Vertebroplastia percutánea en fracturas vertebrales osteoporóticas / Percutaneous vertebroplasty for osteoporotic vertebral fractures

La osteoporosis es una enfermedad sistémica que deteriora la calidad del hueso y su arquitectura. Como consecuencia, predispone a fracturas por fragilidad, entre las cuales las fracturas vertebrales son frecuentes. Estas se asocian a una gran morbimortalidad. La vertebroplastia ha surgido en 1984 como alter-nativa terapéutica para tratar algunos tumores vertebrales y fracturas vertebrales osteoporóticas dolorosas. Este procedimiento consiste en la inyección de cemento guiado por imágenes, para estabilizar la vértebra fracturada y disminuir el dolor. La vertebroplastia puede ser realizada con anestesia local, sedación o anestesia general. La fuga de cemento fuera de la vértebra es una complicación común; sin embargo esto no suele tener traducción clínica y solamente se trata de un hallazgo imagenológico. En este artículo revisaremos las indicaciones, contraindicaciones, la eficacia, controversias y las complicaciones de la vertebroplastia percutánea. (AU)

Osteoporosis is a systemic disease characterized by bone quality deterioration. As a consequence of this deterioration, osteoporosis results in high fracture risk due to bone fragility. Fractures to the spine are common in this scenario, and relate to an increased morbi-mortality. Vertebroplasty emerged in 1984 as an alternative to treat painful vertebral tumors and osteoporotic vertebral fractures. This procedure relies on image guided cement injection to achieve pain relief and strengthen the vertebral body. Vertebroplasty can be performed under local anesthesia, mild sedation, or general anesthesia. Among its complications, cement leakage is common but it is rarely associated with any symptoms and it is usually an imaging finding. In this article, we will review indications and contraindications, effectiveness, controversies and complications related to percutaneous vertebroplasty. (AU)

Conventional endodontic retreatment of persistent pain on previously treated tooth in an elderly patient: A case report

@#Clinical evaluation for a successful root canal treatment is assessed by various criteria, which are clinical, histopathological, and radiographical criteria. Therefore, failure of endodontic treatment can be described as a recurrence of clinical symptoms, with the presence of a periapical radiolucency or both. Failure factors in the treatment are frequently related to persistent infection. Conventional endodontic retreatment is indicated for symptomatic previously treated teeth or asymptomatic teeth with inadequately done initial endodontic treatment to avoid potential recurrence. Endodontic retreatment in elderly patients is a great challenge because the clinician has to reassure both the physical and psychological factors of the patient to determine whether to save a tooth or perform an extraction. Some difficulties may also be found in root canal retreatment, including finding the root canal hole or root canal blockage found in parts of the root canal that have not been repaired in the previous treatment. A 60-year-old female patient came with the chief complaint of recurrent pain, and subjective discomfort in the maxillary left central incisor. The patient had anxiety about the dental treatment. The tooth had a history of root canal treatment four months ago. The clinical examination showed a positive response to the percussion test. The radiographical analysis showed a root canal underfilling, 2-3 mm short of length from the apex. The tooth was diagnosed as a previously treated tooth with symptomatic apical periodontitis. Endodontic retreatment was performed based on the patient’s clinical condition and consent, followed by composite restoration. The clinical and radiographic re-evaluation after four weeks of follow-up revealed an excellent condition. This favorable result showed that a conventional retreatment plan of persistent pain on the previously treated tooth in an elderly patient led to progressive healing, and a longer follow-up was advised.

Role of neuron and non-neuronal cell communication in persistent orofacial pain

It is well known that trigeminal nerve injury causes hyperexcitability in trigeminal ganglion neurons, which become sensitized. Long after trigeminal nerve damage, trigeminal spinal subnucleus caudalis and upper cervical spinal cord (C1/C2) nociceptive neurons become hyperactive and are sensitized, resulting in persistent orofacial pain. Communication between neurons and non-neuronal cells is believed to be involved in these mechanisms. In this article, the authors highlight several lines of evidence that neuron-glial cell and neuron macrophage communication have essential roles in persistent orofacial pain mechanisms associated with trigeminal nerve injury and/or orofacial inflammation.

Personality, coping and atypical facial pain. Case reports / Personalidade, enfrentamento e dor facial atípica. Relato de casos

ABSTRACT BACKGROUND AND OBJECTIVES: Idiopathic facial pain is a chronic condition with unknown etiology and pathophysiology. Its diagnostic criteria depend on the exclusion of any somatic cause of orofacial pain. Several studies have investigated anxiety and depression, but there is a lack of publications about personality. The objective of this study was to describe three cases of patients with idiopathic facial pain that had their temperament and character evaluated in order to verify the relation between the findings with pain behavior and pain characteristics. The instruments used were a free interview and the Temperament and Character Inventory. CASE REPORTS: Case 1 was proactive and had high scores of cooperativity and self-transcendence correspondent to the well-coping behavior. On the other side, cases 2 and 3 showed similarities about their harm avoidance, novelty seeking and poor coping, correspondent to a self-protective insecure personality. CONCLUSION: These cases show the importance of personality assessment in order to determine coping strategies in complex chronic facial pain such as idiopathic facial pain.

RESUMO JUSTIFICATIVA E OBJETIVOS: Dor facial idiopática persistente é uma condição crônica cujas etiologia e fisiopatologia permanecem obscuras. Os critérios diagnósticos dependem da exclusão de todas as possíveis causas somáticas de dor orofacial. Vários estudos investigaram frequentes comorbidades psiquiátricas como ansiedade e depressão, mas há carência de estudos que tenham observado aspectos de personalidade nesses doentes. O objetivo deste estudo foi descrever três casos de pacientes com dor facial idiopática persistente que foram avaliados quanto a traços de personalidade e de caráter, bem como a associação desses traços com as características da dor e o comportamento doloroso. Os instrumentos utilizados foram a entrevista livre e o Inventário de Caráter e Temperamento de Cloninger. RELATO DOS CASOS: O caso 1 apresentava traços de proatividade e altos índices de cooperatividade e autotranscendência, correspondentes com seu perfil de bom enfrentamento. Por outro lado, os casos 2 e 3 apresentaram similaridades quanto à evitação de dor, busca por novidades e enfrentamento pobre, o que correspondeu a uma personalidade insegura e autoprotetora. CONCLUSÃO: Esses casos mostram a importância de abordar a personalidade do paciente para que estratégias de enfrentamento adequadas sejam estabelecidas para a dor facial crônica complexa.

A Case of Persistent Pain After Operation of Dissecting Thoracic Aortic Aneurysm Successfully Treated with Oriental Medicine / 日本東洋医学雑誌

Postsurgical persistent pain, once entrenched, may be resistant to western medical treatments. A 39-year-old man who underwent thoracic repair with blood vessel prosthesis for dissecting aneurysm was presented to our pain clinic due to postoperative persistent pain. He complained his pain mainly around the sternum on which skin became keloid scar and presented tactile allodynia. Initially, we treated the patient with pregabalin, duloxetine and tramadol/acetaminophen fixed-dose combination tablets, leading to no pain relief. Then, we started the treatments with Kampo medicine as well as Yamamoto New Scalp Acupuncture and Unblocking acupuncture. We initially treated him with keishibukuryogan (TJ-23 ; Tsumura ®, Japan) and saikokeishito (TJ-10 ;Tsumura ®, Japan) based on the signs of blood stasis, hypochondrial resistance and pain, but no relief of pain was obtained. Thus, we administered ogikeishigomotsuto in addition to the above Kampo formulas. His pain was gradually decreased with increasing doses of ogi from 3 to 10 g/day and aconite tuber from 1.5 to 6 g/day due to cold sensation, and finally disappeared at 20 months since the start of Kampo treatments. The duration of effectiveness for relieving his pain with acupuncture was gradually increased in proportion to his pain relief. Our experiences suggest that ogikeishigomotsuto with aconite tuber as well as acupuncture may be optimal treatments for the patients with cold sensation suffering from postsurgical persistent pain.

The Analgesic Effect of a Curcumin Analogue 1,5-bis(4’-hydroxy-3’-methoxyphenyl)-1,4-pentadien-3-on (Gamavuton-0) in acute and persistent pain.

Gamavuton-0 (GVT-0), a curcumin analogue, has been reported to have antiinflammatory and antioxidant activity, however, its analgesic activity has not yet been investigated. This research purpose is to study the effect of GVT-0 on acute and persistent pain using Modified Hot Plate (MHP) method and Formalin test, respectively, on male Swiss mice. In MHP method, the five groups of animals were pretreated with GVT-0 (10, 20, 40, and 80 mg/kg, orally) and indomethacin (4 mg/kgBB, i.p, for positive control), respectively, and immediately followed by stimulation with the carrageenan in sterile saline with a final volume of 50 μl in the left paw. The animals were then placed in hot plate (51oC). The latency time was determined at 90 min post-challenge. In the Formalin test, the six groups of animals were pretreated with GVT-0 (10, 20, 40 and 80 mg/kg, orally), morphine (5 mg/kgBB, i.p), and indomethacin (4 mg/kgBB, i.p) respectively, 60 min prior to the injection of 1.0% aqueous formalin (20 μl) administered by the intraplantar route into the right hindpaw. The licking time was measured at the first 5 min (initial phase, neurogenic) and 10-30 min after formalin injection (late phase, inflammatory). Result showed that GVT-0 has analgesic effect on acute pain using MHP method with ED50 of 27,69 mg/kgBW (p.o). While using Formalin test, GVT-0 showed analgesic activity with ED50 of 109,02 mg/kgBW (p.o) in initial phase, and ED50 of 13,53 mg/kgBW (p.o) in late phase. These results suggest that GVT-0 is a potential candidate for new antiinflammatory and analgesic agent that can be used for the treatment of different painful condition.

Attenuated Glial K+ Clearance Contributes to Long-Term Synaptic Potentiation Via Depolarizing GABA in Dorsal Horn Neurons of Rat Spinal Cord

It has been reported that long-term enhancement of superficial dorsal horn (DHs) excitatory synaptic transmission underlies central sensitization, secondary hyperalgesia, and persistent pain. We tested whether impaired clearance of K+ and glutamate by glia in DHs may contribute to initiation and maintenance of the CNS pain circuit and sensorimotor abnormalities. Transient exposure of the spinal cord slice to fluorocitrate (FC) is shown to be accompanied by a protracted decrease of the DHs optical response to repetitive electrical stimulation of the ipsilateral dorsal root, and by a similarly protracted increase in the postsynaptic response of the DHs like LTP. It also is shown that LTP(FC) does not occur in the presence of APV, and becomes progressively smaller as [K+]o in the perfusion solution decreased from 3.0 mM to 0.0 mM. Interestingly LTP(FC) is reduced by bath application of Bic. Whole-cell patch recordings were carried out to evaluate the effects of FC on the response of DHs neurons to puffer-applied GABA. The observations reveal that transient exposure to FC is reliably accompanied by a prolonged (>1 hr) depolarizing shift of the equilibrium potential for the DHs neuron transmembrane ionic currents evoked by GABA. Considered collectively, the findings demonstrate that LTP(FC) involves (1) elevation of [K+]o in the DHs, (2) NMDAR activation, and (3) conversion of the effect of GABA on DHs neurons from inhibition to excitation. It is proposed that a transient impairment of astrocyte energy production can trigger the cascade of dorsal horn mechanisms that underlies hyperalgesia and persistent pain.

Dor crônica pós-operatória: relato de casos / Postoperative chronic pain: case reports.

JUSTIFICATIVA E OBJETIVOS: A prevalência da dor crônica pós-operatória é alta e envolve vários mecanismos relacionados ao paciente e ao procedimento cirúrgico realizado. O objetivo deste estudo foi relatar dois casos de dor crônica pós-operatória em tipos diferentes de procedimento cirúrgicos.RELATO DOS CASOS: Caso 1: Paciente do sexo masculino, 38 anos, submetido a tratamento cirúrgico de fratura fechada de punho esquerdo. Evoluiu com dor contínua, de forte intensidade, queimação e choque, nos 1º e 2º quirodáctilos, sendo reoperado após 30 e 60 dias, devido à dor. Houve piora do quadro doloroso e dificuldade à movimentação do punho, com dor em queimação no antebraço e mão esquerdos, de forte intensidade, contínua, associada a episódios dolorosos paroxísticos iniciados na cicatriz cirúrgica irradiando para todo o antebraço e mão. A telerradiografia do punho esquerdo mostrou correção anatômica da fratura e a eletroneuromiografia (ENM), lesão do nervo radial superficial. Foi feito bloqueio do gânglio estrelado (BGE), amitriptilina (25 mg/dia) e alongamentos do punho, antebraço e braço que proporcionou alivio parcial da dor. Caso 2: Paciente do sexo feminino, 63 anos, submetida à blefaroplastia superior e inferior bilateral com objetivo estético, evoluiu com dor periorbitária, em queimação e choque. Na primeira avaliação, a paciente relatou sentir, desde o pós-operatório imediato, dor em queimação, contínua de moderada intensidade, que se exacerbava ao toque e ao frio e dor em choque, de moderada intensidade agravada pelo ato de piscar. Tratada com gel tópico de amitriptilina a 2%, duas vezes ao dia com alívio completo da dor em queimação.CONCLUSÃO: Dor iniciada no pós-operatório imediato de forte intensidade com lesão nervosa confirmada no primeiro caso e presumida no segundo, alerta para a importância de medidas preventivas cirúrgicas e anestésicas para diminuir a ocorrência da dor crônica pós-operatória.

BACKGROUND AND OBJECTIVES: Postoperative chronic pain prevalence is high and involves several mechanisms related to patients and to surgical procedures. This study aimed at reporting two postoperative chronic pain cases after different surgical procedures.CASE REPORTS: Case 1: Male patient, 38 years old, submitted to surgical treatment of left wrist closed fracture. He evolved with continuous and severe pain, burning and shock in first and second fingers being re-operated after 30 and 60 days due to pain. There has been worsening of pain and difficulty to move the wrist, with severe burning pain in left forearm and hand, associated to paroxysmal painful episodes starting at the surgical scar and irradiating to the whole forearm and hand. Left wrist teleradiography showed anatomic correction of fracture and electroneuromyography (ENM) should superficial radial nerve injury. Stellate ganglion was blocked (SGB), amitriptyline (25 mg/day) and wrist, forearm and arm elongation, which provided partial pain relief. Case 2: Female patient, 63 years old, submitted to bilateral upper and lower cosmetic blepharoplasty, who evolved with periorbital burning and shock pain. During the first evaluation patient reported feeling moderate burning pain since the immediate postoperative period, which was exacerbated by touch and cold, and moderate shock pain worsened by blinking. Patient was treated with amitriptyline topic gel at 2% twice a day with total burning pain relief. CONCLUSION: Severe pain started in the immediate postoperative period with confirmed nervous injury in the first case and presumed nervous injury in the second, calling the attention to the importance of surgical and anesthetic preventive measures to decrease the incidence of postoperative chronic pain.

Superoxide and Nitric Oxide Involvement in Enhancing of N-methyl-D-aspartate Receptor-Mediated Central Sensitization in the Chronic Post-ischemia Pain Model

BACKGROUND: Recent studies indicate that reactive oxygen species (ROS) are involved in persistent pain, including neuropathic and inflammatory pain. Since the data suggest that ROS are involved in central sensitization, the present study examines the levels of activated N-methyl-D-aspartate (NMDA) receptors in the dorsal horn after an exogenous supply of three antioxidants in rats with chronic post-ischemia pain (CPIP). This serves as an animal model of complex regional pain syndrome type-I induced by hindpaw ischemia/reperfusion injury. METHODS: The application of tight-fitting O-rings for a period of three hours produced CPIP in male Sprague-Dawley rats. Allopurinol 4 mg/kg, allopurinol 40 mg/kg, superoxide dismutase (SOD) 4,000 U/kg, N-nitro-L-arginine methyl ester (L-NAME) 10 mg/kg and SOD 4,000 U/kg plus L-NAME 10 mg/kg were administered intraperitoneally just after O-ring application and on the first and second days after reperfusion. Mechanical allodynia was measured, and activation of the NMDA receptor subunit 1 (pNR1) of the lumbar spinal cord (L4-L6) was analyzed by the Western blot three days after reperfusion. RESULTS: Allopurinol reduced mechanical allodynia and attenuated the enhancement of spinal pNR1 expression in CPIP rats. SOD and L-NAME also blocked spinal pNR1 in accordance with the reduced mechanical allodynia in rats with CPIP. CONCLUSION: The present data suggest the contribution of superoxide, produced via xanthine oxidase, and the participation of superoxide and nitric oxide as a precursor of peroxynitrite in NMDA mediated central sensitization. Finally, the findings support a therapeutic potential for the manipulation of superoxide and nitric oxide in ischemia/reperfusion related pain conditions.