Complete resolution of postherpetic neuralgia following pallidotomy: case report

The authors report on a female patient with left-dominant Parkinson’s disease with motor fluctuations and levodopa-induced dyskinesias and comorbid postherpetic neuralgia (PHN), who underwent a right-sided pallidotomy. Besides a substantial improvement in her Parkinson’s symptoms, she reported an immediate and complete disappearance of PHN. This neuralgia had been long-standing, pharmacologically refractory, and severe (preoperative Brief Pain Inventory [BPI] pain severity score of 8.0, BPI pain interference score of 7.3, short-form McGill Pain Questionnaire sensory pain rating index of 7 and affective pain rating index of 10, Present Pain Intensity rank value of 4, and visual analog scale score of 81 mm; all postoperative scores were 0). She continued to be pain free at 16 months postoperatively.This peculiar finding adds substantially to the largely unrecognized evidence for the role of the pallidum in pain processing, based on previous electrophysiological, metabolic, anatomical, pharmacological, and clinical observations. Therefore, the potential of the pallidum as a neurosurgical target for neuropathic pain warrants further investigation.

Patient Perception and Duration of Pain after Microdirect Laryngoscopy

Objective Postoperative pain is an important part of the patient’s surgical experience. The objective was to evaluate patient perception and duration of pain after microdirect laryngoscopy (MDL). Study Design Case series with planned data collection. Setting Tertiary care, academic center. Subjects and Methods Adult patients undergoing MDL were administered the short-form McGill Pain Questionnaire (SF-MPQ) before surgery and on postoperative days (PODs) 1, 3, and 7. Demographic and clinical data were collected. Results In total, 130 patients (mean age 52.6 years, 84 male) participated in the study. About 46.2% required analgesia on POD 1, but only 23.1% required opioids. Overall, mild levels of pain were reported on the SF-MPQ: sensory score, affective score, total score, present pain intensity (PPI), and visual analog scale (VAS). Patients reported a significant increase in pain on POD 1, with decreases in pain on PODs 3 and 7. Pain score returned to preoperative values for total score and affective score on POD 7 but remained significantly elevated for PPI, VAS, and sensory score. None of the following factors were associated with increased pain: age, sex, body mass index, Mallampati score, Cormack score, laryngoscope used, type of MDL, time under anesthesia, employment status, intubation, Voice Handicap Index 10, and chronic pain history. Conclusion Although mild levels of pain were reported after MDL, the pain persisted for up to 7 days. No demographic or clinical factors were found to be associated with increased pain. This study was one of the few prospective studies evaluating pain after MDL.

Multidimensional features of pain in patients with chronic neck pain

Introduction: Chronic neck pain is associated with significant health costs and loss of productivity at work. Objective: to assess pain and disability in individuals with chronic neck pain. Methods: 31 volunteers with chronic neck pain, mean age 29, 65 years, were assessed using the McGill Pain Questionnaire in Brazilian version (Br-MPQ) and Neck Disability Index (NDI). The Br-MPQ analysis was performed based on the numerical values associated with the words selected to describe the experience of pain (Pain Rating Index - PRI), and present pain intensity (PPI). NDI was used to evaluate the influence of neck pain in performance of everyday tasks. Finally, we investigated the association between PPI and NDI. Results: PRI revealed that the most significant dimension was the sensory pain (70%), and the number of chosen words was 10 (2,62) out of 20 words. Mean PPI value was 1,23 (0,76) in five points; 40% of participants described pain intensity as moderate. NDI score was 9,77 (3,34), indicating mild disability. There was a positive association between disability and pain intensity (r = 0,36; p =0,046). Pain intensity and duration of pain were not associated. Conclusions: Findings of this study identified important information related to neck pain experienced by patients when suffering from chronic neck pain, moreover, the association between disability and pain intensity reinforces the importance of complementary investigation of these aspects to optimize function in them.

Efficacy of Mindfulness-Based Cognitive Therapy on Late Post-Treatment Pain in Women Treated for Primary Breast Cancer: A Randomized Controlled Trial

Purpose To assess the efficacy of mindfulness-based cognitive therapy (MBCT) for late post-treatment pain in women treated for primary breast cancer. Methods A randomized wait list–controlled trial was conducted with 129 women treated for breast cancer reporting post-treatment pain (score ≥ 3 on pain intensity or pain burden assessed with 10-point numeric rating scales). Participants were randomly assigned to a manualized 8-week MBCT program or a wait-list control group. Pain was the primary outcome and was assessed with the Short Form McGill Pain Questionnaire 2 (SF-MPQ-2), the Present Pain Intensity subscale (the McGill Pain Questionnaire), and perceived pain intensity and pain burden (numeric rating scales). Secondary outcomes were quality of life (World Health Organization-5 Well-Being Index), psychological distress (the Hospital Depression and Anxiety Scale), and self-reported use of pain medication. All outcome measures were assessed at baseline, postintervention, and 3-month and 6-month follow-up. Treatment effects were evaluated with mixed linear models. Results Statistically significant time × group interactions were found for pain intensity (d = 0.61; P = .002), the Present Pain Intensity subscale (d = 0.26; P = .026), the SF-MPQ-2 neuropathic pain subscale (d = 0.24; P = .036), and SF-MPQ-2 total scores (d = 0.23; P = .036). Only pain intensity remained statistically significant after correction for multiple comparisons. Statistically significant effects were also observed for quality of life (d = 0.42; P = .028) and nonprescription pain medication use (d = 0.40; P = .038). None of the remaining outcomes reached statistical significance. Conclusion MBCT showed a statistically significant, robust, and durable effect on pain intensity, indicating that MBCT may be an efficacious pain rehabilitation strategy for women treated for breast cancer. In addition, the effect on neuropathic pain, a pain type reported by women treated for breast cancer, further suggests the potential of MBCT but should be considered preliminary.

Cabazitaxel in docetaxel-pretreated metastatic castration resistant prostate cancer (mCRPC): Canadian experience.

e16082 Background: Cabazitaxel/prednisone (CbzP) improves survival in docetaxel resistant mCRPC. Canadian investigators collected safety, QoL and efficacy data in patients (pts) from a global Expanded Access Program. Methods: Following progression on or after docetaxel, all pts received cabazitaxel 25 mg/m² IV q3wkly and prednisone 10 mg daily. Safety and QoL were collected at baseline and at each cycle. Adverse events were graded according to NCI CTCAE v 4.0. Present pain intensity (PPI) and analgesic scores were assessed using the McGill-Melzack questionnaire. QoL was assessed using FACT-P and EQ 5D-3L. PSA was done at the investigator's discretion at each cycle and at the end of treatment. Results: 61 pts were enrolled at 9 centers. Median age was 65 (18% ≥ 75); 92% were ECOG 0/1; 89% had bone metastases and 21% had visceral metastases. Pts had a median of 9 cycles (median cumulative dose 675 mg/m2) of prior docetaxel, and 38% had progressed on or within 3 months of it. Notably 26 pts (43%) had also received and progressed on prior Abiraterone Acetate (AA) given before (5pts), or after docetaxel (21 pts). Half the patients (51%) received >6 cycles of CbzP. Median relative dose intensity was 99%. At cycle 1, 31% received prophylactic G-CSF. Main grade 3+ toxicities were anemia 9.8%, diarrhea 8.2%, fatigue 8.2% and febrile neutropenia 6.6%. Peripheral neuropathy was uncommon (4.9% ; no grade 3+). There was 1 treatment related death (1.6%) due to abdominal sepsis. Compared to baseline, PPI scores improved despite stable analgesic use and were significant at cycles 2, 4, 9 (p<0.05). The FACT-P prostate specific questions showed significant improvements in the first 4 cycles (p<0.05). On the EQ-5D-3L the percentage of patients reporting “no problem” for the pain domain by the last cycle increased. The PSA response rate (≥50% decrease) was 48.7% in 39 evaluable pts and was similar in AA pretreated and non-pretreated pts (47.1% and 50.0% respectively). Conclusions: In routine clinical practice, CbzP treatment was clinically manageable and toxicities were similar to the TROPIC study. PPI and QoL data support a palliative benefit of CbzP. PSA response rate was 48.7% and similar in AA pretreated and non-pretreated pts.

Quality of life (QoL) of patients with metastatic castration resistant prostate cancer (mCRPC) treated with cabazitaxel.

e16088 Background: The effects of cabazitaxel on QoL, pain response and preference/utility data have not been well studied in men with CRPC treated post-docetaxel. As part of a single-arm multicenter Sanofi-funded Early Access Program (EAP) for cabazitaxel, QoL data were collected on Canadian patients. Methods: Between May 2011 and February 2012, 61 patients (pts) were enrolled at 9 centers. QoL was assessed at the start of each cycle using the FACT-P and its subscales, and the EQ 5D-3L. EQ 5D-3L health state index (HIS) data were converted into utility values (Canadian tariff, Bansback 2011). Present pain intensity (PPI) and analgesic scores were assessed using the McGill-Melzack questionnaire. Results: QoL data were evaluable in 55 pts. Baseline pt characteristics were: median age 65 years (range, 42-79), 92.7% of pts were ECOG PS 0 or 1, 87% had bone metastases, and 56% (31/55) received at least 6 cycles of cabazitaxel. Statistically significant changes from baseline in mean QoL scores were observed on FACT-P total score at cycle 2, and prostate cancer specific subscale (PCS) at cycles 1 to 4. As a measure of QoL response, increases were observed and maintained for > 2 consecutive cycles in 9% (>16 points) and 25% (≥10) of pts for FACT-P total score. Improvements to the level of Minimal Important Differences (MID) (Cella 2009) maintained for > 2 consecutive cycles were observed in 36% of pts for FACT-P total score (MID=6), 49% for PCS subscale (MID=2), and 26% for PCS-Pain subscale (MID=2), respectively. The percentage of pts reporting "no problem" in the EQ-5D pain/discomfort domain were above baseline levels at every cycle and improved from baseline to end of treatment from 19% to 29% (p < 0.05). Other EQ-5D dimensions (anxiety/depression, mobility, self-care and usual activities) remained stable over the course of treatment. Improvement from baseline in utility value (HIS) was observed at cycle 4 with a utility value of 0.769 (vs 0.713 at baseline). PPI scores improved despite stable analgesic use and were significantly different from baseline at cycles 2, 4 and 9. Conclusions: Data from this EAP suggest improvements in QoL, pain and prostate cancer specific symptoms with second-line cabazitaxel treatment. Clinical trial information: NCT01254279.

Multivariate Prognostic Modeling of Persistent Pain Following Lumbar Discectomy

Background: Persistent postsurgical pain (PPSP) affects between 10% and 50% of surgical patients, the development of which is a complex and poorly understood process. To date, most studies on PPSP have focused on specific surgical procedures where individuals do not suffer from chronic pain before the surgical intervention. Individuals who have a chronic nerve injury are likely to have established peripheral and central sensitization which may increase the risk of developing PPSP. Concurrent analyses of the possible factors contributing to the development of PPSP following lumbar discectomy have not been examined. Objective: The aim of this study is to identify risk and protective factors that predict the course of recovery following lumbar discectomy and to develop an easily applicable preoperative multivariate prognostic model for the occurrence of PPSP in this patient cohort. Study Design: A prospective study of elective lumbar discectomy with a 3 month follow-up. Setting: University setting in Ireland Methods: All ASA I-II patients, (n = 53, 18-65 years old), undergoing elective lumbar discectomy at a single institute were included and followed for a 3 month period postsurgery. Preoperative potential predictors were collected: age, gender, pain intensity (McGill score, visual analog scale [VAS], Present Pain Intensity), degree of dysfunction (Roland-Morris Function score), psychological status (pain catastrophizing, anxiety, and depression scores), health-related quality of life (SF36), quantitative sensory testing (QST), inflammatory biomarkers, and a genetic pain profile. The proposed primary outcome was significant pain reduction (VAS > 70%) 3 months following surgery compared to the preoperative pain intensity. Results: A final prediction model was obtained using a multivariate logistic regression in combination with bootstrapping techniques for internal validation. Twenty (37.7%) patients developed PPSP. Independent predictor factors included age (odds ratio [OR] = 1.0 per year), present pain intensity (OR = 0.6), and degree of dysfunction (OR = 1.2). The concordance index C (.658) supports a good monotonic association (where perfect prediction is 1) and the Akaike’s information criteria indicated a good fit of the model. Inclusion of additional measured parameters (QST, biomarker, or genotyping) did not improve the model. Limitations: Before this internally validated model can be integrated into clinical practice, and used for patient counselling and quality assurance purposes, external validation studies are necessary. Conclusions: We demonstrated that the occurrence of PPSP can be predicted using a small set of variables easily obtained at the preoperative visit. This a prediction rule that could further optimize perioperative pain treatment and reduce attendant complications by allowing the preoperative classification of surgical patients according to their risk of developing PPSP. Key words: Persistent post surgical pain, predictive modeling, prognostic, lumbar discectomy

Use of pain at baseline and pain progression to predict overall survival (OS) in patients (pts) with docetaxel pretreated metastatic castration-refractory prostate cancer (CRPC): Results from the SPARC trial

5148 Background: First-line chemotherapy trials have reported that pain predicts OS in CRPC. We report relationships between OS and baseline pain –a major component of CRPC patient reported outcomes (PRO) –and pain at progression, for docetaxel pre-treated patients in a second-line chemotherapy trial in CRPC. Methods: Docetaxel pre-treated pts (N = 488) were analyzed from the multi-national, randomized, double-blind SPARC trial, comparing second-line satraplatin + prednisone vs placebo + prednisone in 950 metastatic CRPC pts. Daily pain intensity and narcotic analgesic use were recorded as a PRO from one week prior to randomization until end-of-study. Pain was measured by the 6-point Present Pain Intensity (PPI) component of the McGill-Melzack Pain Questionnaire. After randomization, weekly PPI scores were calculated as the mean of the daily PPI scores (using ≥3 daily measurements/week). Baseline pain was the mean of ≥5 daily PPI scores recorded during 7 days preceding randomization. An independent blinded review committee (IRC) determined pain progression (defined as an increase in weekly PPI score ≥1 point from baseline or ≥2 points from nadir, or a >25% increase from baseline in weekly average analgesic score for ≥2 consecutive weeks). To examine the effects of pain on OS, pts were categorized as “no pain” (PPI ≤1) or pain (PPI ≥2) by baseline assessment; and, as either pain progressors or pain non-progressors. Results: Shortened OS was observed in pts with baseline pain; median survival of 178 pts with pain was 44 weeks vs 72 weeks for 287 pts without pain (Strat. Log-rank p < 0.0001, Strat. HR 0.59; 95% CI: 0.48–0.74). IRC found disease progression in 414 (84.4%) of the docetaxel pre-treated pts with 196 of these pts showing pain progression. Pain progression was strongly linked to OS with 196 pain progressors having median OS of 47 weeks compared to 71 weeks for 292 pain non-progressors (Strat. Log-Rank p = 0.0022; Strat. HR 0.71; 95% CI: 0.57–0.87). Conclusions: Both pain at baseline and pain at progression are important prognostic indicators of OS in metastatic CRPC pts failing first-line docetaxel. [Table: see text]