Ziconotide for spinal cord injury‐related pain

Abstract

Background

Central neuropathic pain related to spinal cord injury is notoriously difficult to treat. So far most pharmacological and surgical options have shown but poor results. Recently ziconotide has been approved for use both neuropathic and non‐neuropathic pain. In this cohort study, we assessed responder rate and long‐term efficacy of intrathecal ziconotide in patients with pain related to spinal cord injury.

Methods

Patients presenting chronic neuropathic related to spinal cord lesions that was refractory to medical pain management were considered for inclusion. Those accepting were tested by lumbar puncture injection of ziconotide or continuous intrathecal infusion and if a significant decrease in pain scores (>40%) was noted they were implanted with a continuous infusion pump. They were then followed up for at least 1 year with constant assessment of the evolution of pain and side effects.

Results

Out of the 20 patients tested 14 had a decrease in pain scores of more than 40% but only 11 (55%) were implanted with permanent pumps due to side effects and patient choice. These were followed up on average for 3.59 years (±1.94) and in eight patients an above threshold decrease in pain scores was maintained. Overall in patients that responded to the test baseline VAS was 7.91 and 4.31 at last follow‐up with an average dose of 7.2 μg of ziconotide per day. Six patients (30%) did not respond to any test and in three patients side effects precluded pump implantation. No significant long‐term effects of the molecule were noted.

Conclusion

This study shows response to intrathecal ziconotide test in 40% of the patients of a very specific population in whom other therapeutic options are not available. This data justifies the development further studies such as a long‐term randomized controlled trial.

Significance

Intrathecal Ziconotide is a posible alternative for the treatment of pain in patients with spinal cord injury and below level neuropathic pain.

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William “Ed” Kois: whistleblower who exposed substandard care at a US veterans hospital

bmj;366/aug30_4/l5325/FAF1faPeter Biello/New Hampshire Public RadioA specialist in rehabilitation and pain management, William “Ed” Kois was not your typical doctor. He swore a lot,1 he wore a goatee...

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Risk and Prognostic Factors of Low Back Pain: Repeated Population-based Cohort Study in Sweden

Study Design. Prospective longitudinal cohort study. Objective. To determine the associations for workload and health-related factors with incident and recurrent low back pain (LBP), and to determine the mediating role of health-related factors in associations between physical workload factors and incident LBP. Summary of Background Data. It is not known whether the risk factors for the development of LBP are also prognostic factors for recurrence of LBP and whether the associations between physical workload and incident LBP are mediated by health-related factors. We used data from the Swedish Longitudinal Occupational Survey of Health study. Those responding to any two subsequent surveys in 2010 to 2016 were included for the main analyses (N = 17,962). Information on occupational lifting, working in twisted positions, weight/height, smoking, physical activity, depressive symptoms, and sleep problems were self-reported. Incident LBP was defined as pain limiting daily activities in the preceding three months in participants free from LBP at baseline. Recurrent LBP was defined as having LBP both at baseline and follow-up. For the mediation analyses, those responding to three subsequent surveys were included (N = 3516). Methods. Main associations were determined using generalized estimating equation models for repeated measures data. Mediation was examined with counterfactual mediation analysis. Results. All risk factors at baseline but smoking and physical activity were associated with incident LBP after adjustment for confounders. The strongest associations were observed for working in twisted positions (risk ratio  = 1.52, 95% CI 1.37, 1.70) and occupational lifting (risk ratio  = 1.52, 95% CI 1.32, 1.74). These associations were not mediated by health-related factors. The studied factors did not have meaningful effects on recurrent LBP. Conclusion. The findings suggest that workload and health-related factors have stronger effects on the development than on the recurrence or progression of LBP, and that health-related factors do not mediate associations between workload factors and incident LBP. Level of Evidence: 3

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Intrathecal dexmedetomidine versus magnesium sulfate for postoperative analgesia and stress response after cesarean delivery; randomized controlled double‐blind study

Abstract

Background

Various adjuvants were added to intrathecal anesthetics to improve quality of the block and postoperative analgesia. We hypothesized that intrathecal dexmedetomidine and magnesium sulfate (MgSO₄) may add similar effects. Our objectives were to compare their effects as adjuvants to intrathecal bupivacaine on postoperative analgesia, stress hormones, sedative properties and the neonatal outcome after cesarean section.

Methods

A randomized double‐blind controlled study; ninety parturients were divided into three groups. All patients received intrathecal hyperbaric bupivacaine 12.5mg. NaCl 0.9% was added to intrathecal block in group C, 5μg dexmedetomidine in the group D and 50mg MgSO₄ in group M. Visual analogue scale (VAS) score, stress hormones were assessed within the first 12 postoperative hours, sensory block, and neonatal outcome were also assessed.

Results

VAS scores were significantly lower in groups D & M. Onset of postoperative pain was significantly prolonged in group D. Time to peak sensory level was shorter in group D. Sedation score was significantly higher in group D only after 30 minutes of intrathecal block. Although stress hormones increased in all groups during intraoperative and postoperative periods, their levels were significantly lower in group D compared to other groups. No differences were noted regarding neonatal outcomes.

Conclusion

Intrathecal dexmedetomidine is superior to intrathecal MgSO₄ during cesarean section with regard to duration of analgesia, pain severity, and stress hormone levels. Dexmedetomidine has a rapid onset and longer duration of sensory block compared to MgSO₄. No significant adverse effects to the parturients or newborns.

This article is protected by copyright. All rights reserved.

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Effect of local infiltration with oxytocin on hemodynamic response to surgical incision and postoperative pain in patients having open laparoscopic surgery under general anesthesia

Abstract

Background

Preemptive analgesia encompasses different perioperative interventions that have the final aim of decreasing postoperative pain and improving recovery. Recently, peripheral analgesic effects of oxytocinergic modulation have been suggested. In this regard, we tested the potential analgesic effects of subcutaneous oxytocin (OT) infiltration in patients submitted to laparoscopic cholecystectomy.

Methods

Thirty patients with similar general characteristics and medical physical conditions were evaluated. The patients were assigned by simple random selection to one of three groups: (a) OT group (n = 10), which received preincisional subcutaneous OT (4 µg/4 ml saline) in the surgical sites for trocar placements; (b) Lidocaine group (n = 10), which received subcutaneous lidocaine 1% (4 ml) in the surgical sites; and (c) Control group (n = 10), which did not receive any treatment. Then we measured the effect of those treatments on the hemodynamic variations produced as responses to the surgical incisions and trocar insertions (open port placements using the Hasson technique). Moreover, we assessed the intensity of postoperative pain with the visual analogue scale during recovery and 24 hr after surgery.

Results

Hemodynamic parameters were stable in both intervention groups (subcutaneous OT and lidocaine) during the surgical incisions and trocar placements, whereas a most likely sympathetic activation due to trocar insertions (open port placements) was not blunted in the placebo group. Furthermore, postoperative pain was diminished in both OT and lidocaine groups when compared to the control group.

Conclusions

Preincisional subcutaneous OT administration reduced the hemodynamic response produced by the latter. Furthermore, OT also diminished postoperative pain.

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Visual attention to pain cues for impending touch versus impending pain: An eye tracking study

Abstract

Background

In this eye tracking study, we evaluated pain‐related biases in orienting and maintenance of gaze within impending touch versus impending pain tasks and examined features of pain resilience as individual difference influences on potential biases.

Methods

Gaze preferences of healthy adults (25 women and 39 men) were assessed during standardized pain‐neutral (P‐N) image pair presentations (2,000 ms) of an impending touch task versus an impending pain task whereby image pair offsets were followed by potential non‐painful touch and potential pain stimulation, respectively.

Results

Within each task, participants were significantly more likely to fixate first upon pain images in P‐N pairs and maintain gaze on these images for longer overall durations during trials. Between task comparisons indicated pain‐related biases in orienting and maintenance were significantly stronger when image pairs signalled potential pain rather than impending touch. Finally, within the impending pain task, higher scores on the behaviour perseverance dimension of pain resilience were related to shorter first fixation durations and overall gaze durations towards pain images.

Conclusions

Supporting specific threat interpretation model premises, comparatively more threatening external pain cues for impending pain were characterized by gaze biases reflecting pronounced early attentional capture and subsequent prolonged vigilance. However, elevations in self‐reported behavioural perseverance in spite of pain corresponded to an increased capacity to disengage from pain images that signalled potential pain.

Significance

Gaze biases were assessed within a comparatively benign “impending touch” paradigm versus a higher threat, impending pain task. Early capture and maintenance of gaze towards pain images were more pronounced on the latter task, although pain resilient participants were able to disengage more easily from pain images signalling possible pain.

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Discharged and dismissed: A qualitative study with back pain patients discharged without treatment from orthopaedic consultations

Abstract

Background

Consultation‐based reassurance for patients with low back pain (LBP) in primary care has been shown to be associated with patients' outcomes. Little is known about the role of reassurance in people with LBP consulting with orthopaedic spinal care teams. Reassurance may be important, especially in cases where surgery is not indicated and patients are discharged without treatment.

Methods

Semi‐structured interviews were conducted with 30 patients with chronic disabling musculoskeletal LBP who had recently consulted with spinal orthopaedic care teams. Interviews were audio recorded, transcribed, coded and analysed.

Results

Most patients reported feeling dismissed and discouraged. Patients perceived that they needed specific behaviours from practitioners in order to feel sufficiently reassured to commit to self‐management. These behaviours group into four domains: “Knowing my whole story” (evidence that practitioners read the case notes; were familiar with the patients' previous health care history; carried out tests and a physical examination and gathered information about the patients' lifestyle), “Seeing the right person” (showing empathy; listening; building rapport and demonstrating that they are qualified and experienced), “Nothing to worry about” (reducing generic reassuring statements but increasing validating statements recognizing suffering) and “Getting to grips with my problem” (providing explanations and a clear management plan). In the absence of these behaviours, patients rejected advice to self‐manage, reported distress, anger and intention to re‐consult.

Conclusion

Effective communication with patients attending spinal orthopaedic care settings is important, especially when no active treatment is being offered.

Significance

This study describes narratives from patients discharged without surgery following consultations with orthopaedic professionals for persistent and debilitating lower back pain. Findings suggest that these interactions are distressful to patients, and that patients require comprehensive and specific reassurance to promote self‐management. The findings contribute a unique insight into the special needs of people with complex pain problems and provide guidance to improve consultation‐based reassurance in orthopaedic spinal care settings.

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