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Verma A, Francois E, Maiti T, Cassidy L, Tolba R. Dorsal root ganglion stimulator-A targeted therapy for post-herpetic neuralgia: The Middle East Experience. Pain Pract 2024; 24:567-572. [PMID: 38050874 DOI: 10.1111/papr.13325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Post herpetic neuralgia (PHN) is a chronic neuropathic pain syndrome which presents after an episode of herpes zoster caused by the reactivation of varicella zoster virus. Conservative treatment starts with pharmacological measures using Anti-epileptics and Antidepressants. Some patients also respond well to epidural steroid injections too, but the effect is usually short lasting. Dorsal Root Ganglion Stimulator (DRG-S) has recently been suggested as a new treatment modality for PHN due to its selective targeting of the pathophysiologic focus. CASE SERIES We are reporting three cases, who were suffering from neuropathic pain after an episode of herpes zoster. Pain and pain related suffering scores were high, even with multiple antiepileptics and opioid medications. They underwent DRG-S implant and appreciated more than 50% reduction of their pain score, meaningful reduction in the dose of medications along with significant improvement of their general well being measured using Generalized Anxiety Disorder Questionnaire (GAD-7), pain disability index (PDI), and 9 Question Patient Health Questionnaire (PHQ-9). To our knowledge this is the first report on DRG stimulator from the Middle East Region. CONCLUSION DRG-S has potential to be a preferable treatment option in patients with refractory PHN and acts as a specific targeted therapy in the treatment of these patients.
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Affiliation(s)
- Amit Verma
- Anaesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Eric Francois
- Anaesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Tanmoy Maiti
- Neurosurgical Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Leanne Cassidy
- Anaesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Reda Tolba
- Anaesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
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2
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Isagulyan ED, Semenov DE, Tomskiy AA. [Neurosurgical treatment of postherpetic neuralgia]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:154-157. [PMID: 38465825 DOI: 10.17116/jnevro2024124021154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Postherpetic neuralgia is a chronic and debilitating condition that can occur following an episode of herpes zoster (shingles). It is characterized by severe, persistent pain in the area where the shingles rash occurred. While various treatment approaches exist, including medications and non-invasive therapies, some cases of postherpetic neuralgia may require neurosurgical intervention. Neurosurgical treatment options for postherpetic neuralgia aim to alleviate the pain by targeting the affected nerves or neural pathways. One common approach is spinal cord stimulation (SCS). In SCS, electrodes are implanted along the spinal cord, and electrical impulses are delivered to interfere with the transmission of pain signals. This technique can modulate pain perception and significantly reduce the intensity and frequency of postherpetic neuralgia symptoms. Neurosurgical treatment of postherpetic neuralgia is typically considered when conservative measures have failed to provide sufficient relief. However, it is crucial for patients to undergo a comprehensive evaluation and consultation with a neurosurgeon to determine the most appropriate treatment approach based on their specific condition and medical history. The risks, benefits, and potential outcomes of neurosurgical interventions should be carefully discussed between the patient and their healthcare provider to make an informed decision.
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Affiliation(s)
| | - D E Semenov
- Burdenko Neurosurgery Institute, Moscow, Russia
| | - A A Tomskiy
- Burdenko Neurosurgery Institute, Moscow, Russia
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3
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Erken B, Edipoglu IS. Efficacy of High-Voltage Pulsed Radiofrequency of the Dorsal Root Ganglion for Treatment of Chronic Lumbosacral Radicular Pain: A Randomized Clinical Trial. Neuromodulation 2024; 27:135-140. [PMID: 36463027 DOI: 10.1016/j.neurom.2022.10.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 10/13/2022] [Accepted: 10/31/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Pulsed radiofrequency (PRF) is an efficacious treatment for patients with lumbosacral radicular pain, but the optimal radiofrequency parameters are inadequately described. We hypothesized that high-voltage radiofrequency therapy around the dorsal root ganglion can be more effective and enduring than the standard voltage PRF therapy. MATERIALS AND METHODS This was a prospective and randomized study. Patients were divided into two groups. In group 1 (high-voltage group), PRF was applied at 60 V to the patients. Patients in group 2 (low-voltage group) received PRF treatment at 45 V. The patients were evaluated using a numeric rating scale (NRS) and the Oswestry Disability Index (ODI). Evaluation scales were repeated before the intervention and at the first and sixth months after the treatment. RESULTS The study included 41 analyzed patients. There was no statistically significant difference between the groups at the first-month NRS (p > 0.05). Sixth-month NRS scores were lower in the high-voltage group (p = 0.016). The groups showed no statistically significant differences in the one-month ODI scores (p > 0.05). When the NRS values were analyzed with linear regression, a positive correlation was found between the sixth-month NRS values and high-voltage PRF (odds ratio: 0.385; p = 0.013). Comparison of the treatment success in terms of time showed statistically significant results in both groups in the first and sixth months (p < 0.05). CONCLUSIONS The results of our study revealed that both low- and high-voltage PRF are effective. Because of the lower sixth-month NRS values in the high-voltage group and the similar complication rate, it was considered that high-voltage PRF can be a promising application.
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Affiliation(s)
- Burak Erken
- Department of Anesthesiology, Division of Pain Medicine, Çam ve Sakura City Hospital, Istanbul, Turkey
| | - Ipek S Edipoglu
- Department of Anaesthesia, University Hospital Lewisham, London, UK.
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4
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Özge A, Domaç FM, Tekin N, Sünbül EA, Öksüz N, Atalar AÇ, Çallı SY, Fidan YS, Evlice A, Beştepe EE, İzci F, Küsbeci ÖY, Demirel EA, Velioğlu SK, Ungan M. One Patient, Three Providers: A Multidisciplinary Approach to Managing Common Neuropsychiatric Cases. J Clin Med 2023; 12:5754. [PMID: 37685821 PMCID: PMC10488785 DOI: 10.3390/jcm12175754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/27/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Neuropsychiatric cases require a multidisciplinary approach for effective management. This paper presented case-based discussions on migraine, dementia, epilepsy, mood disorders, neuralgia, and psychosis from the perspectives of a family physician, neurologist, and psychiatrist. The goal was to highlight the importance of collaboration between healthcare providers in managing these complex cases. METHODS The paper was based on the proceedings of the Mediterranean Neuropsychiatry Symposium, where experts from family medicine, neurology, and psychiatry came together for comprehensive case-based discussions. The CARE framework (Case Report, Appraisal, Research, and Education) was developed to guide reporting and evaluation of case reports in clinical practice. RESULTS Six cases were presented and discussed, highlighting the importance of a multidisciplinary approach in managing neuropsychiatric cases. The cases included chronic migraine with medication overuse, memory dysfunction with language and behavioral problems, refractory epileptic seizures with subjective sensory symptoms, bipolar affective disorder with normal pressure hydrocephalus, postherpetic neuralgia in a case with bipolar affective disorder, and psychosis with recurrent attacks with the abuse of several substances. CONCLUSION A biopsychosocial multidisciplinary approach is essential for managing neuropsychiatric cases effectively on behalf of the patients and public health of the country. The CARE framework can guide the reporting and evaluation of case reports in clinical practice, ensuring that patients receive comprehensive and effective care. Healthcare providers should collaborate to provide the best possible care for patients with complex and multifaceted needs.
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Affiliation(s)
- Aynur Özge
- Department of Neurology, School of Medicine, Mersin University, Mersin 33110, Türkiye;
| | - Füsun Mayda Domaç
- Department of Neurology, Erenkoy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye;
| | - Nil Tekin
- Department of Family Medicine, Izmir Faculty of Medicine, University of Health Sciences, İzmir 35330, Türkiye;
- Department of Family Medicine, Tepecik Education and Research Hospital, University of Health Sciences, İzmir 35330, Türkiye
| | - Esra Aydın Sünbül
- Department of Psychiatry, Erenköy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye; (E.A.S.); (S.Y.Ç.); (Y.S.F.); (E.E.B.); (F.İ.)
| | - Nevra Öksüz
- Department of Neurology, School of Medicine, Mersin University, Mersin 33110, Türkiye;
| | - Arife Çimen Atalar
- Neurology Department, Kanuni Sultan Süleyman Education and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye;
| | - Sümeyye Yasemin Çallı
- Department of Psychiatry, Erenköy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye; (E.A.S.); (S.Y.Ç.); (Y.S.F.); (E.E.B.); (F.İ.)
| | - Yağmur Sever Fidan
- Department of Psychiatry, Erenköy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye; (E.A.S.); (S.Y.Ç.); (Y.S.F.); (E.E.B.); (F.İ.)
| | - Ahmet Evlice
- Department of Neurology, School of Medicine, Çukurova University, Adana 01330, Türkiye;
| | - Engin Emrem Beştepe
- Department of Psychiatry, Erenköy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye; (E.A.S.); (S.Y.Ç.); (Y.S.F.); (E.E.B.); (F.İ.)
| | - Filiz İzci
- Department of Psychiatry, Erenköy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye; (E.A.S.); (S.Y.Ç.); (Y.S.F.); (E.E.B.); (F.İ.)
| | - Özge Yılmaz Küsbeci
- Neurology Department, Medical Faculty, Izmir University of Economics, Izmir 35330, Türkiye;
| | - Esra Acıman Demirel
- Department of Neurology, Zonguldak Bulent Ecevit University of Medicine, Zonguldak 67100, Türkiye;
| | - Sibel K. Velioğlu
- Clinical Neurophysiology Unit, Neurology Department, Medical Faculty, Karadeniz Technical University, Trabzon 61080, Türkiye;
| | - Mehmet Ungan
- Department of Family Medicine, Medical Faculty, Ankara University, Ankara 06100, Türkiye;
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Batten TJ, Evans JP, Burden EG, Mak WK, White W, Smith CD. Suprascapular nerve blockage for painful shoulder pathology - a systematic review and meta-analysis of treatment techniques. Ann R Coll Surg Engl 2023; 105:589-598. [PMID: 35976156 PMCID: PMC10471442 DOI: 10.1308/rcsann.2022.0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Suprascapular nerve blockade (SSNB) through injection (SSNBi) and/or pulsed radiofrequency (PRF) provide options for the management of painful shoulder pathology. Multiple techniques for delivery of SSNB are described but no consensus on optimal symptom control is available. This systematic review and meta-analysis aims to assess patient-focussed outcomes in SSNB and explore the impact of variation in the technical application of this treatment modality. METHODS MEDLINE, Embase and CINAHL were searched for case series, cohort studies and randomised control trials published from database inception until 28 January 2021. Articles reporting use of SSNBi or PRF for treatment of shoulder pain with a minimum 3 months follow-up were included. Patient-reported outcome measures (PROMs) were extracted and the pooled standardised mean difference (SMD), weighted by study size, was reported. Quality of methodology was assessed using Wylde's nonsummative four-point system. FINDINGS Of 758 references, 18 studies were included, totalling 704 SSNB. Average pain improvement at 3 months was 52.3%, with meta-analysis demonstrating a SMD of 2.37. Whereas SSNBi combined with PRF shows the greatest SMD of 2.75, this did not differ significantly from SSNBi or PRF when used as monotherapy. Location of treatment and the guidance technique used did not influence outcome. CONCLUSION SSNBi and PRF provide safe and effective treatment for shoulder pain, as judged by PROMs. This may be of particular value in aging or comorbid patients and with surgical restrictions during the COVID-19 pandemic. Regardless of technique, patients experience a marked improvement in pain that is maintained beyond 3 months.
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Affiliation(s)
- TJ Batten
- Royal Devon and Exeter Foundation Trust, UK
| | | | - EG Burden
- Royal Devon and Exeter Foundation Trust, UK
| | - WK Mak
- Royal Devon and Exeter Foundation Trust, UK
| | - W White
- Royal Devon and Exeter Foundation Trust, UK
| | - CD Smith
- Royal Devon and Exeter Foundation Trust, UK
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6
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Isagulyan E, Tkachenko V, Semenov D, Asriyants S, Dorokhov E, Makashova E, Aslakhanova K, Tomskiy A. The Effectiveness of Various Types of Electrical Stimulation of the Spinal Cord for Chronic Pain in Patients with Postherpetic Neuralgia: A Literature Review. Pain Res Manag 2023; 2023:6015680. [PMID: 37007861 PMCID: PMC10065853 DOI: 10.1155/2023/6015680] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 01/31/2023] [Accepted: 02/15/2023] [Indexed: 04/04/2023]
Abstract
Introduction Postherpetic neuralgia (PHN) is a severe condition that remains a challenge to treat. Spinal cord stimulation (SCS) is used in cases of insufficient efficacy of conservative treatment. However, in contrast to many other neuropathic pain syndromes, there is a huge problem in reaching long-term stable pain relief in patients with PHN using conventional tonic SCS. The objective of this article was to present a review of the current management strategies of PHN, their efficacy, and safety. Materials and Methods We searched for articles containing the keywords "spinal cord stimulation AND postherpetic neuralgia," "high-frequency stimulation AND postherpetic neuralgia," "burst stimulation AND postherpetic neuralgia" and "dorsal root ganglion stimulation AND postherpetic neuralgia" in Pubmed, Web of Science, and Scopus databases. The search was limited to human studies published in the English language. There were no publication period limitations. Bibliographies and references of selected publications on neurostimulation for PHN were further manually screened. The full text of each article was studied once the abstract was analyzed by the searching reviewer and found appropriate. The initial search yielded 115 articles. Initial screening based on abstract and title allowed us to exclude 29 articles (letters, editorials, and conference abstracts). The full-text analysis allowed us to exclude another 74 articles (fundamental research articles, research utilizing animal subjects, and systemic and nonsystemic reviews) and results of PHN treatment presented with other conditions, leaving 12 articles for the final bibliography. Results 12 articles reporting on the treatment of 134 patients with PHN were analyzed, with a disproportionally large amount of traditional SCS treatment than that to alternative SCS: DRGS (13 patients), burst SCS (1 patient), and high-frequency SCS (2 patients). Long-term pain relief was achieved in 91 patients (67.9%). The mean VAS score improvement was 61.4% with a mean follow-up time of 12.85 months. Although the number of patients in alternative SCS studies was very limited, almost all of them showed good responses to therapy with more than 50% VAS improvement and reduction of analgesic dosage. The article contains a review analysis of 12 articles concerning the current methods of treatment for postherpetic neuralgia including conservative treatment, spinal cord stimulation, and novel neuromodulation strategies. Available information on the pathophysiology of PHN and the effect or stimulation on its course, together with a number of technical nuances concerning various types of neurostimulation are also elucidated in this article. A number of alternative invasive treatments of PHN are also discussed. Conclusions Spinal cord stimulation is an established treatment option for patients with pharmacologically resistant PHN. High-frequency stimulation, burst stimulation, and dorsal root ganglion stimulation are promising options in the management of PHN due to the absence of paresthesias which can be painful for patients with PHN. But more research is still required to recommend the widespread use of these new methods.
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Affiliation(s)
- Emil Isagulyan
- Burdenko Institute of Neurosurgery, National Medical Research Center for Neurosurgery Named after Academician N. N. Burdenko, 4th Tverskaya-Yamskaya Street 16, Moscow 125047, Russia
| | - Vasily Tkachenko
- Central State Medical Academy of Russian Federation, Marshalla Timoshenko Street, 19, Moscow 121359, Russia
| | - Denis Semenov
- Burdenko Institute of Neurosurgery, National Medical Research Center for Neurosurgery Named after Academician N. N. Burdenko, 4th Tverskaya-Yamskaya Street 16, Moscow 125047, Russia
| | - Svetlana Asriyants
- Burdenko Institute of Neurosurgery, National Medical Research Center for Neurosurgery Named after Academician N. N. Burdenko, 4th Tverskaya-Yamskaya Street 16, Moscow 125047, Russia
| | - Evgeny Dorokhov
- Burdenko Institute of Neurosurgery, National Medical Research Center for Neurosurgery Named after Academician N. N. Burdenko, 4th Tverskaya-Yamskaya Street 16, Moscow 125047, Russia
| | - Elizaveta Makashova
- Burdenko Institute of Neurosurgery, National Medical Research Center for Neurosurgery Named after Academician N. N. Burdenko, 4th Tverskaya-Yamskaya Street 16, Moscow 125047, Russia
| | - Karina Aslakhanova
- Burdenko Institute of Neurosurgery, National Medical Research Center for Neurosurgery Named after Academician N. N. Burdenko, 4th Tverskaya-Yamskaya Street 16, Moscow 125047, Russia
| | - Alexei Tomskiy
- Burdenko Institute of Neurosurgery, National Medical Research Center for Neurosurgery Named after Academician N. N. Burdenko, 4th Tverskaya-Yamskaya Street 16, Moscow 125047, Russia
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7
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Sag AA, Bittman R, Prologo F, Friedberg EB, Nezami N, Ansari S, Prologo JD. Percutaneous Image-guided Cryoneurolysis: Applications and Techniques. Radiographics 2022; 42:1776-1794. [DOI: 10.1148/rg.220082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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8
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Pastrak M, Visnjevac O, Visnjevac T, Ma F, Abd-Elsayed A. Safety of Conventional and Pulsed Radiofrequency Lesions of the Dorsal Root Entry Zone Complex (DREZC) for Interventional Pain Management: A Systematic Review. Pain Ther 2022; 11:411-445. [PMID: 35434768 PMCID: PMC9098700 DOI: 10.1007/s40122-022-00378-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/15/2022] [Indexed: 11/29/2022] Open
Abstract
Study Design Systematic literature review. Objective The goal of this systematic review is to assess the clinical safety and potential complications of conventional and pulsed radiofrequency ablations targeting dorsal root entry zone complex (DREZC) components in the treatment of chronic pain. Background There is a growing popularity for the use of radiofrequency ablation (RFA) techniques targeting DREZC components by pain management physicians for an increasing variety of indications. To date, we lack a systematic review to describe the safety and the type of complications associated with these procedures. Methods This was a systematic literature review. This systematic search was limited to peer-reviewed literature using “radiofrequency ablation” as a search keyword using PubMed’s database for manuscripts published between inception and December 2020. Abstracts that involved the application of radiofrequency currents, of any modality, to DREZC components for the treatment of pain were included for full-text review. Search was limited to original data describing clinical outcomes following RFA performed for pain indications only, involving the DREZC components outlined above, in human subjects, and written in English. The primary outcomes were complications associated with conventional RFA and pulsed radiofrequency ablation (PRF). Complications were categorized as type 1 (persistent neurological deficits or other serious adverse events, defined as any event that resulted in permanent of prolonged injury; type 2 (transient neuritis or neurological deficits, or other non-neurological non-minor adverse event); type 3 (minor adverse events (e.g., headache, soreness, bruising, etc.). Results Of the 62 selected manuscripts totaling 3157 patients, there were zero serious adverse events or persistent neurological deficits reported. A total of 36 (1.14%) transient neurological deficits, cases of transient neuritis, or non-minor adverse events like uncomplicated pneumothorax were reported. A total of 113 (3.58%) minor adverse events were reported (bruising, transient site soreness, headache). Conclusions This systematic review indicates that the use of RFA lesion of the DREZC for interventional pain management is very safe. There were no serious adverse effects with a sizable sample of randomized controlled trial (RCT), prospective observational, and retrospective studies.
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Affiliation(s)
- Mila Pastrak
- School of Medicine, University College Cork, Cork, Ireland
| | - Ognjen Visnjevac
- Faculty of Health Sciences, McMaster University, Hamilton, ON Canada
- Bloor Pain Specialists, Toronto, ON Canada
- Cleveland Clinic Canada, Toronto, ON Canada
| | - Tanja Visnjevac
- Faculty of Health Sciences, McMaster University, Hamilton, ON Canada
| | - Frederick Ma
- Faculty of Health Sciences, McMaster University, Hamilton, ON Canada
| | - Alaa Abd-Elsayed
- Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
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Hidaka K, Maruta T, Koshida T, Kurogi M, Kage Y, Kouroki S, Shirasaka T, Takeya R, Tsuneyoshi I. Extracellular signal-regulated kinase phosphorylation enhancement and Na V1.7 sodium channel upregulation in rat dorsal root ganglia neurons contribute to resiniferatoxin-induced neuropathic pain: The efficacy and mechanism of pulsed radiofrequency therapy. Mol Pain 2022; 18:17448069221089784. [PMID: 35418262 PMCID: PMC9019323 DOI: 10.1177/17448069221089784] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Pulsed radiofrequency (PRF) therapy is one of the most common treatment options for neuropathic pain, albeit the underlying mechanism has not been hitherto elucidated. In this study, we investigated the efficacy and mechanism of PRF therapy on resiniferatoxin (RTX)-induced mechanical allodynia, which has been used as a model of postherpetic neuralgia (PHN). Adult male rats were intraperitoneally injected with a vehicle or RTX. Furthermore, PRF current was applied on a unilateral sciatic nerve in all RTX-treated rats. On both ipsilateral and contralateral sides, the paw mechanical withdrawal thresholds were examined and L4-6 dorsal root ganglia (DRG) were harvested. In the DRG of rats with RTX-induced mechanical allodynia, NaV1.7, a voltage-gated Na+ channel, was upregulated following the enhancement of extracellular signal-regulated kinase phosphorylation. Early PRF therapy, which was applied 1 week after RTX exposure, suppressed this NaV1.7 upregulation and showed an anti-allodynic effect; however, late PRF therapy, which was applied after 5 weeks of RTX exposure, failed to inhibit allodynia. Interestingly, late PRF therapy became effective after daily tramadol administration for 7 days, starting from 2 weeks after RTX exposure. Both early PRF therapy and late PRF therapy combined with early tramadol treatment suppressed NaV1.7 upregulation in the DRG of rats with RTX-induced mechanical allodynia. Therefore, NaV1.7 upregulation in DRG is related to the development of RTX-induced neuropathic pain; moreover, PRF therapy may be effective in the clinical management of patients with PHN via NaV1.7 upregulation inhibition.
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Affiliation(s)
- Kotaro Hidaka
- Faculty of Medicine, Department of Anesthesiology, 12952University of Miyazaki, Miyazaki, Japan
| | - Toyoaki Maruta
- Faculty of Medicine, Department of Anesthesiology, 12952University of Miyazaki, Miyazaki, Japan
| | - Tomohiro Koshida
- Faculty of Medicine, Department of Anesthesiology, 12952University of Miyazaki, Miyazaki, Japan
| | - Mio Kurogi
- Faculty of Medicine, Department of Anesthesiology, 12952University of Miyazaki, Miyazaki, Japan
| | - Yohko Kage
- Faculty of Medicine, Department of Pharmacology, 12952University of Miyazaki, Miyazaki, Japan
| | - Satoshi Kouroki
- Faculty of Medicine, Department of Anesthesiology, 12952University of Miyazaki, Miyazaki, Japan
| | - Tetsuro Shirasaka
- Faculty of Medicine, Department of Anesthesiology, 12952University of Miyazaki, Miyazaki, Japan
| | - Ryu Takeya
- Faculty of Medicine, Department of Pharmacology, 12952University of Miyazaki, Miyazaki, Japan
| | - Isao Tsuneyoshi
- Faculty of Medicine, Department of Anesthesiology, 12952University of Miyazaki, Miyazaki, Japan
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10
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Saxena AK, Singh A, Chilkoti GT, Sharma T, Banerjee BD, Das S, Singhal A. Modulation of signal transduction gene expression following pulsed radiofrequency in dorsal root ganglia and pregabalin therapy. Pain Manag 2021; 12:347-356. [PMID: 34786952 DOI: 10.2217/pmt-2021-0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: A randomized controlled study was conducted to assess modulation of signal transduction genes (PKA, PKC and ERK) following integrated multimodal approach encompassing pulsed radiofrequency treatment (PRF) of dorsal root ganglion and pregabalin in thoracic postherpetic neuralgia (PHN). Clinical variables such as pain intensity and quality of life were also explored. Material & methods: A total of 40 Patients of PHN were recruited. 20 patients randomly assigned to each of the two groups, group PP administered PRF with pregabalin and group SP administered pregabalin alone. Results: Significant downregulation of PKA and ERK observed in group PP at end of 10th week (p < 0.05). A significantly positive correlation demonstrated between Visual analog scale scores and signal transduction genes expression in PHN patients. Conclusion: Downregulation of all three signal transduction genes was observed following the integrated multimodal approach; however, significant downregulation was observed with PKA and ERK only. A positive correlation observed between signal transduction gene expression and visual analog scale scores signify their role in the pathogenesis of PHN.
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Affiliation(s)
- Ashok Kumar Saxena
- Department of Anaesthesiology, Critical care & Pain Medicine, University College of Medical Sciences & Guru Tegh Bahadaur Hospital, Delhi, 110095, India
| | - Anshul Singh
- Department of Anaesthesiology, Critical care & Pain Medicine, University College of Medical Sciences & Guru Tegh Bahadaur Hospital, Delhi, 110095, India
| | - Geetanjali T Chilkoti
- Department of Anaesthesiology, Critical care & Pain Medicine, University College of Medical Sciences & Guru Tegh Bahadaur Hospital, Delhi, 110095, India
| | - Tusha Sharma
- Department of Environmental Biochemistry & Molecular Biology, University College of Medical Sciences & Guru Tegh Bahadur Hospital, Dilshad garden, Delhi, 110095, India
| | - Basu Dev Banerjee
- Department of Environmental Biochemistry & Molecular Biology, University College of Medical Sciences & Guru Tegh Bahadur Hospital, Dilshad garden, Delhi, 110095, India
| | - Swati Das
- Department of Anaesthesiology, Critical care & Pain Medicine, University College of Medical Sciences & Guru Tegh Bahadaur Hospital, Delhi, 110095, India
| | - Archana Singhal
- Department of Dermatology, University College of Medical Sciences & G.T.B. Hospital, Dilshad Garden, Delhi, 110095, India
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11
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Vuka I, Marciuš T, Došenović S, Ferhatović Hamzić L, Vučić K, Sapunar D, Puljak L. Efficacy and Safety of Pulsed Radiofrequency as a Method of Dorsal Root Ganglia Stimulation in Patients with Neuropathic Pain: A Systematic Review. PAIN MEDICINE 2021; 21:3320-3343. [PMID: 32488240 DOI: 10.1093/pm/pnaa141] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Pulsed radiofrequency (PRF) is a nonablative pain treatment that uses radiofrequency current in short high-voltage bursts, resulting in interruption of nociceptive afferent pathways. We conducted a systematic review with the aim to create a synthesis of evidence about the efficacy and safety of PRF applied to the dorsal root ganglion (DRG) for the treatment of neuropathic pain. METHODS We searched MEDLINE, CINAHL, Embase, and PsycINFO through January 8, 2019, as well as ClinicalTrials.gov and the clinical trial register of the World Health Organization. All study designs were eligible. We assessed risk of bias using the Cochrane tool for randomized controlled trials and the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I). We assessed level of evidence using the Oxford tool and quality of evidence with GRADE. RESULTS We included 28 studies with participants suffering from lumbosacral, cervical, or thoracic radicular pain, post-herpetic neuralgia, neuropathicbone pain in cancer patients, or carpal tunnel syndrome. Only five studies were randomized controlled trials (RCTs), while others were of nonrandomized designs, predominantly before and after comparisons. A total of 991 participants were included, with a median number (range) of 31 (1-101) participants. Only 204 participants were included in the RCTs, with a median number (range) of 38 (23-62) participants. The overall quality of evidence was low, as the majority of the included studies were rated as evidence level 4 or 5. The quality of evidence was very low. CONCLUSIONS Evidence about the efficacy and safety of PRF of the DRG for the treatment of neuropathic pain is based mainly on results from very small studies with low evidence quality. Current research results about the benefits of PRF of the DRG for the treatment of neuropathic pain should be considered preliminary and confirmed in high-quality RCTs with sufficient numbers of participants.
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Affiliation(s)
- Ivana Vuka
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | - Tihana Marciuš
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | - Svjetlana Došenović
- Department of Anaesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Lejla Ferhatović Hamzić
- Department of Proteomics, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Katarina Vučić
- Department for Safety and Efficacy Assessment of Medicinal Products, Agency for Medicinal Products and Medical Devices, Zagreb, Croatia
| | - Damir Sapunar
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia.,Centre for Evidence-Based Medicine and Health Care, Catholic University of Croatia, Zagreb, Croatia
| | - Livia Puljak
- Centre for Evidence-Based Medicine and Health Care, Catholic University of Croatia, Zagreb, Croatia
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Effect of gold nanoparticle treated dorsal root ganglion cells on peripheral neurite differentiation. Toxicol In Vitro 2021; 74:105175. [PMID: 33865945 DOI: 10.1016/j.tiv.2021.105175] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/10/2021] [Accepted: 04/12/2021] [Indexed: 12/19/2022]
Abstract
The use of gold nanoparticles (AuNps) in applications connected to the peripheral nervous system (PNS) holds much promise in terms of therapeutic and diagnostic strategies. Despite their extensive use, a clear understanding of their effects on neurons and glia in the PNS is lacking. In this study, we set out to examine the effects of AuNps on dorsal root ganglion (DRG) cells, and how such AuNp-exposed cells could in-turn affect neurite differentiation. DRG cultures were exposed to mono-dispersed spherical-shaped AuNps of diameter 24.3 ± 2.3, 109.2 ± 14.7 or 175 ± 19.2 nm at varying concentrations. Cellular uptake and viability were quantified using flow-cytometry. Neurite differentiation was quantified using neurite tracing analysis in PC-12 and DRG neurons exposed to conditioned media derived from AuNp-treated DRG cells. Both neurons and glia were found to internalize AuNps. DRG cell viability was significantly reduced upon treatment with higher concentration of 175 nm sized AuNps, while 24 nm and 109 nm sized AuNps had no effect. Further, conditioned media from AuNp-treated DRG cells produced comparable neurite outgrowth and neurite branching measurement as controls in PC-12 and DRG neurons. DRG cells were quite resilient to AuNp exposure in mild-moderate concentration. AuNp-exposed DRG cells, irrespective of size and concentration range tested, did not affect neuronal differentiation.
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13
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Han Z, Hong T, Ding Y, Wang S, Yao P. CT-Guided Pulsed Radiofrequency at Different Voltages in the Treatment of Postherpetic Neuralgia. Front Neurosci 2020; 14:579486. [PMID: 33390880 PMCID: PMC7775564 DOI: 10.3389/fnins.2020.579486] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/18/2020] [Indexed: 12/14/2022] Open
Abstract
Background Postherpetic neuralgia (PHN) is a form of long-lasting neuropathic pain that can severely affect patients’ quality of life. Pulsed radiofrequency (PRF) has been proven to be effective in treating PHN, but the optimal radiofrequency parameters are still not well defined. This retrospective study aimed to compare the efficacy and safety of CT-guided PRF at three different voltages for the treatment of PHN patients. Methods This study included 109 patients with PHN involving the thoracic dermatome who were treated in the Department of Pain Management of Shengjing Hospital, China Medical University, from January 2017 to May 2019. They were divided into three groups based on the PRF voltage used: group A (45 V), group B (55 V), and group C (65 V). The PRF therapy (voltage 45, 55, and 65 V) was performed in all patients by targeting the thoracic dorsal root ganglion. After surgery, patients were followed at 3 days, 1 month, 3 months, 6 months, and 12 months. Observation at each follow-up included basic patient characteristics, visual analog scale (VAS), 36-Item Short Form Health Survey (SF-36) scores, patient satisfaction, complications, and side effects. Results Visual analog scale scores decreased and SF-36 scores increased for all patients in the three groups at each post-operative time point (1, 3, 6, and 12 months; all P < 0.01). Pain relief, improvement in quality of life, and overall satisfaction were more significant for patients in group C than for those in groups A and B at the 3-, 6-, and 12-month follow-ups (all P < 0.05). Patients in group B had lower VAS scores and higher overall satisfaction levels than those in group A (both P < 0.01). A small number of patients from each group (n ≤ 3) experienced mild intraoperative and post-operative complications, which bore no relationship with group assignment (all P > 0.05). At post-operative day 3, patients in group C had skin numbness affecting a larger area than patients in the other two groups (both P < 0.05), but the differences were no longer statistically significant at day 30 after the operation. All patients experienced a drop in numbness area of more than 30% after surgery. Conclusion Compared with PFR at 45 and 55 V, PFR at 65 V had superior efficacy in treating PNH, with a favorable safety profile.
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Affiliation(s)
- Zhenkai Han
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang, China
| | - Tao Hong
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yuanyuan Ding
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shimeng Wang
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang, China
| | - Peng Yao
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang, China
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Aggarwal A, Suresh V, Gupta B, Sonthalia S. Post-herpetic Neuralgia: A Systematic Review of Current Interventional Pain Management Strategies. J Cutan Aesthet Surg 2020; 13:265-274. [PMID: 33911406 PMCID: PMC8061658 DOI: 10.4103/jcas.jcas_45_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Post-herpetic neuralgia (PHN) is usually a constant or intermittent burning, stabbing, or sharp shooting pain with hyperalgesia or allodynia, persisting beyond the healing of herpetic skin lesions. This review was carried out in concordance to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We used PICOS (Population, Intervention, Control, and Outcome Study) design for inclusion of potential studies into this review. Online literature available in PubMed, Cochrane, and Embase was searched for studies from January 1995 till March 2020, which evaluated interventional treatments in PHN by an independent reviewer, using the relevant medical subject heading (MeSH) terms. We analyzed the following outcome parameters with regard to each intervention—pain status at predefined fixed intervals after the intervention, quality of sleep using any of the reported questionnaires, analgesic consumption, functional evaluation, and quality of life assessment after the intervention. Conclusion: Interventional pain management options provide effective and long-lasting pain relief to patients not responding to medical management. The choice of intervention will depend on the region involved, cost, and invasiveness. Simple procedures such as intercostal nerve blocks/neurolysis, stellate ganglion blocks, paravertebral neurolysis, epidural steroid injections, and dorsal root ganglion–radiofrequency ablation are effective interventions, and if they fail, spinal cord stimulators could be effective in the hands of experienced pain physicians.
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Affiliation(s)
| | - Varun Suresh
- Department of Anaesthesiology, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Bhavna Gupta
- Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Sidharth Sonthalia
- Director & Senior Consultant Dermatologist, SKINNOCENCE: The Skin Clinic, Gurgaon, India
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15
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Huang RY, Poree L, Ho KY, Tsai SY, Liu YC, Tan PH, Wen YR. Behavioral Survey of Effects of Pulsed Radiofrequency on Neuropathic and Nociceptive Pain in Rats: Treatment Profile and Device Implantation. Neuromodulation 2020; 24:1458-1466. [PMID: 32558126 DOI: 10.1111/ner.13169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Pulsed radiofrequency (PRF) stimulation is widely used for intractable pain; however, there is no consensus on treatment protocols and appropriate types of pain. We compared effectiveness of bipolar and unipolar PRF on neuropathic or inflammatory pains, and of targets at the dorsal root ganglion (DRG) and sciatic nerve (SN). We also examined efficacy of repetitive PRF stimulations. This preclinical study could serve as an extensive survey before human trials. MATERIALS Spare nerve injury (SNI)-induced neuropathic pain and complete Freund's adjuvant (CFA) injection-induced inflammatory pain were used. Behavioral responses were measured using von Frey test, acetone test, and Hargreave's test at preinjury and postinjury time points. In both models, we evaluated results of DRG stimulation with unipolar PRF (45 V) versus bipolar PRF (5 V), stimulation at DRG vs. SN, and repetitive stimulations. RESULTS Both unipolar and bipolar PRFs reduced SNI- or CFA-induced pain for a similar duration. In the SNI model, PRF-DRG had a stronger effect on tactile pain than PRF-SN but lower effect on cold allodynia, whereas in the CFA model PRF-DRG and PRF-SN showed similar effects. Repetitive PRF stimulation, by open technique or implantation method, produced analogous effect by each stimulus, and no evident analgesic tolerance or neurological deficit was shown. CONCLUSIONS PRF temporarily attenuates neuropathic and inflammatory pain. Bipolar PRF generates significant analgesia with a much lower electrical power than unipolar PRF. Meanwhile, the minor variant effects between PRF-DRG and PRF-SN may indicate distinct mechanisms. The sustained-analgesia by repetitive treatments suggests implantation technique could be a promising choice.
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Affiliation(s)
- Ren-Yu Huang
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Lawrence Poree
- Department of Anesthesia, University of California at San Francisco, San Francisco, CA, USA
| | - Kok-Yuen Ho
- Raffles Pain Management Centre, Raffles Hospital, Singapore, Singapore
| | - Shih-Ying Tsai
- Department of Anesthesiology, School of Medicine, China Medical University, Taichung, Taiwan
| | - Yu-Chen Liu
- Department of Anesthesiology, China Medical University Hospital, Taichung, Taiwan
| | - Ping-Heng Tan
- Department of Biomedical Engineering, E-DA Hospital, I-Shou University, Kaohsiung, Taiwan.,Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Yeong-Ray Wen
- Department of Anesthesiology, School of Medicine, China Medical University, Taichung, Taiwan.,Department of Anesthesiology, China Medical University Hospital, Taichung, Taiwan.,Department of Anesthesiology, Pain Management and Research Center, China Medical University Hospital, Taichung, Taiwan.,Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University, Taichung, Taiwan
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16
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Texakalidis P, Tora M, Boulis N. Neurosurgeons’ Armamentarium for the Management of Refractory Postherpetic Neuralgia: A Systematic Literature Review. Stereotact Funct Neurosurg 2019; 97:55-65. [DOI: 10.1159/000499476] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/04/2019] [Indexed: 11/19/2022]
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17
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Ding Y, Yao P, Li H, Zhao R, Zhao G. Evaluation of combined radiofrequency and chemical blockade of multi-segmental lumbar sympathetic ganglia in painful diabetic peripheral neuropathy. J Pain Res 2018; 11:1375-1382. [PMID: 30100752 PMCID: PMC6067610 DOI: 10.2147/jpr.s175514] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Painful diabetic peripheral neuropathy (PDPN) is one of the most common complications of diabetes. PDPN seriously affects the quality of life and is difficult to treat; therefore, there is an urgent need for new cost-effective treatment methods for PDPN. Objective To investigate the efficacy and safety of radiofrequency thermocoagulation (RF) combined with anhydrous ethanol (AE) chemical blockade of lumbar sympathetic ganglia (LSG) in patients with PDPN using computed tomography (CT). Study design Retrospective comparative study. Setting Shengjing Hospital of China Medical University. Methods Ninety patients diagnosed with PDPN were enrolled in this study. The patients were randomly divided into AE group (A, n=30), RF group (B, n=30), and RF+ AE group (C, n=30). The follow-up included preoperative basic conditions, visual analog scale (VAS), the total remission rate (TRR), skin temperature (ST) and the improvement of numbness and hyperalgesia in the lower extremities, complications, and degree of satisfaction (DOS) before and after surgery. Results Postoperative VASs were significantly decreased compared to preoperative VASs in all groups (P<0.05). The VAS in group A began to increase 3 months (3M) after surgery; VAS scores at 3M, 6 months (6M) and 1 year (1Y) were significantly different compared to group B and C (P<0.05); VAS in group B began to increase after 6M; VAS scores at 6M and 1Y were significantly different compared to group C (P<0.05); Moreover, group C maintained relatively long duration of pain relief. TRR in group A, group B and group C at 1Y after operation was 66.7%, 73.3% and 93.3%, respectively; TRR in group C was statistically different compared to groups A and B (P<0.05). Higher ST in the lower extremities was observed after surgery in all groups compared to peroration (P<0.05); nonetheless, the difference was not statistically significant. The numbness and hyperalgesia improved in all three groups after surgery compared to preoperational time, the numbness in group C was significantly higher compared to groups A and B. In addition, no severe complications were observed. At 6M and 1Y after surgery, the degree of satisfaction in patients from group C was significantly higher compared to groups A and B. Conclusion Radiofrequency thermocoagulation combined with AE chemical blockade of the LSG was safe and effective. Nevertheless, the details underlying analgesic mechanisms still need to be investigated.
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Affiliation(s)
- Yuanyuan Ding
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang, China
| | - Peng Yao
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang, China
| | - Hongxi Li
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang, China
| | - Rongjie Zhao
- Class 5 of 2020 Session, Shenyang No. 20 High School, Shenyang, China
| | - Guangyi Zhao
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China,
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Comparison of efficacy of continuous epidural block and pulsed radiofrequency to the dorsal root ganglion for management of pain persisting beyond the acute phase of herpes zoster. PLoS One 2017; 12:e0183559. [PMID: 28827823 PMCID: PMC5565119 DOI: 10.1371/journal.pone.0183559] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 08/07/2017] [Indexed: 01/20/2023] Open
Abstract
Background There is little evidence regarding the effectiveness of intervention methods in the treatment of zoster-related pain (ZAP) after the acute phase of zoster. Generally, if ZAP remains after more than 180 days from its onset, the likelihood of pain reduction is very low; this condition is considered as a “well established” post-herpetic neuralgia (PHN). Although the clinical efficacy of intrathecal steroid injection and spinal cord stimulation (SCS) for ZAP management has been reported, these interventions are not widely used due to inherent disadvantages. Continuous epidural block is widely used in clinical practice, and the effectiveness of pulsed radiofrequency (PRF) to the dorsal root ganglion (DRG) in the treatment of ZAP already has been reported. Objectives The purpose of this study was to compare the clinical efficacy of continuous epidural block and DRG PRF beyond acute phase of zoster, bur before PHN was well established (from 30 days to180 days after zoster onset). Study design Retrospective comparative study. Methods A total of 42 medical records were analyzed. Patients were divided into two groups according to the type of procedure utilized: continuous epidural block (continuous epidural group) and DRG PRF (PRF group). The clinical efficacy of the procedure was evaluated using a numeric rating scale (NRS) and the medication dose before and 1 to 6 months after the procedure. Results There was a significant decrease in the NRS value with time in both groups. However, this decrease was more significant in the PRF group than in the continuous epidural group. The medication doses decreased significantly in the PRF group over time, but not in the continuous epidural group. The rate of clinically meaningful PHN (NRS≥3) was also lower in the PRF group than in the continuous epidural group. Conclusions This study revealed that DRG PRF was more effective than a continuous epidural block in treating ZAP after the acute phase of zoster. A neuromodulation method such as DRG PRF may be a useful option for reducing the progression of neuropathic changes caused by the persistent transmission of a pain signal after the acute phase of zoster.
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Park SK, Choi YS. Treatment Option for Refractory Postherpetic Neuralgia – Transversus Abdominis Plane (TAP) Block: Two Case Reports. Anesth Pain Med 2016; 7:e41378. [PMID: 28920039 PMCID: PMC5554424 DOI: 10.5812/aapm.41378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/18/2016] [Accepted: 11/20/2016] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sun Kyung Park
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, School of Medicine, Jeju National University, Jeju, South Korea
| | - Yun Suk Choi
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, School of Medicine, Jeju National University, Jeju, South Korea
- Corresponding author: Yun Suk Choi, Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, School of Medicine, Jeju National University, Jeju, South Korea. Tel: +82-647172026, Fax: +82-647172042, E-mail:
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20
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Xie GL, Guo DP, Li ZG, Liu C, Zhang W. Application of radiofrequency thermocoagulation combined with adriamycin injection in dorsal root ganglia for controlling refractory pain induced by rib metastasis of lung cancer (a STROBE-compliant article). Medicine (Baltimore) 2016; 95:e4785. [PMID: 27749531 PMCID: PMC5059033 DOI: 10.1097/md.0000000000004785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
This study aimed to observe the therapeutic effects and adverse reactions of radiofrequency thermocoagulation combined with adriamycin injection in dorsal root ganglia on lung cancer rib metastasis-related refractory pain which has no response to conventional therapy.This study contained 27 patients with lung cancer rib metastasis-related moderate or severe pain which had no response to conventional therapy. Under computed tomography (CT)-guidance, radiofrequency puncture need reached the corresponding intervertebral foramens to ensure needle point near dorsal root ganglia (DRG) by sensory and motor stimulation tests, and then radiofrequency thermocoagulation was performed on each corresponding DRG followed by injection of 0.5 to 1 mL of adriamycin (0.5%). The conditions of pain and complications were observed before management and 3 days, 1 month, and 3 months after management, respectively.Numerical rating scale (NRS) scores and dosage of morphine were all significantly decreased after management as compared with those before management (all P < 0.01). Although the number of patients with chest wall numbness was significantly increased after management as compared with that before management (all P < 0.01), the degree of chest wall numbness was tolerable. There were no statistical differences between before and after management in nausea and vomiting, and constipation.CT-guided radiofrequency thermocoagulation combined with adriamycin injection in DRG can effectively control lung cancer rib metastasis-related pain which has no response to conventional therapy. This combinatory treatment regimen is featured by better therapeutic effects and a few complications, so it is worthy of being recommended in clinical application.
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Affiliation(s)
- Guang-lun Xie
- Doctor on-the-job of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Department of Pain, Henan Provincial Tumor Hospital, Zhengzhou, China
| | - Da-peng Guo
- Department of Pain, Henan Provincial Tumor Hospital, Zhengzhou, China
| | - Zhi-gang Li
- Department of Pain, Henan Provincial Tumor Hospital, Zhengzhou, China
| | - Chang Liu
- Department of Pain, Henan Provincial Tumor Hospital, Zhengzhou, China
| | - Wei Zhang
- Department of Anesthesiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Correspondence: Wei Zhang, Number one, Constructive East Road, Zhengzhou City, China (e-mail: )
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21
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Paster Z, Morris CM. Treatment of the Localized Pain of Postherpetic Neuralgia. Postgrad Med 2015; 122:91-107. [DOI: 10.3810/pgm.2010.01.2103] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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22
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Dworkin RH, O’Connor AB, Kent J, Mackey SC, Raja SN, Stacey BR, Levy RM, Backonja M, Baron R, Harke H, Loeser JD, Treede RD, Turk DC, Wells CD. Interventional management of neuropathic pain: NeuPSIG recommendations. Pain 2013; 154:2249-2261. [PMID: 23748119 PMCID: PMC4484720 DOI: 10.1016/j.pain.2013.06.004] [Citation(s) in RCA: 281] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 05/24/2013] [Accepted: 06/03/2013] [Indexed: 11/30/2022]
Abstract
Neuropathic pain (NP) is often refractory to pharmacologic and noninterventional treatment. On behalf of the International Association for the Study of Pain Neuropathic Pain Special Interest Group, the authors evaluated systematic reviews, clinical trials, and existing guidelines for the interventional management of NP. Evidence is summarized and presented for neural blockade, spinal cord stimulation (SCS), intrathecal medication, and neurosurgical interventions in patients with the following peripheral and central NP conditions: herpes zoster and postherpetic neuralgia (PHN); painful diabetic and other peripheral neuropathies; spinal cord injury NP; central poststroke pain; radiculopathy and failed back surgery syndrome (FBSS); complex regional pain syndrome (CRPS); and trigeminal neuralgia and neuropathy. Due to the paucity of high-quality clinical trials, no strong recommendations can be made. Four weak recommendations based on the amount and consistency of evidence, including degree of efficacy and safety, are: 1) epidural injections for herpes zoster; 2) steroid injections for radiculopathy; 3) SCS for FBSS; and 4) SCS for CRPS type 1. Based on the available data, we recommend not to use sympathetic blocks for PHN nor radiofrequency lesions for radiculopathy. No other conclusive recommendations can be made due to the poor quality of available data. Whenever possible, these interventions should either be part of randomized clinical trials or documented in pain registries. Priorities for future research include randomized clinical trials, long-term studies, and head-to-head comparisons among different interventional and noninterventional treatments.
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Affiliation(s)
- Robert H. Dworkin
- Departments of Anesthesiology and Neurology and Center for Human Experimental Therapeutics, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA
| | | | - Joel Kent
- University of Rochester, Rochester, NY, USA
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Koning MV, Koning NJ, Koning HM, van Kleef M. Relationship between Sensory Stimulation and Side Effects in Percutaneous Radiofrequency Treatment of the Trigeminal Ganglion. Pain Pract 2013; 14:581-7. [PMID: 24152209 DOI: 10.1111/papr.12124] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 08/15/2013] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The objective of this study was to determine the efficacy of percutaneous radiofrequency (RF) treatment of the trigeminal ganglion for treating patients with trigeminal neuralgia, to determine which patients have a long-term benefit, and to evaluate the effect of RF parameters. METHODS A retrospective study in 28 consecutive patients in combination with a follow-up questionnaire (n = 26, 93% response). RESULTS An initial treatment effect of 89% was observed, 60% sustained at 12-month follow-up. Major side effects were hypesthesia (56%), dry eye (20%), and masseter muscle weakness (12%). A lower sensory stimulation threshold during treatment was associated with better patient satisfaction (P = 0.016), improved pain relief (P = 0.039), and trended toward more hypesthesia (P = 0.077). DISCUSSION This low-volume study reported treatment effects in an older population that were similar to previous studies. Only a higher incidence of hypesthesia was detected by long-term follow-up. This study supported the high efficiency of RF treatment, but there was a high level of side effects. Most notable, low sensory stimulation was associated with increased hypesthesia, whereas higher stimulation levels yielded less effectiveness. Further investigation of an optimal sensory stimulation range for percutaneous RF treatment of the trigeminal ganglion was found to be warranted.
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Affiliation(s)
- Mark V Koning
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nick J Koning
- Departments of Anesthesiology and Cardiothoracic Surgery, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands.,Department of Integrated Neurovascular Biology, INSERM U1083, CNRS UMR 6214, LUNAM University, Université d'Angers, Angers, France
| | - Henk M Koning
- Department of Pain Therapy, Medical Center Jan van Goyen, Amsterdam, The Netherlands
| | - Maarten van Kleef
- Department of Anesthesiology and Pain Management, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Anesthesiology and Pain Management, VU University Medical Center, Amsterdam, The Netherlands
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Abstract
Postherpetic neuralgia is a chronic pain condition that develops in some patients after the resolution of herpes zoster, and has no medical cure. Medications used to treat chronic pain do not hasten resolution of the disorder and may impair function. In this brief case report, we describe our experience with excision and implantation to muscle of peripheral sensory nerves in the affected dermatomes as a novel surgical treatment to reduce pain and improve quality of life for patients with this condition. Of the 3 treated patients, all had resolution of chronic pain after surgery. It is concluded that peripheral nerve surgery offers a promising option to improve pain and quality of life in postherpetic neuralgia patients, without affecting systemic functioning.
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Abdulla A, Adams N, Bone M, Elliott AM, Gaffin J, Jones D, Knaggs R, Martin D, Sampson L, Schofield P. Guidance on the management of pain in older people. Age Ageing 2013; 42 Suppl 1:i1-57. [PMID: 23420266 DOI: 10.1093/ageing/afs200] [Citation(s) in RCA: 342] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
This guidance document reviews the epidemiology and management of pain in older people via a literature review of published research. The aim of this document is to inform health professionals in any care setting who work with older adults on best practice for the management of pain and to identify where there are gaps in the evidence that require further research. The assessment of pain in older people has not been covered within this guidance and can be found in a separate document (http://www.britishpainsociety.org/pub_professional.htm#assessmentpop). Substantial differences in the population, methods and definitions used in published research makes it difficult to compare across studies and impossible to determine the definitive prevalence of pain in older people. There are inconsistencies within the literature as to whether or not pain increases or decreases in this age group, and whether this is influenced by gender. There is, however, some evidence that the prevalence of pain is higher within residential care settings. The three most common sites of pain in older people are the back; leg/knee or hip and 'other' joints. In common with the working-age population, the attitudes and beliefs of older people influence all aspects of their pain experience. Stoicism is particularly evident within this cohort of people. Evidence from the literature search suggests that paracetamol should be considered as first-line treatment for the management of both acute and persistent pain, particularly that which is of musculoskeletal origin, due to its demonstrated efficacy and good safety profile. There are few absolute contraindications and relative cautions to prescribing paracetamol. It is, however, important that the maximum daily dose (4 g/24 h) is not exceeded. Non-selective non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution in older people after other safer treatments have not provided sufficient pain relief. The lowest dose should be provided, for the shortest duration. For older adults, an NSAID or cyclooxygenase-2 (COX-2) selective inhibitor should be co-prescribed with a proton pump inhibitor (PPI), and the one with the lowest acquisition cost should be chosen. All older people taking NSAIDs should be routinely monitored for gastrointestinal, renal and cardiovascular side effects, and drug–drug and drug–disease interactions. Opioid therapy may be considered for patients with moderate or severe pain, particularly if the pain is causing functional impairment or is reducing their quality of life. However, this must be individualised and carefully monitored. Opioid side effects including nausea and vomiting should be anticipated and suitable prophylaxis considered. Appropriate laxative therapy, such as the combination of a stool softener and a stimulant laxative, should be prescribed throughout treatment for all older people who are prescribed opioid therapy. Tricyclic antidepressants and anti-epileptic drugs have demonstrated efficacy in several types of neuropathic pain. But, tolerability and adverse effects limit their use in an older population. Intra-articular corticosteroid injections in osteoarthritis of the knee are effective in relieving pain in the short term, with little risk of complications and/or joint damage. Intra-articular hyaluronic acid is effective and free of systemic adverse effects. It should be considered in patients who are intolerant to systemic therapy. Intra-articular hyaluronic acid appears to have a slower onset of action than intra-articular steroids, but the effects seem to last longer. The current evidence for the use of epidural steroid injections in the management of sciatica is conflicting and, until further larger studies become available, no firm recommendations can be made. There is, however, a limited body of evidence to support the use of epidural injections in spinal stenosis. The literature review suggests that assistive devices are widely used and that the ownership of devices increases with age. Such devices enable older people with chronic pain to live in the community. However, they do not necessarily reduce pain and can increase pain if used incorrectly. Increasing activity by way of exercise should be considered. This should involve strengthening, flexibility, endurance and balance, along with a programme of education. Patient preference should be given serious consideration. A number of complementary therapies have been found to have some efficacy among the older population, including acupuncture, transcutaneous electrical nerve stimulation (TENS) and massage. Such approaches can affect pain and anxiety and are worth further investigation. Some psychological approaches have been found to be useful for the older population, including guided imagery, biofeedback training and relaxation. There is also some evidence supporting the use of cognitive behavioural therapy (CBT) among nursing home populations, but of course these approaches require training and time. There are many areas that require further research, including pharmacological management where approaches are often tested in younger populations and then translated across. Prevalence studies need consistency in terms of age, diagnosis and terminology, and further work needs to be done on evaluating non-pharmacological approaches.
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Park HW, Ahn SH, Son JY, Kim SJ, Hwang SJ, Cho YW, Lee DG. Pulsed Radiofrequency Application Reduced Mechanical Hypersensitivity and Microglial Expression in Neuropathic Pain Model. PAIN MEDICINE 2012; 13:1227-34. [DOI: 10.1111/j.1526-4637.2012.01453.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Affiliation(s)
- Gunnvald Kvarstein
- Department of Pain Management and Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Akural E, Järvimäki V, Korhonen R, Kautiainen H, Haanpää M. Pulsed radiofrequency in peripheral posttraumatic neuropathic pain: A double blind sham controlled randomized clinical trial. Scand J Pain 2012; 3:127-131. [PMID: 29913831 DOI: 10.1016/j.sjpain.2012.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 04/30/2012] [Indexed: 10/28/2022]
Abstract
Background and purpose Pulsed radiofrequency (PRF) is widely used for the treatment of chronic pain, although its mechanism of action is not known. The evidence of efficacy of PRF for neuropathic pain (NP) conditions is limited. A double-blind, randomized, sham-controlled parallel study was conducted to evaluate the efficacy and safety of PRF in the treatment of peripheral posttraumatic NP. Methods Forty-five patients with peripheral posttraumatic NP in their upper or lower limb were randomly assigned to receive PRF or sham treatment to the injured peripheral nerve (s) causing peripheral posttraumatic NP. Only patients whose pain intensity was at least 5 on numerical rating scale (NRS) 0-10 and who had suffered from their NP for at least 6 months were included. All patients had dynamic mechanical allodynia or pinprick hyperalgesia in their painful area. They had achieved temporary pain relief of at least 50% with a local nerve block performed at a previous visit. The primary efficacy variable was the difference in 3-day mean pain intensity score from the baseline to 3 months. Other variables included response defined as ≥30% reduction in mean pain intensity at 3 months compared to baseline, Neuropathic Pain Scale (NPS) results, health related quality of life (SF-36) and adverse effects. The skin was anesthetized with 1% lidocaine. A radiofrequency needle was introduced through the skin, and then guided to a SMK cannula (52, 100 or 144mm depending on the target nerve) with 4 or 5mm active tip (SMK-C5-4, SMK-C10-5, SMK-C15-5, Radionics®, Burlington, MA, USA). The nerve was located accurately by stimulating at 50 Hz (threshold <0.5 V). Sham treatment or PRF was applied for 120s 1-4 times at each treatment point (Radionics®, Burlington, MA, USA). The total treatment time was up to 8 min. Both patients and clinicians were blinded during the whole treatment and follow-up period. Results Forty-three patients were included in the analyses. There was no statistically significant difference between PRF and sham treatment for the primary outcome efficacy variable. Seven patients (3 in PRF group and 4 in sham treatment group) achieved ≥30% pain relief (difference between groups was not significant). There was no statistically significant difference in the NPS or any dimension of SF-36 between the treatments. Eighteen patients reported adverse effects. They were mild and did not necessitate any treatment. Transient pain was reported by 17 patients, local irritation by 5 patients and local inflammation by 1 patient. There was no significant difference between the groups in the presence of adverse effects. Conclusions PRF was well tolerated, but this study failed to show efficacy of PRF over sham treatment for peripheral posttraumatic NP. Implications Based on our results, we do not recommend PRF for peripheral posttraumatic NP. More research of the possible use of PRF for various pain conditions is needed to determine its role in the management of prolonged pains.
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Affiliation(s)
- Ethem Akural
- Department of Anesthesiology, Oulu University Hospital, Oulu, Finland.,Pain Clinic, Helsinki University Central Hospital, Helsinki, Finland
| | - Voitto Järvimäki
- Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Raija Korhonen
- Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Hannu Kautiainen
- Unit of Family Practice, Central Hospital Jyväskylä, Kuopio, Finland.,Unit of Primary Health Care, Kuopio University Hospital, Kuopio, Finland
| | - Maija Haanpää
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland.,Etera Mutual Pension Insurance Company, Kuopio, Finland
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Evidence for Interventional Procedures as an Adjunct Therapy in the Treatment of Shingles Pain. Adv Skin Wound Care 2012; 25:276-84; quiz 285-6. [DOI: 10.1097/01.asw.0000415345.22307.f3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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West M, Wu H. Pulsed Radiofrequency Ablation for Residual and Phantom Limb Pain: A Case Series. Pain Pract 2010; 10:485-91. [DOI: 10.1111/j.1533-2500.2009.00353.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vallejo R, Benyamin RM, Aliaga L. Radiofrequency vs. pulse radiofrequency: The end of the controversy. ACTA ACUST UNITED AC 2010. [DOI: 10.1053/j.trap.2010.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Delaney A, Colvin LA, Fallon MT, Dalziel RG, Mitchell R, Fleetwood-Walker SM. Postherpetic neuralgia: from preclinical models to the clinic. Neurotherapeutics 2009; 6:630-7. [PMID: 19789068 PMCID: PMC5084285 DOI: 10.1016/j.nurt.2009.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 07/09/2009] [Indexed: 01/12/2023] Open
Abstract
Postherpetic neuralgia (PHN), a common complication of herpes zoster, which results from reactivation of varicella zoster virus, is a challenging neuropathic pain syndrome. The incidence and severity of herpes zoster and PHN increases with immune impairment or age and may become a greater burden both in terms of health economics and individual suffering. A clearer understanding of the underlying mechanisms of this disease and translation of preclinical outcomes to the clinic may lead to more efficacious treatment options. Here we give an overview of recent findings from preclinical models and clinical research on PHN.
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Affiliation(s)
- Ada Delaney
- grid.4305.20000000419367988Centre for Neuroregeneration, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, EH16 4SB UK
| | - Lesley A. Colvin
- grid.4305.20000000419367988Department of Anaesthesia, Critical Care, and Pain Medicine, University of Edinburgh, Edinburgh, UK
| | - Marie T. Fallon
- grid.4305.20000000419367988Edinburgh Cancer Research Centre, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - Robert G. Dalziel
- grid.4305.20000000419367988The Roslin Institute and Centre for Infectious Diseases, University of Edinburgh, Edinburgh, UK
| | - Rory Mitchell
- grid.4305.20000000419367988Centre for Integrative Physiology, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Susan M. Fleetwood-Walker
- grid.4305.20000000419367988Centre for Neuroregeneration, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, EH16 4SB UK
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Lee SH, Lee CJ, Lee JY, Kim TH, Sim WS, Lee SY, Hwang HY. Fluoroscopy-guided pudendal nerve block and pulsed radiofrequency treatment : A case report. Korean J Anesthesiol 2009; 56:605-608. [PMID: 30625798 DOI: 10.4097/kjae.2009.56.5.605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Pudendal nerve block (PNB) is performed for differential diagnosis and treatment of chronic pelvic and perineal pain. Several block methods, such as transvaginal, transperineal, computerized tomography-, ultrasound- and fluoroscopy-guided approach are currently under practice. Compared to others, a fluoroscopy-guided approach has several advantages, such as its relatively low cost, facility and ease of landmark recognition. We depicted a fluoroscopy-guided PNB technique to selectively block and elaborate a pulsed radiofrequency treatment in a 51-year-old man with chronic pelvic and perineal pain. The patient had undergone a ganglion of impar block with a limited pain relief. Thereafter, a PNB was performed and the pain was relieved significantly for 2 weeks. Further PNB with a pulsed radiofrequency treatment reduced the pain for more than 8 weeks. The pain relief sustained up to the time of this report. The fluoroscopy-guided PNB and pulsed radiofrequency treatment allowed simplicity in manipulation and precision in performing the procedures with a favorable outcome.
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Affiliation(s)
- Sang Hyun Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Chul Joong Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Jin Young Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Tae Hyeong Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Woo Seok Sim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Suk Young Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Hee Youn Hwang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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