Dextrose Prolotherapy for Occipital Neuralgia Management

Background: Occipital neuralgia defined as a pain such as being stabbed in the skin according to the dermatomes of the greater occipital nerves (GON) and lesser occipital nerves (LON). Case: An 80-year-old male patient diagnosed with occipital neuralgia. Previously, patients were diagnosed with lung cancer six months ago and planned for follow-up chemotherapy. Patient already receive medications including paracetamol, Non-steroidal anti-inflammatory drugs (NSAIDs), minor tranquilizers, and antidepressants, but the pain still exist. Patient then scheduled to receive blocks of GON and LON-ultrasound-guided using plain lidocaine 2% and steroids dexamethasone 10 mg. Fifteen days later, patient receive perineural deep injection along with prolo-hydrodissection in GON and LON using dextrose 15% and local anesthesia lidocaine plain 2% with a volume of 3 cc each nerve. The intervention give a positive outcomes, pain is reduced with NRS rest 0-1, NRS motion 2-3, hearing improves, and the noise in the ear disappears. The patient can sleep using a pillow. Conclusion: Block GON and LON, perineural deep injection along with prolo-hydrodissection provides a positive outcome for occipital neuralgia pain management. This case showed an opportunity for pain specialist to develop pain intervention based on prolotherapy.

Expert review and recommendations for the management of acute, chronic, and neuropathic pain in Qatar

Background: Pain management is an evolving area of expertise in Qatar. Gaps in knowledge, inadequate training for physicians and nurses, and the absence of policies/guidelines are the main barriers to effective pain management in Qatar. In addition, the use of certain pain medication, especially opioids, is highly regulated, limiting their availability in outpatient pain management. These factors are responsible for the undertreatment of pain in Qatar. This study aimed to standardize evidence-based local recommendations for pharmacological treatment of pain in Qatar. Methods: An expert panel of physicians from different disciplines, with experience in diagnosis and treatment of the three pain types (i.e., acute, chronic, and neuropathic), was convened for two face-to-face meetings in Doha, Qatar, on November 29, 2019, and on February 22, 2020, with subsequent virtual meetings. A literature search was performed on Medline and Google Scholar databases from inception till December 2019, and all relevant articles were selected. Based on these articles and repeated feedback from the authors, the final pain treatment protocols were developed.Results: Recommendations for the treatment of acute pain, based on pain severity, followed three approaches: acetaminophen/paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) for mild pain and moderate pain and referral to a pain specialist for severe pain. Acetaminophen/paracetamol or NSAIDs is recommended for chronic pain, and the use of opioids was strongly discouraged because of its long-term side effects. For neuropathic pain, tricyclic antidepressants or gabapentin or pregabalin or serotonin-norepinephrine reuptake inhibitors were recommended first-line agents. Non-responders must be referred to neurologists or a pain specialist. Conclusion: The expert panel provides recommendations for the management of acute, chronic, and neuropathic pain based on international guidelines adapted to local practice and treatment availability in Qatar. More importantly, the panel has recommended taking extreme caution in the use of opioids for long-term management of chronic pain and to refer the patient to a pain specialist clinician as required.

Neuropathic Pain in Breast Cancer: A Cohort Study in 279 Patients with a Total of 1141 High-Concentration Capsaicin Patch Applications

Background: Peripheral neuropathic pain (PNP) is frequent in patients with breast cancer (BC) and BC survivors (BCSs). Data supporting the use of high-concentration (179 mg) capsaicin patches (HCCP) in PNP in oncology are limited. This observational study evaluated the effectiveness and safety of HCCP applications in BCSs/BC patients with PNP. Methods: The study took place in the Anaesthesiology and Pain Medicine department of a French comprehensive cancer centre (Angers, France). For all patients treated with HCCP from 01-Jan-2014 to 18-Dec-2018 data have been collected retrospectively over this period, and for those continuing to receive HCCP after 18-Dec-2018 data collection continued prospectively until 14-Oct-2020. Treatment with HCCP was at the entire discretion of the treating pain specialists. Independent pain specialists completed the Clinical Global Impression of Change (CGIC) for each included patient based on data extracted from patient’s electronic medical record completed by the treating pain specialist after each HCCP application. Results: This study included 279 patients (1141 HCCP applications). Patients were on average 59.2 years old; 54.5% had received at least one medication for their PNP before entering the study. PNP was most frequently caused by surgery (62.4%) followed by chemotherapy (11.8%) and radiotherapy (6.5%). Patients received on average 4.1 repeated HCCP applications; 68.8% received HCCP as an add-on to systemic therapy and 27.9% as first-line therapy. A complete/important analgesic effect was reported at least once by 82.3% of patients; 6.0% of patients reported no effect at all. Complete/important effect was observed in 70.7% and 56.0% of applications in post-surgical PNP existing for <12 months and >10 years, and 52.7% and 52.3% of applications in chemotherapy- or radiotherapy-induced PNP respectively. HCCP application was associated with application site reactions in 54.4% of patients with burning sensation or pain (45.9%) and erythema (30.8%) being the most frequently reported. High blood pressure was reported in 7.2% and frostbite, likely due to local cooling, in 1.4% of patients. Conclusions: This real-world chart review evaluating HCCP under usual practice conditions in a large cohort of patients provides important effectiveness and safety information to clinicians when considering topical options to treat PNP in BCSs/BC patients. Trial registration: Not applicable

Regenerative Pain Medicine, the New Era of Interventional Pain Management, Restart Now!

Musculoskeletal conditions become the leading contributor of the total years lived disability (YLD) by causing 21.3% of the YLDs, after mental and behavioral problems. Several musculoskeletal conditions give a disproportional impact on low back pain, one of the leading causes of disability. Lateral epicondylitis with a prevalence of 1-2%, commonly suffered by adults in their 30-65 years old. Epicondylitis was also suffered by a small population of athletes, such as professional tennis players (10% of epicondylitis population). The severe repetitive injuries that affect the individual daily activity also increase the daily health care cost. Osteoarthritis and tendinopathy often become the cause of pain and musculoskeletal disability. However, the etiology of pain in osteoarthritis is multifactorial. The incidence of osteoarthritis reaches 6% in 30 years old population and increases due to aging. Degenerative disease, the reduction of function or structure of the tissue or organ due to aging, encourages the pain specialist to perform a reliable pain management/therapy. Prolotherapy, especially dextrose prolotherapy, has become a promising technique by providing a safe degenerative therapy, easy to performed, and highly available in health facilities. Nowadays, it is necessary to pay more attention to causative-based treatment strategies than symptom-based treatment. A multidisciplinary team is also needed to provide appropriate treatment.

Multidisciplinary consensus recommendations for the management of non-spine bone metastases: Results of a modified Delphi process in a community-academic partnership.

e24092 Background: Local therapy for bone metastases is becoming increasingly complex, but national guidelines remain limited. We leveraged a community-academic partnership to develop consensus recommendations for multidisciplinary treatment of non-spine bone metastases which are generalizable to diverse practice settings. Methods: We convened a group of 15 physicians (9 radiation oncologists, 2 orthopaedic surgeons, 2 medical oncologists, 1 interventional radiologist, 1 interventional pain specialist) treating bone metastases across 4 institutions from Apr 2020-Feb 2021. We distributed a survey to identify questions warranting consensus development in the treatment of non-spine bone metastases. A literature review was conducted to inform answer statements, and evidence was rated using the Strength of Recommendation Taxonomy. A modified Delphi process was employed to reach consensus defined (a priori) as ³75% of respondents indicating “agree” or “strongly agree”. Results: A total of 16 questions were identified, including indications for multidisciplinary discussion or referral (n=4), appropriate use and duration of RT (n=4), and handling of systemic therapies during RT (n=5). After 2 rounds of modified Delphi process, consensus has been reached on 9 questions (see Table). Strength of Recommendation was rated A (1/9, 11%), B (5/9, 56%), or C (3/9, 33%). Conclusions: Our consensus process provides guidance for management of non-spine bone metastases that expands upon current guidelines. We also highlight areas where prospective trials are needed, including the role of RT prior to stabilization surgery and the selection of patients for ablative treatment. [Table: see text]

Cancer, cancer pain and the ‘Cancer Pain Initiative’

The number of cancer patients has been steadily increasing and with it the number of cancer related pain patients is also increasing. Cancer pain (CP) is the most unique and versatile pain, regarding type, intensity, site, variations and the needed management modalities. No one pain specialist or the pain center can be capable of adequately manage every cancer patient. In this background, an idea to confront this menace at a national level with a combined effort is presented. If implemented it is hoped that the CP patients will get rid of at least the worry about their excruciating pain. The idea of the ‘Cancer Pain Initiative’ has been in circulation for quite some time, but needs to be discussed at various levels. Key words: Cancer; Cancer pain; Pain management Citation: Khan TH. Cancer, cancer pain and the ‘Cancer Pain Initiative’. Anaesth. pain intensive care 2021;25(2):126–12. DOI: 10.35975/apic.v25i2.1482

Making music to making lives better: A transition from musician to health professional

The day my pain specialist told me I would never be pain-free again, I knew my music career was over. I was 21 years old, and had been in constant pain for about two years. I had experienced intermittent jaw pain for about 10 years, but having braces on my teeth, and later having my wisdom teeth removed was supposed to fix it. It did not. The day of my surgery was the last time I had been pain free, even for a second. The years that followed were horrible, and my life was turned upside down.

A Rural Tele-Video Model: Results From Educating Practitioners About Opioids and Alternative Pain Management

Providers in Arkansas wrote 105.4 opioid prescriptions for every 100 persons in 2017-nearly twofold greater than the average U.S. rate of 58.7 opioid prescriptions (CDC, 2017). This makes AR the second highest opioid prescribing state. AR-IMPACT (Arkansas Improving Multi-Disciplinary Pain Care and Treatment) is a tele-video case conference education model which was designed to improve AR providers’ knowledge and behavior in pain management and improve awareness of opioid-sparing alternatives. Conference panelists include a geriatrician, psychiatrist, physical therapist, psychologist, pharmacist, a chronic pain specialist and various guest speakers such as the Arkansas Drug Director. During weekly tele-video conferences, relevant actionable cases were presented regarding treating diverse patients who have chronic pain. AR-IMPACT provided hundreds of practitioners with up-to-date data and education regarding opioid use and misuse, methods and resources regarding titrating and eliminating opioids, and viable alternative pain-management solutions such as motivational interviewing and dry-needling. This poster will present the background of the opioid crisis in rural Arkansas followed by the specifics of the development and application of the AR-IMPACT tele-video model. Specific older adult cases studies, quantitative and qualitative outcomes, feedback from presenters and participants, and lessons learned will be reviewed. Specifically, lessons learned center around the practitioners’ culture of pain management and how that culture must evolve and change. New methods of pain management must be taught to practitioners and patients and adopted as the new norm. This will demonstrate that programs like AR-IMPACT are crucial in helping make that cultural change happen.

Expert System for Mandibular Condyle Detection and Osteoarthritis Classification in Panoramic Imaging Using R-CNN and CNN

Temporomandibular joint osteoarthritis (TMJ OA) is a degenerative condition of the TMJ led by a pathological tissue response of the joint under mechanical loading. It is characterized by the progressive destruction of the internal surfaces of the joint, which can result in debilitating pain and joint noise. Panoramic imaging can be used as a basic screening tool with thorough clinical examination in diagnosing TMJ OA. This paper proposes an algorithm that can extract the condylar region and determine its abnormality by using convolutional neural networks (CNNs) and Faster region-based CNNs (R-CNNs). Panoramic images are collected retrospectively and 1000 images are classified into three categories—normal, abnormal, and unreadable—by a dentist or orofacial pain specialist. Labels indicating whether the condyle is detected and its location enabled more clearly recognizable panoramic images. The uneven proportion of normal to abnormal data is adjusted by duplicating and rotating the images. An R-CNN model and a Visual Geometry Group-16 (VGG16) model are used for learning and condyle discrimination, respectively. To prevent overfitting, the images are rotated ±10° and shifted by 10%. The average precision of condyle detection using an R-CNN at intersection over union (IoU) >0.5 is 99.4% (right side) and 100% (left side). The sensitivity, specificity, and accuracy of the TMJ OA classification algorithm using a CNN are 0.54, 0.94, and 0.84, respectively. The findings demonstrate that classifying panoramic images through CNNs is possible. It is expected that artificial intelligence will be more actively applied to analyze panoramic X-ray images in the future.

Point-of-care ultrasound for the pediatric regional anesthesiologist and pain specialist: a technique review

Point-of-care ultrasound (PoCUS) has been well described for adult perioperative patients; however, the literature on children remains limited. Regional anesthesiologists have gained interest in expanding their clinical repertoire of PoCUS from regional anesthesia to increasing numbers of applications. This manuscript reviews and highlights emerging PoCUS applications that may improve the quality and safety of pediatric care.In infants and children, lung and airway PoCUS can be used to identify esophageal intubation, size airway devices such as endotracheal tubes, and rule in or out a pulmonary etiology for clinical decompensation. Gastric ultrasound can be used to stratify aspiration risk when nil-per-os compliance and gastric emptying are uncertain. Cardiac PoCUS imaging is useful to triage causes of undifferentiated hypotension or tachycardia and to determine reversible causes of cardiac arrest. Cardiac PoCUS can assess for pericardial effusion, gross ventricular systolic function, cardiac volume and filling, and gross valvular pathology. When PoCUS is used, a more rapid institution of problem-specific therapy with improved patient outcomes is demonstrated in the pediatric emergency medicine and critical care literature.Overall, PoCUS saves time, expedites the differential diagnosis, and helps direct therapy when used in infants and children. PoCUS is low risk and should be readily accessible to pediatric anesthesiologists in the operating room.