Utilization of Intravenous Lidocaine Infusion for the Treatment of Refractory Chronic Pain

Case report: safety and efficacy of lidocaine infusion for the treatment of intractable zoster-associated neuralgia in solid organ transplant recipients

Introduction

Solid organ transplant recipients are at high risk for developing severe zoster-associated neuralgia, and the pharmaceutic therapies of pain management for these patients with limited organ function are challenging. Intravenous lidocaine infusion showed positive analgesic effects and is used for the management of neuropathic pain. This case series reports the safety and effectiveness of intravenous lidocaine infusion in the treatment of intractable zoster-associated neuralgia in solid organ transplant recipients.

Case series presentation

Five solid organ transplant recipients suffering from refractory zoster-associated neuralgia (numeric rating scale 8-10, despite using high doses of antiepileptic drugs or combined with opioids) were enrolled. Intravenous lidocaine (5 mg/kg ideal bodyweight) was administered over 1.5 h with the monitoring of vital signs. Pain intensity, patient satisfaction, adverse events, typical liver, and kidney function were evaluated. All subjects reported high satisfaction with their treatment and effective pain relief at the 6-month follow-up. One patient experienced short and mild numbness in the mouth and dizziness after the therapy, but no major adverse reactions were reported.

Conclusion

This case series provides evidence that intravenous lidocaine infusion provided effective pain relief as an analgesic treatment option for transplant patients with intractable zoster-associated neuralgia.

Intravenous Lidocaine for the Management of Chronic Pain: A Narrative Review of Randomized Clinical Trials

Background

Chronic pain remains a serious health problem with significant impact on morbidity and well-being. Available treatments have only resulted in relatively modest efficacy. Thus, novel therapeutic treatments with different mechanisms have recently generated empirical interest. Lidocaine is postulated to provide anti-inflammatory and anti-nociceptive effect through its action at the N-methyl-D-aspartate (NMDA) and voltage gated calcium receptors. Emerging research indicates that lidocaine could be a reasonable alternative for treating chronic pain.

Objective

Considering the evidence surrounding lidocaine's potential as a therapeutic modality for chronic pain, we conducted a narrative review on the evidence of lidocaine's therapeutic effects in chronic pain.

Methods

A review of the PubMed, and Google scholar databases was undertaken in May 2022 to identify completed studies that investigated the effectiveness of lidocaine in the treatment of chronic pain from database inception to June 2022.

Results

A total of 25 studies were included in the narrative review. Findings on available studies suggest that intravenous infusion of lidocaine is an emerging and promising option that may alleviate pain in some clinical populations. Our narrative synthesis showed that evidence for intravenous lidocaine is currently mixed for a variety of chronic pain syndromes. Findings indicate that evidence for efficacy is limited for: CRPS, and cancer pain. However, there is good evidence supporting the efficacy of intravenous lidocaine as augmentation in chronic post-surgical pain.

Conclusion

Lidocaine may be a promising pharmacologic solution for chronic pain. Future investigation is warranted on elucidating the neurobiological mechanisms of lidocaine in attenuating pain signaling pathways.

Local subcutaneous lidocaine injection for the treatment of complex regional pain syndrome: a case report and literature review

A 14-year-old child was diagnosed with complex regional pain syndrome (CRPS) after bromhidrosis surgery. She experienced a stinging, knife-like, and intermittent attack pain, accompanied by numbness of both upper limbs and limited movements. Ultrasound-guided radiofrequency surgery on the peripheral nerve did not reduce pain. Then, gabapentin 300 mg three times a day and 2% lidocaine by local subcutaneous injection once a day for 3 days were administrated. After the local subcutaneous injection of lidocaine, the pain was significantly relieved, and the pain induced by skin touch at the scar disappeared. No pain recurred after the 1-month follow-up. An evidence-based literature review showed that local or systemic intravenous lidocaine was used to reduce adult CRPS symptoms but less has been reported in children. In our case, a local subcutaneous injection of 2% lidocaine in a child for CRPS treatment was reported to be effective in relieving complex local pain with favorable outcomes. Though further high-quality randomized controlled trials are needed to investigate the effects and safety of local subcutaneous lidocaine injection on pain relief in children with CRPS, it could still provide a relatively safe and effective adjuvant therapy for minor patients.

Comparison of Perioperative Pregabalin and Duloxetine for Pain Management After Total Knee Arthroplasty: A Double-Blind Clinical Trial

Background

Chronic residual pain after total knee arthroplasty (TKA) is one of the challenges of postoperative pain management. Duloxetine, by controlling neuropathic pain, and pregabalin, by affecting nociceptors, can effectively manage postoperative pain.

Objectives

This study aimed to compare the effect of perioperative oral duloxetine and pregabalin in pain management after knee arthroplasty.

Methods

In this clinical trial, 60 patients scheduled for TKA under spinal anesthesia were randomly assigned to one of three groups A (pregabalin 75 mg), B (duloxetine 30 mg), and C (placebo). Drugs were administered 90 minutes before, 12, and 24 hours after surgery. The visual analog scale (VAS) score for pain, the first analgesic request time, postoperative analgesic consumption (i.v. paracetamol), and WOMAC score six months after surgery were recorded.

Results

The VAS score and analgesic consumption 48 hours after TKA in groups A and B significantly decreased compared to the placebo (P < 0.05). The first analgesic request time was longer in groups A and B than in group C (P < 0.05). While the differences were statistically significant, they are most likely not clinically significant. The WOMAC score before and six months after arthroplasty did not differ between the groups (P > 0.05).

Conclusions

Perioperative oral pregabalin and duloxetine similarly reduce pain and the need for analgesic consumption within 48 hours after TKA but do not affect knee mobility status.

Current Strategies in Pain Regimens for Robotic Urologic Surgery: A Comprehensive Review

Context

Robotic surgery is becoming the most common approach in minimally invasive urologic procedures. Robotic surgery offers less pain to patients because of smaller keyhole incisions and less tissue retraction and stretching of fascia and muscular fibers. Tailored pain regimens have also evolved and allowed patients to feel minimal to no discomfort after robotic urologic surgery, allowing in parallel better surgical outcomes. This study aims to analyze the most current pain regimens in robotic urologic surgery and to evaluate the most current pain protocols and corresponding outcomes.

Evidence Acquisition

A literature review was performed of published manuscripts utilizing Pubmed and Google Scholar on pain protocols for patients undergoing robotic urologic surgery.

Results

Multimodal analgesia is gaining ground in robotic urologic surgery. Regional analgesia includes four major modalities: Neuroaxial analgesia, intercostal blocks, tranvsersus abdominis plane blocks, and paravertebral blocks. Each approach has a different injection site, region of analgesia coverage, and duration of coverage depending upon local anesthesia and/or adjuvant utilized with advantages and disadvantages that make each modality unique and efficacious.

Conclusions

Robotic urologic surgery has offered the advantage of smaller incisions, faster recovery, less postoperative opioid consumption, and better surgical outcomes. Neuraxial, intercostal, transversus abdominis plane, and quadratus lumborum blocks are the best and most adopted approaches which offer optimal outcomes to patients.

Infusion Therapy in the Treatment of Neuropathic Pain

PURPOSE OF REVIEW

Neuropathic pain is a prevalent and burdensome condition. While oral medical therapies are the first-line treatment for refractory neuropathic pain, in some cases, infusion therapy may be employed. This article is a systematic review of recent publications regarding epidemiologic, pathophysiologic, diagnostic, and therapeutic advancements in the treatment of neuropathic pain using intravenous infusion therapy. Special consideration will be given to relevant and practically used agents and available information on outcomes.

RECENT FINDINGS

Individuals with neuropathic pain from various etiologies (e.g. trigeminal neuralgia, post-herpetic neuralgia, diabetic neuropathy) often find short-term relief from infusion therapies. However, it is difficult to generalize the findings of these studies to form a standard treatment regimen. The purpose of this paper is to provide clinicians an up-to-date summary of recent literature regarding several infusion therapies in treating neuropathic pain.

Effects of Ketamine and Lidocaine Infusion on Acute Pain after Elective Open Abdominal Surgery, a Randomized, Double-Blinded Study

Background: Most patients suffer from moderate to severe pain after elective laparotomy. They often require opioids to alleviate their pain. Opiates invariably induce certain side effects and, occasionally, dependence. Intraoperative infusion of lidocaine and low-dose ketamine reduces postoperative pain and analgesic requirements. This study aims to evaluate the effects of simultaneous infusion of lidocaine and ketamine during open abdominal surgery on the postoperative pain severity and analgesic consumption. Methods: In this randomized, double-blinded, single-center study that was performed in Iran, 80 patients scheduled for elective open abdominal surgery under general anesthesia were enrolled in two LK and P groups. Group LK (n=40) received lidocaine-ketamine infusion, and group P (n=40) received placebo (normal saline). Both infusions were started thirty minutes after initiation of surgery and were terminated once the surgery was completed. For postoperative pain management, patient-controlled analgesia (PCA), including fentanyl and paracetamol, was administered for both groups. All patients were evaluated for pain visual analogue scale (VAS) and total adjunctive analgesic (diclofenac suppository) consumption within the first 24 hours after the surgery. The data were analyzed using SPSS. P values <0.05 were considered significant. Results: Intraoperative infusion of Lidocaine and Ketamine resulted in desirable postoperative pain control. Patients of LK group demonstrated a significant reduction in the pain score at 1, 6, 12, 18, and 24 hours after termination of surgery (p<0.001). It also resulted in a decreased requirement for postoperative analgesics, as cumulative analgesic consumption was decreased meaningfully in the patients of LK group (p<0.001). Conclusion: Intravenous infusion of lidocaine and ketamine during elective open abdominal surgery reduces pain intensity and analgesic requirements in the first 24 hours postoperatively, without major additional side effects.

Management of Postoperative Pain in Patients Following Spine Surgery: A Narrative Review

Perioperative pain management is a unique challenge in patients undergoing spine surgery due to the increased incidence of both pre-existing chronic pain conditions and chronic postsurgical pain. Peri-operative planning and counseling in spine surgery should involve an interdisciplinary approach that includes consideration of patient-level risk factors, as well as pharmacologic and non-pharmacologic pain management techniques. Consideration of psychological factors and patient focused education as an adjunct to these measures is paramount in developing a personalized perioperative pain management plan. Understanding the currently available body of knowledge surrounding perioperative opioid management, management of opioid use disorder, regional/neuraxial anesthetic techniques, ketamine/lidocaine infusions, non-opioid oral analgesics, and behavioral interventions can be useful in developing a comprehensive, multi-modal treatment plan among patients undergoing spine surgery. Although many of these techniques have proved efficacious in the immediate postoperative period, long-term follow-up is needed to define the impact of such approaches on persistent pain and opioid use. Future techniques involving the use of precision medicine may help identify phenotypic and physiologic characteristics that can identify patients that are most at risk of developing persistent postoperative pain after spine surgery.

Novel Local Anesthetics in Clinical Practice: Pharmacologic Considerations and Potential Roles for the Future

The treatment of pain, both acute and chronic, has been a focus of medicine for generations. Physicians have tried to develop novel ways to effectively manage pain in surgical and post-surgical settings. One intervention demonstrating efficacy is nerve blocks. Single-injection peripheral nerve blocks (PNBs) are usually preferred over continuous PNBs, since they are not associated with longer lengths of stay. The challenge of single injection PNBs is their length of duration, which at present is a major limitation. Novel preparations of local anesthetics have also been studied, and these new preparations could allow for extended duration of action of anesthetics. An emerging preparation of bupivacaine, exparel, uses a multivesicular liposomal delivery system which releases medication in a steady, controlled manner. Another extended-release local anesthetic, HTX-011, consists of a combination of bupivacaine and low-dose meloxicam. Tetrodotoxin, a naturally occurring reversible site 1 sodium channel toxin derived from pufferfish and shellfish, has shown the potential to block conduction of isolated nerves. Neosaxitoxin is a more potent reversible site 1 sodium channel toxin also found in shellfish that can also block nerve conduction. These novel formulations show great promise in terms of the ability to prolong the duration of single injection PNBs. This field is still currently in development, and more researchers will need to be done to ensure the efficacy and safety of these novel formulations. These formulations could be the future of pain management if ongoing research continues to prove positive effects and low side effect profiles.

Management of pain using magnesium sulphate: A narrative review

Pain is one of the most complex and unpleasant sensory and emotional human experiences. Pain relief continues to be a major medical challenge. The application of systemic opioid and regional analgesia techniques has facilitated a decrease in the occurrence and gravity of pain. Magnesium has an evolving role in pain management. Magnesium sulphate (MgSO4), the pharmacological form of magnesium, is a physiological voltage-dependent blocker of N-methyl-D-aspartate (NMDA)-coupled channels. In terms of its antinociceptive role, magnesium blocks calcium influx, which inhibits central sensitization and decreases preexisting pain hypersensitivity. These properties have encouraged the research of magnesium as an adjuvant agent for intra- and post-operative analgesia. Moreover, the mentioned magnesium impacts are also detected in patients with neuropathic pain. Intravenous magnesium sulphate, followed by a balanced analgesia, decreases opioid consumption. This review has focused on the existing evidence concerning the role of magnesium sulphate in pain management in situations including neuropathic pain, postherpetic neuralgia, trigeminal neuralgia, migraine, and post-operative pain. Additional studies are required to improve the use of magnesium sulphate for pain to increase the quality of life of patients.

The Effect of Pneumoperitoneum-induced Hypertension During Laparoscopic Cholecystectomy Under General Anesthesia on Postoperative Pain: A Randomized Clinical Trial

Background: Acute postoperative pain is a significant cause of morbidities. This study aimed to evaluate the effect of intraoperative blood pressure during laparoscopic cholecystectomy under general anesthesia on postoperative pain in patients without underlying disorders. Methods: In this randomized clinical trial, 72 patients undergoing general anesthesia for elective laparoscopic cholecystectomy were randomly assigned into two groups: Group A with higher than baseline preoperative blood pressure (MAP allowed to increase up to 20% higher than baseline MAP by inducing pneumoperitoneum) and group B with normal to low blood pressure (MAP deliberately controlled at a tight limit from normal baseline MAP values to 20% less than baseline by titrating TNG infusion). The Visual Analog Scale (VAS) after 2, 8, 12, and 24 hours of surgery, and the total dose of meperidine used to manage postoperative pain were recorded and compared between the two groups. Results: The pain scores in group A were significantly lower than group B (P = 0.001). The postoperative analgesia request time was different between the two groups (P = 0.53). During the first 24 hours, the total meperidine consumption dose in group A was significantly lower than in group B (P = 0.001). Conclusions: High intraoperative blood pressure may affect the postoperative pain after laparoscopic cholecystectomy and lead to less postoperative pain score and analgesic requirements.

Comparison of Intraperitoneal Bupivacaine and Intravenous Ketorolac for Postoperative Pain Management Following Laparoscopic Cholecystectomy

Background

Postoperative pain following laparoscopic cholecystectomy (LC) arises from incision sites and residual intraperitoneal CO₂ gas. Opioids as a class of pain-relieving drugs are broadly used to control pain after LC; however, these drugs can cause various side effects.

Objectives

The purpose of this study was to compare the efficacy of intraperitoneal injection of bupivacaine with that of intravenous ketorolac in managing postoperative pain in patients who had undergone LC.

Methods

This randomized, double-blind clinical trial was carried out on patients who had undergone LC. Ninety patients who had undergone elective LC were randomly divided into 3 groups (n = 30 for each group). Group A received 40 mL of 0.25% bupivacaine solution intraperitoneally at the end of the operation; group B received 30 mg of ketorolac intravenously 30 minutes before surgery and every 8 hours after surgery, and patients in group C received normal saline intraperitoneally and intravenous injection. The patients were postoperatively assessed for Visual Analog Scale (VAS) scores, postoperative opioid consumption, shoulder pain, side effects (sedation, nausea, and vomiting), and satisfaction. The data were analyzed using SPSS. P values < 0.05 were considered significant.

Results

The intraperitoneal injection of bupivacaine and intravenous injection of ketorolac were significantly effective in reducing postoperative abdominal pain, shoulder pain, and incidence of nausea and vomiting compared to the placebo group (P < 0.001). Although intraperitoneal bupivacaine and intravenous ketorolac had no significant difference in pain relief compared with each other, patients in both bupivacaine and ketorolac groups were significantly more satisfied with their analgesia compared to the control group (P < 0.001).

Conclusions

Intraperitoneal injection of bupivacaine and intravenous injection of ketorolac both are safe and effective methods to control pain, nausea, and vomiting after LC.

Mirogabalin as a Novel Gabapentinoid for the Treatment of Chronic Pain Conditions: An Analysis of Current Evidence

: Neuropathic pain is a challenge for physicians to treat and often requires a multimodal approach with both pharmacologic and lifestyle interventions. Mirogabalin, a potent, selective ligand of the α2δ-1 and α2δ-2 subunits of voltage-gated calcium channels (VGCCs), provides analgesia by inhibiting neurotransmitter release at the presynaptic end of the neuron. Mirogabalin offers more sustained analgesia than its gabapentinoid counterparts in addition to a wider safety margin for adverse events. Recent clinical trials of mirogabalin have demonstrated both efficacy and tolerability of the drug for the treatment of diabetic peripheral neuropathic pain and postherpetic neuralgia, leading to its approval in Japan. While still not yet FDA approved, mirogabalin is still in its infancy and offers potential into the treatment of neuropathic pain and its associated comorbidities.

Pain Control After Mastectomy in Transgender Patients: Ultrasound-guided Pectoral Nerve Block II Versus Conventional Intercostal Nerve Block: A Randomized Clinical Trial

Background

Mastectomy is sometimes performed in transgender patients, which may damage the regional nerves such as the pectoral and intercostobrachial nerves, leading to postoperative pain. An ultrasound-guided nerve block can be used to track and block the nerves properly.

Objectives

This study aimed to compare the ultrasound-guided type-II pectoral nerve block with the blind (conventional) intercostal nerve block (ICNB) for pain control after breast tissue reconstruction surgery in transgender patients.

Methods

In the present single-blind randomized clinical trial, 47 patients were randomly divided into two groups: (A) Ultrasound-guided type-II pectoral nerve block (n = 23) and (B) blind intercostal nerve block (n = 24). After nerve block in both groups, pain intensity at 3, 6, 12, and 24 hours after surgery, upper limb paresthesia, frequency of nausea and vomiting, shortness of breath, hematoma, and the length of hospital stay were assessed.

Results

Patients who received the ultrasound-guided type-II pectoral nerve block had a greater reduction in pain intensity (24 h after surgery), opioid use (24 h after surgery), nausea, vomiting, and hospital stay than those who received ICNB, whereas the recovery time did not differ between the study groups.

Conclusions

The pectoral nerve block under ultrasound guidance, compared to the intercostal nerve block, in transgender patients can reduce the required dosage of opioids within 24 hours, pain intensity within 24 hours after surgery, the incidence of postoperative nausea, and vomiting, and the hospital stay of patients.

Antibiotics for Spinal Cord Stimulation Trials and Implants: A Survey Analysis of Practice Patterns

Background

Spinal cord stimulation (SCS) is an established treatment modality for neuropathic pain. Published guidelines exist to aid physicians in proper antibiotic use during and after spinal cord stimulation trials and implants. In this brief review, we present and analyze the current antibiotic practice patterns of clinicians.

Methods

The study protocol was reviewed and granted an exemption by an Institutional Review Board. The survey queried practice parameters in regards to spinal cord stimulation therapy. The American Society of Regional Anesthesia and Pain Medicine (ASRA) and Society of Interventional Spine (SIS) distributed the survey to their active members by emails with a web link to the survey.

Results

Our results indicate that 82% and 69% of physicians do not utilize nasal swabs for methicillin-sensitive Staphylococcus aureus (MSSA) or methicillin-resistant Staphylococcus aureus (MRSA), respectively, prior to SCS trial and implantation. During trials, 47% providers administer a single dose of antibiotics, 35% administer antibiotics for the duration of the trial, and 17% do not administer antibiotics. During implantation, 44% of physicians administer a single dose during the procedure, 11% administer antibiotics up to 24 hours, 24% administer antibiotics between 3-5 days, 14% administer antibiotics for more than 5 days, and 4% do not administer antibiotics.

Conclusions

Our study suggests a portion of pain physicians do not adhere to the Neuromodulation Appropriateness Consensus Committee (NACC) guidelines in regards to antibiotic administration for SCS trial and implantation. Further analysis and surveys would allow insight into common practices. More information and education would be beneficial to optimize peri-procedure antibiotic use to reduce infection risk and decrease antimicrobial resistance.

Comparison of Intraoperative Infusion of Remifentanil Versus Fentanyl on Pain Management in Patients Undergoing Spine Surgery: A Double Blinded Randomized Clinical Trial

Background

Remifentanil is an ultra-short-acting opioid which facilitates hemodynamic management. However, there are concerns about postoperative Remifentanil hyperalgesia because of its potent fast onset and offset.

Objectives

The aim of this study was to determine visual analog scale (VAS), postoperative pain, and morphine used in two groups after spine surgery.

Methods

In this randomized clinical trial study, 60 patients aged 18 - 60 years old, according to the American Society of Anesthesiology (ASA) I - II, who underwent spinal canal stenosis or scoliosis surgery, were divided into two groups. In the control group, patients received 0.07 - 0.1 µg/kg/h intraoperative Fentanyl infusion, and in the intervention group 0.1 - 0.2 µg/kg/min remifentanil was infused during the surgery. Both groups received 15 mg/kg intravenous Acetaminophen 20 minutes before the end of the surgery. Postoperative pain score and morphine consumption were measured 6, 12, 24, and 48 hours after discharge from the post-anesthesia care unit (PACU).

Results

During the first 12 hours, VAS and morphine consumption were significantly higher in remifentanil group (P < 0.001). However, no significant difference was found between the two groups in morphine consumption 12 - 48 hours after surgery.

Conclusions

These findings suggest that Remifentanil infusion during surgery may increase postoperative pain. Also, VAS and morphine consumption were higher during the first 12 hours.

Evaluation of the Effect of Intranasal Lidocaine in the Treatment of Spasticity in Patients with Traumatic Brain Injury

Background

Spasticity following traumatic brain injury (TBI) is one of the most significant barriers of returning patients to their normal life. Spasticity caused by TBI does not have a specific or definitive treatment, and the clinical effect of pharmacologic treatments has not been significant.

Methods

In this single-arm study, we evaluated 15 patients. For each patient with spasticity, treatment with oral baclofen 25 mg was started three times a day as a part of standard therapy. After 48 hours, if the spasticity did not decrease by at least one score in the Modified Tardieu or Ashworth scales, lidocaine 0.5% was administered as a continuous intranasal infusion. The initial dose of lidocaine was 1 mg/min, which was gradually increased to 2 mg/min. Spasticity and the frequency of spasms were assessed by Ashworth and modified tardieu scales (MTS) and Spasm Frequency Score (SFS), respectively. Heart rate (HR), respiratory rate (RR), mean arterial blood pressure (MAP), Richmond Agitation-Sedation Scale (RASS), Glasgow Coma Scale (GCS), and arterial oxygen saturation (SP_o2) of patients were recorded during nine days of treatment. All data were analyzed by SPSS version 21. P-value less than 0.05 was considered as statistically significant.

Results

Out of 15 participants in this study, 13 (86.7%) were male, and 2 (13.3%) were female (mean age: 29.26 ± 12.5 years). There were no significant differences in Ashworth Scale, Modified Tradieu Scale, RASS Score, GCS Score, MAP, SP_o2 percentage, HR, RR, and the number of spasms per day between the time of initiation of treatment and the second day of baclofen treatment (P > 0.05). Evaluation of spasticity using Ashworth scale on the first and last days of lidocaine treatment showed a significant decrease in the mean spasticity (3.46 ± 0.51 and 1.46 ± 0.91, respectively; P < 0.001). Spasticity assessment using the MTS showed a significant reduction in the mean of the last day of treatment compared to the mean of the first day of treatment (3.6 ± 0.5 and 1.26 ± 0.51, respectively; P < 0.001). This decrease was also seen in the mean of the last day of treatment compared to the first day in SFS (13.3 ± 3.88 and 3.8 ± 0.51, respectively; P < 0.001). Comparison of HR, RR, MAP, RASS, GCS, and SP_o2 on the first and last days of treatment did not show any statistical differences.

Conclusions

Although continuous intranasal treatment with lidocaine can be effective in spasm reduction of patients with TBI, further studies with larger sample sizes and longer follow-up periods are required.

A Comprehensive Update of the Current Understanding of Chronic Fatigue Syndrome

This is a comprehensive literature review of chronic fatigue syndrome (CFS). We provide a description of the background, etiology, pathogenesis, diagnosis, and management regarding CFS. CFS is a multifaceted illness that has many symptoms and a wide array of clinical presentations. As of recent, CFS has been merged with myalgic encephalomyelitis (ME). Much of the difficulty in its management has stemmed from a lack of a concrete understanding of its etiology and pathogenesis. There is a potential association between dysfunction of the autoimmune, neuroendocrine, or autonomic nervous systems and the development of CFS. Possible triggering events, such as infections followed by an immune dysregulation resulting have also been proposed. In fact, ME/CFS was first described following Epstein Barr virus (EBV) infections, but it was later determined that it was not always preceded by EBV infection. Patient diagnosed with CFS have shown a noticeably earlier activation of anaerobic metabolism as a source of energy, which is suggestive of impaired oxygen consumption. The differential diagnoses range from tick-borne illnesses to psychiatric disorders to thyroid gland dysfunction. Given the many overlapping symptoms of CFS with other illnesses makes diagnosing it far from an easy task. The Centers for Disease Control and Prevention (CDC) considers it a diagnosing of exclusion, stating that self-reported fatigue for at minimum of six months and four of the following symptoms are necessary for a proper diagnosis: memory problems, sore throat, post-exertion malaise, tender cervical or axillary lymph nodes, myalgia, multi-joint pain, headaches, and troubled sleep. In turn, management of CFS is just as difficult. Treatment ranges from conservative, such as cognitive behavioral therapy (CBT) and antidepressants, to minimally invasive management. Minimally invasive management involving ranscutaneous electrical acupoint stimulation of target points has demonstrated significant improvement in fatigue and associated symptoms in a 2017 randomized controlled study. The understanding of CFS is evolving before us as we continue to learn more about it. As further reliable studies are conducted, providing a better grasp of what the syndrome encompasses, we will be able to improve our diagnosis and management of it.

A Comparative Study of Valsalva Maneuver, Lidocaine, and Valsalva Maneuvers with Administration of Lidocaine to Reduce the Pain Associated with Administration of Etomidate During General Anesthesia

Objectives

The purpose of this study is a comparison of Valsalva, lidocaine, and Valsalva with administration of lidocaine to reduce the pain associated with administration of etomidate.

Methods

The present study is a clinical trial study. The number of samples in each group was 30 and a total of 90 people were selected. This study was a clinical trial and the subjects were randomly divided into three groups: Group 1: Valsalva, 2: Lidocaine, 3: Valsalva and Lidocaine. Pain due to etomidate was rated on a VAS from 1 (painless) to 3 (worst imaginable pain) and their information was recorded. The collected information was entered into SPSS 22 and analyzed with appropriate statistical tests.

Results

A total of 90 subjects participated in the present study and were divided into 3 groups: Valsalva, lidocaine, and Valsalva with lidocaine. No significant difference was observed between demographic variables in the study groups. There was a significant relationship between severity of pain in the three groups. According to the results, the highest pain intensity was in the Valsalva group and the lowest pain intensity was in the Valsalva with lidocaine group.

Conclusions

Valsalva with lidocaine reduces the severity of pain caused by etomidate to a greater extent than other groups.

Efficacy of Dry Needling and Acupuncture in the Treatment of Neck Pain

CONTEXT

Neck pain is a common phenomenon and affects a large segment of the population. Chronic neck pain, lasting more than 3 months, likely occurs in 10% - 30% of patients with acute neck pain and affects up to 288 million cases globally, carrying a significant cost in terms of quality of life, disability, and healthcare dollars. Here we review neck pain background, acupuncture and the evidence that exist to support acupuncture use in chronic neck pain.

RESULTS

Neck pain not only affects quality of life directly, but also contributes to depression, job dissatisfaction and reduced productivity. Unfortunately, neck pain is strongly linked to office and computer work and is likely to continue increasing in prevalence. Traditional treatments, such as analgesics, physical therapy, exercise, and non-invasive therapy bring some relief, and invasive therapy is indicated if anatomical pathologies exist. Acupuncture is a form of integrative medicine, originally described and practiced in traditional Chinese medicine and now expanded to include methods including acupressure, dry needling, and others. Traditionally, it focused on restoring the patient's flow of Qi by puncturing specific points along the meridians. It has previously been shown to be effective in other forms of chronic pain and disability. Clinical trials studying acupuncture for neck pain have shown significant reduction in both pain and associated symptoms. These therapies are reviewed in this text.

CONCLUSIONS

Neck pain is a common and significant global problem. Acupuncture, dry needling, and cupping were all shown to be effective in alleviating pain both immediately after treatment, as well as provide long-lasting relief. These treatments are generally safe and inexpensive and should be considered as part of a multimodal approach for the treatment of neck pain. More head-to-head studies will provide better data to support a choice of a specific treatment over another.

Dorsal Root Ganglion (DRG) and Chronic Pain

Context

Chronic neuropathic pain is a common condition, and up to 11.9% of the population have been reported to suffer from uncontrolled neuropathic pain. Chronic pain leads to significant morbidity, lowered quality of life, and loss of workdays, and thus carries a significant price tag in healthcare costs and lost productivity. dorsal root ganglia (DRG) stimulation has been recently increasingly reported and shows promising results in the alleviation of chronic pain. This paper reviews the background of DRG stimulation, anatomical, and clinical consideration and reviews the clinical evidence to support its use.

Evidence Acquisition

The DRG span the length of the spinal cord and house the neurons responsible for sensation from the periphery. They may become irritated by direct compression or local inflammation. Glial cells in the DRG respond to nerve injury, producing inflammatory markers and contribute to the development of chronic pain, even after the resolution of the original insult. While the underlying mechanism is still being explored, recent studies explored the efficacy of DRG stimulation and neuromodulation for chronic pain treatment.

Results

Several reported cases and a small number of randomized trials were published in recent years, describing different methods of DRG stimulation and neuromodulation with promising results. Though evidence quality is mostly low, these results provide evidence to support the utilization of this technique.

Conclusions

Chronic neuropathic pain is a common condition and carries significant morbidity and impact on the quality of life. Recent evidence supports the use of DRG neuromodulation as an effective technique to control chronic pain. Though studies are still emerging, the evidence appears to support this technique. Further studies, including large randomized trials evaluating DRG modulation versus other interventional and non-interventional techniques, are needed to further elucidate the efficacy of this method. These studies are also likely to inform the patient selection and the course of treatment.

Efficacy of Acupuncture in the Treatment of Chronic Abdominal Pain

Context

Abdominal pain is a widespread complaint and is one of the common reasons leading patients to seek medical care, either in emergency situations or with their primary providers. While acute abdominal pain is a better defined, usually surgical condition, chronic abdominal pain requires longer, typically lifelong, therapy. Chronic abdominal pain may also present with acute flares and complications. Here we review seminal and novel evidence discussing the use of acupuncture in the treatment of abdominal pain, indications, and conditions that may benefit from this approach.

Evidence Acquisition

Chronic abdominal pain is a common complaint causing significant morbidity and disability and has a hefty price tag attached. Recent studies show it may be prevalent in as much as 25% of the adult population. It is defined as three episodes of severe abdominal pain over the course of three months. Chronic abdominal pain could be the result of chronicity of acute pain or of chronic pain syndromes, most commonly IBD syndromes and IBS. While a plethora of treatments exists for both conditions, these treatments usually fall short of complete symptom control, and there is a need for complementary measures to curb disability and increase the quality of life in these patients. Acupuncture is a form of integrative medicine that has long been used in Chinese and traditional medicine, based on the rebalancing of the patient’s Qi, or Ying/Yang balance. It has been shown to be effective in treating several other conditions, and novel evidence may expand its use into other fields as well. Clinical trials studying acupuncture in chronic pain conditions have been promising, and recent evidence supports the use of abdominal pain in chronic abdominal pain conditions as well. Though not curative, acupuncture is a complementary approach that helps reduce symptoms and improved quality of life.

Conclusions

Chronic abdominal pain is a widespread condition, mostly affected by the IBS and IBD spectrum. Etiologies are still being studied for these conditions, and while novel treatment approaches are absolute game changers for these patients, many continue to experience some level of symptoms and disability. Acupuncture may provide further alleviation of these symptoms in select patients, thus improving quality of life, reducing disability, and saving healthcare dollars. It is a largely safe and inexpensive method that may significantly contribute to the quality of life of selected patients.

Etiology Diagnosis and Management of Radial Nerve Entrapment

Context

The anatomy of the radial nerve is prone to entrapment, each with different symptomology. Compression of entrapment of the radial nerve can occur near the radiocapitellar joint, the spiral groove, the arcade of Frohse, the tendon of the extensor carpi radialis brevis (ECRB), and at the radial tunnel. Those who require repetitive motions are at increased risk of peripheral neuropathy syndromes, including repetitive pronation and supination, trauma, or systemic disease; however, t the influence of all risk factors is not well understood. Depending on the location of entrapment, radial nerve entrapment syndrome presents different symptoms. It may include both a motor component and a sensory component. The motor component includes a dropped arm, and the sensory component can include pain and paresthesia in the distribution of the radial nerve that resolves with rest and exacerbates by repetitive pronation and supination.

Evidence Acquisition

Diagnostic evaluation for radial nerve entrapment, apart from clinical symptoms and physical exam, includes electromyography, nerve conduction studies, ultrasonography, and magnetic resonance imaging. Conservative management for radial nerve entrapment includes oral anti-inflammatory medications, activity modification, and splinting. Some recently performed studies mentioned promising minimally invasive techniques, including corticosteroid injections, peripheral nerve stimulation, and pulsed radiofrequency.

Results

When minimally invasive techniques fail, open or endoscopic surgery can be performed to release the nerve

Conclusions

Endoscopic surgery has the benefit of decreasing incision size and reducing time to functional recovery.

Utilization of Magnesium for the Treatment of Chronic Pain

Context

The International Association for the Study of Pain (IASP) defines chronic pain as pain that persists or recurs for longer than 3 months. Chronic pain has a significant global disease burden with profound effects on health, quality of life, and socioeconomic costs.

Evidence Acquisition

Narrative review.

Results

There are several treatment options, including pharmacological therapy, physical rehabilitation, psychological therapies, and surgical interventions, for chronic pain management. Magnesium has been FDA-approved for several indications including hypomagnesemia, arrhythmia, prevention of seizures in eclampsia/preeclampsia, and constipation. Magnesium has been used for numerous off-label uses, notably for acute and chronic pain management. The mechanism of magnesium in pain management is primarily through its action as a voltage-gated antagonist of NMDA receptors, which are involved in pain transduction.

Conclusions

This narrative review will focus on the current evidence and data surrounding the utilization of magnesium as a treatment option for chronic pain.

Surgical and Non-surgical Treatment Options for Piriformis Syndrome: A Literature Review

Context

Piriformis syndrome is a solely clinical diagnosis that often eludes the practitioner and goes underdiagnosed. PS is a pain syndrome and for those it affects, causes persistent pain and limits daily activity and work capacity. It is a form of deep gluteal syndrome that needs to be considered on the differential of low back pain as it comprises between 0.3% - 6% of all low back pain cases and is frequently underdiagnosed. Piriformis syndrome may be primary due anatomic anomalies or secondary, though the majority of cases are secondary to some insult. The objective of this manuscript is to provide a description of the epidemiology and presentation of piriformis as well as both non-operative and operative treatment options. We review all of the recent clinical evidence regarding the aforementioned therapies.

Evidence Acquisition

Literature searches were performed using the below MeSH Terms using Mendeley version 1.19.4. Search fields were varied until further searches revealed no new articles. All articles were screened by title and abstract. Decision was made to include an article based on its relevance and the list of final articles was approved three of the authors. This included reading the entirety of the article. Any question regarding the inclusion of an article was discussed by all authors until an agreement was reached.

Results

Medical management and physical therapy show some promise; however, when conservative treatment fails minimally invasive methods such as steroid injections, botulinum toxin injections, dry needling are all efficacious and there is substantial clinical evidence regarding these therapies. In those patients in which minimally invasive techniques do not result in an adequate relief of pain and return of function, endoscopic release can be considered. Endoscopic release is far superior to open release of the piriformis syndrome given the higher success and lower rate of complications.

Conclusions

Piriformis syndrome is an important differential diagnosis in the work up of lower back pain and should not be ruled out with proper examination and testing. Clinicians should consider medical management and conservative management in the initial treatment plan for piriformis syndrome. There are many options within the conservative management and the literature shows much promise regarding these. Physical therapy, steroid injections, botulinum toxin injections, and dry needling are all potentially effective therapies with few adverse effects. Surgical options remain as gold standard, but only when conservative management has failed and the symptoms are significant to affect daily living activities. Endoscopic decompression of the sciatic nerve with or without release of the piriformis muscle has a reported high likelihood of success and a low complication rate. Current literature supports the preference of the endoscopic approach over the open approach due to improved outcomes and decreased complications. Further research is to well define the metrics for the diagnosis of piriformis syndrome and may include a need to develop diagnostic criteria.

Intraoperative Hypotension Increased Risk in the Oncological Patient

Patient safety advocacy involves avoiding, preventing, and amelioration of adverse outcomes or injuries caused by the process of healthcare rather than a patient's underlying medical illness. Intraoperative hypotension (IOH), a common morbid event, reduces perfusion to critical organs and tissues and has a wide incidence, depending on how it is defined. IOH has adverse intraoperative and postoperative consequences, which make its prevention important to improve patient outcomes. Certain populations have even greater consequences related to IOH, and clinicians must understand these risks. In this narrative review, we examine the risk of intraoperative hypotension in the oncological patient population.