Publications by authors named "Farnad Imani"

96 Publications

Adjuvant Drugs for Peripheral Nerve Blocks: The Role of Alpha-2 Agonists, Dexamethasone, Midazolam, and Non-steroidal Anti-inflammatory Drugs.

Anesth Pain Med 2021 Jun 4;11(3):e117197. Epub 2021 Jul 4.

Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, USA.

Adjuvant drugs for peripheral nerve blocks are a promising solution to acute postoperative pain and the transition to chronic pain treatment. Peripheral nerve blocks (PNB) are used in the brachial plexus, lumbar plexus, femoral nerve, sciatic nerve, and many other anatomic locations for site-specific pain relief. However, the duration of action of a PNB is limited without an adjuvant drug. The use of non-opioid adjuvant drugs for single-shot peripheral nerve blocks (sPNB), such as alpha-2 agonists, dexamethasone, midazolam, and non-steroidal anti-inflammatory drugs, can extend the duration of local anesthetics and reduce the dose-dependent adverse effects of local anesthetics. Tramadol is a weak opioid that acts as a central analgesic. It can block voltage-dependent sodium and potassium channels, cause serotonin release, and inhibit norepinephrine reuptake and can also be used as an adjuvant in PNBs. However, tramadol's effectiveness and safety as an adjuvant to local anesthetic for PNB are inconsistent. The effects of the adjuvants on neurotoxicity must be further evaluated with further studies to delineate the safety in their use in PNB. Further research needs to be done. However, the use of adjuvants in PNB can be a way to help control postoperative pain.
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http://dx.doi.org/10.5812/aapm.117197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8438706PMC
June 2021

Adjuvant Drugs for Peripheral Nerve Blocks: The Role of NMDA Antagonists, Neostigmine, Epinephrine, and Sodium Bicarbonate.

Anesth Pain Med 2021 Jun 5;11(3):e117146. Epub 2021 Jul 5.

Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, USA.

The potential for misuse, overdose, and chronic use has led researchers to look for other methods to decrease opioid consumption in patients with acute and chronic pain states. The use of peripheral nerve blocks for surgery has gained increasing popularity as it minimizes peripheral pain signals from the nociceptors of local tissue sustaining trauma and inflammation from surgery. The individualization of peripheral nerve blocks using adjuvant drugs has the potential to improve patient outcomes and reduce chronic pain. The major limitations of peripheral nerve blocks are their limited duration of action and dose-dependent adverse effects. Adjuvant drugs for peripheral nerve blocks show increasing potential as a solution for postoperative and chronic pain with their synergistic effects to increase the duration of action and decrease the required dosage of local anesthetic. N-methyl-d-aspartate (NMDA) receptor antagonists are a viable option for patients with opioid resistance and neuropathic pain due to their affinity to the neurotransmitter glutamate, which is released when patients experience a noxious stimulus. Neostigmine is a cholinesterase inhibitor that exerts its effect by competitively binding at the active site of acetylcholinesterase, which prevents the hydrolysis of acetylcholine and subsequently retaining acetylcholine at the nerve terminal. Epinephrine, also known as adrenaline, can potentially be used as an adjuvant to accelerate and prolong analgesic effects in digital nerve blocks. The theorized role of sodium bicarbonate in local anesthetic preparations is to increase the pH of the anesthetic. The resulting alkaline solution enables the anesthetic to more readily exist in its un-ionized form, which more efficiently crosses lipid membranes of peripheral nerves. However, more research is needed to show the efficacy of these adjuvants for nerve block prolongation as studies have been either mixed or have small sample sizes.
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http://dx.doi.org/10.5812/aapm.117146DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8438710PMC
June 2021

Comparison of Dexmedetomidine and Dexamethasone as Adjuvants to Ultra-Sound Guided Interscalene Block in Arthroscopic Shoulder Surgery: A Double-Blinded Randomized Placebo-Controlled Study.

Anesth Pain Med 2021 Jun 4;11(3):e117020. Epub 2021 Jul 4.

Department of Anesthesiology, Montefiore Medical Center, Bronx, NY, USA.

Background: Interscalene block is one of the popular methods for decreasing pain and analgesic consumption after shoulder arthroscopic surgeries.

Objectives: The objective is to compare the analgesic duration of effects of dexmedetomidine and dexamethasone as adjuvants to 0.5% ropivacaine in ultrasound-guided interscalene blocks for arthroscopic shoulder surgery in an ambulatory setting.

Methods: In this randomized controlled trial, 117 adult patients candidate for ambulatory arthroscopic shoulder surgery under general anesthesia were divided into three groups to perform an ultra-sound guided interscalene block before the surgery. The ropivacaine (control) group received ropivacaine 0.5% 20 mL, group Dexamethasone received ropivacaine 0.5% 20 mL plus 4mg dexamethasone, and group dexmedetomidine received ropivacaine 0.5% 20 mL plus 75 mcg of dexmedetomidine. Time to return of sensory function, of motor function, of first pain sensation, amount of opioid medication consumed at 24 hours and 48 hours post-operatively were measured.

Results: The 24-hour median (25th- 75th percentile) opioid consumption in morphine equivalents was similar between groups 22.5 mg (10 - 30), 15 mg (0 - 30), and 15 mg (0 - 20.6) in the ropivacaine, dexmedetomidine, and dexamethasone groups, respectively (P = 0.130). The median (25th- 75th percentile) 48 hours post-operatively, the median opioid consumption in morphine equivalents was 40 mg (25 - 67.5) in the ropivacaine group, 30 mg (22 - 50.6) in the dexamethasone group, and 52.5 mg (30 - 75) in the dexmedetomidine group (P = 0.278). The median 24-hour pain scores were 6 (5 - 8) in the ropivacaine control group, 7 (5.5 - 8) in the dexamethasone group, and 7 (4 - 9) in the dexmedetomidine group (P = 0.573).

Conclusions: There was no statistical difference in opioid consumption at 24 and 48 hours post-operatively when comparing dexmedetomidine, dexamethasone, and no adjuvant. However, intraoperative opioid use was significantly lower with dexmedetomidine compared to dexamethasone and plain 0.5% ropivacaine. The safe side effect profile of dexmedetomidine makes it a reasonable alternative as an adjuvant for peripheral nerve blockade when dexamethasone use may be contraindicated.
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http://dx.doi.org/10.5812/aapm.117020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8438728PMC
June 2021

Programmable Pump for Intrathecal Morphine Delivery to Cisterna Magna: Clinical Implications in Novel Management of Refractory Pain Above Middle Thoracic Vertebrae Level Utilizing a Prospective Trial Protocol and Review.

Anesth Pain Med 2021 Jun 29;11(3):e115873. Epub 2021 Jun 29.

Department of Anesthesiology, Anesthesia and Operation Center, Chinese PLA General Hospital, Beijing, China.

Background: The cisterna Intrathecal Drug Delivery system (IDDS) with morphine has proven to be effective in treating refractory cancer pain above the middle thoracic vertebrae level in some countries. However, it has not been fully investigated in others. We designed the current project to investigate the efficacy and safety of cisterna IDDS for pain relief in refractory pain above the middle thoracic vertebrae level in advanced cancer patients.

Methods: This study protocol allows for eligible cancer patients to receive the cisterna IDDS operation. Pain intensity (Visual Analogue scale, VAS), quality of life (36-Item Short-Form Health Survey, SF-36), and depression (Self-Rating Depression scale, SDS) are assessed along with side effects in the postoperative follow-up visits. Recent literature suggests a potential role for cisterna IDDS morphine delivery for refractory pain states above the middle thoracic level.

Conclusion: The results of this study may provide further evidence that cisterna IDDS of morphine can serve as an effective and safe pain relief strategy for refractory pain above the middle thoracic vertebrae level in advanced cancer patients.
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http://dx.doi.org/10.5812/aapm.115873DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8438709PMC
June 2021

A Comprehensive Update of the Current Understanding of Chronic Fatigue Syndrome.

Anesth Pain Med 2021 Jun 26;11(3):e113629. Epub 2021 Jun 26.

Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA.

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.
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http://dx.doi.org/10.5812/aapm.113629DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8438707PMC
June 2021

COVID-19 Related Acro-Ischemic Neuropathic-like Painful Lesions in Pediatric Patients: A Case Series.

Anesth Pain Med 2021 Apr 18;11(2):e113760. Epub 2021 Apr 18.

Department of MESVA, University of L'Aquila, L'Aquila, Italy.

Background: A variety of skin manifestations have been associated with COVID-19 infection. Acral lesions on hands and feet, closely resembling chilblains, have been reported in association with COVID-19, which are nonspecific. These acro-ischemic painful lesions have been described mainly in asymptomatic and mildly symptomatic pediatric COVID-19 positive patients, without a precise pathogenetic mechanism. COVID-19-induced chilblains may portend an indolent course and a good outcome. In young patients, the IFN-1 response induces microangiopathic changes and produces a chilblain lupus erythematosus-like eruption with vasculitic neuropathic pain features.

Objectives: This paper presented a case series of pediatric patients with COVID-19-related skin lesions and neuropathic-like pain.

Methods: Clinical outcomes were collected from 11 patients diagnosed with painful erythematous skin lesions with neuropathic-like pain and positive IgG for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Results: It is a mildly symptomatic condition not related to severe pain rates, and it is treated with paracetamol due to the transitory nature of the problem, which provides good results.

Conclusions: A particular point of interest is skin lesion manifestation as a further indirect sign of SARS-CoV-2 infection. Due to the initial manifestation of chilblains in pauci-symptomatic pediatric patients, they need to be immediately tested and isolated. Chilblains can be considered a clinical clue to suspect SARS-CoV-2 infection and help in early diagnosis, patient triage, and infection control.
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http://dx.doi.org/10.5812/aapm.113760DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314085PMC
April 2021

Pulmonary Embolism and Cardiac Tamponade in Critical Care Patients with COVID-19; Telemedicine's Role in Developing Countries: Case Reports and Literature Review.

Anesth Pain Med 2021 Apr 7;11(2):e113752. Epub 2021 Apr 7.

Anesthesia Department, Ain Shams University, Cairo, Egypt.

Introduction: In this study, two cases that demonstrate the importance of bedside echocardiography and hands-off telemedicine technology for diagnosis and intervention in patients with coronavirus disease 2019 (COVID-19) are discussed.

Case Presentation: We report two cases of cardiac emergency associated with COVID-19. Case 1 is a 50-year-old female patient with chronic hypertension and chronic renal failure. Case 2 is a 64-year-old female with atrial fibrillation and recent stroke. Both were admitted to an isolation intensive care unit that was designated specifically to patients with COVID-19.

Conclusions: During admission, both patients had sudden deterioration characterized by oxygen desaturation and hypotension necessitating inotropic support. As a result, for both patients, bedside echocardiography was performed by the attending intensivist. Echocardiographic findings showed cardiac tamponade and acute pulmonary embolism, respectively, which were confirmed by a cardiologist through telemedicine technology. Proper emergency management was initiated, and both patients recovered well. Limited bedside transthoracic echocardiography had a front-line impact on the treatment and outcome of the two patients with COVID-19. By implementing telemedicine technology, the lives of two patients were saved, demonstrating the significance of telemedicine in isolation intensive care units in the developing countries during the COVID-19 pandemic.
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http://dx.doi.org/10.5812/aapm.113752DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314078PMC
April 2021

Anesthesia Considerations for Cataract Surgery in Patients with Schizophrenia: A Narrative Review.

Anesth Pain Med 2021 Apr 11;11(2):e113750. Epub 2021 Apr 11.

Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran.

Schizophrenia is ranked among the top 10 global burdens of disease. About 1% of people meet the diagnostic criteria for this disorder over their lifetime. Schizophrenic patients can develop cataract, particularly related to age and medications, requiring surgery and anesthesia. Many concerning factors, including cognitive function, anxiety, behavioral issues, poor cooperation and paroxysmal movements, may lead to general anesthesia as the default method. Antipsychotic agents should be continued during the perioperative period if possible. Topical/regional anesthesia is suitable in most schizophrenic patients undergoing cataract surgery. It reduces potential drug interactions and many postoperative complications; however, appropriate patient selection is paramount to its success. General anesthesia remains the primary technique for patients who are considered unsuitable for the topical/regional technique. Early involvement of a psychiatrist in the perioperative period, especially for patients requiring general anesthesia, is beneficial but often under-utilized. This narrative review summarizes the anesthetic considerations for cataract surgery in patients with schizophrenia.
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http://dx.doi.org/10.5812/aapm.113750DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314087PMC
April 2021

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

Anesth Pain Med 2021 Apr 3;11(2):e113627. Epub 2021 Apr 3.

Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA.

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.
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http://dx.doi.org/10.5812/aapm.113627DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314077PMC
April 2021

Efficacy of Acupuncture in the Treatment of Chronic Abdominal Pain.

Anesth Pain Med 2021 Apr 17;11(2):e113027. Epub 2021 Mar 17.

LSU Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA.

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.
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http://dx.doi.org/10.5812/aapm.113027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314076PMC
April 2021

Dorsal Root Ganglion (DRG) and Chronic Pain.

Anesth Pain Med 2021 Apr 28;11(2):e113020. Epub 2021 Mar 28.

Georgetown University School of Medicine, Washington, DC, USA.

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.
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http://dx.doi.org/10.5812/aapm.113020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314073PMC
April 2021

Comparison of Ultrasound-Guided Supra-scapular Plus Axillary Nerve Block with Interscalene Block for Postoperative Pain Management in Arthroscopic Shoulder Surgery; A Double-Blinded Randomized Open-Label Clinical Trial.

Anesth Pain Med 2021 Apr 2;11(2):e112540. Epub 2021 May 2.

Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran.

Background: Post-arthroscopic shoulder surgery pain is severe enough to interfere with initial recovery and rehabilitation.

Objectives: We aimed to evaluate the analgesic effects of postoperative ultrasound-guided suprascapular plus axillary nerve blocks superficial subepidermal axon bundles (SSAB) with interscalene block (ISB) in arthroscopic shoulder surgery.

Methods: In this single-blind randomized, open-label clinical trial, 80 candidates of elective arthroscopic shoulder surgery were randomly allocated to receive either SSAB or ISB at a postoperative care unit. The severity of resting and changing position pain was measured using visual analogue scale (VAS) score at 4h, 8h, 12h, 16h, and 24h, postoperatively. Timing of first opioid request, 24h dose requirement, patients' satisfaction rate, and side effects were also recorded. All registered data were analyzed using SPSS software version 23 for Windows (SPSS, Chicago, IL).

Results: Resting and changing position pain scores were comparable between SSAB and ISB groups in the most time intervals. At 12h, moving and resting pain was significantly lower in ISB than SSAB group, while moving pain was more severe in ISB group at 24h assessment. Patient satisfaction scores were comparable between the two groups except for 12h assessment. Time to first analgesic requirement and total dose of 24h opioid requirement were not significantly different between the two groups.

Conclusions: Suprascapular plus axillary nerve block could be an effective and safe alternative for interscalene block for pain management after arthroscopic shoulder surgery.
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http://dx.doi.org/10.5812/aapm.112540DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314074PMC
April 2021

Improved Pain Control with Combination Spinal Cord Stimulator Therapy Utilizing Sub-perception and Traditional Paresthesia Based Waveforms: A Pilot Study.

Anesth Pain Med 2021 Feb 22;11(1):e113089. Epub 2021 Feb 22.

Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.

Background: Chronic back and neck pain affects 20% of Americans. Spinal cord stimulation (SCS) is an effective therapy for otherwise refractory chronic pain. Traditional SCS relies on low-frequency stimulus in the 40 - 60 Hz range causing robust paresthesia in regions overlapping with painful dermatomes.

Objectives: This study aims to determine the effect of superimposing sub-perception stimulation in patients who previously had good long-term relief with paresthesia.

Methods: This is a prospective observational trial examining patients who had previously been implanted with paresthesia based SCS for failed back surgery syndrome (FBSS) or complex regional pain syndrome (CRPS). These patients presented for implantable pulse generator (IPG) replacement based on battery depletion with an IPG capable of combined sub-perception and paresthesia based SCS therapy. Patients were assessed immediately following the exchange and four weeks later using a telephone survey. Their pain was assessed on each follow up using a Numerical Rating scale (NRS); the primary outcome was the change in NRS after four weeks from the exchange day. Secondary outcomes included paresthesia changes, which included the subjective quality of sensation generated, the overall subjective coverage of the painful region, subjective variation of coverage with positional changes, and global perception of the percentage improvement in pain.

Results: Based on our clinic registry, 30 patients were eligible for IPG exchange, 16 were consented for follow up and underwent an exchange, and 15 were available for follow up four weeks following. The average NRS decreased from 7.47 with traditional SCS to 4.5 with combination therapy. 80% of patients reported an improvement in the quality of paresthesia over traditional SCS therapy, and in most patients, this translated to significantly improved pain control.

Conclusions: Our findings suggest improved pain relief in patients who had previously had good results with paresthesia based therapy and subsequently underwent IPG exchange to a device capable of delivering combined sub-perception stimulation. The mechanism of action is unclear though there may be an additive and/or synergistic effect of the two waveforms delivered. Larger studies with long-term follow-up are needed to elucidate the durability of pain relief and the precise mechanism by which combined subperception and paresthesia based SCS may improve overall patient outcomes.
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http://dx.doi.org/10.5812/aapm.113089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8241823PMC
February 2021

Evaluation of Adding Dexmedetomidine to Ropivacaine in Pediatric Caudal Epidural Block: A Randomized, Double-blinded Clinical Trial.

Anesth Pain Med 2021 Feb 28;11(1):e112880. Epub 2021 Feb 28.

Department of Anesthesiology, University at Buffalo, Buffalo, USA.

Background: Caudal block is one of the methods of pain management performed following lower abdominal surgery, though having its own limitations.

Objectives: In the present study, the effects and side effects of adding dexmedetomidine to ropivacaine in the caudal epidural block were investigated in children after lower abdominal surgery.

Methods: In this randomized, double-blinded clinical trial, 46 children aged three to six years were divided into two groups to perform a caudal block following lower abdominal surgery under general anesthesia. The injectable solution contained ropivacaine in the R group (1 mL/kg ropivacaine 0.2%), as the control group, and dexmedetomidine (2 µg/kg) and ropivacaine 0.2% (1 mL/kg) in the DR group. The pain score (modified CHEOPS score), duration of analgesia, amount of analgesia consumed (i.v. paracetamol), hemodynamic changes, and possible adverse effects were assessed at one, two, and six hours in both groups.

Results: The pain score at one and two hours showed no significant difference between the two study groups (P > 0.05). In the DR group, however, the pain score at the sixth hour was significantly lower, and the duration of analgesia was longer (P = 0.001). The amount of analgesic consumption was also lower in the DR group (P = 0.001). However, there was no significant difference in systolic blood pressure and heart rate (P < 0.05), in the case of diastolic blood pressure, a significant difference (P < 0.05) was seen (DR group lower than the R group). There was no statistically significant difference between the study groups in the duration of surgery, recovery time, and side effects (P < 0.05).

Conclusions: In the present study, the addition of dexmedetomidine to ropivacaine in the caudal epidural blockade improved postoperative analgesia without significant adverse effects in pediatric patients.
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http://dx.doi.org/10.5812/aapm.112880DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8241816PMC
February 2021

Topical Sevoflurane: A Novel Treatment for Chronic Pain Caused by Venous Stasis Ulcers.

Anesth Pain Med 2021 Feb 24;11(1):e112832. Epub 2021 Feb 24.

LSU Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA.

In the US, an estimated 1 - 2% of chronic venous insufficiency (CVI) patients (of 6 - 7 million nationwide) develop at least one venous stasis ulcer (VSU) during their illness. Of these, approximately 40% develop subsequent ulcers, making VSU prognostically poor. Current management of VSU is costly, with poor prognosis, high recurrence rate, inadequate pain management, and significantly reduced quality of life (QoL). Topical volatile anesthetic agents, such as sevoflurane, offer improved pain relief and symptom control in patients suffering from chronic VSU. The immediate impact of topical sevoflurane in reducing pain associated with ulcer bed debridement has several implications in improving the quality of life in patients with CVI induced ulcers and in the prognosis and healing of the ulcers. This review summarizes a topical formulation of a volatile anesthetic and its implications for the management of VSUs.
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http://dx.doi.org/10.5812/aapm.112832DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8241821PMC
February 2021

Intraoperative Hypotension Increased Risk in the Oncological Patient.

Anesth Pain Med 2021 Feb 24;11(1):e112830. Epub 2021 Feb 24.

LSU Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA.

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.
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http://dx.doi.org/10.5812/aapm.112830DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8241822PMC
February 2021

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

Anesth Pain Med 2021 Feb 2;11(1):e112825. Epub 2021 Feb 2.

Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, USA.

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.
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http://dx.doi.org/10.5812/aapm.112825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8241586PMC
February 2021

Etiology Diagnosis and Management of Radial Nerve Entrapment.

Anesth Pain Med 2021 Feb 14;11(1):e112823. Epub 2021 Feb 14.

Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA.

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.
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http://dx.doi.org/10.5812/aapm.112823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8236840PMC
February 2021

Utilization of Magnesium for the Treatment of Chronic Pain.

Anesth Pain Med 2021 Feb 6;11(1):e112348. Epub 2021 Feb 6.

LSU Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA.

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.
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http://dx.doi.org/10.5812/aapm.112348DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8236839PMC
February 2021

Inferior Hypogastric Block for the Treatment of Chronic Pelvic Pain.

Anesth Pain Med 2021 Feb 16;11(1):e112225. Epub 2021 Feb 16.

LSU Health Shreveport, Department of Anesthesiology, Shreveport, LA.

Context: Pelvic pain is described as pain originating from the visceral or somatic system localizing to the pelvis, the anterior abdominal wall at the level of or below the umbilicus, lumbosacral back in either men or women.

Evidence Acquisition: Narrative review.

Results: Chronic pelvic pain can be a complex disorder that may involve multiple systems such as urogynecological, gastrointestinal, neuromusculoskeletal, and psychosocial systems. The etiopathogenesis for chronic pain remains unknown for many patients. For achieving optimal patient management, a multimodal and individualized assessment of each patient is the best strategy.

Conclusions: There are non-pharmacologic treatments as well as pharmacologic treatments. In addition to these treatment options, inferior hypogastric plexus block is a promising treatment modality.
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http://dx.doi.org/10.5812/aapm.112225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8241820PMC
February 2021

Comparison of Spinal Versus Epidural Analgesia for Vaginal Delivery: A Randomized Double Blinded Clinical Trial.

Anesth Pain Med 2021 Feb 1;11(1):e108335. Epub 2021 Mar 1.

Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran.

Background: Recently, one of the problems in developing countries is pregnant women who insist on cesarean section for fear of painful vaginal delivery. There are various methods to reduce labor pain, including medical and non-medical methods. Neuraxial analgesia is classified as one of the best ways to reduce labor pain. Epidural analgesia is a classic and popular procedure to decrease labor pain. Nevertheless, other methods, such as spinal or combined spinal-epidural analgesia, is more effective compared with the epidural.

Objectives: In this study, we investigated a single intrathecal versus epidural injection in pregnant women during childbirth.

Methods: In our research, after obtaining informed consent, the patients were randomly assigned to two equal groups: epidural and spinal. Each group contained 50 parturient women in advanced labor. In the epidural group, 2.5 mL isobaric bupivacaine 0.5%, sufentanil (0.2 mcg/mL), and 7 mL saline 0.9% were injected by an 18-gauge Tuohy needle at the L4-5 or L5-S1 intervertebral space, and in the spinal group, 0.5 mL isobaric bupivacaine 0.5%, 2.5 mcg sufentanil, and 0.5 mL saline 0.9% were injected by a 25-gauge pencil-point Quincke needle at the L4-5 or L5-S1 intervertebral spaces. For pain intensity, the visual analog scale (VAS) was used at serial intervals, and other variables, such as the onset and duration of analgesia, hypotension, neonatal APGAR score, fetal heart rate (FHR) changes, and other variables were examined.

Results: The mean time to onset analgesic effect was 4.6 min in the spinal group compared with 12.5 minutes in the epidural (P < 0.001). Duration of analgesia was 121 minutes in the spinal group compared with 104 min in the epidural group (P < 0.001). The time to reach the maximum block was 8.4 min in the spinal group vs. 22.2 min in the epidural group (P < 0.001). The duration of the second and third gestation stages was the same in both groups.

Conclusions: Spinal analgesia is short and easy to perform and does not require advanced equipment and technical experience. Spinal analgesia can be a good option for labor analgesia and leads to achieving a lower pain score than epidural analgesia.
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http://dx.doi.org/10.5812/aapm.108335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8241817PMC
February 2021

Carpal Tunnel Release Surgery- A Systematic Review of Open and Endoscopic Approaches.

Anesth Pain Med 2020 Dec 26;10(6):e112291. Epub 2020 Dec 26.

Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA.

Context: Carpal tunnel syndrome (CTS) is the most frequent peripheral compression-induced neuropathy observed in patients worldwide. Surgery is necessary when conservative treatments fail and severe symptoms persist. Traditional Open carpal tunnel release (OCTR) with visualization of carpal tunnel is considered the gold standard for decompression. However, Endoscopic carpal tunnel release (ECTR), a less invasive technique than OCTR is emerging as a standard of care in recent years.

Evidence Acquisition: Criteria for this systematic review were derived from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two review authors searched PubMed, MEDLINE, and the Cochrane Database in May 2018 using the following MeSH terms from 1993-2016: 'carpal tunnel syndrome,' 'median nerve neuropathy,' 'endoscopic carpal tunnel release,' 'endoscopic surgery,' 'open carpal tunnel release,' 'open surgery,' and 'carpal tunnel surgery.' Additional sources, including Google Scholar, were added. Also, based on bibliographies and consultation with experts, appropriate publications were identified. The primary outcome measure was pain relief.

Results: For this analysis, 27 studies met inclusion criteria. Results indicate that ECTR produced superior post-operative pain outcomes during short-term follow-up. Of the studies meeting inclusion criteria for this analysis, 17 studies evaluated pain as a primary or secondary outcome, and 15 studies evaluated pain, pillar tenderness, or incision tenderness at short-term follow-up. Most studies employed a VAS for assessment, and the majority reported superior short-term pain outcomes following ECTR at intervals ranging from one hour up to 12 weeks. Several additional studies reported equivalent pain outcomes at short-term follow-up as early as one week. No study reported inferior short-term pain outcomes following ECTR.

Conclusions: ECTR and OCTR produce satisfactory results in pain relief, symptom resolution, patient satisfaction, time to return to work, and adverse events. There is a growing body of evidence favoring the endoscopic technique for pain relief, functional outcomes, and satisfaction, at least in the early post-operative period, even if this difference disappears over time. Several studies have demonstrated a quicker return to work and activities of daily living with the endoscopic technique.
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http://dx.doi.org/10.5812/aapm.112291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8207842PMC
December 2020

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

Anesth Pain Med 2020 Dec 2;10(6):e112290. Epub 2021 Jan 2.

Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA.

Context: Chronic pain accounts for one of the most common reasons patients seek medical care. The financial burden of chronic pain on health care is seen by direct financial cost and resource utilization. Many risk factors may contribute to chronic pain, but there is no definite risk. Managing chronic pain is a balance between maximally alleviating symptoms by utilizing a therapeutic regimen that is safe for long-term use. Currently, non-opioid analgesics, NSAIDs, and opioids are some of the medical treatment options, but these have numerous adverse effects and may not be the best option for long-term use. However, Lidocaine can achieve both central and peripheral analgesic effects with relatively few side effects, which may be an ideal compound for managing chronic pain.

Evidence Acquisition: This is a Narrative Review.

Results: Infusion of lidocaine (2-(diethylamino)-N-(2,6-dimethylphenyl)acetamide), an amino-amide compound, is emerging as a promising option to fill the therapeutic void for treatment of chronic pain. Numerous studies have outlined dosing protocols for lidocaine infusion for the management of perioperative pain, outlined below. While there are slight variations in these different protocols, they all center around a similar dosing regimen to administer a bolus to reach a rapid steady state, followed by infusion for up to 72 hours to maintain the therapeutic analgesic effects.

Conclusions: Lidocaine may be a promising pharmacologic solution with a low side effect profile that provides central and peripheral analgesia. Even though the multifaceted mechanism is not entirely understood yet, lidocaine may be a promising novel remedy in treating chronic pain in various conditions.
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http://dx.doi.org/10.5812/aapm.112290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8207879PMC
December 2020

Postoperative Pain Management: Role of Dexmedetomidine as an Adjuvant.

Anesth Pain Med 2020 Dec 2;10(6):e112176. Epub 2021 Jan 2.

Pain Medicine HUB, Department of Anesthesiology and Intensive Care, "San Giuliano" Hospital, ASL Napoli2 Nord, Giugliano, Italy.

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http://dx.doi.org/10.5812/aapm.112176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8207883PMC
December 2020

An Update on Treatment Modalities for Ulnar Nerve Entrapment: A Literature Review.

Anesth Pain Med 2020 Dec 24;10(6):e112070. Epub 2020 Dec 24.

Southcoast Health Physicians Group Pain Medicine, Wareham, Massachusetts.

Context: Ulnar nerve entrapment is a relatively common entrapment syndrome second only in prevalence to carpal tunnel syndrome. The potential anatomic locations for entrapment include the brachial plexus, cubital tunnel, and Guyon's canal. Ulnar nerve entrapment is more so prevalent in pregnancy, diabetes, rheumatoid arthritis, and patients with occupations involving periods of prolonged elbow flexion and/or wrist dorsiflexion. Cyclists are particularly at risk of Guyon's canal neuropathy. Patients typically present with sensory deficits of the palmar aspect of the fourth and fifth digits, followed by motor symptoms, including decreased pinch strength and difficulty fastening shirt buttons or opening bottles.

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 artice. Any question regarding the inclusion of an article was discussed by all authors until an agreement was reached.

Results: X-ray and CT play a role in diagnosis when a bony injury is thought to be related to the pathogenesis (i.e., fracture of the hook of the hamate.) MRI plays a role where soft tissue is thought to be related to the pathogenesis (i.e., tumor or swelling.) Electromyography and nerve conduction also play a role in diagnosis. Medical management, in conjunction with physical therapy, shows limited promise. However, minimally invasive techniques, including peripheral percutaneous electrode placement and ultrasound-guided electrode placement, have all been recently studied and show great promise. When these techniques fail, clinicians should resort to decompression, which can be done endoscopically or through an open incision. Endoscopic ulnar decompression shows great promise as a surgical option with minimal incisions.

Conclusions: Clinical diagnosis of ulnar nerve entrapment can often be delayed and requires the suspicion as well as a thorough neurological exam. Early recognition and diagnois are important for early institution of treatment. A wide array of diagnostic imaging can be useful in ruling out bony, soft tissue, or vascular etiologies, respectively. However, clinicians should resort to electrodiagnostic testing when a definitive diagnois is needed. Many new minimally invasive techniques are in the literature and show great promise; however, further large scale trials are needed to validate these techniques. Surgical options remains as a gold standard when adequate symptom relief is not achieved through minimally invasive means.
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http://dx.doi.org/10.5812/aapm.112070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8207847PMC
December 2020

Peripheral Neuromodulation for the Management of Headache.

Anesth Pain Med 2020 Dec 30;10(6):e110515. Epub 2020 Nov 30.

Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA.

Context: Neuromodulation is an expanding field of study for headache treatment to reduce pain by targeting structures within the nervous system that are commonly involved in headache pathophysiology, such as the vagus nerve (VNS), occipital nerves, or sphenopalatine ganglion (SPG) for stimulation. Pharmaceutical medical therapies for abortive and prophylactic treatment, such as triptans, NSAIDs, beta-blockers, TCAs, and antiepileptics, are effective for some individuals, but the role that technology plays in investigating other therapeutic modalities is essential. Peripheral neuromodulation has gained popularity and FDA approval for use in treating certain headaches and migraine headache conditions, particularly in those who are refractory to treatment. Early trials found FDA approved neurostimulatory implant devices, including and , improved patient-oriented outcomes with reductions in headaches per month (frequency) and severity.

Evidence Acquisition: This was a narrative review. The sources for this review are as follows: Searching on PubMed, Google Scholar, Medline, and ScienceDirect from 1990 - 2019 using keywords: Peripheral Neuromodulation, Headache, vagus nerve, occipital nerves, sphenopalatine ganglion.

Results: The first noninvasive neurostimulator device approved for migraine treatment was the Cefaly device, an external trigeminal nerve stimulation device (e-TNS) that transcutaneously excites the supratrochlear and supraorbital branches of the ophthalmic nerve. The second noninvasive neurostimulation device receiving FDA approval was the single-pulse transcranial magnetic stimulator, , positioned at the occiput to treat migraine with aura. GammaCore is a handheld transcutaneous vagal nerve stimulator applied directly to the neck at home by the patient for treatment of cluster headache (CH) and migraine. Several other devices are in development for the treatment of headaches and target headache evolution at different levels and inputs. The Scion device is a caloric vestibular stimulator (CVS) which interfaces with the user through a set of small cones resting in the ear canal on either side and held in place by modified over-ear headphones. The pulsante SPG Microstimulator is a patient-controlled device implanted in the patient's upper jaw via an hour-long oral procedure to target the sphenopalatine ganglion. The occipital nerve stimulator (ONS) is an invasive neuromodulation device for headache treatment that consists of an implanted pulse generator on the chest wall connected to a subcutaneous lead with 4 - 8 electrodes that is tunneled the occiput.

Conclusions: The aim of this review is to provide a comprehensive overview of the efficacy, preliminary outcomes, and limitations of neurostimulatory implants available for use in the US and those pending further development.
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http://dx.doi.org/10.5812/aapm.110515DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8207880PMC
December 2020

Adding Ozone to Dextrose and Somatropin for Intra-articular Knee Prolotherapy: A Randomized Single-Blinded Controlled Trial.

Anesth Pain Med 2020 Oct 7;10(5):e110277. Epub 2020 Nov 7.

Division of Pain Medicine, Department of Anesthesiology, College of Medicine, University of Illinois, Chicago, USA.

Background: Prolotherapy, as an alternative therapy, has emerged as an effective treatment for chronic musculoskeletal injury, including knee osteoarthritis (OA). Several studies have mention ozone as a potential treatment for these diseases, which is based on analgesic, anti-inflammatory, and anti-oxidant.

Objectives: The current study aimed to investigate the effect of adding ozone gas to hypertonic dextrose and somatropin for knee prolotherapy in patients with knee OA. For this purpose, pain, knee stiffness, and physical activity are measured.

Methods: Sixty patients with chronic knee OA were randomly assigned into two groups of DS and DSO. The DS group received intra-articular hypertonic dextrose (10 ml) plus 4 IU somatropin (4 IU), and the DSO group received 10 ml ozone 25 mcg plus intervention in the DS group. This procedure was performed three times (first, third, and fifth weeks). WOMAC score was examined during the third, fifth, and sixteenth weeks.

Results: The mean WOMAC score of the DS group was decreased significantly (P < 0.001) sixteen weeks after providing the intervention (before 64.9 ± 10.6, vs. after 49.2 ± 9.0). A similar decrease (P < 0.001) was observed in the DSO group (before 64.1 ± 11.3, vs. after 41.3 ± 8.0). The decrease of the WOMAC score in the third and sixteenth weeks after providing the intervention was significant in the DSO group compared to the DS group (P < 0.005).

Conclusions: For patients with knee OA, prolotherapy with ozone plus hypertonic dextrose and somatropin was more effective in sedating the pain and improving the stiffness and function of the knee than dextrose and somatropin alone.
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http://dx.doi.org/10.5812/aapm.110277DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8207853PMC
October 2020

Accuracy of the Diagnostic Tests of Sacroiliac Joint Dysfunction.

J Chiropr Med 2020 Mar 12;19(1):28-37. Epub 2020 Sep 12.

Department of Sports and Exercise Medicine, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.

Objective: The purpose of this study was to assess the reliability and validity of motion palpation and pain provocation compared with sacroiliac joint (SIJ) block as the gold-standard assessment method of patients with sacroiliac joint dysfunction (SIJD).

Methods: A cross-sectional study was conducted in the Department of Sports and Exercise Medicine at Rasool Akram Hospital. Forty-eight patients suspected of having SIJD were selected from a total of 150 patients on the basis of a combination of symptoms, physical tests, and magnetic resonance imaging findings. The patients suspected of having SIJD received the SIJ block, to which the accuracy of all the physical tests was compared. Sensitivity, specificity, and positive and negative predictive values were calculated for each test. The receiver operating characteristic curve and the area under the receiver operating characteristic curve were measured.

Results: The Flexion, Abduction and External Rotation (FABER) test had the highest specificity and positive predictive values of the physical tests. Furthermore, the combination of the FABER test and the thigh thrust test improved overall diagnostic ability more so than any of the other test combinations.

Conclusion: A combination of the motion and provocation tests increased specificity and positive predictive values, and the FABER test had the highest of these single values. The palpation tests did not change after the SIJ block, suggesting that their accuracy cannot be determined using this method.
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http://dx.doi.org/10.1016/j.jcm.2019.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646135PMC
March 2020

The Current Clinically Relevant Findings on COVID-19 Pandemic.

Anesth Pain Med 2020 Apr 25;10(2):e103819. Epub 2020 Apr 25.

Paolo Procacci Foundation, Via Tacito 7, 00193, Rome, Italy.

The emergence of a novel coronavirus and coronavirus disease 2019 (COVID-19) represents a challenge to global healthcare. In the past 20 years, this is the third coronavirus that jumped the species barrier and infected humans. It is highly contagious but associated with low pathogenicity. First identified in Wuhan, China, a city of over 11 million, the disease has since spread to every continent except Antarctica. About 15% to 20% of all cases may be called severe, and it is believed many cases are asymptomatic. The average age of a person with COVID has been reported as 49 years. Worse outcomes are associated with geriatric populations and those with underlying diseases such as cardiovascular, respiratory disorders, and/or diabetes. The coronavirus, like other coronaviruses, is highly contagious and has a latency period of about 14 days. Most patients present with fever and a dry cough, but fever may be absent. Differential diagnosis can be challenging since influenza may present with similar symptoms. Chest radiography or computed tomography may be used to find evidence of secondary pneumonia. Nosocomial infection is of concern, and it has been reported that 3.8% of all cases with COVID-19 in that country involve healthcare workers in China. Most patients have mild disease, and supportive care suffices. A variety of repurposed and investigational drugs are being evaluated. There are currently no antiviral therapies or vaccines, even if many therapies are proposed. Hand hygiene, social distancing, and scientifically sound information are the best strategies at the moment to combat this epidemic.
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http://dx.doi.org/10.5812/aapm.103819DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7352949PMC
April 2020

Endoscopic Neuromodulation of Suprascapular Nerve in Chronic Shoulder Pain: A Case Report.

Anesth Pain Med 2020 Apr 21;10(2):e103624. Epub 2020 Apr 21.

Valle Giulia Hospital, Roma, Italy.

Shoulder pain is very frequent, especially in middle-aged male adults. Its treatment may be very problematic, mainly in patients who cannot rest and stop their work. At present, it is treated with analgesics, physiotherapy, infiltration of corticosteroids, and/or radiofrequency neuromodulation of the suprascapular nerve. This may be effective but not easy to do. Its efficacy is limited in time, especially because the approach to the nerve trunk may be problematic for its anatomical nature. Ultrasonography has helped, but it is not always completely helpful, due to the small dimension and the complexity of the anatomical structure. In this case report, we describe a more helpful approach to the nerve trunk using an endoscopic technique. The results are very promising. However, larger studies would be necessary to make clear its usefulness.
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http://dx.doi.org/10.5812/aapm.103624DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7352948PMC
April 2020
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