Regional Anesthesia and Pain Medicine最新文献

{"title":"Wnt5a in keratinocytes contributes to complex regional pain syndrome through the activation of NR2B and MMP9 in rats.","authors":"He Zhu, Bei Wen, Jijun Xu, Li Xu, Yuguang Huang","doi":"10.1136/rapm-2024-106139","DOIUrl":"https://doi.org/10.1136/rapm-2024-106139","url":null,"abstract":"<p><strong>Background: </strong>Complex regional pain syndrome (CRPS) is a chronic pain condition characterized by inflammatory features, though the underlying mechanisms remain partly understood. Our study examined whether Wnt5a in skin keratinocytes contributes to CRPS-related pain hypersensitivity by activating downstream N-methyl-D-aspartate receptor subunit 2B (NR2B) and matrix metalloproteinase-9 (MMP9) signaling in rats.</p><p><strong>Methods: </strong>We developed a cell-culture model to mimic the local inflammation of CRPS and a rat model to mimic the chronic post-ischemia pain experienced by CRPS patients. Mechanical and heat pain thresholds in the hind paw were measured using an electronic von Frey apparatus and a radiant heat device. Western blotting and immunofluorescence were used to examine the expressions of NR2B and MMP9 in the skin and dorsal root ganglion (DRG), and immunofluorescence staining of connexin 43 (Cx43) and protein gene product 9.5 (PGP9.5) were conducted to explore the interaction between keratinocytes and nerve fibers in the skin.</p><p><strong>Results: </strong>In cell culture, Wnt5a was expressed in keratinocytes and contributed to cellular injury by increasing the levels of NR2B and MMP9. The mechanical and heat pain thresholds measured in the hind paw were decreased in CRPS rats, indicating increased pain sensitivity. The inhibition of Wnt5a alleviated these CRPS-related pain hypersensitivities. High levels of Cx43 and PGP9.5 staining were observed in the epidermis of CRPS rats, suggesting an interaction between keratinocytes and nerve fibers that may contribute to CRPS. Additionally, upregulations of NR2B and MMP9 in the DRG may further exacerbate pain.</p><p><strong>Conclusions: </strong>Skin keratinocytes may play an essential role in the pathophysiology of CRPS. Wnt5a signaling may increase pain sensitivity by upregulating downstream NR2B and MMP9, thereby contributing to CRPS.</p>","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":" ","pages":""},"PeriodicalIF":5.1,"publicationDate":"2025-03-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143626830","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Use and safety of corticosteroid injections in joints and musculoskeletal soft tissue: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, and the International Pain and Spine Intervention Society.","authors":"Honorio T Benzon, David Anthony Provenzano, Ameet Nagpal, Dmitri Souza, Maxim S Eckmann, Ariana M Nelson, Maged Mina, Alaa Abd-Elsayed, Dalia Elmofty, Andrea L Chadwick, Tina L Doshi, Carlos A Pino, Maunak Rana, Shalini Shah, Hariharan Shankar, Alison Stout, Elizabeth Smith, Salahadin Abdi, Steven P Cohen, Joshua A Hirsch, Byron J Schneider, Laxmaiah Manchikanti, Timothy P Maus, Samer Narouze, Harsha Shanthanna, Ajay D Wasan, Thanh D Hoang, Jessica Rivera, Christine Hunt, John D FitzGerald","doi":"10.1136/rapm-2024-105656","DOIUrl":"10.1136/rapm-2024-105656","url":null,"abstract":"<p><strong>Background: </strong>Intra-articular corticosteroid (IACS) injection and peri-articular corticosteroid injection are commonly used to treat musculoskeletal conditions. Results vary by musculoskeletal region, but most studies report short-term benefit with mixed results on long-term relief. Publications showed adverse events from single corticosteroid injections. Recommended effective doses were lower than those currently used by clinicians.</p><p><strong>Methods: </strong>Development of the practice guideline for joint injections was approved by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine and the participating societies. A Corticosteroid Safety Work Group coordinated the development of three guidelines: peripheral nerve blocks and trigger points; joints; and neuraxial, facet, and sacroiliac joint injections. The topics included safety of the technique in relation to landmark-guided, ultrasound-guided, or radiology-aided injections; effect of the addition of the corticosteroid on the efficacy of the injectate; and adverse events related to the injection. Experts on the topics were assigned to extensively review the literature and initially develop consensus statements and recommendations. A modified version of the US Preventive Services Task Force grading of evidence and strength of recommendation was followed. A modified Delphi process was adhered to in arriving at a consensus.</p><p><strong>Results: </strong>This guideline focuses on the safety and efficacy of corticosteroid joint injections for managing joint chronic pain in adults. The joints that were addressed included the shoulder, elbow, hand, wrist, hip, knee, and small joints of the hands and feet. All the statements and recommendations were approved by all participants and the Board of Directors of the participating societies after four rounds of discussion. There is little evidence to guide the selection of one corticosteroid over another. Ultrasound guidance increases the accuracy of injections and reduces procedural pain. A dose of 20 mg triamcinolone is as effective as 40 mg for both shoulder IACS and subacromial subdeltoid bursa corticosteroid injections. The commonly used dose for hip IACS is 40 mg triamcinolone or methylprednisolone. Triamcinolone 40 mg is as effective as 80 mg for knee IACS. Overall, IACS injections result in short-term pain relief from a few weeks to a few months. The adverse events include an increase in blood glucose, adrenal suppression, detrimental effect on cartilage lining the joint, reduction of bone mineral density, and postoperative joint infection.</p><p><strong>Conclusions: </strong>In this practice guideline, we provided specific recommendations on the role of corticosteroids in joint, bursa, and peritendon injections for musculoskeletal pain.</p>","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":" ","pages":""},"PeriodicalIF":5.1,"publicationDate":"2025-03-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143525284","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Obturator canal block: a concept beyond novelty.","authors":"Xavier Sala-Blanch, Hipolito Labandeyra","doi":"10.1136/rapm-2025-106393","DOIUrl":"https://doi.org/10.1136/rapm-2025-106393","url":null,"abstract":"","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":" ","pages":""},"PeriodicalIF":5.1,"publicationDate":"2025-03-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143626827","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"2024 John J Bonica Award Lecture: Less is More.","authors":"Jan Van Zundert","doi":"10.1136/rapm-2024-106283","DOIUrl":"https://doi.org/10.1136/rapm-2024-106283","url":null,"abstract":"<p><p>'Less is More' reflects the idea of Ludwig Mies van der Rohe, who only retained the essentials in his designs. This principle is also applicable in different areas of pain medicine.Several pioneers have worked hard to introduce the multidisciplinary approach to obtain the most appropriate treatment for the patient. Most of those pioneers received the Bonica Award before me, and I am happy that those persons mentored me and stimulated me in understanding pain management and developing my career. Pain management has known a great evolution, from accepting pain because of an underlying disease to recognizing pain as the fifth vital sign. The rise in interest in (interventional) pain management evolved parallel to the introduction of evidence-based medicine. Most physicians welcome reviews summarizing the available literature. There are many pitfalls of systematic reviews and meta-analyses, such as the interpretation of the information, which is predominantly done by epidemiologists, who have little clinical background to make a distinction between the effect of the treatment in different diagnoses. Guidelines are based on correct diagnosis, weighing the potential for complications against the anticipated benefits, are progressively introduced and should guide physicians in establishing a treatment plan. A group of physicians normally prepares these guidelines.The golden rule in the treatment selection is 'Less is More'.</p>","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":" ","pages":""},"PeriodicalIF":5.1,"publicationDate":"2025-03-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143588230","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comparison of femoral triangle plus iPACK blocks with femoral triangle block alone for anterior cruciate ligament reconstruction: a randomized controlled clinical trial on postoperative pain and knee function.","authors":"Fabrice Ferré, Lise Boussaguet, Nicolas Vari, Fabien Pillard, Laetitia Bosch, Anne Ferrier, Cyndie Ba, Bernard Tissot, Rémi Menut, Matt Kurrek, François Labaste, Etienne Cavaignac, Vincent Minville","doi":"10.1136/rapm-2024-106108","DOIUrl":"https://doi.org/10.1136/rapm-2024-106108","url":null,"abstract":"<p><strong>Background: </strong>Anterior cruciate ligament reconstruction (ACLR) can cause severe postoperative pain. However, consensus regarding the most effective regional analgesia is lacking. We hypothesized that, compared with femoral triangle block (FTB) and local infiltration analgesia, adding an iPACK block would decrease postoperative morphine consumption.</p><p><strong>Methods: </strong>Patients scheduled for ACLR under general anesthesia were randomly allocated to the FTB (n=45) or the FTB+iPACK group (n=45). The primary outcome was the cumulative oral morphine equivalent (OME) consumption during the first two postoperative days. Secondary outcomes were maximum pain scores, opioid adverse effects, and knee functional scores (Knee Injury and Osteoarthritis Outcome (KOOS), International Knee Documentation Committee (IKDC) and Lysholm) 3, 6, and 9 months after surgery.</p><p><strong>Results: </strong>Compared with FTB, FTB+iPACK resulted in similar OME consumption (median (IQR)=50 (14-103) vs 60 (32-89) mg, respectively; median of the difference (95% CI): 5 (-14, 28) mg, p=0.49). No significant intergroup differences were found in terms of pain scores, opioid-related side effects, or functional knee recovery. Pain and symptoms subscales of KOOS and IKDC at 9 months were higher for patients with an OME consumption <50 mg within the first two postoperative days, but these statistical differences did not reach the minimal clinically important difference.</p><p><strong>Conclusions: </strong>iPACK block has no additional analgesic benefits for primary ACLR in the setting of a multimodal analgesia regimen including FTB and local infiltration analgesia.</p><p><strong>Trial registration number: </strong>NCT05136352.</p>","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":" ","pages":""},"PeriodicalIF":5.1,"publicationDate":"2025-03-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143588235","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Spinal cord stimulation trial-to-implant ratios: relic or requisite?","authors":"Jay Karri, Eellan Sivanesan, Ryan S D'Souza","doi":"10.1136/rapm-2025-106447","DOIUrl":"https://doi.org/10.1136/rapm-2025-106447","url":null,"abstract":"<p><p>The trial-to-implant ratio for spinal cord stimulation (SCS) has long served as a cornerstone metric for optimizing patient selection and cost containment. Historically, screening trials played a pivotal role in identifying non-responders, thereby minimizing unnecessary permanent implantations. The utility of the trial paradigm is supported by Medicare data from 2009, which reported a trial-to-implant ratio of 42.5%. However, advancements in SCS technology have significantly transformed the neuromodulation landscape and have been associated with higher rates of trial success. By 2018, the Medicare data showed trial-to-implant ratios exceeding 63%, with randomized clinical trials from 2020 to 2021 reporting ratios exceeding 80%-90%. These significant increases in trial-to-implant ratios suggest that only a minority of SCS candidates do not undergo a subsequent permanent device implantation. As such, re-evaluation of the trial-to-implant paradigm, from the perspective of practicing pain physicians in the USA, in light of evolving clinical practices and economic pressures, is warranted. This discourse explores the benefits and limitations of the trial-to-implant ratio, emphasizing its role as a safeguard against overutilization and a tool for standardizing clinical practices but weighed against its shortcomings including a lack of alignment with long-term outcomes, underscore the need for alternative metrics that include per capita trial utilization and explant-to-implant ratios. European responses to similar questions have resulted in utilizing validated symptom screening tools and direct-to-implant pathways in lieu of a screening trial altogether as potential strategies to optimize SCS utilization while maintaining cost-effectiveness. As healthcare systems adapt to advancements in neuromodulation, a balanced perspective on trial-to-implant ratios and complementary metrics is essential to ensure equitable access, sustainable outcomes and evidence-based care for the future of SCS therapy.</p>","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":" ","pages":""},"PeriodicalIF":5.1,"publicationDate":"2025-03-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143588238","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Potential electrochemical reactions provoked by prolonged electrical stimulation and neuromodulation: in vitro porcine model.","authors":"Jonathan Jenkin Tsui, Jeremy Hopkin Tsui","doi":"10.1136/rapm-2022-104234","DOIUrl":"10.1136/rapm-2022-104234","url":null,"abstract":"","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":" ","pages":"276-277"},"PeriodicalIF":5.1,"publicationDate":"2025-03-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9414283","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Axonal sensitivity and block dynamics.","authors":"J A Wildsmith","doi":"10.1136/rapm-2024-105950","DOIUrl":"10.1136/rapm-2024-105950","url":null,"abstract":"<p><p>The role of differential nerve block in the development of analgesia after erector spinae plane block has been questioned. While highly myelinated nerves are more sensitive to local anesthetics than unmyelinated ones in vitro, factors influencing drug diffusion, particularly pKa, are more relevant in the clinical setting. Bupivacaine (the drug most used for an 'analgesic' effect) has a relatively high pKa (8.1), and only 15% of it is present in the lipid permeant, unionized form at pH 7.4 so it will penetrate unmyelinated C fibers relatively easily, but the myelin sheaths around other fiber types are a significant barrier to drug diffusion. The greater sensitivity of myelinated axons to local anesthetic action will only be apparent if the drug can reach their membranes in significant concentrations. In the very dynamic situation pertaining to a local anesthetic injection (no matter the site), diffusion factors mean that the concentration of the drug around the axons is likely to be very low and may result in an effect on unmyelinated fibers only.</p>","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":" ","pages":"280-282"},"PeriodicalIF":5.1,"publicationDate":"2025-03-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142632763","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Abdominal field blocks in minimally invasive surgery and the cutaneous sensory block area.","authors":"Renuka M George, Sylvia H Wilson","doi":"10.1136/rapm-2025-106559","DOIUrl":"https://doi.org/10.1136/rapm-2025-106559","url":null,"abstract":"","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":" ","pages":""},"PeriodicalIF":5.1,"publicationDate":"2025-03-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143568866","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Application of restorative neurostimulation for chronic mechanical low back pain in an older population with 2-year follow up.","authors":"Ardeshir Ardeshiri, Marco Amann, Simon Thomson, Christopher J Gilligan","doi":"10.1136/rapm-2023-105032","DOIUrl":"10.1136/rapm-2023-105032","url":null,"abstract":"<p><strong>Introduction: </strong>Data on the Medicare-aged population show that older patients are major consumers of low back pain (LBP) interventions. An effective approach for patients with mechanical LBP that has been refractory to conservative management is restorative neurostimulation. The efficacy of restorative neurostimulation has been demonstrated in multiple prospective studies, with published follow-up over 4 years, showing a consistent durable effect.</p><p><strong>Methods: </strong>To further examine the effect of restorative neurostimulation in an older demographic, data from three clinical studies were aggregated: ReActiv8-B prospectively followed 204 patients, ReActiv8-C study prospectively followed 87 patients and ReActiv8-PMCF prospectively followed 42 patients.Two hundred and sixty-one patients were identified with complete 2-year follow-up and divided into cohorts of equal size based of age quartiles.At 2 years from device activation, patients in either cohort were classified by change in disability (Oswestry Disability Index (ODI)) or change in pain score(NRS/VAS) and assessed as proportion of patients per group at each time point. Additionally, health-related quality of life (HRQoL) (EQ5D-5L) was longitudinally compared with baseline. Differences in proportions were assessed using χ² and continuous variables by repeated measures analysis of variance.</p><p><strong>Results: </strong>The oldest quartile (n=65) had a median age of 60 (56-82) years compared with the entire population (n=261) who had a median age of 49 (22-82) years. The completer analysis on patients with 2 years of continuous data showed improvement of a 50% in pain was achieved by 62% and 65% and a 15-point ODI improvement in 48% and 60% in the oldest quartile and entire population, respectively. HRQoL (EuroQol 5-Dimension) improved from baselines of 0.568 and 0.544 to 0.763 and 0.769 in the oldest quartile and entire population respectively. All age quartiles improved statistically and clinically over baseline.</p><p><strong>Conclusions: </strong>This aggregate analysis of three independent studies provides insight into the performance of restorative neurostimulation in an older population. Patients derived significant and clinically meaningful benefit in disability, pain and HRQoL. When compared with a similarly indicated cohort of younger patients, there were no statistically or clinically significant differences.</p>","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":" ","pages":"231-236"},"PeriodicalIF":5.1,"publicationDate":"2025-03-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12015028/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140068895","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}