Milwaukee, Wisconsin.,Children's Wisconsin, Milwaukee, Wisconsin
| | - Lynn Rusy
- Medical College of Wisconsin, Milwaukee, Wisconsin.,Children's Wisconsin, Milwaukee, Wisconsin
| | - Gwendolyn Hoben
- Medical College of Wisconsin, Milwaukee, Wisconsin.,Children's Wisconsin, Milwaukee, Wisconsin
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Javed S, Abdi S. Use of anticonvulsants and antidepressants for treatment of complex regional pain syndrome: a literature review. Pain Manag 2020; 11:189-199. [PMID: 33183126 DOI: 10.2217/pmt-2020-0060] [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: 11/21/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is characterized by pain accompanied by symptoms including skin changes, sensory, motor, trophic changes and autonomic dysfunction. Anticonvulsants and antidepressants are commonly prescribed for neuropathic pain conditions; however, evidence is sparse whether these drugs are effective in reducing CRPS-related pain. As such, Pubmed was searched for studies published from January 1990 through March 2020; 13 studies were included in this review. Overall, evidence is considered insufficient for use of gabapentinoids for CRPS-related pain. However, three randomized controlled trials (RCTs) did find gabapentin to result in significant improvement in pain whereas one RCT reported use of amitriptyline to be equally as effective as gabapentin. Multiple case reports discussing the efficacy of pregabalin in pediatric CRPS patients, with relatively short duration of disease and underlying psychiatric illness, have been reported, but these findings need to be validated with RCTs.
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Affiliation(s)
- Saba Javed
- University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Salahadin Abdi
- University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Egunsola O, Wylie CE, Chitty KM, Buckley NA. Systematic Review of the Efficacy and Safety of Gabapentin and Pregabalin for Pain in Children and Adolescents. Anesth Analg 2019; 128:811-819. [DOI: 10.1213/ane.0000000000003936] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Factors affecting phantom limb pain in patients undergoing amputation: retrospective study. J Anesth 2019; 33:216-220. [PMID: 30603827 DOI: 10.1007/s00540-018-2599-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 12/15/2018] [Indexed: 01/19/2023]
Abstract
PURPOSE The efficacy of preemptive analgesia for prevention of phantom limb pain has been controversial although pain management before amputation is empirically important. The aim of this study was to determine the associated factors with perioperative phantom limb pain. METHODS Following approval by the Medical Ethics Committee in our university, medical records of patients receiving limb amputation surgery in our hospital between April 1, 2013 and October 31, 2017 were retrospectively reviewed. To determine which pre-operative factors could affect the development of phantom limb pain, we performed univariate analysis to find candidate factors (p < 0.05), and then did multivariate regression analysis. RESULTS Incidence of phantom limb pain was 50% (22/44). There was no difference between the groups in types of anesthesia and post-operative pain levels. The multivariate logistic regression including possible confounders suggested that diabetes mellitus and uncontrollable preoperative pain with non-steroidal anti-inflammatory drugs (NSAIDs) were independently associated with the development of phantom limb pain (Adjusted odds ratio (OR) 0.238 [95% confidential interval (CI) 0.0643-0.883], p = 0.032, Adjusted OR 6.360 [95% CI 1.280-31.50], p = 0.024, respectively). CONCLUSION The types of anesthesia and the degree of postoperative pain were not related to the development of phantom limb pain. The present data suggest that insufficient preoperative pain with NSAIDs and diabetes mellitus would give an impact on the development of phantom limb pain.
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DeMoss P, Ramsey LH, Karlson CW. Phantom Limb Pain in Pediatric Oncology. Front Neurol 2018; 9:219. [PMID: 29686645 PMCID: PMC5900013 DOI: 10.3389/fneur.2018.00219] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 03/21/2018] [Indexed: 11/13/2022] Open
Abstract
Phantom limb pain (PLP) is a prevalent problem for children and adolescents undergoing amputation due to cancer treatment. The symptoms are wide ranging from sharp to tingling. PLP in children typically lasts for a few minutes but can be almost constant and can be highly distressing. This focused review describes the characteristics, epidemiology, mechanisms, and evidence-based treatment of PLP in pediatric populations, focusing on pediatric cancer. In pediatric oncology, the administration of chemotherapy is a risk factor that potentially sensitizes the nervous system and predisposes pediatric cancer patients to develop PLP after amputation. Gabapentin, tricyclic antidepressants, opiates, nerve blocks, and epidural catheters have shown mixed success in adults and case reports document potential utility in pediatric patients. Non-pharmacologic treatments, such as mirror therapy, psychotherapy, and acupuncture have also been used in pediatric PLP with success. Prospective controlled trials are necessary to advance care for pediatric patients with PLP.
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Affiliation(s)
- Patrick DeMoss
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, United States
| | - Logan H Ramsey
- School of Medicine, University of Mississippi Medical Center, Jackson, MS, United States
| | - Cynthia Windham Karlson
- Division of Hematology/Oncology, Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, United States
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