Consensus recommendations for managing osteoarthritic pain with topical NSAIDs in Asia-Pacific.

Osteoarthritis prevalence is expected to increase markedly in the Asia-Pacific region due to rapid population aging. Identifying effective and safe therapeutic options to manage osteoarthritic pain is viewed as a priority. The Asia-Pacific Experts on Topical Analgesics Advisory Board developed consensus statements for use of topical NSAIDs in musculoskeletal pain. Evidence supporting these statements in osteoarthritic pain was reviewed. Best available evidence indicates that topical NSAIDs have a moderate effect on relief of osteoarthritic pain, comparable to that of oral NSAIDs but with a better risk-to-benefit ratio. International clinical practice guidelines recommend topical NSAIDs on par with or ahead of oral NSAIDs for pain management in patients with knee and hand osteoarthritis, and as the first-line choice in persons aged ≥75 years.

Monoclonal antibodies for chronic pain: a practical review of mechanisms and clinical applications.

Context: Monoclonal antibodies are being investigated for chronic pain to overcome the shortcomings of current treatment options. Objective: To provide a practical overview of monoclonal antibodies in clinical development for use in chronic pain conditions, with a focus on mechanisms of action and relevance to specific classes. Methods: Qualitative review using a systematic strategy to search for randomized controlled trials, systematic and nonsystematic (narrative) reviews, observational studies, nonclinical studies, and case reports for inclusion. Studies were identified via relevant search terms using an electronic search of MEDLINE via PubMed (1990 to June 2017) in addition to hand-searching reference lists of retrieved systematic and nonsystematic reviews. Results: Monoclonal antibodies targeting nerve growth factor, calcitonin gene-related peptide pathways, various ion channels, tumor necrosis factor-α, and epidermal growth factor receptor are in different stages of development. Mechanisms of action are dependent on specific signaling pathways, which commonly involve those related to peripheral neurogenic inflammation. In clinical studies, there has been a mixed response to different monoclonal antibodies in several chronic pain conditions, including migraine, neuropathic pain conditions (e.g., diabetic peripheral neuropathy), osteoarthritis, chronic back pain, ankylosing spondylitis, and cancer. Adverse events observed to date have generally been mild, although further studies are needed to ensure safety of monoclonal antibodies in early stages of development, especially where there is an overlap with non-pain-related pathways. High acquisition cost remains another treatment limitation. Conclusion: Monoclonal antibodies for chronic pain have the potential to overcome the limitations of current treatment options, but strategies to ensure their appropriate use need to be determined.

Critical Values of Facet Joint Angulation and Tropism in the Development of Lumbar Degenerative Spondylolisthesis: An International, Large-Scale Multicenter Study by the AOSpine Asia Pacific Research Collaboration Consortium.

STUDY DESIGN: An international, multicenter cross-sectional image-based study performed in 33 institutions in the Asia Pacific region. OBJECTIVE: The study addressed the role of facet joint angulation and tropism in relation to L4-L5 degenerative spondylolisthesis (DS). METHODS: The study included 349 patients (63% females; mean age: 61.8 years) with single-level DS; 82 had no L4-L5 DS (group A) and 267 had L4-L5 DS (group B). Axial computed tomography and magnetic resonance imaging were utilized to assess facet joint angulations and tropism (i.e., asymmetry between facet joint angulations) between groups. RESULTS: There was a statistically significant difference between group A (left mean: 46.1 degrees; right mean: 48.2 degrees) and group B (left mean: 55.4 degrees; right mean: 57.5 degrees) in relation to bilateral L4-L5 facet joint angulations (p < 0.001). The mean bilateral angulation difference was 7.4 and 9.6 degrees in groups A and B, respectively (p = 0.025). A critical value of 58 degrees or greater significantly increased the likelihood of DS if unilateral (adjusted OR: 2.5; 95% CI: 1.2 to 5.5; p = 0.021) or bilateral facets (adjusted OR: 5.9; 95% CI: 2.7 to 13.2; p < 0.001) were involved. Facet joint tropism was found to be relevant between 16 and 24 degrees angulation difference (adjusted OR: 5.6; 95% CI: 1.2 to 26.1; p = 0.027). CONCLUSIONS: In one of the largest studies assessing facet joint orientation in patients with DS, greater sagittal facet joint angulation was associated with L4-L5 DS, with a critical value of 58 degrees or greater increasing the likelihood of the condition for unilateral and bilateral facet joint involvement. Specific facet joint tropism categories were noted to be associated with DS.

Is lumbar facet joint tropism developmental or secondary to degeneration? An international, large-scale multicenter study by the AOSpine Asia Pacific Research Collaboration Consortium.

BACKGROUND: Facet joint tropism is asymmetry in orientation of the bilateral facets. Some studies have shown that tropism may increase the risk of disc degeneration and herniations, as well as degenerative spondylolisthesis (DS). It remains controversial whether tropism is a pre-existing developmental phenomena or secondary to progressive remodeling of the joint structure due to degenerative changes. As such, the following study addressed the occurrence of tropism of the lower lumbar spine (i.e. L3-S1) in a degenerative spondylolisthesis patient model. METHODS: An international, multi-center cross-sectional study that consisted of 349 patients with single level DS recruited from 33 spine institutes in the Asia Pacific region was performed. Axial MRI/CT from L3-S1 were utilized to assess left and right facet joint sagittal angulation in relation to the coronal plane. The angulation difference between the bilateral facets was obtained. Tropism was noted if there was 8° or greater angulation difference between the facet joints. Tropism was noted at levels of DS and compared to immediate adjacent and distal non-DS levels, if applicable, to the index level. Age, sex-type and body mass index (BMI) were also noted and assessed in relation to tropism. RESULTS: Of the 349 subjects, there were 63.0 % females, the mean age was 61.8 years and the mean BMI was 25.6 kg/m(2). Overall, 9.7, 76.5 and 13.8 % had L3-L4, L4-L5 and L5-S1 DS, respectively. Tropism was present in 47.1, 50.6 and 31.3 % of L3-L4, L4-L5 and L5-S1 of levels with DS, respectively. Tropism involved 33.3 to 50.0 % and 33.3 to 58.8 % of the immediate adjacent and most distal non-DS levels from the DS level, respectively. Patient demographics were not found to be significantly related to tropism at any level (p > 0.05). CONCLUSIONS: To the authors' knowledge, this is one of the largest studies conducted, in particular in an Asian population, addressing facet joint tropism. Although levels with DS were noted to have tropism, immediate adjacent and distal levels with no DS also exhibited tropism, and were not related to age and other patient demographics. This study suggests that facet joint tropism or perhaps subsets of facet joint orientation may have a pre-disposed orientation that may be developmental in origin or a combination with secondary changes due to degenerative/slip effects. The presence of tropism should be noted in all imaging assessments, which may have implications in treatment decision-making, prognostication of disease progression, and predictive modeling. Having a deeper understanding of such concepts may further elaborate on the precision phenotyping of the facets and their role in more personalized spine care. Additional prospective and controlled studies are needed to further validate the findings.

An International Multicenter Study Assessing the Role of Ethnicity on Variation of Lumbar Facet Joint Orientation and the Occurrence of Degenerative Spondylolisthesis in Asia Pacific: A Study from the AOSpine Asia Pacific Research Collaboration Consortium.

Study Design A multinational, multiethnic, cross-sectional image-based study was performed in 33 institutions, representing 10 countries, which were part of the AOSpine Asia Pacific Research Collaboration Consortium. Objective Lumbar facet joint orientation has been reported to be associated with the development of degenerative spondylolisthesis (DS). The role of ethnicity regarding facet joint orientation remains uncertain. As such, the following study was performed across a wide-ranging population base to assess the role of ethnicity in facet joint orientation in patients with DS in the Asia Pacific region. Methods Lateral standing X-rays and axial magnetic resonance imaging scans were obtained for patients with lumbar DS. The DS parameters and facet joint angulations were assessed from L3-S1. Sex, age, body mass index (BMI), and ethnicity were also noted. Results The study included 371 patients with known ethnic origin (mean age: 62.0 years; 64% males, 36% females). The mean BMI was 25.6 kg/m(2). The level of DS was most prevalent at L4-L5 (74.7%). There were 28.8% Indian, 28.6% Japanese, 18.1% Chinese, 8.6% Korean, 6.5% Thai, 4.9% Caucasian, 2.7% Filipino, and 1.9% Malay patients. Variations in facet joint angulations were noted from L3 to S1 and between patients with and without DS (p < 0.05). No differences were noted with regards to sex and overall BMI to facet joint angulations (p > 0.05); however, increasing age was found to increase the degree of angulation throughout the lumbar spine (p < 0.05). Accounting for age and the presence or absence of DS at each level, no statistically significant differences between ethnicity and degree of facet joint angulations from L3-L5 were noted (p > 0.05). Ethnic variations were noted in non-DS L5-S1 facet joint angulations, predominantly between Caucasian, Chinese, and Indian ethnicities (p < 0.05). Conclusions This study is the first to suggest that ethnicity may not play a role in facet joint orientation in the majority of cases of DS in the Asia-Pacific region. Findings from this study may facilitate future comparative studies in other multiethnic populations. An understanding of ethnic variability may assist in identifying those patients at risk of postsurgical development or progression of DS. This study also serves as a model for large-scale multicenter studies across different ethnic groups and cultural boundaries in Asia.

Result of percutaneous disc decompression using nucleoplasty in Thailand: a randomized controlled trial.

BACKGROUND: Chronic low back pain is a major social, economic and healthcare issue in the Thailand. Percutaneous techniques are rapidly replacing traditional open surgery in operations requiring discectomy, decompression and fusion. The percutaneous access to the disc was first used in the 1950s to biopsy the disc with needles. Percutaneous access to the disc using endoscopic techniques was developed in the 1970s. Nucleoplasty has emerged as one of the minimally invasive techniques for treatment of low back pain and lower extremity pain due to contained herniated discs which utilizes coblation technology for ablating and coagulating the nucleus for a partial disc removal. OBJECTIVE: Evaluate the effectiveness of Nucleoplasty on pain in activity and improvement in MRI in patients with radicular or axial low back pain secondary to contained herniated discs. DESIGN: Prospective, Randomized, Control Trial. MATERIAL AND METHOD: Sixty-four patients were randomized in two groups equally. Thirty-two patients had undergone Nucleoplasty and another thirty-two patients had undergone conservative treatment. Patients were evaluated at 1, 3, 6 and 12 months postoperatively and were asked to quantify their pain using a visual analog scale ranging from 0 to 10. Data were compared between baselines and at 1, 3, 6 and 12 months post-treatment. Pre-nucleoplasty MRI and Post-nucleoplasty 3 months were compared to evaluate the decrease of bulging disc. RESULTS: Reported pain and medication use were significantly decreased and functional status was improved at 1, 3, 6 and 12 months following Nucleoplasty (p-values < or = 0. 001 for all outcome measures at all time periods) and also the bulging disc was significantly decreased 3 months following nucleoplasty. CONCLUSION: Nucleoplasty appears to be safe and effective in Thailand. Is an effective procedure for patients presenting with discogenic back and/or radicular pain that have failed conservative therapies and are not considered candidates for open surgical interventions. A result of this analysis indicated that PDD using Coblation technology, also referred to as nucleoplasty, is an effective procedure for patients presenting with discogenic back and/or leg pain who have failed conservative therapies and are not considered candidates for open surgical interventions.

The effect of learning curve on the results of percutaneous transforaminal endoscopic lumbar discectomy.

OBJECTIVE: To demonstrate the correlation of postoperative visual analog scale (VAS) of leg pain and adequacy of disc decompression with the learning curve of the surgeon who performed PTELD. MATERIAL AND METHOD: The authors retrospectively reviewed 50 matched criteria patients arranged into 5 groups which were categorized by the period of operation from January 2010 to May 2011 successively. Each patient's preoperative and postoperative VAS of leg pain at 1-week, 3-week, and 6-week follow-up were analyzed and demonstrated the correlation with the learning curve. Additionally, the authors also showed the alteration of thecal sac expansion between the preoperative and the postoperative MRI to demonstrate the learning curve during the different operative period. RESULTS: The VAS of leg pain as well as the mean differences of VAS of leg pain in each groups of patient were improved at each postoperative period follow-up and have a statistically significant improvement at 6-week follow-up. When the authors analyzed the mean differences VAS at pre- and post-operative 6-week follow-up among each groups of patients, it demonstrated that the learning curve had the progressive effect on the result of the operation. Also for the adequacy of disc decompression, the improvement of the thecal sac expansion was established when the amount of surgical volume was increased. CONCLUSION: The amount of surgical volume in focus of PTELD has an influence in the improvement of the VAS of leg pain and the adequacy of disc decompression. However, the patient selection such as types of disc herniation is also play an important role in accomplishment.

Cross-cultural adaptation to the Thai language of the neuropathic pain diagnostic questionnaire (DN4).

OBJECTIVE: To cross-culturally adapt the neuropathic pain diagnostic questionnaire (DN4) to Thai language MATERIAL AND METHOD: Phase 1: Forward and backward translation followed by assessment of semantic equivalence. Phase 2: Testing of the questionnaire in 30 neuropathic pain patients who were seen and diagnosed by experts, followed by modifications to produce a final version. RESULTS: All the Thai translated pain descriptors except 'tingling' got high percentages of understanding among neuropathic pain patients in the first round of testing. After some adaptation of the Thai word for 'tingling' had been made, the new translated word was retested, and all subjects doing the retest understood the word very well. CONCLUSION: The Thai DN4 questionnaire was systematically translated and validated. This offers a simple Thai neuropathic pain diagnostic tool for clinical use.

The orientation of facet joints and transverse articular dimension in degenerative spondylolisthesis.

OBJECTIVES: To determine whether the orientation of facet joints, facet tropism and transverse articular dimension could play a role in degenerative spondylolisthesis. MATERIAL AND METHOD: MRI study of L4-5 level of twenty degenerative spondylolisthesis and age-matched twenty control group were included. The orientation of facet joints, transverse articular dimension (TAD) and cosine facet orientation of TAD were measured with two independent observers. RESULTS: The facet orientation of more than 43 degrees and cosine facet orientation of TAD less than 7.4 were statistically significant for developing degenerative spondylolisthesis (p < 0.05). CONCLUSION: The facet orientation of degenerative spondylolisthesis patients was more sagittal orientation than the the control group, and the cosine facet orientation of TAD was also less than the control group.