Neuropathic pain is defined as a lesion or disease of the somatosensory system, and may involve the central or peripheral nervous systems. Treatment of neuropathic pain is a challenge for clinicians involved in affected patients' care. In 2007, the first guidelines for the treatment of neuropathic pain in the Canadian context were produced by the Canadian Pain Society. This update to these guidelines incorporates new evidence published since the first guidelines were released.
Neuropathic pain (NeP), generated by disorders of the peripheral and central nervous system, can be particularly severe and disabling. Prevalence estimates indicate that 2% to 3% of the population in the developed world suffer from NeP, which suggests that up to one million Canadians have this disabling condition. Evidence-based guidelines for the pharmacological management of NeP are therefore urgently needed. Randomized, controlled trials, systematic reviews and existing guidelines focusing on the pharmacological management of NeP were evaluated at a consensus meeting. Medications are recommended in the guidelines if their analgesic efficacy was supported by at least one methodologically sound, randomized, controlled trial showing significant benefit relative to placebo or another relevant control group. Recommendations for treatment are based on degree of evidence of analgesic efficacy, safety, ease of use and cost-effectiveness. Analgesic agents recommended for first-line treatments are certain antidepressants (tricyclics) and anticonvulsants (gabapentin and pregabalin). Second-line treatments recommended are serotonin noradrenaline reuptake inhibitors and topical lidocaine. Tramadol and controlled-release opioid analgesics are recommended as third-line treatments for moderate to severe pain. Recommended fourth-line treatments include cannabinoids, methadone and anticonvulsants with lesser evidence of efficacy, such as lamotrigine, topiramate and valproic acid. Treatment must be individualized for each patient based on efficacy, side-effect profile and drug accessibility, including cost. Further studies are required to examine head-to-head comparisons among analgesics, combinations of analgesics, long-term outcomes, and treatment of pediatric and central NeP.
BackgroundAlthough the value of ultrasound-guided (USG) lumbar medial branch blocks (MBB) has previously been examined in several clinical trials, blocking the L5 dorsal ramus (DR) remains a technical challenge and we sought to examine the accuracy of a novel technique targeting this level.MethodsIn this prospective cohort study, 115 patients scheduled for an L4 MBB and L5 DR block underwent an ultrasound scan to assess their lower spine sonoanatomy. Subjects in whom the necessary landmarks could be visualized underwent a USG L5 DR block using a pivot technique, which involved redirecting a needle from its position on the L5 transverse process after an L4 MBB. Success was determined by a blinded observer who examined the contrast distribution on postprocedural X-ray images. In addition to the final needle position, performance time, the number of needle passes, and any complication were recorded.ResultsA total of 100 patients had a USG block and 15 patients (13%) were excluded because of poor landmark visibility. The latter group presented a significantly higher body mass index (38.90±7.50 vs 26.31±4.25 kg/m2, p=0.004). A total of five failures were noted (95% success rate), this included three patients with transitional anatomy in whom needles were placed at the wrong level and two cases of incomplete contrast coverage possibly related to the partial intravascular injection. Performance time was 153.93±41.56 s and the median number of needle passes was 2 (range 4). No significant complications were noted.ConclusionThe pivot technique provides a reliable approach for USG L5 DR ramus blocks.Trial registration numberNCT03805906
This paper describes the research work being carried out by the Transforming Pain Research Group -the only group whose work is exclusively focused on the use of immersive VR for chronic pain management. Unlike VR research for acute or short-term pain, which relies on pain "distraction," this research posits a new paradigm for the use of VR. In addition to providing an overview of our work, the present paper also describes one of our current works in detail: the Virtual Meditative Walk.
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