Intraoperative CT (AIRO®) navigation as a new tool in percutaneous retrogasserian alcohol rhizolysis for trigeminal neuralgia.
Lorenzo Bertulli (Lugano | CH)
Martina Dalolio (Lugano | CH)
Background and objectives
The percutaneous alcoholization of the gasserian ganglion through the foramen ovale for the treatment of trigeminal neuralgia is well known and has been applied extensively since the early 1980s. It is usually less discomfortable to the patient compared to radiofrequency thermocoagulation. Despite this, even today reaching the target is difficult, with the consequent possible ineffectiveness of treatment or an increased risk of serious complications, including carotid artery puncture or alcohol injection in the temporal subarachnoid space. This is because of the difficulty to visualize the foramen ovale on x-ray/fluoroscopy and to the anatomy of the foramen itself, whose walls could be very oblique or irregular due to arthrotic phenomena.
Our goal is to optimize the alcoholization procedure by improving the visualization and approach to the foramen ovale using intraoperative CT navigation.
Under general anesthesia, the head is fixed in a carbon Mayfield clamp, slightly extended in neutral position; intraoperative CT-scan (AIRO®) is acquired and navigation precision (Brainlab®) is checked. The needle entry point is at 2.5 cm from the mouth corner. A 11 cm 18G needle is navigated applying a reference star to allow optimal navigation and visualization of the foramen ovale in the three planes. The needle is millimetrically carefully inserted beyond the foramen and between 0.7 and 1 ml of ethanol 96% is injected. If needed, a cisternography can easily be performed too. The slow insertion and the precise trajectory of the needle also minimize muscle trauma.
Percutaneous retrogasserian alcohol rhizolysis is a very effective and painless treatment for trigeminal neuralgia. Intraoperative CT navigation can improve precision, safeness and effectiveness of the procedure.
Brainspotting, shaking and tapping: new approaches to the unholy trinity "trauma, anxiety and chronic pain"
Hildegard Nibel (Zürich | CH)
In recent years, the limitations of "talking cures" have become increasingly apparent. Even if patients are aware of their dysfunctional behavioral patterns and even if they would like to behave differently, these changes in thinking and behavior are often not successful. Therefore, many therapeutic techniques have been developed over the last 30 years that systematically incorporate physical sensations into the therapeutic process in order to achieve faster and more lasting improvements in health and well-being. From our point of view, the most promising techniques at present are the Emotional Freedom Technique EFT by Gary Craig, Brainspotting by David Grand, the Save and Sound Protocol SSP by Stephen Porges, and the Tension & Trauma Release Exercises TRE by David Berceli.
I. EFT is still a relatively conventional therapy approach, comparable to EMDR Eye Movement Desensitization and Reprocessing. The "problem" and a positive self-affirmation have to be verbalised, so the therapeutic effect still requires the use of language.
Meta-analyses have shown that this standard intervention is more effective in panic and anxiety disorders than the previous gold standard cognitive behavioural therapy. EFT is now recommended as first choice intervention by the National Institutes of Health in the USA and UK.
II. Brainspotting is a further development of the proven trauma therapy technique EMDR. However, now painful experiences no longer have to be consciously recalled, but the client follows the therapist's pointing stick to find areas of the brain were negative experiences are stored, not just traumatic ones. Through this systematic activation of points of view ("spots") stress disorders are dissolved (Grand 2014).
III. The Save & Sound Protocol SSP by Stephen Porges (2016) is a result of his polyvagal theory, developed to help autistic children. Porges discovered that all mammals have a tiny muscle in the middle ear that is normally activated when in company with other mammals and their vocalization is amplified and ambient sounds are attenuated or even filtered out. Further, nerve fibres connect the musculus stapedius to the heart, so the heart rate and the contractions of the heart muscle are regulated towards well-being.
IV. The TRE Tension and trauma Release Exercises by David Berceli are based on the natural human reflex to move into the fetal position ("fetal response) when threatened and to release the tension of the psoas muscle when the threat is over.
Psychosocial resources and chronic pain in individuals with spinal cord injury: evidence from the second Swiss national community survey
Céline Braunwalder (Bern | CH)
Study Design: Cross-sectional
Objective: To strengthen the evidence on the associations of a broad set of psychosocial resources with pain and pain-related factors in individuals with spinal cord injury (SCI) and chronic pain.
Setting: Community, Switzerland.
Methods: Data from 1,064 participants with chronic pain who participated in the second community survey of the Swiss Spinal Cord Injury Cohort Study (Survey 2017) were analysed. Multiple linear regression modelling was performed to test the hypotheses that psychosocial resources (self-efficacy, self-esteem, purpose in life, optimism/energy, hope, social support, sense of belonging) are negatively associated with pain and pain-related factors (pain intensity, pain interference, depressive symptoms). study of the second community survey of the Swiss Spinal Cord Injury Cohort Study (Survey 2017)
Results: Higher self-esteem, optimism, and hope were related to lower pain interference in fully adjusted models and all psychosocial resources under study were negatively associated with depressive symptoms in final models. However, neither of the psychosocial resources was related to pain intensity when models were adjusted for pain interference and depressive symptoms.
Conclusion: These findings strengthen the evidence that psychosocial resources are associated with pain-related factors (i.e. pain interference and depressive symptoms), and support the notion that psychosocial resources might be promising targets for interventions in individuals with SCI and chronic pain.
The role of endogenous opioids in mediating the pleasant feeling of pain relief in humans
Laura Sirucek (Zurich | CH)
Background & Objectives. Endogenous opioids mediate the pleasurable responses to positively reinforcing rewarding stimuli such as palatable food . Yet, also the reduction or omission of a negative experience can be rewarding (negative reinforcement). As such, pain relief leads to negative reinforcement  and evokes a pleasant feeling in humans . While it has been shown that the feeling of pleasure associated with positive reinforcement is at least partly mediated via endogenous opioids , it is currently unknown if similar neurochemical mechanisms are involved in the pleasant feeling evoked by pain relief. The present study tested if endogenous opioid blockade using naltrexone diminishes the subjective feeling of pain relief in humans.
Materials & Methods. Twenty-seven healthy participants (mean age ± SD: 21.70 ± 2.77 years; 14 f) completed two identical experimental sessions, one with placebo and one with naltrexone, following a randomized, placebo-controlled, double-blind, counter-balanced, within-subject study design. Pain relief was induced by superficial cooling after heat stimulation of capsaicin-sensitized skin. Heat-stimulations were perception-adjusted to two pain intensities, i.e., '170' and '195' on an intensity rating scale ranging from 0 "No sensation" to 200 "Most intense pain tolerable" with 100 being the pain threshold. Participants rated the relief and pleasantness in response to the cooling.
Results. Endogenous opioid blockade by naltrexone diminished relief and pleasantness ratings compared to placebo (F[1,177.5]=9.29, p=0.0027). The relief/pleasantness reduction by naltrexone was greater in participants who reported higher relief/pleasantness in the placebo session (relief at '170': rho=-0.37, p=0.060; pleasantness at '170': rho=-0.56, p=0.0027, relief at '195': rho=-0.49, p=0.016; pleasantness at '195': rho=-0.43, p=0.04).
Conclusion. These results provide evidence that endogenous opioids play a role in mediating the pleasant feeling of pain relief in humans. Further, the results indicate that individual differences in the endogenous opioid system are related to the magnitude of experienced pain relief. Clinically, the rewarding nature of pain relief and its underlying mechanisms require consideration because of their potential reinforcing effects on behaviors that might be beneficial short-term but maladaptive long-term.
Comprehensiveness and Validity of Multidimensional Assessment in Patients with Chronic Low Back Pain
Thomas Benz (Bad Zurzach | CH)
Background & Objectives. Multidimensional chronic low back pain (CLBP) syndrome affects physical activity and function, health-related quality-of-life and employment state. The aim of this study was to examine how the complexity of the syndrome can be comprehended and the validity of single measurement scales in the multidimensional and comprehensive assessment in patients with CLBP before and after a standardized 4-week interdisciplinary pain program.
Material & Methods. This prospective cohort study assessed 177 patients by the Short Form 36 (SF-36), the Multidimensional Pain Inventory (MPI), the Symptom Checklist-90-Revised (SCL-90-R), and the Oswestry Disability Index (ODI), and by 2 functional performance tests, the Back Performance Scale (BPS) and the 6-Minute Walking Distance (6MWD). Comprehensiveness and overlap of the constructs were cross-sectionally and longitudinally quantified by bivariate correlations, explorative factor analysis, and effect sizes (ES).
Results. Patients included in this study were of 48.0 years (+/-12.7) and 59.3% female. Correlations of baseline scores ranged from r=–0.01 (BPS with MPI Life control) to r=0.76 (SF-36 Mental health with MPI Negative mood). SF-36 Physical functioning correlated highest with functional performance tests (r=0.58 BPS, 0.67 6MWD) and ODI (0.56). Correlations of change scores (difference of follow-up – baseline score) were consistent but weaker. Factor analysis revealed 2 factors: psychosocial and pain & function (totally explained variance 44.0–60.9%). In all 3 analyses, psychosocial factors loaded strongest (up to 0.89 SCL-90-R) on the first factor, covering 2/3 of the explained variance. Pain and function(ing) loaded stronger on the second factor (up to 0.81 SF-36 Physical functioning). All scales showed improvements by ES ranging from 0.16–0.67.
Conclusions. High levels of explained variance in the factor analysis and improvements on all used scales illustrated the complexity of the CLBP syndrome comprising much more dimensions of health and quality of life than only back related function. Some of the physical scales of the pain-specific MPI and ODI showed moderate to high construct overlap as well as the affective health scales of the SF-36, the MPI, and the SCL-90-R. The broad spectrum of measured constructs was proven by the fact that many scales showed only partial convergence in the same domain.
Pain trajectories based on routine pain scores predict chronic postoperative pain by early pain intensity, but not by the slope of pain resolution
Sarah Grosse (Chêne-Bougeries | CH)
Background & Objectives
Chronic postsurgical pain (CPSP) remains highly prevalent and is a major cause of incomplete recovery (1). An effective prevention of chronic pain depends on the correct identification of patients at risk. Therefore, understanding risk factors is crucial. It has been hypothesized that the dynamic of the acute pain evolution should be more predictive than pain intensity (2,3).
In this study we aimed to investigate the predictive capacity of the acute pain trajectory modelled into a regression line and its parameters as compared to that of the daily average pain intensity.
Material & Methods
For our study, we included patients from the ongoing study ALDO who were randomly recruited from the operative room schedule. We selected only elective surgeries known to be at risk for CPSP. For the first five postoperative days, pain scores at rest were collected by nurses on the ward. Chronic pain was assessed 6 months later with a definition of CPSP being a score of ≥ 3/10 on the numerical rating scale (NRS). We used logistic regression to test the slope and intercept of the regression line as well as average daily scores as predictive factors for chronic pain 6 months after surgery.
Of the initially 233 patients included, we had complete data for 99 patients. The analysis of those showed a predictive capacity for the intercept of the trajectory’s regression line (p-value =0.01) and for the daily average pain at 24, 48, 72 and 96 hours postoperatively (p-value < 0.01). The estimate of the beta-coefficient for the daily average pain yielded an OR =1.51 at 24h, OR= 1.6 at 48h, OR= 1.95 at 72h and OR =1.49 at 96h. The slope of the regression line failed to predict chronic pain in our study.
Our study confirms that acute pain intensity (mean daily scores and intercept of the pain trajectory) predicts chronic pain. We could not prove a better predictive capacity of a dynamic approach using the slope of a linear pain trajectory. There is a need to investigate whether a nonlinear statistic method would show otherwise.
DETECTION OF SOCIAL PROBLEMS IN CHRONIC PAIN PATIENTS USING A NEW QUESTIONNAIRE
André Ljutow (Nottwil | CH)
Background and aims: According to the bio-psycho-social model of disease social problems may be the origin of chronic pain or may contribute to the persistence of pain. As social counselling in most countries is not part of the medical system social problems are often not addressed properly. Previous studies revealed a high burden of social problems in chronic pain patients.
Methods: Based on a previously developed structured interview a questionnaire was developed asking for nonsatisfactory conditions in family relations, housing conditions, social contacts, income and insurance matters. The results are interpreted on the data background from our pain questionnaire, including information on pain intensity, chronicity of pain, pain grading scale, depression and anxiety symptoms etc.
Results: Correlations between social burden and chronic pain are described statistically. The results point out the necessity to address social matters assessing chronic pain.
Conclusions: The questionnaire offers an approach to social problems in chronic pain patients and allows to monitor progress in social counselling.
Fear avoidance beliefs limit lumbar spine flexion during object lifting in pain-free adults – A protective strategy with negative consequences?
Michael Meier (Zurich | CH)
Background & Objectives
There is a long-held belief that physical activities such as lifting with a flexed spine is harmful for the back and causes low back pain (LBP), potentially contributing to pain-related fear (PRF). In LBP patients, it has been demonstrated that elevated PRF is linked to less lumbar flexion during object lifting, probably to protect the back. Such a protective strategy is suggested to predispose individuals to persistent back problems in the long term. It is unknown if such protective strategies already exist in pain-free individuals which would yield potential insights into how a person might react when they experience LBP. Therefore, this study aimed at investigating a potential relationship between PRF and and spine kinematics during lifting in pain-free subjects.
Material & Methods
57 pain-free adults (mean age=29.5y, 27 females) completed the “Tampa Scale for Kinesiophobia” questionnaire for the general population (TSK-G). Task-specific PRF was evaluated using the “Photograph Daily Activities Series” scale (PHODA), including a picture of a person lifting an object with a flexed back (PHODA-lift).Participants were equipped with 58 retro-reflective markers, including markers on the spinous processes of C7,T3,T5,T7,T9,T11 as well as L1-L5 and the sacrum. A system with 20 infrared cameras was used to derive the 3D trajectories of the markers for the calculation of sagittal spinal curvature angles. Subsequently, subjects were asked to lift (lifting-up) and put back down (putting-down) a 5kg-box. Mutiple linear regression analyses were carried out using one-dimensional Statistical-Parametric-Mapping (SPM 1D, alpha-level=0.05) which permitted time-sensitive analyses.
A significant negative relationship between the PHODA-lift score and lumbar curvature angles during the lifting-up (time window: 9-92%, -0.313≤r≥-0.310,p=0.007) and putting-down cycles (time window: 17-60%,-0.315≤r≥-0.306,p=0.028) was found. Additional analysis revealed that these time-dependent relationships were driven by motion of the lower lumbar region (L4-L5). No relationships were found for thoracic curvature angles. Furthermore, no significant relationships between TSK-G, PHODA-total score and spinal curvature angles were found.
Our results indicate that protective movement strategies can be driven by distinct beliefs about the harmfulness of daily activities such as lifting with a flexed spine, in the absence of (experimental) pain.
Imaging Neurovascular Uncoupling In Acute Migraine With Aura With Susceptibility Weighted Imaging
Frauke Kellner-Weldon (Luzern | CH)
Background and Objectives: Migraine with aura (MwA) in the emergency setting is common and sometimes difficult to distinguish from mimicking conditions. Our study aimed at evaluating the frequency of regions of prominent focal veins (PFV) on susceptibility imaging (SWI) in the acute phase.
Material & Methods: Between 2011 and 2018 we evaluated symptoms and MR imaging of adult patients with acute MwA attacks (< 5 days after onset of symptoms). Abnormal imaging was visually scored in 12 ROIs on both hemispheres distributed on 3 slices. The severity score ranged from 0-3.
Results: 638 patients (436 female) mean age 37.39 y, (18-89 ± 14.13) were included. SWI was abnormal in 18.8% of patients. The inferior and posterior medial temporal lobe and the occipital lobe were most often affected. SWI was more likely abnormal when MR was performed within 24 hours with an average around 5 hours after symptom onset. The side of aura symptoms and hemispheric imaging alteration in patients with abnormal SWI was highly significant (p < .001).
Conclusion: In the acute episode of MwA, SWI imaging can show a combination of increased deoxygenation. This study provides confidence in linking PFV to acute MwA.
Extended overview of the longitudinal pain-depression association: a comparison of 6 naturalistic cohort studies of specific chronic pain conditions
Thomas Benz (Bad Zurzach | CH)
Background & Objectives. The cross-sectional relationship between pain and depression has stimulated research and generated a huge body of scientific literature over the years. The aim was to quantify and to compare the associations between longitudinal changes in pain and depression in different chronic pain conditions.
Material & Methods. Data were retrieved from 6 naturalistic, observational cohort studies. From baseline to the 6-month follow-up, the score changes on the Short Form (36) Health Survey (SF-36) bodily pain (pain) and the SF-36 mental health (depression) scales (0=worst, 100=best) were quantified, using partial correlations obtained by multivariate regression. Adjustment was performed by age, living alone/with partner, education level, number of comorbidities, baseline pain and baseline depression.
Results. Stronger associations were found between changes in levels of pain and depression for neck pain after whiplash (n=103, mean baseline pain=21.4, mean baseline depression=52.5, adjusted correlation r=0.515), knee osteoarthritis (n=177, 25.4, 64.2, r=0.502), low back pain (n=134, 19.0, 49.4, r=0.495), and fibromyalgia (n=125, 16.8, 43.2, r=0.467) than for lower limb lipedema (n=68, 40.2, 62.6, r=0.452) and shoulder arthroplasty (n=153, 35.0, 76.4, r=0.292). Those correlations were somewhat correlated to baseline pain (rank r=–0.429) and baseline depression (rank r=–0.314).
Conclusions. Moderate associations between changes in pain and depression levels were demonstrated across 5 of 6 different chronic pain conditions, in which relatively high pain levels persisted after conservative therapy. The associations between pain change and depression change tended to be stronger if pain and depression were worse at baseline. These two observed dose-response relationships are indicative of a certain degree of causal interference. Our results suggest that relieving pain may lead to the relief of depression and vice versa.