Utilization of Magnesium for the Treatment of Chronic Pain

The effect of magnesium sulfate on emergence agitation in surgical adult patients undergoing general anesthesia: A systematic review and meta-analysis of randomized controlled trials

STUDY OBJECTIVE

Investigating the effect of magnesium sulfate (MS) on emergence agitation (EA) in adult surgical patients following general anesthesia (GA).

DESIGN

Systematic literature review and meta-analysis (PROSPERO number: CRD42023461988).

SETTING

Review of published literature.

PATIENTS

Adults undergoing GA.

INTERVENTIONS

Intravenous administration of MS.

MEASUREMENTS

We searched PubMed/MEDLINE, EMBASE, the Cochrane Library, Scopus, and Web of Science for publications until September 14, 2023. The primary outcome was the incidence of EA, while the secondary outcomes included the impact of MS on postoperative agitation score (PAS), emergence variables and adverse events. Relative risk (RR) with 95% confidence interval (CI) measured dichotomous outcome, while standardized mean difference (SMD) or mean difference (MD) with 95% CI measured continuous outcomes.

MAIN RESULTS

Meta-analysis of five randomized controlled trials (RCTs) indicated that MS was associated with a lower incidence of EA at various time points (0 min: RR = 0.62, 95% CI [0.41, 0.95]; p = 0.183, I2 = 43.6%; 5 min: RR = 0.29, 95% CI [0.16, 0.52]; p = 0.211, I2 = 36%; 10 min: RR = 0.14, 95% CI [0.06, 0.32]; p = 0.449, I2 = 0%; 15 min: RR = 0.11, 95% CI [0.02, 0.55]; p = 0.265, I2 = 19.5%; 30 min: RR = 0.05, 95% CI [0.00, 0.91]; the postoperative period: RR = 0.21, 95% CI [0.09, 0.49]; p = 0.724, I2 = 0%;). Additionally, MS was associated with a reduced PAS at various time points except for 0 min. However, no significant differences were observed in extubation time, the length of stay in the post-anesthesia care unit, postoperative nausea and vomiting or total complications.

CONCLUSIONS

Limited available evidence suggests that MS was associated with a lower incidence of EA. Nevertheless, further high-quality studies are warranted to strengthen and validate the effect of MS in preventing EA in adult surgical patients.

Integrating mechanistic-based and classification-based concepts into perioperative pain management: an educational guide for acute pain physicians

Chronic pain begins with acute pain. Physicians tend to classify pain by duration (acute vs chronic) and mechanism (nociceptive, neuropathic and nociplastic). Although this taxonomy may facilitate diagnosis and documentation, such categories are to some degree arbitrary constructs, with significant overlap in terms of mechanisms and treatments. In clinical practice, there are myriad different definitions for chronic pain and a substantial portion of chronic pain involves mixed phenotypes. Classification of pain based on acuity and mechanisms informs management at all levels and constitutes a critical part of guidelines and treatment for chronic pain care. Yet specialty care is often siloed, with advances in understanding lagging years behind in some areas in which these developments should be at the forefront of clinical practice. For example, in perioperative pain management, enhanced recovery protocols are not standardized and tend to drive treatment without consideration of mechanisms, which in many cases may be incongruent with personalized medicine and mechanism-based treatment. In this educational document, we discuss mechanisms and classification of pain as it pertains to commonly performed surgical procedures. Our goal is to provide a clinical reference for the acute pain physician to facilitate pain management decision-making (both diagnosis and therapy) in the perioperative period.

Effects of intraoperative Magnesium sulfate infusion on emergency agitation during general anesthesia in patients undergoing radical mastectomy: a randomized controlled study

BACKGROUND

Emergency agitation is a common postoperative complication in patients under general anesthesia, which can lead to unpredictable damages such as shedding of drainage tube and bleeding from the wound. The purpose of the study is to investigate whether intraoperative infusion of Magnesium Sulfate reduces the incidence of emergency agitation (EA) in patients undergoing radical mastectomy, and to evaluate its safety and efficacy.

METHODS

A total of 70 patients were randomly assigned to two groups: the Magnesium group (M group) and the control group (C group). After a routine intravenous anesthetic induction, patients in the M group received a 30 mg/kg bolus of intravenous magnesium during the first hour and then a continuous infusion of 10 mg/kg ×h until the end of the surgery, patients in the C group received 0.9% saline at the same volume and rate. The sedation-agitation scale (SAS) and the visual analogue scale were used to assess agitation and pain, respectively.

RESULTS

Compared to the C group, the M group reduced the incidence of EA significantly (odds ratio 0.26, 95% confidence interval 0.09-0.71, P = 0.009). The postoperative pain score of the magnesium sulfate group(0(0,1)) was lower than that of the control group(2(0,3)) at T0 (P = 0.011). Additionally, the M group required a lower dosage of remifentanil during surgery compared to the C group(300.4 ± 84 versus 559.3 ± 184 µg, respectively, P<0.001).

CONCLUSIONS

the intraoperative infusion of magnesium sulfate is a safe and effective method for reducing the incidence of emergency agitation in patients undergoing radical mastectomy.

TRAIL REGISTRATION

The study was registered in Chictr.org with the identifier: ChiCTR2300070595 on 18/04/2023.

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.

Pain Management in Older Adults with Chronic Wounds

Older people often suffer from different types of ulcers, with the most prevalent being chronic leg ulcers (CLUs) and diabetic foot ulcers. There are major issues in the current medical approach because these ulcers are hard to heal, and, in the case of CLUs, very painful and with a high frequency of relapse. Older people complain of pain more frequently than young people, frequently due to a combination of painful chronic wounds with other comorbidities (e.g. arthritis, peripheral arterial disease, vertebrogenic pain syndrome). However, chronic pain appears to be managed better by older people because the pain sensitivity is downregulated and the pain threshold is higher in older people. Pain management of chronic wounds is often insufficient, especially in older individuals. It is highly important to use non-traumatic wound dressings and pay attention to patients' feelings and fears because pain in chronic ulcers can impair wound healing. Key factors include good preparation for dressing change and adequate analgesia, ideally a combination of topical and oral agents.

Evaluation of the Effects of Oral Magnesium Sachet on the Prevention of Spinal Anesthesia-Induced Headache After Cesarean Section: A Randomized Clinical Trial

Background: Post-dural puncture headache (PDPH) is a common complication of spinal anesthesia. It often goes away after a few days but may be more severe in some patients and persists for weeks. Objectives: This study aimed to evaluate the effect of oral magnesium on the prevention of PDPH after cesarean section for the first time. Methods: In this double-blind, randomized clinical trial, 100 candidates for elective cesarean section under spinal anesthesia were randomly divided into 2 groups: (i) the intervention group that received 300 mg of oral magnesium powder and (ii) the control group that received starch powder. The frequency and severity of headache and amount of analgesic consumption in both groups were measured 1, 2, and 3 days after cesarean section. Data were analyzed using SPSS version 22 at 95% CI. Results: The frequency of PDPH 1, 2, and 3 days after surgery was 8% vs 24% (P = 0.029), 10% vs 26% (P = 0.039), and 12% vs 18% (P = 0.401) in the intervention and control groups, respectively. The mean and SD of pain severity was 0.52 ± 1.83 vs 1.5 ± 2.84 (P = 0.03) on the first day, 0.70 ± 2.19 vs 1.58 ± 2.86 (P = 0.05) on the second day, and 0.82 ± 2.32 vs 1.18 ± 2.62 on the third day (P = 0.43) in the intervention and control groups, respectively. Although more patients in the control group received rescue analgesia, no significant difference was seen between the 2 study groups. Conclusions: In women candidates for cesarean section, oral administration of 300 mg magnesium 2 hours before surgery significantly reduces the frequency and severity of PDPH, but its impact on reducing analgesic consumption is not significant.

Anesthetic Conversion of Preexisting Labor Epidural Analgesia for Emergency Cesarean Section and Efficacy of Levobupivacaine with or Without Magnesium Sulphate: A Prospective Randomized Study

Background: For pregnant women who require an emergency cesarean section (CS), extending labor epidural analgesia as quickly as feasible to good quality anesthesia is a critical issue. This indicates the presence of functional labor epidural analgesia and reduces the need for general anesthesia. Addition of magnesium increases anesthetic and analgesic qualities of epidural anesthesia. Objectives: The purpose of this trial was to assess the role of adding magnesium sulfate (MgSO4) with levobupivacaine to speed up the conversion of labor epidural analgesia into enough anesthesia for emergency CS. Methods: Fifty parturients were randomly assigned to receive 19.5 mL of levobupivacaine 0.5% with either 0.5 mL of normal saline 0.9% (Group I) or 0.5 mL of MgSO4 10% (Group II) after receiving labor epidural analgesia. We documented the onset of block (loss of pinprick to T6), number of patients needing additional analgesia, the time needed for sensory and motor blockade to recover, and the adverse effects. Results: The frequency of patients receiving intraoperative supplements was comparable in the study groups (P = 0.491), although the onset of the block was faster in Group II than in Group I (P = 0.000*). Group II took substantially longer to recover from sensory and motor blockade than Group I (P = 0.001* and P = 0.001*, respectively). In both groups, the occurrence of adverse events was similar. Conclusions: Adding 50 mg of MgSO4 to levobupivacaine 0.5% accelerated the epidural top, and both sensory onset and motor blocks period were prolonged as compared to levobupivacaine alone when extending epidural analgesia for emergency CS.

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.

The effect of magnesium sulfate on emergence agitation in children undergoing general anesthesia: A systematic review and meta-analysis

STUDY OBJECTIVE

Emergence agitation (EA) is a common complication in pediatric patients after general anesthesia. The effectiveness of magnesium sulfate in decreasing the incidence of EA in children remains controversial. Therefore, a systematic review and meta-analysis was performed to assess the efficacy of magnesium sulfate in preventing EA in pediatric patients following general anesthesia.

DESIGN

Systematic review and meta-analysis.

SETTING

PubMed, Embase, Web of Science, and Cochrane Library were searched to identify eligible randomized controlled trials from their respective database inception dates to June 30, 2021.

PATIENTS

Pediatric patients (< 18 years old) undergoing general anesthesia.

INTERVENTIONS

Intravenous administration of magnesium sulfate.

MEASUREMENTS

The primary outcome of the meta-analysis was EA incidence. The risk of bias of the included studies was evaluated using the revised Cochrane risk of bias tool for randomized trials (RoB 2.0). Grading of Recommendations, Assessment, Development, and Evaluation was applied to assess the level of certainty.

MAIN RESULTS

Eight studies with 635 participants were identified. The forest plot revealed no significant difference in the incidence of EA between patients treated with magnesium sulfate and the control group (risk ratio = 0.69, 95% confidence interval [0.44, 1.07]; P = 0.10, I² = 74%, moderate level of certainty). Additionally, magnesium sulfate did not reduce postoperative pediatric anesthesia emergence delirium scores but prolonged the emergence time. No significant differences were observed in postoperative complications (nausea, vomiting, laryngospasm, breath-holding, coughing, oxygen desaturation, and cardiac arrhythmias).

CONCLUSIONS

Administration of magnesium sulfate during general anesthesia did not affect the occurrence of EA in pediatric patients. However, magnesium sulfate can prolong the emergence time without adverse effects. PROSPERO registration number: CRD42021252924.

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.

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.

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.

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.

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.

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.

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.