Chinese Association for the Study of Pain:Experts consensus on ultrasound-guided injections for the treatment of spinal pain in China(2020 edition)

Spinal pain(SP)is a common condition that has a major negative impact on a patient’s quality of life.Recent developments in ultrasound-guided injections for the treatment of SP are increasingly being used in clinical practice.This clinical expert consensus describes the purpose,significance,implementation methods,indications,contraindications,and techniques of ultrasound-guided injections.This consensus offers a practical reference point for physicians to implement successfully ultrasound-guided injections in the treatment of chronic SP.

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.

Effect of microenvironment modulation on stem cell therapy for spinal cord injury pain

Spinal cord injury （SCI） currently ranks second after mental retarda- tion among neurological disorders in terms of cost to society. Pain is a debilitating consequence of SCI related to the nature of the lesion, neurological structures damaged, and secondary pathophysiological changes of surviving tissues （Yezierski, 2005; D＇Angelo et al., 2013）.

The hypothalamic-spinal dopaminergic system:a target for pain modulation

Nociceptive signals conveyed to the dorsal horn of the spinal cord by primary nociceptors are subject to extensive modulation by local neurons and by supraspinal descending pathways to the spinal cord before being relayed to higher brain centers. Descending modulatory pathways to the spinal cord comprise,among others, noradrenergic, serotonergic, γ-aminobutyric acid(GABA)ergic, and dopaminergic fibers.The contributions of noradrenaline, serotonin, and GABA to pain modulation have been extensively investigated. In contrast, the contributions of dopamine to pain modulation remain poorly understood.The focus of this review is to summarize the current knowledge of the contributions of dopamine to pain modulation. Hypothalamic A11 dopaminergic neurons project to all levels of the spinal cord and provide the main source of spinal dopamine. Dopamine receptors are expressed in primary nociceptors as well as in spinal neurons located in different laminae in the dorsal horn of the spinal cord, suggesting that dopamine can modulate pain signals by acting at both presynaptic and postsynaptic targets. Here, I will review the literature on the effects of dopamine and dopamine receptor agonists/antagonists on the excitability of primary nociceptors, the effects of dopamine on the synaptic transmission between primary nociceptors and dorsal horn neurons, and the effects of dopamine on pain in rodents. Published data support both anti-nociceptive effects of dopamine mediated by D2-like receptors and pro-nociceptive effects mediated by D1-like receptors.

Proteomic analysis of the dorsal spinal cord in the mouse model of spared nerve injury-induced neuropathic pain

Peripheral nerve injury often causes neuropathic pain and is associated with changes in the expression of numerous proteins in the dorsal horn of the spinal cord. To date, proteomic analysis method has been used to simultaneously analyze hundreds or thousands of proteins differentially expressed in the dorsal horn of the spinal cord in rats or dorsal root ganglion of rats with certain type of peripheral nerve injury. However, a proteomic study using a mouse model of neuropathic pain could be attempted because of abundant protein database and the availability of transgenic mice. In this study, whole proteins were extracted from the ipsilateral dorsal half of the 4th-6th lumbar spinal cord in a mouse model of spared nerve injury（SNI）-induced neuropathic pain. In-gel digests of the proteins size-separated on a polyacrylamide gel were subjected to reverse-phase liquid-chromatography coupled with electrospray ionization ion trap tandem mass spectrometry（MS/MS）. After identifying proteins, the data were analyzed with subtractive proteomics using ProtAn, an in-house analytic program. Consequently, 15 downregulated and 35 upregulated proteins were identified in SNI mice. The identified proteins may contribute to the maintenance of neuropathic pain,and may provide new or valuable information in the discovery of new therapeutic targets for neuropathic pain.

Effects of morphine and electroacupuncture on substance P level in spinal cord and their relation to pain threshold in rats

Immunoreactive substance P(Ir-SP)level,and substance P likeimmunoreactivity(SP-Li)in the spinal cord were observed with radioimmunoassay andimmunohistochemistry in rats after they were given an intraperitoneal injection of mor-phine(7.5mg/kg)or electroacupunctured(3V and 3Hz)on the “Jiaji point”.It wasfound that the pain threshold(PT),Ir-SP level and SP-Li in the dorsal horn of the spi-nal cord were more significantly increased in the animals after the administration ofmorphine or electroacupuncture than in the control(P【0.05～0.01).The combined effectsof morphine and electropacupuncture were even more powerful than either of the agentswas administered singly.Naloxone could block the analgesic effect and the elevation ofIr-SP due to morphine or electroacupuncture.The findings suggest that there is a synergismbe tween morphine and electroacupuncture and the analgesic effect of the 2 depends uponthe increase of Ir-SP level of the spinal cord mediated through the opiate receptors.

Orofacial inflammatory pain affects the expression of MT1 and NADPH-d in rat caudal spinal trigeminal nucleus and trigeminal ganglion

Very little is known about the role of melatonin in the trigeminal system, including the function of melatonin receptor 1. In the present study, adult rats were injected with formaldehyde into the right vibrissae pad to establish a model of orofacial inflammatory pain. The distribution of melatonin re- ceptor 1 and nicotinamide adenine dinucleotide phosphate diaphorase in the caudal spinal trigeminal nucleus and trigeminal ganglion was determined with immunohistochemistry and histo- chemistry. The results show that there are significant differences in melatonin receptor 1 expression and nicotinamide adenine dinucleotide phosphate diaphorase expression in the trigeminal ganglia and caudal spinal nucleus during the early stage of orofacial inflammatory pain. Our findings sug- gest that when melatonin receptor 1 expression in the caudal spinal nucleus is significantly reduced, melatonin＇s regulatory effect on pain is attenuated.

Low-dose radiation on spinal cord might be a new therapy for intractable chronic cancer and non-cancer pain

Intractable chronic pain is a great challenge in clinic.Central sensitization based on the positive changes of dendritic spines is the main mechanism of intractable chronic pain.And low-dose radiation has been proved to regulate the changes of dendritic spines negatively.Hence,we make a hypothesis that low-dose radiation could relieve cancer and noncancer pain through negatively regulating the shape and reducing the number and density of dendritic spines in the spinal cord.This method is supposed to be a new therapy for intractable chronic pain by expanding indication to non-cancer pain,translocating radiation site from where the tumor exists to special segments of spinal cord and keeping radiation dose at a low level.This therapy would be reliable for relieving non-cancer pain and supply more choices for relieving cancer pain.

Topographical Anatomical Neuropathic-Pain Guided (TANG) Mapping: A Tool Derived from a Patient Perspective to Facilitate the Transition from Spinal Cord Stimulator Trial to Potential Permanent Implantation

Introduction: Collecting a patient’s pain scores and the analgesic effect achieved during spinal cord stimulation (SCS) trials can be difficult, and no standard exists for doing so. We propose a topographical mapping tool that was derived from a patient’s perspective. Case: A 60-year-old man with postherpetic neuralgia (PHN) underwent a SCS trial after conservative treatment failed to relieve his pain. During the SCS trial, with the SCS off and on in five different settings, he recorded pain levels in each of the six different painful zones he identified. The data collected were transferred to a topographical and anatomical map, which helped the physicians to better understand the effects of the SCS at different settings. Ultimately, the data collected by the patient helped the physicians to implant a permanent SCS successfully. Conclusions: Patient pain diaries have been used in pain medicine for years. This particular patient’s collection of pain scores and SCS effects inspired the construction of a more standardized tool for collecting such data during SCS trials. We propose that use of our Topographical Anatomical Neuropathic-pain Guided (TANG) mapping tool will enable physicians to choose SCS lead positions more precisely than is currently possible.

Acetylcholine participates in pain modulation by influencing endogenous opiate peptides in rat spinal cord

The spinal cord is a necessary pathway that transfers the body nociceptive inputs to the brain, and endo-genous opiate peptides (EOP) play an important role in pain modulation. Our previous work has proven that arginine vasopressin (AVP) antinociception in the caudate nucleus (CdN) relates with the acetylcholine (Ach) system mainly. The communication was de-signed to investigate the interrelations between Ach system and EOP system at the spinal level during pain process. The results showed that: 1) pain stimulation increased L-enkephalin (L-Ek), β-endorphin (β-Ep), dynorphin A1-13(DynA1-13), Ach and choline (Ch, an Ach metabolic product) concentrations in the spinal cord;2) Ach increased L-Ek, β-Ep and DynA1-13 concentrations in the spinal cord;and 3) Atropine (M-receptor inhibitor) or hexahydric gallamine (N-receptor inhibitor) decreased L-Ek, β-Ep and DynA1-13 concentrations in the spinal cord. The data suggested that Ach antinociception was involved in the EOP system at the spinal level.

Epidural Blood Patch for Treatment of Postdural Puncture Headache in a Patient with Spinal Fusion and Recent Implantation of Intrathecal Pain Pump

We present an interesting case report of a 49-year-old female who presented with symptoms of post-dural puncture headache following implantation of an intrathecal pain pump. Her history was complicated by previous multi-level spinal fusion with hardware. The patient was evaluated and felt to be a candidate for epidural blood patch, which she elected to proceed with. Under fluoroscopic guidance epidural blood patch was successfully performed. Immediately following the procedure the patient noted significant improvement in the headache and six hours following the procedure was headache free and remained so at follow up three weeks later.

Spinal Cord Stimulation (SCS) for Pain Control in a Quadriplegic Patient: A Case Report

Background: There are reports of pain relief from spinal cord stimulation (SCS) in patients with incomplete spinal cord injuries. However, the results for pain relief from SCS in patients with complete spinal cord injury are dismal. Patients with complete spinal cord injury therefore are generally not considered suitable candidates for SCS. The authors report a case in which a quadriplegic patient with cervical spinal cord injury got significant pain relief from spinal cord stimulation. Methods: The patient is 41 years old with quadriplegia secondary to C5-6 injury. He has no function below the level of the injury except for a few patchy areas of sensation. Ten years after the injury the patient had hemorrhoidectomy. This resulted in severe pain in the anal pain. The treatment for pain failed conservative treatment. He however did have good response to a trial of spinal cord stimulation through an epidural lead placed at T8-T9 vertebral body level. Permanent implantation of spinal cord stimulator was therefore performed. Results: At preoperative evaluation the patient rated his pain as a 7/10. Presently at 2 years’ follow-up the patient rates his pain at 1/10. Conclusions: Spinal cord stimulation proved to be a successful means of achieving adequate pain relief in a patient who had complete loss of motor function below the level of the injury. Therefore, although patients with such condition are unlike to benefit from SCS it is worthwhile trying this treatment if no other option is available there.

Spinal processing of bee venom-induced pain and hyperalgesia

Subcutaneous injection of bee venom causes long-term neural activation and hypersensitization in the dorsal horn of the spinal cord,which contributes to the development and maintenance of various pain-related behaviors.The unique behavioral 'phenotypes' of nociception and hypersensitivity identified in the rodent bee venom test are believed to reflect a complex pathological state of inflammatory pain and might be appropriate to the study of phenotype-based mechanisms of pain and hyperalgesia.In this review,the spinal processing of the bee venom-induced different 'phenotypes' of pain and hyperalgesia will be described.The accumulative electrophysiological,pharmacological,and behavioral data strongly suggest that different 'phenotypes' of pain and hyperalgesia are mediated by different spinal signaling pathways.Unraveling the phenotype-based mechanisms of pain might be useful in development of novel therapeutic drugs against complex clinic pathological pain.

An Analysis of Pain Following Traumatic Spinal Cord Injury among Adults in Zimbabwe

The purpose of the study was to analyse on pain following traumatic spinal cord injury, its prevalence, the types of pain present, the common treatments used and their perceived effectiveness in the management of these reported pain types. A cross sectional study was carried out at St Giles Rehabilitation Centre and from members of the Spinal Injuries Association of Zimbabwe (SIAZ). A researcher-administered questionnaire was used to collect data from 24 participants with traumatic spinal cord injury. The questionnaire elicited information on demographic data, pain characteristics and the perceived effectiveness of the common treatments used. Among the 24 participants in the study, 17 were males (70.8%) and 7 were females (29.2%). Pain prevalence was 79.2% among the study participants and approximately a fifth (21.03%) of all participants rated their pain as severe. Eight (33.3%) of the participants had neuropathic pain while 11 (45.8%) had both nociceptive and neuropathic pain types. However, no association was found between sex, age, time post injury when tested against the presence of pain (p > 0.05). Weather changes aggravated almost every type of pain reported. Both pharmacological and non-pharmacological methods were used to manage the pain but their perceived effectiveness was rated as low. The majority of the traumatic spinal cord injured people experienced some pain and this pain was severe in a fifth of all participants. Pain significantly affected their quality of life. Physiotherapists and other medical professionals need to be aware of this and should employ pain reducing modalities and empathy when dealing with these patients.

Combined Sacral Nerve Roots Stimulation and Low Thoracic Spinal Cord Stimulation for the Treatment of Chronic Pelvic Pain

Some pelvic pain syndromes are very resistant to medical treatment. Several studies have demonstrated that sacral neuromodulation, which has been successfully used for the treatment of bladder dysfunction, incontinence, urinary retention and urinary frequency [1]-[3], can be successfully used for the treatment of chronic pelvic pain [4]-[7]. Several studies have also demonstrated significant involvement of dorsal column pathways in the transmission of visceral pelvic pain [8] and the successful use of spinal cord stimulation for the treatment of chronic pelvic pain [9]. We report three cases of severe chronic pelvic pain that failed conservative treatment modalities. Placement of a combined sacral nerve roots stimulator and a low thoracic spinal cord stimulator resulted in a significant pain relief and improvement in daily life activities. We believe that this combination may help patients suffering from chronic pelvic pain resistant to medical management.

药物疗法、神经阻滞联合脊柱调整治疗带状疱疹相关性神经痛的临床效果

目的探讨药物疗法、神经阻滞联合脊柱调整治疗带状疱疹相关性神经痛(ZAP)的临床效果。方法将97例ZAP患者随机分为观察组49例和对照组48例。对照组患者接受药物疗法联合神经阻滞治疗,观察组患者在对照组治疗方案的基础上,接受脊柱调整(头颈段、胸椎段及腰骶段)治疗。分别采用疼痛视觉模拟量表(VAS)、焦虑自评量表(SAS)、抑郁自评量表(SDS)、匹兹堡睡眠质量指数(PSQI)评估两组患者的疼痛状况、焦虑状况、抑郁状况及睡眠质量。比较两组患者治疗前、治疗后1个月和3个月的疼痛VAS评分、SAS评分、SDS评分、PSQI评分,治疗后的临床疗效,以及治疗期间的不良反应发生率。结果两组患者的疼痛VAS评分、SAS评分、SDS评分、PSQI评分比较,差异有统计学意义(P<0.05),疼痛VAS评分、SAS评分、SDS评分、PSQI评分有随时间延长而降低的趋势(P<0.05),分组与时间存在交互效应(P<0.05);治疗后1个月及3个月,观察组的疼痛VAS评分、SAS评分、SDS评分、PSQI评分低于对照组(P<0.05)。治疗后3个月,观察组的总有效率高于对照组(P<0.05)。治疗期间,两组患者均未发生严重不良反应,观察组严重疼痛、头晕、便秘的发生率低于对照组(P<0.05)。结论药物疗法、神经阻滞联合脊柱调整治疗能够有效地改善ZAP患者的疼痛、焦虑状态、抑郁状态及睡眠质量,具有良好的临床效果,且安全性较高。

Analgesic effect of intrathecal bumetanide is accompanied by changes in spinal sodium-potassium-chloride co-transporter 1 and potassium-chloride co-transporter 2 expression in a rat model of incisional pain

Accumulating evidence has demonstrated that the sodium-potassium-chloride co-transporter 1 and potassium-chloride co-transporter 2 have a role in the modulation of pain transmission at the spinal level through chloride regulation in the pain pathway and by effecting neuronal excitability and pain sensitization. The present study aimed to investigate the analgesic effect of the speciifc sodium-potassium-chloride co-transporter 1 inhibitor bumetanide, and the change in spinal sodium-potassium-chloride co-transporter 1 and potassium-chloride co-transporter 2 expression in a rat model of incisional pain. Results showed that intrathecal bumetanide could decrease cumulative pain scores, and could increase thermal and mechanical pain thresholds in a rat model of incisional pain. Sodium-potassium-chloride co-transporter 1 expression in-creased in neurons from dorsal root ganglion and the deep laminae of the ipsilateral dorsal horn following incision. By contrast, potassium-chloride co-transporter 2 expression decreased in neurons of the deep laminae from the ipsilateral dorsal horn. These ifndings suggest that spinal sodium-potassium-chloride co-transporter 1 expression was up-regulated and spinal potassi-um-chloride co-transporter 2 expression was down-regulated following incision. Intrathecal bumetanide has analgesic effects on incisional pain through inhibition of sodium-potassi-um-chloride co-transporter 1.

脊柱-骨盆矢状位参数与腰椎退行性疾病术后持续性下腰痛的关系

目的 分析脊柱-骨盆矢状位序列参数变化与腰椎退行性疾病(degenerative lumbar disease,DLD)患者术后持续性下腰痛的关系。方法 选取天津市人民医院2019年6月至2022年6月行单节段腰椎融合内固定术治疗的86例DLD患者,根据术后是否发生持续性下腰痛分为腰痛组和非腰痛组。腰痛组34例,男10例,女24例;年龄32~77岁,平均(59.36±8.65)岁。非腰痛组52例,男21例,女31例;年龄30~78岁,平均(56.81±8.03)岁。比较两组患者一般资料、手术前后疼痛视觉模拟评分(visual analogue score,VAS)、日本骨科协会(Japanese orthopaedic association,JOA)腰椎功能评分及脊柱-骨盆矢状位序列参数[腰椎前凸角(lumbar lordosis,LL)、骨盆入射角(pelvic incidence,PI)、骨盆倾斜角(pelvic tilt,PT)、骶骨倾斜角(sacral slope,SS)]。分析术后持续性下腰痛发生的影响因素,分析手术前后脊柱-骨盆矢状位序列参数变化值与VAS、JOA评分变化值的相关性,分析手术前后脊柱-骨盆矢状位序列参数变化值及相关影响因素预测术后发生持续性下腰痛的价值。结果 腰痛组骨质疏松、术中骨性终板损伤发生率(47.06%、23.53%)高于非腰痛组(15.38%、1.92%);腰痛组术后3个月VAS、PT高于非腰痛组,JOA评分、LL、SS低于非腰痛组,ΔVAS、ΔJOA、ΔLL、ΔPI、ΔPT、ΔSS小于非腰痛组(P<0.05);DLD患者ΔLL、ΔPT、ΔSS均与ΔVAS、ΔJOA间存在正相关关系(P<0.05),ΔPI与ΔVAS、ΔJOA间无明显相关性(P>0.05);骨质疏松、术中骨性终板损伤、ΔLL、ΔPT、ΔSS均为DLD患者术后发生持续性下腰痛的影响因素(P<0.05);ΔLL、ΔPT、ΔSS预测DLD患者术后发生持续性下腰痛的曲线下面积(area under the curve,AUC)分别为0.776、0.825、0.731;与ΔLL、ΔPT、ΔSS单独预测比较,ΔLL、ΔPT、ΔSS联合预测的AUC(0.939)明显增大,净重新分类指数、综合判别改善指数均>0(P<0.05)。结论 脊柱-骨盆矢状位序列参数变化与DLD患者腰椎术后持续性下腰痛的发生有关,且在预测术后发生持续性下腰痛方面具有良好应用价值。

运动引导想象训练对脊髓神经减压术后患者神经病理性疼痛和睡眠障碍的影响

目的探讨运动引导想象训练对脊髓神经减压术后患者神经病理性疼痛和睡眠障碍的影响。方法选取脊柱外科收治的62例行脊髓神经减压术且存在神经病理性疼痛和睡眠障碍的患者为研究对象,采用随机数字表法将其分为对照组和观察组,各31例。对照组实施术后常规护理,观察组在对照组基础上进行运动引导想象训练。比较2组神经病理性疼痛程度和睡眠质量。结果2组疼痛评分在时间效应、组间效应及交互效应方面比较,差异均有统计学意义(F时间=429.691,P<0.001;F_(组间)=7.063,P<0.001;F_(交互)=25.634,P<0.001);2组匹兹堡睡眠质量指数量表评分在时间效应、组间效应及交互效应方面比较,差异均有统计学意义(F时间=790.029,P<0.001;F_(组间)=46.914,P<0.001;F_(交互)=180.366,P<0.001)。结论运动引导想象训练可以缓解脊髓神经减压术后患者的神经病理性疼痛和睡眠障碍,值得临床推广应用。

退行性腰椎管狭窄患者椎间孔镜术后下腰痛的危险因素及风险预测模型构建

目的分析退行性腰椎管狭窄(DLSS)患者椎间孔镜术后下腰痛的危险因素及风险预测模型构建。方法本研究采用前瞻性分析,纳入2020年7月至2022年7月南阳市中心医院收治的86例行经皮椎间孔镜手术治疗的DLSS患者为研究对象,术后随访3个月,根据术后下腰痛发生情况,分为发生组和未发生组,分析两组患者临床资料,采用多因素logistic回归分析DLSS患者椎间孔镜术后下腰痛发生的影响因素,构建风险预测模型,绘制受试者工作特征(ROC)曲线评估风险模型的预测效能。结果随访3个月,86例DLSS患者行椎间孔镜术后发生下腰痛患者21例,发生率为24.42%(21/86);发生组骨质疏松、术中清理椎间隙、术后椎管内无菌性炎症、首次锻炼时间与未发生组比较,差异无统计学意义(P<0.05);经多因素logistic回归分析,结果显示,骨质疏松、术中清理椎间隙、术后椎管内无菌性炎症、首次接受锻炼时间均是DLSS患者椎间孔镜术后下腰痛发生的危险因素(P<0.05);构建风险模型,验证模型显示C-index值为0.870,具有良好区分度,绘制标准曲线显示,校准曲线和Y-X直线相近,模型准确度良好;对模型预测效能进行验证,结果显示,风险模型评估DLSS患者椎间孔镜术后下腰痛发生的曲线下面积(AUC)为0.870,95%CI为0.779~0.961,P<0.001。结论DLSS患者行椎间孔镜术后下腰痛发生率较高,合并骨质疏松、术中未清理椎间隙、有术后椎管内无菌性炎症、首次接受锻炼时间延长均是DLSS患者行椎间孔镜术后发生下腰痛的危险因素,基于以上因素构建的风险模型对DLSS患者行椎间孔镜术后是否发生下腰痛具有较高的评估价值。