Chronic Pain Following Fracture-Related Surgery: Posttraumatic Rather Than Postsurgical Origin Promotes Chronification-A Prospective Observational Study With 1-Year Follow-up

Preoperative Anxiolysis and Treatment Expectation (PATE Trial): open-label placebo treatment to reduce preoperative anxiety in female patients undergoing gynecological laparoscopic surgery - study protocol for a bicentric, prospective, randomized-controlled trial

One of the most common concerns of patients undergoing surgery is preoperative anxiety, with a prevalence of up to 48%. The effects of preoperative anxiety continue beyond the preoperative period and are associated with more severe postoperative pain and poorer treatment outcomes. Treatment options for preoperative anxiety are often limited as sedatives cause side effects and their efficacy remains controversial. Placebo research has shown that optimization of positive treatment expectations, as can be achieved through placebo administration and education, has clinically relevant effects on preoperative anxiety, pain and treatment outcomes. As the administration of masked placebos raises ethical questions, clinical studies have increasingly focused on the use of open, non-deceptive placebo administration (open-label placebo, OLP). The use of OLPs to reduce preoperative anxiety and modify clinically relevant postoperative outcomes has not yet been investigated. This bicentric, prospective, randomized-controlled clinical trial (PATE Trial; German Registry for Clinical Studies DRKS00033221), an associated project of the Collaborative Research Center (CRC) 289 "Treatment Expectation", aims to alleviate preoperative anxiety by optimizing positive treatment expectations facilitated by OLP. Furthermore, this study examines a potential enhancement of these effects through aspects of observational learning, operationalized by a positive expectation-enhancing video. In addition, patient's perspective on the self-efficacy and appropriateness of OLPs prior to surgery will be assessed. To achieve these objectives, female patients will be randomized into three groups before undergoing gynecological laparoscopic surgery. One group receives the OLP with a positive rationale conveyed by a study physician. A second group receives the same intervention, OLP administration and rationale provided by a physician, and additionally watches a video on OLP presenting a satisfied patient. A third group receives standard treatment as usual (TAU). Outcome measures will be effects on preoperative anxiety and postoperative experience, particularly visceral and somatic postoperative pain. As the non-deceptive administration of placebos; when indicated; may yield positive outcomes without side effects, and as current treatment of preoperative anxiety is limited, evidence from clinical placebo research has the potential to improve outcomes and patient experience in the surgical setting.

Peripheral Nerve Stimulation for Treating Acute Pain Following Traumatic Fracture: A Case Report of Rapid-Onset Analgesia Without Motor Blockade

Analgesia following acute traumatic fracture remains a clinical challenge. Pain relief via peripheral nerve stimulation (PNS) is a promising treatment modality due to its opioid-sparing effects and rapid, reversible sensory blockade without motor blockade. We present the case of a patient who suffered a traumatic tibial plateau fracture. A popliteal sciatic PNS device was placed on postoperative day 1 following inadequate pain control. The patient reported marked pain relief, a significant reduction in morphine milligram equivalent (MME) utilization, and improved early functional recovery. The PNS lead was removed at the patient's 2-month follow-up visit without any adverse events.

The impact of specialized nursing care at fracture sites coordinated with disease progression monitoring in thoracolumbar spine fractures

PURPOSE

This study aims to investigate the impact of specialized nursing care at fracture sites coordinated with disease progression monitoring in thoracolumbar spine fractures.

MATERIALS AND METHODS

Patients diagnosed with definitive thoracolumbar spine fractures and underwent surgical treatment at our hospital between February 2022 and August 2023 were selected. Patients were divided into a treatment group (specialized nursing care at fracture sites coordinated with disease progression monitoring) and a control group (conventional care) based on different nursing methods.

RESULTS

A comparative assessment was conducted to evaluate the role and significance of specialized nursing care at fracture sites coordinated with disease progression monitoring in thoracolumbar spine fracture rehabilitation. The results showed that compared to conventional care, specialized nursing care at fracture sites coordinated with disease progression monitoring could better promote the recovery of patients' neurological functions, alleviate pain, and effectively improve symptoms and functional recovery, thus enhancing patients' quality of life and satisfaction.

CONCLUSION

The study confirms the effectiveness of specialized nursing care at fracture sites coordinated with disease progression monitoring in clinical practice post thoracolumbar spine fractures.

Alpha-7 Nicotinic Acetylcholine Receptor Activation Inhibits Trauma Induced Pronociceptive Autoimmune Responses

Both autonomic nervous system dysfunction and immune system activation are characteristic of chronic pain after limb injuries. Cholinergic agonists reduce immune system activation in many settings. We hypothesized, therefore, that alpha-7 nicotinic acetylcholine receptor (α7nAChR) agonist administration would reduce nociceptive and immune changes after tibia fracture and cast immobilization in mice. Fracture mice were treated with either vehicle, a low (.2 mg/kg) dose, or a high (1 mg/kg) dose of the selective α7nAChR agonist PNU-282987 for 4 weeks. We assessed hindpaw allodynia and weight bearing as behavioral outcomes. The assessment of adaptive immune responses included regional lymph node hypertrophy, germinal center formation, α7nAChR expression, and IgM deposition. Assessment of innate immune system activation focused on IL-1β and IL-6 generation in fractured hindlimb skin. We observed that mechanical allodynia and unweighting were alleviated by PNU-282987 treatment. Drug treatment also reduced popliteal lymph node hypertrophy and germinal center formation. Immunohistochemical studies localized α7nAChR to germinal center B lymphocytes, and this expression increased after fracture. Analysis of fracture limb hindpaw skin demonstrated increased inflammatory mediator (IL-1β and IL-6) levels and IgM deposition, which were abrogated by PNU-282987. Serum analyses demonstrated fracture-induced IgM reactivity against keratin 16, histone 3.2, GFAP, and NMDAR-2B. Administration of PNU-282987 reduced the enhancement of IgM reactivity. Collectively, these data suggest that the α7nAChR is involved in regulating posttraumatic innate and adaptive immune responses and the associated nociceptive sensitization. PERSPECTIVE: These studies evaluate the effects of a selective α7nAChR agonist in a tibial fracture/cast immobilization model of limb pain. Administration of the drug reduced nociceptive and functional changes 4 weeks after injury. These novel findings suggest that well-tolerated α7nAChR agonists may be viable analgesics for chronic pain after limb injuries.

Patient's Perception of Outcome after Extracapsular Fractures of the Mandibular Condyle Differs from Objective Evaluation-Experience of a Third-Level Hospital

Background: The aim of this study is to assess patients' subjective perception of treatment outcome after extracapsular fractures of the mandibular condyle. Methods: A questionnaire survey regarding facial nerve palsy (FNP), malocclusion, pain, reduction in maximum mouth opening (MMO) and further discomfort after 3, 6, and 12 months was carried out. Patients aged 18 or more presenting with an extracapsular condylar fracture between 2006 and 2020 were identified by purposive sampling Questionnaires were received from 115 patients. Fractures were classified on the basis of the pre-treatment imaging, the way of treatment was obtained from patients' medical records. Data were analyzed using Pearsons' chi-square-test, descriptive statistics and Student's t-test. Results: 93.0% of the fractures were treated by open reduction and internal fixation (ORIF). MMO reduction was the most common post-treatment complication (55.6%). ORIF was associated with less pain after 3 months (p = 0.048) and lower VAS scores compared to conservative treatment (p = 0.039). Comminuted fractures were more frequently associated with post-treatment malocclusion (p = 0.048), FNP (p = 0.016) and MMO reduction (p = 0.001). Bilateral fractures were significantly accompanied by malocclusion (p = 0.029), MMO reduction (p = 0.038) and pain occurrence (p < 0.001). Conclusions: Patients report less pain after ORIF. Comminuted and bilateral fractures seem to be major risk factors for complications. Subjective perception of complications after extracapsular condylar fractures differs from objectively assessed data.

Role of the Neurologic System in Fracture Healing: An Extensive Review

PURPOSE OF REVIEW

Despite advances in orthopedics, there remains a need for therapeutics to hasten fracture healing. However, little focus is given to the role the nervous system plays in regulating fracture healing. This paucity of information has led to an incomplete understanding of fracture healing and has limited the development of fracture therapies that integrate the importance of the nervous system. This review seeks to illuminate the integral roles that the nervous system plays in fracture healing.

RECENT FINDINGS

Preclinical studies explored several methodologies for ablating peripheral nerves to demonstrate ablation-induced deficits in fracture healing. Conversely, activation of peripheral nerves via the use of dorsal root ganglion electrical stimulation enhanced fracture healing via calcitonin gene related peptide (CGRP). Investigations into TLR-4, TrkB agonists, and nerve growth factor (NGF) expression provide valuable insights into molecular pathways influencing bone mesenchymal stem cells and fracture repair. Finally, there is continued research into the connections between pain and fracture healing with findings suggesting that anti-NGF may be able to block pain without affecting healing. This review underscores the critical roles of the central nervous system (CNS), peripheral nervous system (PNS), and autonomic nervous system (ANS) in fracture healing, emphasizing their influence on bone cells, neuropeptide release, and endochondral ossification. The use of TBI models contributes to understanding neural regulation, though the complex influence of TBI on fracture healing requires further exploration. The review concludes by addressing the neural connection to fracture pain. This review article is part of a series of multiple manuscripts designed to determine the utility of using artificial intelligence for writing scientific reviews.

Do Not Lose Your Nerve, Be Callus: Insights Into Neural Regulation of Fracture Healing

PURPOSE OF REVIEW

Fractures are a prominent form of traumatic injury and shall continue to be for the foreseeable future. While the inflammatory response and the cells of the bone marrow microenvironment play significant roles in fracture healing, the nervous system is also an important player in regulating bone healing.

RECENT FINDINGS

Considerable evidence demonstrates a role for nervous system regulation of fracture healing in a setting of traumatic injury to the brain. Although many of the impacts of the nervous system on fracture healing are positive, pain mediated by the nervous system can have detrimental effects on mobilization and quality of life. Understanding the role the nervous system plays in fracture healing is vital to understanding fracture healing as a whole and improving quality of life post-injury. This review article is part of a series of multiple manuscripts designed to determine the utility of using artificial intelligence for writing scientific reviews.

[Frequency of Chronic Pain after Work-Related Trauma: A Preliminary Status Survey during Workers' Compensation Rehabilitation in a Tertiary Clinic]

BACKGROUND

Chronic pain after trauma and surgery is a long-term complication. Its relevance for patients within the workers' compensation rehabilitation process has not been adequately investigated.

OBJECTIVES

Initial evaluation of frequency of chronic pain after occupational accidents.

METHODS

In 2017, surgical inpatients (18-65 y) treated in a tertiary hospital were asked about chronic pain arising from an occupational trauma recognized by statutory occupation insurance (interval 2.8±6.9 years), regardless of care received, first at the time of hospitalization and then by telephone interview 6 months later. The focus was on patients with a work-related trauma (A) within the past month or (B) >6 months.

PRIMARY OUTCOME

frequency of work trauma-related chronic pain (>6 months) at the initial interview (point prevalence), secondary outcomes: frequency of chronicity at 6 months (A) and persistence of chronic pain (B). Tertiary outcomes: ability to work, occupational injury classification, burden based on pain intensity, localization, and medication, functional deficits due to the existence of chronic pain, and comorbidity.

RESULTS

Out of 415 patients included in the survey, 85% (160/188) reported accident-related chronic pain (predominantly moderate to highly severe in intensity, localized at joints and bones). 90% (131/145) also reported this pain six months later. 67% (64/96) reported chronic pain for the first time. Patients with chronic pain at follow-up (281/369) were less likely to return to work (p=0.003), required analgesics in 60%, were more often comorbid (p<0.002) and had greater functional deficits (p<0.002).

CONCLUSION

Despite the preliminary nature of the data, chronic pain seems to be common after occupational trauma and negatively affects the recovery of work ability in the long term. Based on the present observational data, a further differentiated re-evaluation of prospective data considering therapeutic measures is strongly recommended.

[Application possibilities of digital tools in postoperative pain therapy]

BACKGROUND

Recently, digital tools, such as smartphone-based applications and the use of artificial intelligence have increasingly found their way into pain medicine. This could enable new treatment approaches in postoperative pain management. Therefore, this article provides an overview of various digital tools and their potential application options in postoperative pain management.

MATERIAL AND METHODS

An orienting literature search was carried out in the MEDLINE and Web of Science databases, and a targeted selection of essential key publications was made in order to provide a structured presentation of different current possible applications and a discussion based on the most recent knowledge.

RESULTS

Today, possible applications of digital tools, even if they mostly have only a model character, include pain documentation and assessment, patient self-management and education, pain prediction, decision support for medical staff, and supportive pain therapy, for example in the form of virtual reality and videos. These tools offer advantages such as individualized treatment concepts, addressing specific patient groups, reduction of pain and analgesics, and the potential for early warning or detection of postoperative pain. Furthermore, the challenges of the technical implementation and appropriate user training are highlighted.

CONCLUSION

The use of digital tools, although so far integrated in clinical routine in a relatively selective and exemplary manner, promises to be an innovative approach for personalized postoperative pain therapy in the future. Future studies and projects should help to integrate the promising research approaches into everyday clinical practice.

Acute pain management and long term outcomes

PURPOSE OF REVIEW

The acute inflammatory reaction induced by tissue trauma causes pain but also promotes recovery. Recovery is highly variable among peoples. Effective acute pain (AP) management is very important but remains suboptimal what could affect long term outcomes. The review questions the impact of either failure or effectiveness of AP treatments and the choice of analgesic drugs on different long-term outcomes after tissue trauma.

RECENT FINDINGS

Pain control during mobilization is mandatory to reduce the risk of complications which exacerbate and prolong the inflammatory response to trauma, impairing physical recovery. Common analgesic treatments show considerable variability in effectiveness among peoples what argues for an urgent need to develop personalized AP management, that is, finding better responders to common analgesics and targeting challenging patients for more invasive procedures. Optimal multimodal analgesia to spare opioids administration remains a priority as opioids may enhance neuroinflammation, which underlies pain persistence and precipitates neurocognitive decline in frail patients. Finally, recent findings demonstrate that AP treatments which modulate nociceptive and inflammatory pain should be used with caution as drugs which inhibit inflammation like nonsteroidal antiinflammatory drugs and corticoids might interfere with natural recovery processes.

SUMMARY

Effective and safe AP management is of far greater importance than previously realized. Evidence of suboptimal AP management in many patients and recent reports pointing out the impact of current treatments on long term outcomes argue for further research in the field.

Chronic pain after surgery and trauma: current situation and future directions

Chronic post-surgical pain (CPSP) stands as a major health issue. The unchanged incidence over the last two decades underlines both the failure of predictive models developed until now and the lack of efficacy of common “preventive” strategies (pharmacotherapy and regional analgesic techniques) applied in current clinical practice. The recognition of CPSP as a disease and the release of a common definition of the condition is an important progress in the field. CPSP predictive scores exist but none has presently demonstrated an impact on patient care. New clinical directions based on the resolution of postoperative pain, a complex and highly dynamic process supported by individual pain trajectories, argue for predictive models and preventive strategies extended to the subacute pain period i.e. after hospital discharge.

Use of regional analgesia to prevent the conversion from acute to chronic pain

PURPOSE OF REVIEW

Chronic post-surgical pain (CPSP) prevalence has not changed over the past decades what questions the efficacy of preventive strategies. Regional analgesia is used to control acute pain, but preventive effect on CPSP remains debated. Failures and future application of regional analgesia to prevent transition from acute to chronic pain will be discussed.

RECENT FINDINGS

After thoracotomy, perioperative regional analgesia does not seem to prevent CPSP. After breast cancer surgery, paravertebral block might prevent CPSP intensity and impact on daily life up to 12 months, particularly in high catastrophizing patients. In knee arthroplasty, perioperative regional analgesia or preoperative genicular nerve neuroablation do not prevent CPSP, although current studies present several bias. The protective role of effective regional analgesia and early pain relief in trauma patients deserves further studies.

SUMMARY

Regional analgesia failure to prevent CPSP development should prompt us to reconsider its perioperative utilization. Patients' stratification, for example high-pain responders, might help to target those who will most benefit of regional analgesia. The impact of regional analgesia on secondary pain-related outcomes such as intensity and neuropathic character despite no difference on CPSP incidence requires more studies. Finally, the preventive effect of regional analgesia targeted interventions on CPSP in patients suffering from severe subacute pain deserves to be assessed.