Pain Reduction and Changes in Serum Cortisol, Adrenocorticotropic Hormone, and Glucose Levels after Epidural Injections With Different Doses of Corticosteroid.

BACKGROUND: An epidural steroid injection (ESI) effectively relieves acute lumbar discogenic radicular pain. Corticosteroids, a key ESI component, reduce pain by curbing inflammation and blocking pain signal transmission via C-fibers. While prior research confirms the efficacy of 40 mg and 80 mg methylprednisolone, the effectiveness of lower doses remains uncertain. OBJECTIVES: This trial aimed to compare the pain-relieving effects of ESI using varying methylprednisolone doses (10 mg, 20 mg, and 40 mg). Additionally, it sought to examine changes in fasting plasma glucose (FPG), serum cortisol, and serum adrenocorticotropic hormone (ACTH) levels across these groups. STUDY DESIGN: A prospective observational study. SETTING: Department of Pain Medicine, Affiliated Jinling Hospital, Medical School of Nanjing University, People's Republic of China. METHODS: Ninety-three patients underwent a single epidural injection of methylprednisolone at different doses: 10 mg (n = 28), 20 mg (n = 32), and 40 mg (n = 33). We evaluated their Numeric Rating Scale (NRS-11) score and Oswestry Disability Index (ODI) score at preinjection and 7 days postinjection. We also measured FPG, serum cortisol, and ACTH levels at baseline and one day postinjection. RESULTS: Significant differences were observed in the likelihood of achieving substantial pain relief among the 3 groups at 7 days postinjection. Specifically, 10 mg vs 20 mg had an odds ratio (OR) of 6.546 (95% CI, 1.161 - 26.513, P = 0.008), and 10 mg vs 40 mg had an OR of 7.753 (95% CI, 1.98 - 30.353, P = 0.003). However, there was no significant difference between 40 mg and 20 mg, with an OR of 0.844 (95% CI, 0.239 - 2.987, P = 0.793) in Model 3. Additionally, the baseline NRS-11 score significantly predicted substantial pain relief, with an OR of 0.47 (95% CI, 0.287 - 0.768, P = 0.003). Furthermore, at 7 days postinjection, the ODI score was significantly lower in the 20 mg group (P = 0.007) and the 40 mg group (P < 0.001) compared to the 10 mg group. Moreover, the difference in serum cortisol and FPG between the 40 mg and 10 mg groups was more pronounced (P < 0.01), while the difference in ACTH was similar among all 3 groups (P = 0.191). LIMITATIONS: Potential selection bias and a short follow-up period may have influenced our study, and certain imaging results were omitted from the regression models. CONCLUSIONS: The effectiveness of ESI in relieving pain was found to be similar for both 20 mg and 40 mg doses, but with fewer changes in FPG and serum cortisol levels for the former (which were not statistically significant). As a result, it may be clinically viable to use a 20 mg dose for achieving short-term pain relief. Moreover, the baseline NRS-11 scores were found to be a reliable predictor of pain relief efficacy, with milder baseline pain intensity being associated with better pain relief outcomes.

Programmable Pump for Intrathecal Morphine Delivery to Cisterna Magna: Clinical Implications in Novel Management of Refractory Pain Above Middle Thoracic Vertebrae Level Utilizing a Prospective Trial Protocol and Review.

BACKGROUND: The cisterna Intrathecal Drug Delivery system (IDDS) with morphine has proven to be effective in treating refractory cancer pain above the middle thoracic vertebrae level in some countries. However, it has not been fully investigated in others. We designed the current project to investigate the efficacy and safety of cisterna IDDS for pain relief in refractory pain above the middle thoracic vertebrae level in advanced cancer patients. METHODS: This study protocol allows for eligible cancer patients to receive the cisterna IDDS operation. Pain intensity (Visual Analogue scale, VAS), quality of life (36-Item Short-Form Health Survey, SF-36), and depression (Self-Rating Depression scale, SDS) are assessed along with side effects in the postoperative follow-up visits. Recent literature suggests a potential role for cisterna IDDS morphine delivery for refractory pain states above the middle thoracic level. CONCLUSION: The results of this study may provide further evidence that cisterna IDDS of morphine can serve as an effective and safe pain relief strategy for refractory pain above the middle thoracic vertebrae level in advanced cancer patients.

Intrathecal Morphine Delivery at Cisterna Magna to Control Refractory Cancer-Related Pain: A Prospective Cohort Study.

Background: For patients suffering from primary or metastatic cancer above the middle thoracic vertebrae, refractory pain management still remains a great challenge. Theoretically, inserting a catheter tip into the cisterna magna may be a promising solution. However, at present, there have been no reliable data regarding this novel technique. We therefore investigated the efficacy and safety of an advanced approach for pain relief in a specific population. Methods: Thirty participants from two hospitals received the intrathecal deliveries of opioid to either one of two sites: cisterna magna (n = 15) or lower thoracic region (n = 15). Pain relief (visual analogue scale, VAS), quality of life (short form (36) health survey, SF-36) as well as depression (self-rating depression scale, SDS) were assessed in the follow-up visits and compared between the two groups. Results: Patients receiving intrathecal morphine delivery to cisterna magna achieved greater pain improvement indicated as significant decrease of VAS scores at day 1 and 7, and achieved better improvement in physical function (day 7 and 30), role physical (day 7 and 30), body pain (day 7, 30 and 90), general health (day 7, 30 and 90), vitality (day 7, 30 and 90), social function (day 90), role emotional (day 7 and 90), mental health (day 7, 30 and 90) and SDS (day 1 and 7). Conclusions: Intrathecal morphine delivery to cisterna magna might be an effective and safe technique for patients suffering from cancer at the middle thoracic vertebrae or above to control refractory pain. Trial registration: No. ChiCTR-ONN-17010681.

Proportion of neuropathic pain in the back region in chronic low back pain patients -a multicenter investigation.

Neuropathy can contribute to low back pain (LBP) in the region of the back. Our study investigated the proportion of neuropathic pain (NP) in low back region in chronic LBP patients from multicenter and clinics in China and identified associated factors. Assessment was made using a questionnaire and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS, only tested in low back region), as well as Quantitative Sensory Testing (QST, merely applied to the low back region), the Hospital Anxiety and Depression Scale (HADS) and the Oswestry Disability Index (ODI). Our questionnaire collected demographic information, behavioral habits and medical records. 2116 outpatients over 18 years old complaining of LBP lasting more than 3 months were enrolled in this study. The NP proportion in low back region in chronic LBP patients was 2.8%. Multivariable logistic regression analysis showed that histories of lumbar surgery, abdominal or pelvic surgery, and drinking alcohol were independent positive predictors for LBP of predominantly neuropathic origin (LBNPO), while history of low back sprain and frequently carrying weight as independent negative predictor. Using these parameters may help the identification of patients with chronic LBP likely to develop NP leading to improved treatment outcomes.

Long-Term Intrathecal Analgesia With a Wireless Analgesia Pump System in the Home Care of Patients With Advanced Cancer.

BACKGROUND: Intrathecal analgesia is more effective than conservative delivery methods such as drugs administered orally or intravenously. Programmable devices such as Medtronic's SynchroMed systems have often been applied for long-term intrathecal analgesia. However, the totally implanted systems are very expensive in China. Considering cost-effectiveness, a reliable transmission protocol for a ZigBee-Based wireless analgesia pump system was used for long-term intrathecal analgesia in the home care of patients. METHODS: We retrospectively investigated the efficacy, side effects, and complications of long-term intrathecal analgesia in the home care of patients via the wireless analgesia pump system. Follow-up visits occurred monthly for the initial 3 months after implantation and then every 3 months until patient death, withdrawal from the study, or removal of the device by a designated staff. At each follow-up visit, daily average pain score, pain frequency, satisfaction level, Spitzer Quality of Life Index, and side effects for every patient were recorded. RESULTS: Pain intensity and frequency were significantly decreased by intrathecal analgesia via a wireless analgesia pump system. There were no significant differences in the satisfaction levels between hospitalization and each follow-up visit. The Spitzer Quality of Life Indexes were improved compared with patients who were hospitalized. No serious side effects were observed in this study. CONCLUSION: Intrathecal analgesia is an effective and safe method for control of refractory cancer pain, and wireless analgesia pump systems can be safely and effectively used for long-term intrathecal analgesia management in the home care of patients with advanced cancer.

Spinal Heme Oxygenase-1 (HO-1) Exerts Antinociceptive Effects Against Neuropathic Pain in a Mouse Model of L5 Spinal Nerve Ligation.

OBJECTIVE: Heme oxygenase-1 (HO-1) exerts protective effects against ischemia and inflammation in the central nervous system. However, its role in neuropathic pain is still unclear. This study was undertaken to explore the distribution and possible mechanism of HO-1 in a mouse model of peripheral nerve injury. DESIGN AND METHODS: The experiment was conducted using a mouse model of L5 spinal nerve ligation (SNL). Mice received repeated intraperitoneal injection of Carbon monoxide-releasing molecule-2 (CO-RM-2), HO-1 inducer cobalt protoporphyrin IX (CoPP) or single intraspinal injection of lentivirus (LV) over-expressing HO-1. The behavior analyses were conducted. The distribution and expression of HO-1 in the spinal cord were analyzed. RESULTS: HO-1 but not HO-2 was upregulated in spinal cord microglia cells after nerve injury, and the repeated intraperitoneal administration of CORM-2 (10 mg/kg/d) or CoPP (5 mg/kg/d) both significantly reduced the mechanical allodynia and thermal hyperalgesia induced by SNL (P < 0.01). Intraspinal injection of LV-HO-1 persistently suppresses SNL-induced neuropathic pain (P < 0.01 or P < 0.05), significantly induced the spinal HO-1 protein content (P < 0.01) and inhibited the microglia activation (P < 0.01) 7 days after SNL. CONCLUSION: HO-1 upregulation could elicit potent analgesic effects against neuropathic pain, which might partly be attributed to inhibition of spinal microglia activation. HO-1 signaling pathway may present a novel strategy for the treatment of neuropathic pain.

Spinal translocator protein alleviates chronic neuropathic pain behavior and modulates spinal astrocyte-neuronal function in rats with L5 spinal nerve ligation model.

Recent studies reported the translocator protein (TSPO) to play critical roles in several kinds of neurological diseases including the inflammatory and neuropathic pain. However, the precise mechanism remains unclear. This study was undertaken to explore the distribution and possible mechanism of spinal TSPO against chronic neuropathic pain (CNP) in a rat model of L5 spinal nerve ligation (SNL). Our results showed that TSPO was upregulated in a time-related manner in the spinal dorsal horn after SNL. Spinal TSPO was predominately expressed in astrocytes. A single intrathecal injection of TSPO agonist Ro5-4864, but not TSPO antagonist PK11195, alleviated the mechanical allodynia in a dose-dependent manner. A single intraspinal injection of TSPO overexpression lentivirus (LV-TSPO), but not TSPO inhibited lentivirus (LV-shTSPO), also relieved the development of CNP. Intrathecal administration of 2 µg Ro5-4864 on day 3 induced a significant increase of TSPO protein content at the early stage (days 5-7) while inhibited the TSPO activation during the chronic period (days 14-21) compared with the control group. Ro5-4864 suppressed the astrocytes and p-JNK1 activation and decreased the CXCL1 expression in both in vivo and in vitro studies. Ro5-4864 also attenuated the spinal CXCR2 and p-ERK expressions. These results suggested that early upregulation of TSPO could elicit potent analgesic effects against CNP, which might be partly attributed to the inhibition of CXCL1-CXCR2-dependent astrocyte-to-neuron signaling and central sensitization. TSPO signaling pathway may present a novel strategy for the treatment of CNP.