Use of artificial intelligence in the field of pain medicine

In this editorial we comment on the article“Potential and limitations of ChatGPT and generative artificial intelligence in medial safety education”published in the recent issue of the World Journal of Clinical Cases.This article described the usefulness of artificial intelligence(AI)in medial safety education.Herein,we focus specifically on the use of AI in the field of pain medicine.AI technology has emerged as a powerful tool,and is expected to play an important role in the healthcare sector and significantly contribute to pain medicine as further developments are made.AI may have several applications in pain medicine.First,AI can assist in selecting testing methods to identify causes of pain and improve diagnostic accuracy.Entry of a patient’s symptoms into the algorithm can prompt it to suggest necessary tests and possible diagnoses.Based on the latest medical information and recent research results,AI can support doctors in making accurate diagnoses and setting up an effective treatment plan.Second,AI assists in interpreting medical images.For neural and musculoskeletal disorders,imaging tests are of vital importance.AI can analyze a variety of imaging data,including that from radiography,computed tomography,and magnetic resonance imaging,to identify specific patterns,allowing quick and accurate image interpretation.Third,AI can predict the outcomes of pain treatments,contributing to setting up the optimal treatment plan.By predicting individual patient responses to treatment,AI algorithms can assist doctors in establishing a treatment plan tailored to each patient,further enhancing treatment effectiveness.For efficient utilization of AI in the pain medicine field,it is crucial to enhance the accuracy of AI decision-making by using more medical data,while issues related to the protection of patient personal information and responsibility for AI decisions will have to be addressed.In the future,AI technology is expected to be innovatively applied in the field of pain medicine.The advancement of AI is anticipated to have a positive impact on the entire medical field by providing patients with accurate and effective medical services.

Chronic venous insufficiency, could it be one of the missing pieces in the puzzle of treating pain?

Pain is a common complaint among patients seeking medical care.If left un-treated,pain can become chronic,significantly affecting patients’quality of life.An accurate diagnosis of the underlying cause of pain is crucial for effective treatment.Chronic venous insufficiency(CVI)is frequently overlooked by pain physicians.Moreover,many pain physicians lack sufficient knowledge about CVI.CVI is a common condition resulting from malfunctioning or damaged valves in lower limb veins.Symptoms of CVI,ranging from mild to severe,include pain,heaviness,fatigue,itching,swelling,skin color changes,and ulcers in the lower limbs.Recently,it has become more widely known that these symptoms can be attributed to CVI.Even slight or mild CVI can cause related symptoms.Pain physicians primarily consider neuromusculoskeletal disorders when assessing patients with leg pain,and often neglect the possibility of CVI.In clinical practice,when pain physicians encounter patients with unresolved leg pain,they must assess whether the patients exhibit symptoms of CVI and conduct tests to differ-entiate CVI from other potential causes.

Protocol for lower back pain management: Insights from the French healthcare system

In this editorial we comment on the article published in a recent issue of the World Journal of Clinical Cases.This article described a novel ultrasound-guided lateral recess block approach in treating a patient with lateral recess stenosis.The impact of spinal pain-related disability extends significantly,causing substantial human suffering and medical costs.Each county has its preferred treatment strategies for spinal pain.Here,we explore the lower back pain(LBP)treatment algorithm recommended in France.The treatment algorithm for LBP recommended by the French National Authority for Health emphasizes early patient activity and minimal medication use.It encourages the continuation of daily activities,limits excessive medication and spinal injections,and incorporates psychological assessments and non-pharmacological therapies for chronic cases.However,the algorithm may not aggressively address acute pain in the early stages,potentially delaying relief and increasing the risk of chronicity.Additionally,the recommended infiltrations primarily involve caudal epidural steroid injections,with limited consideration for other injection procedures,such as transforaminal or interlaminar epidural steroid injections.The fixed follow-up timeline may not accommodate patients who do not respond to initial treatment or experience intense pain,potentially delaying the exploration of alternative therapies.Despite these limitations,understanding the strengths and weaknesses of the French approach could inform adaptations in LBP treatment strategies globally,potentially enhancing patient outcomes and satisfaction across diverse healthcare systems.

Management of lymphedema is really a matter in patients with breast cancer

Lymphedema is a prevalent complication affecting patients with breast cancer,greatly impacting their quality of life.This editorial describes diagnostic methods and therapeutic interventions for managing lymphedema in patients with breast cancer.Diagnosis relies on clinical evaluation and objective measures,including arm circumference and volumetric assessments,along with lymphoscintigraphy and ultrasonic measurements.Treatment primarily involves complex decongestive physical therapy,comprising manual lymphatic drainage,compression therapy,exercise,and meticulous skin care.These interventions aim to reduce swelling,alleviate discomfort,and prevent further complications.Additionally,lifestyle modifications such as avoiding extreme temperatures and maintaining proper hygiene are essential.Flavonoids can be used for drug therapy.Despite its prevalence,lymphedema often receives inadequate attention in clinical practice,emphasizing the importance of raising awareness and enhancing medical services for affected individuals.Clinicians play a pivotal role in educating patients about preventive measures and ensuring timely intervention.Overall,a comprehensive approach encompassing early diagnosis,multidisciplinary management,and patient education is essential to mitigate the burden of lymphedema in patients with breast cancer and improve their overall well-being.

Differences between the healthcare systems of Quebec and France for the treatment of pain due to spinal disorders

In Quebec,Canada,the public healthcare system offers free medical services.However,patients with spinal pain often encounter long waiting times for specialist appointments and limited physiotherapy coverage.In contrast,private clinics provide expedited care but are relatively scarce and entail out-of-pocket expenses.Once a patient with pain caused by a spinal disorder meets a pain medicine specialist,spinal intervention is quickly performed when indicated,and patients are provided lifestyle advice.Transforaminal epidural steroid injections are frequently administered to patients with radicular pain,and steroid injections are administered on a facet joint to control low back or neck pain.Additionally,medial branch blocks are performed prior to thermocoagulation.France’s universal healthcare system ensures accessibility at controlled costs.It emphasizes physical activity and provides free physical therapy services.However,certain interventions,such as transforaminal and interlaminar epidural injections,are not routinely used in France owing to limited therapeutic efficacy and safety concerns.This underutilization may be a potential cause of chronic pain for many patients.By examining the differences,strengths,and weaknesses of these two systems,valuable insights can be gained for the enhancement of global spinal pain management strategies,ultimately leading to improved patient outcomes and satisfaction.

Dysphagia in patients with isolated pontine infarction

Little is known about dysphagia after pontine infarction. In this study, we evaluated the incidence of dysphagia after isolated pontine infarction and identified the predictive factors for the occurrence of dysphagia. A total of 146 patients were included in this study. All patients underwent clinical testing for dysphagia within 1 day after admission and at the time of discharge. We compared the incidence of dysphagia between patients with unilateral pontine infarction and those with bilateral pontine infarction. To evaluate the functional status of patients, we investigated their initial modified Rankin Scale（mRS） score and initial National Institutes of Health Stroke Scale（NIHSS） score within 1 day of admission. Of 146 patients, 50（34.2%） had dysphagia initially within 1 day after admission. At the second evaluation at the time of discharge, dysphagia was diagnosed in 24 patients（16.4%）. Patients with bilateral pontine infarction were more likely to present with dysphagia. In addition, clinical severity（in terms of mRS and NIHSS scores） was identified as a predictor of dysphagia in patients with cerebral infarction（multiple binary logistic regression analysis, mRS： P = 0.011, NIHSS： P = 0.004）. Dysphagia frequently occurs in patients with isolated pontine infarction. Clinicians should pay particular attention to the occurrence of dysphagia, especially in patients with bilateral pontine infarction or high functional disability.

Early treadmill exercise increases macrophage migration inhibitory factor expression after cerebral ischemia/reperfusion

The neuroprotective function of macrophage migration inhibitory factor(MIF) in ischemic stroke was rarely evaluated.This study aimed to investigate the effects of early treadmill exercise on recovery from ischemic stroke and to determine whether these effects are associated with the expression levels of MIF and brain-derived neurotrophic factor(BDNF) in the ischemic area.A total of 40 male Sprague-Dawley rats were randomly assigned to the ischemia and exercise group [middle cerebral artery occlusion(MCAO)-Ex,n = 10),ischemia and sedentary group(MCAO-St,n = 10),sham-surgery and exercise group(Sham-Ex,n= 10),or sham-surgery and sedentary group(Sham-St,n = 10).The MCAO-Ex and MCAO-St groups were subjected to MCAO for 60 minutes,whereas the Sham-Ex and Sham-St groups were subjected to an identical operation without MCAO.Rats in the MCAO-Ex and Sham-Ex groups then ran on a treadmill for 30 minutes once a day for 5 consecutive days.After reperfusion,the hanging time tested by the wire hang test was longer and the relative fractional anisotropy determined by MRI was higher in the peri-infarct region of the MCAO-Ex group compared with the MCAO-St group.The expression levels of MIF and BDNF in the peri-infarct region were upregulated in the MCAO-Ex group.Increased MIF and BDNF levels were positively correlated with relative fractional anisotropy changes in the peri-infarct region.There was no significant difference in the levels of MIF and BDNF in the peri-infarct region between the Sham-Ex and Sham-St groups.Our study demonstrated that early exercise(initiated 48 hours after the MCAO) could improve motor and neuronal recovery after ischemic stroke.Furthermore,the increased levels of MIF and BDNF in the peri-infarct region(penumbra) may be one of the mechanisms of enhanced neurological function recovery.All experiments were approved by the Institutional Animal Care and Use Committee in Asan Medical Center in South Korea(2016-12-126).

Motor outcomes of patients with a complete middle cerebral artery territory infarct

Detailed knowledge of motor outcomes enables to establish proper goals and rehabilitation strate-gies for stroke patients. Several previous studies have reported functional or motor outcomes in patients with a middle cerebral artery territory infarct. However, little is known about motor outcome in patients with a complete middle cerebral artery territory infarct. In this study, we investigated the motor outcomes in 23 patients with a complete middle cerebral artery territory infarct. All of these patients received comprehensive rehabilitative management, including movement therapy and neuromuscular electrical stimulation of the affected finger extensors and ankle dorsiflexors, for more than 3 months. Motor outcomes were measured at 6 months after stroke onset using the Medical Research Council, Motricity Index, the modified Brunnstrom Classification, and Functional Ambula-tion Category scores. The motor function of the lower extremities was found to be better than that of the upper extremities. After receiving rehabilitation treatments for 3–6 months, about 70% of these patients were able to walk independently （Functional Ambulation Category scores 3）, but no pa-tient achieved functional hand recovery.

Right lower limb apraxia in a patient with left supplementary motor area infarction: intactness of the corticospinal tract confirmed by transcranial magnetic stimulation

We reported a 50-year-old female patient with left supplementary motor area infarction who presented right lower limb apraxia and investigated the possible causes using transcranial magnetic stimulation. The patient was able to walk and climb stairs spontaneously without any assistance at 3 weeks after onset. However, she was unable to intentionally move her right lower limb although she understood what she supposed to do. The motor evoked potential evoked by transcranial magnetic stimulation from the right lower limb was within the normal range, indicating that the corticospinal tract innervating the right lower limb was uninjured. Thus, we thought that her motor dysfunction was not induced by motor weakness, and confirmed her symptoms as aprax- ia. In addition, these results also suggest that transcranial magnetic stimulation is helpful for diagnosing apraxia.

Ligamentum flavum hematoma following a traffic accident:A case report

BACKGROUND Ligamentum flavum hematoma(LFH)can cause compression of the spinal cord or nerve root,which results in neurological symptoms.We report a case of lumbar radicular pain due to LFH following a traffic accident.CASE SUMMARY A 59-year-old man complained of left buttock and lateral thigh pain that was dull in nature after a traffic accident 18 d prior to presentation.Magnetic resonance imaging(MRI),taken 17 d after the traffic accident,revealed a mass lesion at the L4-5 Level.These MRI findings suggested subacute LFH.The patient’s pain was not alleviated with conservative treatment,including oral medication and epidural steroid injection.After a partial-hemilaminectomy and removal of LFH,the patient’s pain completely disappeared.CONCLUSION Because early operation for decompression is important for a good outcome,clinicians should be able to determine LFH from MRI results and be aware of the possibility of LFH,especially in patients with a history of trauma.

Effects of pulsed radiofrequency on spasticity in patients with spinal cord injury:a report of two cases

Spasticity following spinal cord injury（SCI） results in functional deterioration and reduced quality of life. Herein, we report two SCI patients who presented with good response to pulsed radiofrequency（PRF） for the management of spasticity in the lower extremities. Patient 1（a 47-year-old man） had complete thoracic cord injury and showed a phasic spasticity on the extensor of both knees（3–4 beats clonus per every 30 seconds） and tonic spasticity（Modified Ashworth Scale： 3） on both hip adductors. Patient 2（a 64-yearold man） had incomplete cervical cord injury and showed a right ankle clonus（approximately 20 beats） when he walked. After the application of PRF to both L2 and L3 dorsal root ganglion（DRG）（patient 1） and right S1 DRG（patient 2） with 5 Hz and 5 ms pulsed width for 360 seconds at 45 V under the C-arm guide, all spasticity disappeared or was reduced. Moreover, the effects of PRF were sustained for approximately 6 months with no side effects. We believe that PRF treatment can be useful for patients with spasticity after SCI.

Orthotic approach to prevention and management of diabetic foot:A narrative review

Diabetic foot is a common complication affecting more than one-fifth of patients with diabetes.If not treated in time,it may lead to diabetic foot ulcers or Charcot arthropathy.For the management of diabetic foot,shoe modifications and orthoses can be used to reduce pressure on the affected foot or provide the foot with increased stability.In addition,the shoe modifications and orthotic devices can relieve patient discomfort during walking.Appropriate shoe modifications include changing the insole material,modifying the heel height,adding a steel shank or rocker sole,and using in-depth shoes.Alternatively,a walking brace or ankle-foot orthosis can be used to reduce the pressure on the affected foot.The purpose of this narrative review was to provide a reference guide to support clinicians in prescribing shoe modifications and foot orthoses to treat diabetic foot ulcers and Charcot arthropathy.

Secondary parkinsonism induced by hydrocephalus after subarachnoid and intraventricular hemorrhage

Hydrocephalus can induce secondary parkinsonism（Shahar et al.,1988;Aggarwal et al.,1997;Racette et al.,2004）.Physical factors such as increased ventricular pressure near the upper midbrain and basal ganglia are thought to cause mechanical disruption of dopaminergic systems（i.e.,the nigrostriatal pathways from the medial substantia nigra to the caudate nuclei and putamen and its frontal projection fibers from the basal ganglia）（Asamoto et al., 1998; Yomo et al., 2006）.

Injury of the arcuate fasciculus in a patient with progressive bulbar palsy

The arcuate fasciculus is the neural tract connecting the two major speech centers（Broca’s and Wernicke’s areas）and plays a critical role in language function（Catani and Mesulam,2008）.Injury of this tract can lead to several types of language impairment,including conduction aphasia,Broca’s aphasia,anomic aphasia,and apraxia of speech（Anderson et al.,1999;Bartha and Benke,2003;Catani and Mesulam,2008;Bernal and Ardila,2009;Kim et al.,2011）.

Multiple cranial nerve palsies with small angle exotropia following COVID-19 mRNA vaccination in an adolescent:A case report

BACKGROUND Several vaccines against the severe acute respiratory syndrome coronavirus 2 have been approved and widely distributed,raising public concerns regarding the side effects of immunization,as the incidence of ease.Although many adverse events following the coronavirus disease 2019(COVID-19)vaccine have been reported,neurological complications are relatively uncommon.Herein,we report a rare case of multiple cranial palsies following COVID-19 vaccination in an adolescent patient.CASE SUMMARY A previously healthy,14-year-old Asian girl with facial palsy presented to the emergency department with inability to close the right eye or wrinkle right side of the forehead,and pain in the right cheek.She had received second dose of the COVID-19 mRNA vaccine(Pfizer-BioNTech)18 days before onset of symptoms.She was diagnosed with Bell’s palsy and prescribed a steroid(1 mg/kg/day methylprednisolone)based on symptoms and magnetic resonance imaging findings.However,the next day,all sense of taste was lost with inability to swallow solid food;the gag reflex was absent.Horizontal diplopia was also present.Due to worsening of her condition,she was given high-dose steroids(1g/day methylprednisolone)for 3 days and then discharged with oral steroids.Improvement in the symptoms was noted 4 days post steroid treatment completion.At the most recent follow-up,her general condition was good with no symptoms except diplopia;ocular motility disturbances were noted.Hence,prism glasses were prescribed for diplopia relief.CONCLUSION Small-angle exotropia was observed in the facial,trigeminal,and glossopharyngeal nerve palsies,in our patient.The etiology of this adverse effect following vaccination was thought to be immunological.

Amputation stump management:A narrative review

In this review intended for medical staff involved in patient rehabilitation,we provided an overview of the basic methods for managing amputation stumps.After the amputation surgery,it is imperative to optimize the remaining physical abilities of the amputee through rehabilitation processes,including postoperative rehabilitation,desensitization,and continuous application of soft or rigid dressings for pain reduction and shaping of the stump.Depending on the situation,a prosthesis may be worn in the early stage of recovery or an immediate postoperative prosthesis may be applied to promote stump maturation.Subsequently,to maintain the range of motion of the stump and to prevent deformation,the remaining portion of the limb should be positioned to prevent contracture.Continuous exercises should also be performed to improve muscle strength to ensure that the amputee is able to perform activities of daily living,independently.Additionally,clean wound or edema management of the stump is necessary to prevent problems associated with wearing the prosthesis.Our review is expected to contribute to the establishment of basic protocols that will be useful for stump management from the time of completion of amputation surgery to the fitting of a prosthesis to optimize patient recovery.

Effectiveness of pulsed radiofrequency on the medial cervical branches for cervical facet joint pain

BACKGROUND Cervical facet joint pain(CFP)is one of the most common causes of neck pain and headache.Persistent CFP deteriorates the quality of life of patients and reduces their productivity at work.AIM To investigate the effectiveness of pulsed radiofrequency(PRF)stimulation of cervical medial branches in patients with chronic CFP.METHODS We retrospectively included 21 consecutive patients(age=50.9±15.3 years,range 26-79 years;male:female=8:13;pain duration=7.7±5.0 mo)with chronic CFP,defined as≥4 on the numeric rating scale(NRS).We performed PRF stimulation on the cervical medial branches.The outcomes of the PRF procedure were evaluated by comparing the NRS scores for CFP before treatment and 1 and 3 mo after treatment.Successful pain relief was defined as a≥50%reduction in the NRS score at 3 mo when compared with the pretreatment NRS score.RESULTS No patient had immediate or late adverse effects following PRF.The average NRS score for CFP decreased from 5.3±1.1 at pre-treatment to 2.4±0.6 at the 1 mo follow-up,and 3.1±1.1 at the 3 mo follow-up.Compared to the NRS scores before PRF stimulation,those at 1 and 3 mo after PRF stimulation had significantly decreased.Eleven of the 21 patients(52.4%)reported successful pain relief 3 mo after the PRF procedure.PRF stimulation on cervical medial branches may be a useful therapeutic option to control chronic CFP.CONCLUSION PRF stimulation of the cervical medial branches may be used as an alternative treatment method in patients with CFP.PRF can effectively alleviate CFP,and is safe to perform.

Relationship between treatment types and blood–brain barrier disruption in patients with acute ischemic stroke:Two case reports

BACKGROUND Blood-brain barrier(BBB)disruption plays an important role in the development of neurological dysfunction in ischemic stroke.However,diagnostic modalities that can clearly diagnose the degree of BBB disruption in ischemic stroke are limited.Here,we describe two cases in which the usefulness of dynamic contrastenhanced magnetic resonance imaging(DCE-MRI)in detecting BBB disruption was evaluated after treatment of acute ischemic stroke using two different methods.CASE SUMMARY The two patients of similar age and relatively similar cerebral infarction locations were treated conservatively or with thrombectomy,although their sex was different.As a result of analysis by performing DCE-MRI,it was confirmed that BBB disruption was significantly less severe in the patient who underwent thrombectomy(P=3.3×10^(-7)),whereas the average Ktrans of the contralateral hemisphere in both patients was similar(2.4×10^(-5)min^(-1) and 2.0×10^(-5)min^(-1)).If reperfusion is achieved through thrombectomy,it may indicate that the penumbra can be saved and BBB recovery can be promoted.CONCLUSION Our cases suggest that BBB disruption could be important if BBB permeability is used to guide clinical treatment.

Obturator hernia-a rare etiology of lateral thigh pain:A case report

BACKGROUND Lateral thigh pain is a common complaint in patients visiting a pain clinic.Herein,we describe the case of a patient with lateral thigh pain caused by an obturator hernia.CASE SUMMARY An 83-year-old woman visited the emergency room with suddenly aggravated right lateral thigh pain.Magnetic resonance imaging of the thigh revealed no abnormal findings in the lateral thigh area.However,an obturator hernia between the pectineus and obturator externus muscles was observed by chance.Retroperitoneal computed tomography revealed a herniated small bowel with an incarceration point at the right obturator canal and a dilated loop of the small bowel upstream.Ultrasonography of the right inguinal region revealed a distended bowel loop in the right pectineus muscle.CONCLUSION Our report provides clinicians with information that an obturator hernia can cause lateral thigh pain.

Essentials of thoracic outlet syndrome:A narrative review

Thoracic outlet syndrome(TOS)is a group of diverse disorders involving compression of the nerves and/or blood vessels in the thoracic outlet region.TOS results in pain,numbness,paresthesia,and motor weakness in the affected upper limb.We reviewed the pathophysiology,clinical evaluation,differential diagnoses,and treatment of TOS.TOS is usually classified into three types,neurogenic,venous,and arterial,according to the primarily affected structure.Both true neurogenic and disputed TOS are considered neurogenic TOS.Since identifying the causative lesions is complex,detailed history taking and thorough clinical investigation are needed.Electrodiagnostic and imaging studies are helpful for excluding other possible disorders and confirming the diagnosis of true neurogenic TOS.The existence of a disputed TOS remains controversial.Neuromuscular physicians tend to be skeptical about the existence of disputed TOS,but thoracic surgeons argue that disputed TOS is under-diagnosed.Clinicians who encounter patients with TOS need to understand its key features to avoid misdiagnosis and provide appropriate treatment.