British journal of anaesthesia
-
Cancer-related neuropathic pain is common; it can be disease related or related to the acute or chronic effects of cancer treatment. For example, chemotherapy-induced peripheral neuropathy occurs in 90% of patients receiving neurotoxic chemotherapy. Cancer treatments have become more effective; patients are living longer with cancer and there are more cancer survivors. ⋯ Standard guidelines for the use of anticonvulsants (e.g. pregabalin and gabapentin), antidepressants (e.g. duloxetine and tricyclics), and topical treatments (e.g. capsaicin and lidocaine) may be applicable, but there is a lack of good-quality clinical trials in cancer-related neuropathic pain. Choice is dictated not just by age, drug interactions, and comorbidities, but also by the coexistence of many symptoms in patients with cancer. Treating more than one symptom with a particular neuropathic pain agent can avoid polypharmacy.
-
Review Practice Guideline
Low back and radicular pain: a pathway for care developed by the British Pain Society.
These consensus guidelines aim to provide an overview of best practice for managing chronic spinal pain reflecting the heterogeneity of low back pain. Most guidelines have covered only one aspect of spinal care and thus have been divisive and potentially worsened the quality of care. Additionally, some of the evidence base is subjective and of poor quality. ⋯ It is recognized, however, that there is an urgent need for further good-quality clinical research in this area to underpin future guidelines. Considerable work is still needed to clarify the evidence; however, foundations have been laid with this pathway. Key features include: risk stratification; clarification of intensity of psychological interventions; a logical progression for the management of sciatica; and decision points for considering structural interventions such as spinal injections and surgery.
-
Inflammation is the process by which an organism responds to tissue injury involving both immune cell recruitment and mediator release. Diverse causes of neuropathic pain are associated with excessive inflammation in both the peripheral and central nervous system which may contribute to the initiation and maintenance of persistent pain. Chemical mediators, such as cytokines, chemokines, and lipid mediators, released during an inflammatory response have the undesired effect of sensitizing and stimulating nociceptors, their central synaptic targets or both. ⋯ This review aims to provide an overview of inflammatory mechanisms at differing levels of the sensory neuroaxis with a focus on neuropathic pain. We will compare and contrast neuropathic pain states such as traumatic nerve injury which is associated with a vigorous inflammatory response and chemotherapy induced pain in which the inflammatory response is much more modest. Targeting excessive inflammation in neuropathic pain provides potential therapeutic opportunities and we will discuss some of the opportunities but also the clinical challenges in such an approach.
-
The diagnosis and management of facial pain below the eye can be very different dependant on whether the patient visits a dentist or medical practitioner. A structure for accurate diagnosis is proposed beginning with a very careful history. The commonest acute causes of pain are dental and these are well managed by dentists. ⋯ Red flags include giant cell arteritis which much be distinguished from temporomandibular disorders (TMD), especially in >50 yr olds, and cancer which can present as a progressive neuropathic pain. Burning mouth syndrome is rarely recognized as a neuropathic pain as it occurs principally in peri-menopausal women and is thought to be psychological. Chronic facial pain patients are best managed by a multidisciplinary team.