Pain physician
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Cancer-related neuropathic pain significantly affects patients' quality of life. Despite existing treatments, pain control remains inadequate for many of these patients. There is a lack of strong evidence for the efficacy of the combination of pregabalin, which is often used to treat neuropathic pain, and opioids for treating cancer-related neuropathic pain. ⋯ Pregabalin combined with opioids reduces cancer-related neuropathic pain but increases dizziness, somnolence, and peripheral edema, thus supporting its use in the clinic for treating cancer-related neuropathic pain. However, further high-quality randomized controlled trials are needed to confirm these findings.
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Randomized Controlled Trial
Adjuvants to Conventional Management of Postdural Puncture Headache Following Obstetric Surgery Under Spinal Anesthesia: Mirtazapine vs. Sumatriptan.
Postdural puncture headache (PDPH) is a debilitating, life-altering complication of the administration of obstetric spinal anesthesia (SA). The lack of evidence-based treatment for PDPH necessitates the implementation of new treatment modalities. Mirtazapine is a noradrenergic and specific serotonergic antidepressant that has been used as a prophylactic treatment for chronic tension-type headaches. Few previous studies have assessed the efficacy of sumatriptan in the treatment of PDPH. ⋯ Adding either mirtazapine or sumatriptan to the CM of PDPH following obstetric SA was associated with lower means of headache intensities, higher rates of complete response to medical treatment, and decreased incidence of refractory headaches. As an antiemetic drug, mirtazapine was found to be effective, inexpensive, safe, well-tolerated, and capable of being used on an outpatient basis.
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Chronic low back and lower limb pain occurs in 13% of Americans, and is the leading cause of disability. Patients with this condition have a reduced quality of life, have mental health disorders, and cognitive disfunction. While back pain alone is difficult to manage, back pain with associated leg pain results in further reduced outcomes. Spinal cord stimulation (SCS) is a minimally invasive therapy that has been used for a variety of chronic pain disorders when conservative management strategies have failed. The therapy is appealing because of its ability to provide long-term relief at a reduced cost and it has low rates of serious adverse events. ⋯ The Freedom SCS System is an effective and safe therapy for treating patients with chronic back and leg pain that is resistant to conservative therapy due to nerve compression and CRPS Type I and/or II. These types of patients often report aggravation of symptoms with surgery. Minimal invasive surgery should decrease the chance of extra symptoms.
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Paresthesia-based spinal cord stimulation (SCS) depends upon dorsal column (DC) fiber activation to engage pain-relieving neural mechanisms. However, the mechanisms for 10-kHz paresthesia-free SCS have not been fully elucidated. Preclinical work has shown selective drive of inhibitory dorsal horn neurons, while other hypotheses suggest that DC fibers may be activated. To provide clinical data for guiding mechanism work, we analyzed paresthesia perception thresholds (PPT) over a range of low to high kHz frequency and compared those values to the stimulation parameters from the therapeutic 10-kHz SCS programs used by patients. ⋯ Therapeutic 10-kHz SCS uses stimulation amplitudes far lower than the PPT, providing evidence that therapeutic 10-kHz SCS does not activate dorsal column axons. Additionally, the PPT decreases with increasing kHz frequency, suggesting that a presumed asynchronous pattern of activation from kHz stimulation does not raise the threshold at which sensation occurs.