Background: Chronic pain is a major issue affecting more than 50% of the older population and up to 80% of nursing homes residents. Research on pain in the elderly focuses mainly on the development of clinical tools to assess pain in patients with dementia and cognitive impairment or on the efficacy and tolerability of medications. In this review, we searched for evidence of specific pain mechanisms or modifications in pain signals processing either at the cellular level or in the central nervous system. Methods: Narrative review. Results: Investigation on pain sensitivity led to conflicting results, with some studies indicating a modest decrease in age-related pain sensitivity, while other researchers found a reduced pain threshold for pressure stimuli. Areas of the brain involved in pain perception and analgesia are susceptible to pathological changes such as gliosis and neuronal death and the effectiveness of descending pain inhibitory mechanisms, particularly their endogenous opioid component, also appears to deteriorate with advancing age. Hyperalgesia is more common at older age and recovery from peripheral nerve injury appears to be delayed. In addition, peripheral nociceptors may contribute minimally to pain sensation at either acute or chronic time points in aged populations. Conclusions: Elderly subjects appear to be more susceptible to prolonged pain development, and medications acting on peripheral sensitization are less efficient. Pathologic changes in the central nervous system are responsible for different pain processing and response to treatment. Specific guidelines focusing on specific pathophysiological changes in the elderly are needed to ensure adequate treatment of chronic pain conditions.
Pudendal neuralgia is a common cause of pelvic pain, often difficult to treat with medical management. Nerve blocks can be effective in the short term. Pulsed Radiofrequency application on the pudendal has been investigated in several studies with positive results, however, locating the nerve can be tricky, particularly in overweight patients. We describe two case reports of pudendal neuralgia where, after a procedure on the pudendal nerve without effect, pulsed radiofrequency was applied to the sacral nerve roots S2-S3 with a combined caudal epidural and intraforaminal approach under fluoroscopic guidance. Our results suggest that radiofrequency application with this combined approach can be a feasible technique to treat pudendal neuralgia.
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