Gynecological Pain, Endometriosis, Visceral Disease, and the Viscero-Somatic Connection

Interventional pathway in the management of refractory post cholecystectomy pain (PCP) syndrome: a 6-year prospective audit in 60 patients

OBJECTIVES

Post cholecystectomy pain syndrome can affect over a third of patients undergoing laparoscopic cholecystectomy. Acute exacerbations can result in recurrent emergency admission with excessive healthcare utilization. Standard surgical management appears to focus on visceral aetiology. Abdominal myofascial pain syndrome is a poorly recognised somatic pathology that can cause refractory pain in this cohort. It develops as a result of trigger points in the abdominal musculature. The report describes the pathophysiology and a novel interventional pathway in the management of post cholecystectomy pain secondary to abdominal myofascial pain syndrome.

METHODS

The prospective longitudinal audit was performed at a tertiary pain medicine clinic in a university teaching hospital. Over a six-year period, adult patients with refractory abdominal pain following laparoscopic cholecystectomy were included in a structured interventional management pathway. The pathway included two interventions. Intervention I was a combination of abdominal plane blocks and epigastric port site trigger injection with steroids. Patients who failed to report durable relief (>50% pain relief at 12 weeks) were offered pulsed radiofrequency treatment to the abdominal planes (Intervention II). Outcomes included patient satisfaction, change in opioid consumption and impact on emergency visits.

RESULTS

Sixty patients who failed to respond to standard management were offered the pathway. Four patients refused due to needle phobia. Fifty-six patients received Intervention I. Failure rate was 14% (8/56). Forty-eight patients (48/56, 86%) reported significant benefit at 12 weeks while 38 patients reported durable relief at 24 weeks (38/56, 68%). Nine patients received Intervention II and all (100%) reported durable relief. Emergency admissions and opioid consumption were reduced.

CONCLUSIONS

Abdominal myofascial pain syndrome is a poorly recognised cause of post cholecystectomy pain. The novel interventional management pathway could be an effective solution in patients who fail to benefit from standard management.

Pathophysiology and Management of Abdominal Myofascial Pain Syndrome (AMPS): A Three-Year Prospective Audit of a Management Pathway in 120 Patients

Background

Chronic abdominal wall pain arising from the myofascial structures is termed abdominal myofascial pain syndrome and is an important cause of refractory abdominal pain that utilizes significant health care costs. The current literature is vague on its management.

Design

The author presents a prospective audit of a structured management pathway and discusses the pathophysiology of abdominal myofascial pain syndrome. The objective was to identify an effective and durable treatment for the individual patient and evaluate patient satisfaction with the management pathway.

Methods

Over a three-year period, 120 patients diagnosed with abdominal myofascial pain syndrome were included in a structured management pathway and were prospectively audited at a tertiary care university hospital.

Results

Patient satisfaction with the pathway was high. Trigger point injection with local anesthetic was useful in diagnosis but ineffective in providing durable relief. Trigger point injection with steroids and pulsed radiofrequency treatment of trigger point(s) were effective therapeutic interventions, providing durable relief lasting six months in 32% and 60%, respectively. There was improvement reported in pain intensity scores, quality of life, anxiety, and depression scores following the interventional management of abdominal myofascial pain syndrome.

Conclusions

Abdominal myofascial pain syndrome is often unrecognized, especially in patients with a history of visceral inflammation. The suggested pathway may be an option in its management. Trigger point injection with steroids may have a role in the differential diagnosis of chronic abdominal pain.

Cervical musculoskeletal impairments in migraine and tension type headache: A systematic review and meta-analysis

AIMS

Neck pain is common in migraine and tension type headache (TTH). This review aimed to examine the evidence for cervical musculoskeletal impairments in these headaches.

METHODS

Databases PubMed (Medline), EMBASE, CINAHL, SCOPUS, and Web of Science were searched from inception to December 2018. Observational studies using a comparator group were included. Risk of bias was assessed using the Appraisal tool for Cross-Sectional Studies. Results were pooled using random effects meta-analysis. Level of evidence for each outcome was assigned based on risk of bias, consistency of results and magnitude of difference between participants with headache and controls. (PROSPERO registration: CRD42018083683).

RESULTS

Of 48 studies included, the majority were rated moderate risk of bias due to possible confounding influences. In total, 17 cervical outcomes were assessed, with confidence in findings ranging from very low to moderate levels. Compared to controls, participants with TTH had greater forward head posture (FHP) (MD = -6.18°, 95% CI [-8.18°, -4.18°]) and less cervical range of motion (ROM) (greatest difference transverse plane MD = -15.0°, 95% CI [-27.7°, -2.3°]. Participants with migraine demonstrated minimally reduced cervical ROM (greatest difference sagittal plane MD = -5.4°, 95% CI [-9.9°, -0.9°]. No differences presented in head posture, strength, craniocervical flexion test performance or joint position error between migraineurs and controls.

CONCLUSIONS

TTH presented with more findings of cervical musculoskeletal impairments than migraine however levels of confidence in findings were low. Future studies should differentiate episodic from chronic headache, identify coexisting musculoskeletal cervical disorders, and describe neck pain behaviour in headache.

An Exploratory Study into Objective and Reported Characteristics of Neuropathic Pain in Women with Chronic Pelvic Pain

Chronic pelvic pain (CPP) affects 5.7-26.6% women worldwide. 55% have no obvious pathology and 40% have associated endometriosis. Neuropathic pain (NeP) is pain arising as a consequence of a lesion/disease affecting the somatosensory system. The prevalence of NeP in women with CPP is not known. The diagnosis of NeP is challenging because there is no gold-standard assessment. Questionnaires have been used in the clinical setting to diagnose NeP in other chronic pain conditions and quantitative sensory testing (QST) has been used in a research setting to identify abnormal sensory function. We aimed to determine if women with chronic pelvic pain (CPP) have a neuropathic pain (NeP) component to their painful symptoms and how this is best assessed. We performed an exploratory prospective cohort study of 72 pre-menopausal women with a diagnosis of CPP. They underwent a clinician completed questionnaire (DN4) and completed the S-LANSS and PainDETECT™ questionnaires. Additionally QST testing was performed by a clinician. They also completed a patient acceptability questionnaire. Clinical features of NeP were identified by both questionnaires and QST. Of the women who were NeP positive, 56%, 35% and 26% were identified by the S-LANSS, DN4 and PainDETECT™ respectively. When NeP was identified by questionnaire, the associated laparoscopy findings were similar irrespective of which questionnaire was used. No subject had entirely unchanged QST parameters. There were distinct loss and gain subgroups, as well as mixed alteration in function, but this was not necessarily clinically significant in all patients. 80% of patients were confident that questionnaires could diagnose NeP, and 90% found them easy to complete. Early identification of NeP in women with CPP with a simple questionnaire could facilitate targeted therapy with neuromodulators, which are cheap, readily available, and have good safety profiles. This approach could prevent unnecessary or fertility-compromising surgery and prolonged treatment with hormones.

Endometriosis and abdominal myofascial pain in adults and adolescents

Endometriosis and myofascial pain are common disorders with significant impact on quality of life. Increasingly, these conditions are being recognized as highly interconnected through processes that have been described for more than a century. This review is directed to this interconnection through a description of the relationships of endometriosis to proposed mechanisms of pain and chronic pain physiology; the clinical assessment of myofascial representations of this pain; and an approach to the management of these interconnected disorders.

Bedside testing for chronic pelvic pain: discriminating visceral from somatic pain

Objectives. This study was done to evaluate three bedside tests in discriminating visceral pain from somatic pain among women with chronic pelvic pain. Study Design. The study was an exploratory cross-sectional evaluation of 81 women with chronic pelvic pain of 6 or more months' duration. Tests included abdominal cutaneous allodynia (aCA), perineal cutaneous allodynia (pCA), abdominal and perineal myofascial trigger points (aMFTP) and (pMFTP), and reduced pain thresholds (RPTs). Results. Eighty-one women were recruited, and all women provided informed consent. There were 62 women with apparent visceral pain and 19 with apparent somatic sources of pain. The positive predictive values for pelvic visceral disease were aCA-93%, pCA-91%, aMFTP-93%, pMFTP-81%, and RPT-79%. The likelihood ratio (+) and 95% C.I. for the detection of visceral sources of pain were aCA-4.19 (1.46, 12.0), pCA-2.91 (1.19, 7.11), aMTRP-4.19 (1.46, 12.0), pMFTP-1.35 (0.86, 2.13), and RPT-1.14 (0.85, 1.52), respectively. Conclusions. Tests of cutaneous allodynia, myofascial trigger points, and reduced pain thresholds are easily applied and well tolerated. The tests for cutaneous allodynia appear to have the greatest likelihood of identifying a visceral source of pain compared to somatic sources of pain.