Pain physician
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Current treatments for neuropathic pain are far from satisfactory. Considering the essential contribution of central immune factors to the pathogenesis of neuropathic pain, targeting inflammatory response is well accepted as an effective strategy for treating neuropathic pain. Triptolide has a long history in traditional Chinese medicine for treating inflammatory diseases and has been proven to inhibit cytokines released from glial cells. ⋯ Our data suggest that triptolide may be a potential novel treatment for neuropathic pain through modulating immune response in the spinal dorsal horn.
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Chronic persistent neck pain with or without upper extremity pain is common in the general adult population with a prevalence of 48% for women and 38% for men, with persistent complaints in 22% of women and 16% of men. Multiple modalities of treatment are exploding in managing chronic neck pain along with increasing prevalence. However, there is a paucity of evidence for all modalities of treatments in managing chronic neck pain. Controlled studies have supported the existence of cervical facet or zygapophysial joint pain in 36% to 60% in heterogenous population of these patients. However, these studies also have shown false-positive results in 27% to 63% of patients with a single diagnostic block. ⋯ Diagnostic cervical facet joint nerve blocks are safe, valid, and reliable. The strength of evidence for diagnostic facet joint nerve blocks is good with the utilization of controlled diagnostic blocks with at least 75% pain relief as the criterion standard; however, the evidence is limited for single blocks or dual blocks for relief of 50% to 74% and single blocks with at least 75% pain relief.
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The role of antithrombotic therapy is well known for its primary and secondary prevention of cardiovascular disease by decreasing the incidence of acute cerebral, cardiovascular, peripheral vascular, and other thrombotic events. The overwhelming data show that the risk of thrombotic events is significantly higher than that of bleeding during surgery after antiplatelet drug discontinuation. It has been assumed that discontinuing antiplatelet therapy prior to performing interventional pain management techniques is a common practice, even though doing so may potentially increase the risk of acute cerebral and cardiovascular events. There are no data available concerning these events, specifically in relation to the occurrence of thromboembolic events, even though some data are available concerning bleeding complications. Even then, interventionalists seem to routinely discontinue all antithrombotic therapy prior to all interventional pain management techniques. ⋯ The results illustrate an overwhelming pattern of discontinuing antiplatelet and warfarin therapy as well as aspirin and other NSAIDs prior to performing interventional pain management techniques. However, thromboembolism complications may be 3 times more prevalent than epidural hematomas (162 versus 55 events). It is concluded that clinicians must balance the risks of thromboembolism and bleeding in each patient prior to the routine discontinuation of antiplatelet therapy.
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Neuropathic pain is a relatively common outcome of Lyme disease. Pain management options for these patients have been limited to pharmaceutical treatments. ⋯ Spinal cord stimulation may be an effective option for relieving chronic pain originating from Lyme disease.
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Epidural corticosteroid injection is a commonly used approach for managing back pain of several etiologies. The risk of clinical complications from systemic absorption is felt to be rare. Ritonavir is a protease inhibitor whose potent cytochrome P450 3A4 inhibition is exploited for pharmacologic boosting in human immunodeficiency virus (HIV) infection. ⋯ The preponderance of reported cases of iatrogenic hypercortisolism following injectable corticosteroids has involved triamcinolone acetonide, which may be due to the relatively rapid absorption characteristics and high serum levels of this compound compared with other preparations. For individuals on ritonavir-containing HIV therapy, we recommend close coordination with the involved HIV clinicians prior to use of injectable corticosteroids, and avoidance of injections with triamcinolone acetonide whenever possible. Choosing an alternative corticosteroid preparation to triamcinolone acetonide may reduce the risk of systemic absorption, though more research is needed to confirm this hypothesis.