Pain physician
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Neurolytic celiac plexus block is a well established intervention to palliate pain, and it potentially improves quality of life in patients suffering from an upper abdominal malignancy, specifically pancreatic cancer. ⋯ It may be beneficial for patients with a history of gastritis, duodenitis or GI bleeding to undergo a careful upper GI evaluation prior to celiac plexus neurolysis.
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Relief of regional, non-appendicular pain, particularly low back pain, through spinal cord stimulation (SCS) has proven challenging. Recently, peripheral nerve stimulation (PNS), also known as peripheral nerve field stimulation (PNFS) depending on the stimulation area, has demonstrated efficacy for the treatment of well-localized, small areas of pain involving the abdomen, inguinal region, pelvis, face, occipital area, and low back. More widespread application of peripheral nerve stimulation has been limited by its narrow field of coverage in a larger group of patients with diffuse or poorly localized pain. ⋯ The use of the PNSCT technique allows for significant analgesia for large painful areas that have been poorly captured using traditional SCS techniques and not considered as an option with the current application of peripheral nerve stimulation.
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Case Reports
Sacral nerve stimulation as a treatment modality for intractable neuropathic testicular pain.
Chronic testicular pain, or "chronic orchalgia," is defined as testicular pain 3 months or longer in duration that significantly interferes with the daily activities of the patient. For patients failing to respond to conservative treatment, microsurgical denervation of the spermatic cord, epididymectomy, and vasovasostomy have all shown a degree of relief. However, these are all invasive procedures and no treatment has proven efficacy when these options fail. ⋯ The above case demonstrates the potential benefit of sacral nerve stimulation with neuropathic intractable testicular pain in a patient that failed conservative treatment. In this case, the patient had exhausted medical and surgical management, including advanced interventional pain options. We were unable to find any previous published cases of neurostimulation used as a modality of treatment for testicular pain, and further studies are needed to gain a better understanding of the efficacy in this setting.
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Hydrogen sulfide (H2S) is a malodorous gas which functions as an endogenous gasotransmitter in humans. It is becoming appreciated that H2S may be involved in a wide variety of processes including nociceptive processes. The molecular mechanisms responsible for many of the activities of H2S remain uncertain, however, H2S increases cAMP levels in neuronal and glial cell lines and primary neuron cultures with hyperpolarization. ⋯ A secondary contribution to the facilitation of pronociceptive processes may come from H2S-induced activation. It would appear that much like other gasotransmitters (e.g. nitric oxide), endogenous H2S may be involved in multiple physiologic processes and its effects remain complex, difficult to predict, and may vary depending on the specific environment/circumstances/location where it is generated. A greater understanding of the clinically significant human physiology of H2S and hydrogen sulfide's effects on modulating nociceptive processes may potentially lead to novel targets for improving analgesia.
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We recently reported a novel concept for combining radioactive isotope technology with polymethylmethacrylate (PMMA) cement used for vertebral augmentation and have advocated that pain physicians become aware of this new concept when treating malignant compression fractures. The use of vertebral augmentation for malignant compression fractures is steadily increasing, and the goal of this novel approach would be to stabilize the fractured vertebral body while also controlling proliferation of the tumor cells in the vertebral body that caused the vertebral fracture. This approach would therefore provide mechanical stabilization of the fractured vertebral body at the same time as direct targeting of the cancer cells causing the fracture. ⋯ We also review the potential complications when using radioactive sources in a clinical setting. Understanding the methodologies employed in determining isotope selection empowers the practitioner by fostering understanding of this presently theoretical treatment option. We believe that embedding radioisotopes in PMMA is merely a first step in the road of local treatment for symptomatic local lesions in the setting of systemic disease.