Orofacial pain and fibromyalgia pain: Being aware of comorbid conditions

Orofacial pain originating from myofascial pain of temporomandibular disorders is the second most common source of pain, after tooth pain. However, diagnosis of myofascial pain is challenging due to its characteristic referral pattern. Furthermore, pain arising from structures in the orofacial region may be a presentation of fibromyalgia and treatment directed at temporomandibular disorders fails to alleviate the pain. Similarly, patients with fibromyalgia may present with pain in the orofacial region. The physician in this case should be aware of temporomandibular disorders, its characteristic findings and treatment approaches that might be included in the treatment plan.     

建立三叉神经痛慢性缩窄环术大鼠模型的体会

目的 建立三叉神经痛慢性缩窄环术大鼠模型,并总结经验.方法 经口腔入路暴露并结扎眶下神经,建立三叉神经痛慢性缩窄环术大鼠模型.观察术后不同时段大鼠对机械刺激的反应阈值(疼痛阈值)及相关的痛觉行为变化.结果 手术组术后14 d,在眶下神经支配区域内,大鼠出现痛觉超敏现象,与术前及对照组比较差异有统计学意义(P<0.05).结论 大鼠眶下神经的慢性环扎损伤可导致三叉神经痛出现.     

Sacral Magnetic Stimulation for Pain Relief from Pudendal Neuralgia and Sciatica

INTRODUCTION: Magnetic stimulation of the sacral nerve roots is used for neurologic examination. However, no one has reported therapeutic efficacy of pain relief from pudendal neuralgia with sacral magnetic stimulation. METHODS: Five patients with pudendal neuralgia or sciatica received 30 to 50 pulsed magnetic stimuli of the sacral nerve roots. The median age of the patients was 59 (range, 28–69) years; there were 3 females. RESULTS: Sacral magnetic stimulation immediately eliminated the pain. The pain relief lasted between 30 minutes and 56 days (median, 24 hours). Adverse effects were not observed. CONCLUSIONS: This pilot study indicates that magnetic stimulation of the sacral nerve roots may be a promising therapeutic modality for pain relief from pudendal neuralgia and sciatica. Further studies should be performed to determine the appropriate intensity and frequency, as well as the utility of a second course, of magnetic stimulation treatment.     

Diabetic thoracic polyradiculopathy

Diabetic thoracic polyradiculopathy usually causes severe, chronic abdominal pain in patients with type 2 diabetes of variable duration. Other diabetic complications, weight loss and paretic abdominal wall protrusion are common. Sensory, motor and autonomic functions are affected. The diagnosis can be made from the characteristic history, physical examination findings, paraspinal electromyography, and other procedures. The differential diagnosis includes postherpetic neuralgia, abdominal wall pain, malignancy, and other spinal disorders. The pathology appears to be immune-mediated neurovasculitis resulting in ischemic injury. Traditional therapy is symptomatic, but recent pathological findings and clinical experience suggest that immunotherapy may be effective.     

Oral care for the homebound and institutionalized.

Most patients who are homebound or in LTC facilities have multiple health problems that require the cooperation of many different types of providers. Dentists have a specific role in this process because they can improve the quality of life for the elderly by keeping them free of oral infection, restoring their dentition so they can enjoy eating, and restoring facial esthetics. It should be apparent that dental care for these patients is a complicated process. There are many considerations in prescribing the type of treatment needed by each patient. These include the patient's life span, medical history, drug history, mental status, mobility status, neuromuscular coordination, dental status, previous dental experience, dental expectations, and economic status. This information must be gathered by the dentist from the patient, the family, the nursing staff, and the patient's physician. Furthermore, the dentist also must assess the facilities and equipment available to carry out oral health care. Only after such considerations can a dental treatment plan evolve that is appropriate for the individual concerned. Dental care for one patient may be no treatment whatsoever, whereas a different patient in the same institution may require the most technologically sophisticated care that dentistry has to offer. Finally, the following circumstances should suggest that a homebound or institutionalized patient needs an urgent oral/dental evaluation: General Signs and Symptoms; Orofacial pain, Visible oral infection, Difficulty chewing food, Halitosis/dry burning mouth, Visible oral soft tissue lesions (white, red, or ulcerated). Tooth-related signs and symptoms; Visible dental decay, Loose or mobile teeth, Bleeding or sore gums. Denture-related Signs and Symptoms; Loose, ill-fitting, or worn dentures, Missing denture teeth, Home repairs attempted.     

2017-2019年南阳市带状疱疹后神经痛分析及病毒基因分型研究

目的分析带状疱疹后神经痛及病毒基因分型,指导临床疾病预防与治疗。方法收集2017-2019年41例带状疱疹后神经痛患者临床资料,以187例带状疱疹非神经痛患者作为对照组。收集患者临床资料,调查带状疱疹后神经痛流行病学特征。采用PCR扩增及测序比对方法对病毒进行基因分型并进行单核苷酸多态性分析。结果观察组患者女性32例,占78.05%,男性9例,占21.95%,对照组女性90例,占48.13%,男性97例,占51.87%,两组患者构成差异有统计学意义(χ²=12.1013,P<0.05)。对照组21-40岁、41-60岁和>60岁患者病例数分别为54、61和72例,分别占28.88%、32.62%和38.50%,观察组病例数分别为6、9和26例,分别占14.63%、21.95%和63.41%,两组不同年龄患者构成差异有统计学意义(χ²=8.5154,P<0.05)。带状疱疹后神经痛发病患者中三叉神经受累患者居多;严重型皮损患者、皮损面积>5%的患者居多;带状疱疹后神经痛发病患者中,有前驱痛患者、重度疼痛的患者居多;与对照组相比,观察组有前驱痛、重度疼痛的患者带状疱疹后神经痛发病差异有统计学意义(P<0.05)。带状疱疹后神经痛发病患者中初治时间≥3 d患者居多;与对照组相比,观察组初治时间≥3 d患者带状疱疹后神经痛发病率差异有统计学意义(P<0.05);所有带状疱疹病毒ORF22读码框中,37902、38019、38055、38081、38177、38299六个位点的核苷酸为G、G、C、C、A、A,带状疱疹患者均为J型。结论积极关注高龄女性带状疱疹患者,调查患者受累神经、皮损及疼痛情况,发现症状及时治疗,可以有效预防带状疱疹后神经痛发生。     

Pelvic distress in the aged patient.

Unexplained pelvic distress or pain was observed in the 4 patients of this report (3 women and 1 man), and also in 6 other patients during a 10-year period of neurologic practice. In each of the 4 reported cases, the discomfort was interpreted as sexual. It is suggested that this may be a valid entity and that, as with trigeminal neuralgia and postherpetic neuralgia, it is truly limited to aged patients. The mechanism, incidence and significance are unknown.     

Outcome of cervical spine surgery in patients with rheumatoid arthritis

OBJECTIVES: Cervical spine instability in patients with rheumatoid arthritis (RA) may lead to cervical myelopathy or occipital neuralgia, or both. Morbidity and mortality in patients with RA treated with cervical spine surgery during two years of follow up were evaluated. METHODS: Between 1992 and 1996 55 patients with RA underwent cervical spine surgery because of occipital neuralgia or cervical myelopathy, or both. Patients were classified according to the Ranawat criteria for pain and neurological assessment before operation and three months and two years postoperatively. For occipital neuralgia a successful operation was defined as complete relief of pain and for cervical myelopathy as neurological improvement. RESULTS: Occipital neuralgia was present in 17 patients, cervical myelopathy in 14 patients, and 24 had both. Surgical treatment in the patients with symptoms of occipital neuralgia who were still alive two years after surgery was successful in 18/29 (62%). In the surviving patients with cervical myelopathy neurological improvement of at least one Ranawat class was seen in 16/24 (67%). Postoperative mortality within six weeks was 3/51 (6%). Within two years after the operation 14 /51 (27%) of the patients had died; in most patients the cause of death was not related to surgery. The highest mortality (50%) was found in the group of six patients with quadriparesis and very poor functional capacity (Ranawat IIIB). CONCLUSION: Cervical spine surgery in patients with RA performed because of occipital neuralgia or cervical myelopathy, or both, is successful in most patients who are alive two years after surgery. However, the mortality rate during these two years is relatively high, which seems to be largely related to the severity of the underlying disease and not to the surgery itself.     

Tratamiento del herpes zoster en pacientes inmunocompetentes e inmunodeprimidos

Herpes zoster (HZ) is a clinical manifestation of the reactivation of latent varicella zoster virus infection. Patients may have acute neuritic pain, together with cutaneous vesicular lesions in a dermatomal distribution. Recently, new antiviral drugs have been highly useful in the treatment of patients with HZ, avoiding many of the secondary complications that can appear after this herpetic infection. In addition, the rational and early use of these antiviral drugs may reduce the virulence of postherpetic neuralgia in a substantial proportion of patients. Consequently, guidelines for the management and treatment of patients with HZ should be established. Specifically, guidelines should be established for certain patient groups at risk for an atypical or severe clinical course, such as immunosuppressed patients (those with solid organ transplants, HIV infection or AIDS, or patients under immunosuppressive treatment) or pregnant and pediatric patients. In addition, antiviral treatment must be administered with analgesic drugs to control neuritic pain in all patients with HZ, whether in the acute phase or in the form of postherpetic neuralgia.     

Chronic pain: use of TENS in the elderly

Transcutaneous electrical nerve stimulation (TENS) can be an important adjunct to the management of pain in elderly patients. Chronic neuropathy and postfracture recovery are the leading indications for using the portable stimulative device, although it has also been applied successfully in relieving low-back pain, postherpetic neuralgia, myofascial pain, phantom-limb pain, and advanced, painful malignancies. However, TENS is rarely used alone in pain relief, but instead should be part of a larger management program that may include other modalities.     

Pain control for elderly patients in Japan

Today, approximately 25% of the Japanese population is over 60 years of age, and about 70% of patients who visit the Pain Relief Center, the University of Tokyo Hospital, are elderly (≥ 60 years). The main diseases causing pain in elderly patients include lower back pain and leg pain, post-herpetic neuralgia, trigeminal neuralgia, and cancer. At our pain clinic, these painful conditions are treated with a variety of treatment modalities, including nerve block, sympathetic blockade, phototherapy, acupuncture, epiduroscopy, and pharmacologic treatment such as systemic and/or topical NSAIDs, opioids, antidepressants, anticonvulsants, vasoactive drugs, and local as well as general anesthetics. This paper briefly describes methods of pain control for these diseases, especially focusing on recently developed treatment modalities.     

Postherpetic neuralgia: a workable treatment plan

Management of established postherpetic neuralgia should proceed on several fronts simultaneously and may include pain-oriented treatments that are pharmacologic, neuroaugmentative, anesthetic, physiatric, psychological, and surgical. Many patients develop a pattern of abnormal illness behavior, manifesting loss of interest in work or avocations, social withdrawal, and disturbance of family roles. Improvement in these impairments must be a goal that is as important as amelioration of the pain itself.     

Dental pain in the elderly

Dental pain is a primary precipitator of dental treatment in the elderly population. Yet the pain in an older person is likely to represent a more severe pathosis than in a younger individual. Increased internal mineralization of the teeth with time results in increased brittleness and susceptibility to fracture. Gingival recession exposes softer, more caries-prone areas of teeth to the oral environment. Alteration in salivary volume and composition is a common side effect of many medications; this further compromises the dentition. The sense organs of older teeth are relatively insulated from the oral environment; there is diminished vascular and nervous support of the pulps of older teeth; and incipient dental caries becomes less likely to cause any discomfort. Dental caries in an older individual therefore often presents as an advanced, cavitated lesion, a fractured tooth, or a soft tissue ulceration secondary to either. Soft tissue trauma similarly may be missed until extensive damage has occurred. Innervation of intraoral soft tissue is diminished in elderly subjects, and the healing potential of mucosa may be less as well. Dentures are often responsible for intreoral trauma due to progressive maladaptation, diminished patient coordination, or salivary modification. Inasmuch as both incipient dental caries and incipient soft tissue trauma may fall to signal their presence, regular intrsoral examinations become the most effective means for avoiding advanced dental pathoses and subsequent dental pain in the elderly. This is the 5th paper in the symposium, Pathogenesis and Management of Pain in the Elderly, presented on 9/25/86 during the 16th Annual Meeting of AGE in Washington, D.C. on 9/25/86.     

Cerebrospinal fluid interleukin 8 concentrations and the subsequent development of postherpetic neuralgia

PURPOSE: Other than age, the risk factors for postherpetic neuralgia are not well established. We studied whether the concentration of interleukin 8 in the cerebrospinal fluid is associated with the risk of postherpetic neuralgia. METHODS: We enrolled 170 patients more than 50 years old who had a typical painful and nontrigeminal herpetic rash. Patients were treated with acyclovir; no corticosteroids were given. Cerebrospinal fluid was taken for analysis of interleukin 8 during and at full crusting of the herpetic rash. Age, sex, comorbid conditions, prodromal pain, localization and severity of herpetic rash, number of skin lesions, and degree of pain were recorded. We used multivariate logistic regression modeling to identify significant predictive factors. Receiver operating characteristic (ROC) curves were evaluated to determine the contribution of each factor. RESULTS: Six months after healing, 31 patients (18%) had postherpetic neuralgia; 27 patients still had it after 1 year. Only three variables-age (odds ratio [OR] = 2.7 per 10-year increase; 95% confidence interval [CI]: 1.2 to 6.2), acute pain (OR = 1.8 per unit increase in visual analog scale; 95% CI: 1.2 to 2.8), and interleukin 8 concentration in the cerebrospinal fluid at full crusting of the herpetic rash (OR = 1.6 per 20-microg/L increase; 95% CI: 1.3 to 2.0)-were significant predictors of postherpetic neuralgia at 1 year. Interleukin 8 concentration also had the highest area under the ROC curve at these evaluation points (P <0.001). CONCLUSION: Our results suggest that interleukin 8 concentration in the cerebrospinal fluid at full crusting of herpetic rash may be useful for identifying patients who are likely to develop intractable postherpetic neuralgia.     

Chronic proctalgia and chronic pelvic pain syndromes: new etiologic insights and treatment options

This systematic review addresses the pathophysiology, diagnostic evaluation, and treatment of several chronic pain syndromes affecting the pelvic organs:chronic proctalgia, coccygodynia, pudendal neuralgia, and chronic pelvic pain. Chronic or recurrent pain in the anal canal, rectum, or other pelvic organs occurs in 7% to 24% of the population and is associated with impaired quality of life and high health care costs. However, these pain syndromes are poorly understood, with little research evidence availab...     

Herpes zoster and postherpetic neuralgia in older adults

Herpes zoster (HZ) afflicts millions of older adults annually and causes significant suffering from acute and chronic pain, or postherpetic neuralgia (PHN). HZ is caused by the reactivation of varicella-zoster virus (VZV) in sensory ganglia in the setting of age, disease, and drug-related decline in cellular immunity. VZV-induced neuronal destruction and inflammation cause the pain, interference with activities of daily living, and reduced quality of life. The optimal treatment of HZ requires early antiviral therapy and pain management. For PHN, evidence-based pharmacotherapy can reduce pain burden. The zoster vaccine is effective in reducing pain burden and preventing HZ and PHN in older adults.     

Prevesicular herpes zoster lumbar radiculopathy with transient motor paresis: A case report

Rationale:Herpes zoster frequently causes dermatomal vesicular rash accompanied by severe neuralgia, and reaching a differential diagnosis may be challenging before the appearance of the vesicular rash.Patient concerns:A 40-year-old male patient visited the emergency department with a complaint of sudden onset motor weakness and ipsilateral radiating neuralgia to the Lt. thigh. He had suffered from chickenpox during childhood.Diagnoses:No skin lesion was present at the initial visit. The reverse Straight Leg Raise test was negative. Magnetic resonance imaging showed asymmetrically swollen dorsal root ganglion with Gadolinium enhancement. The vesicular rash that appeared on the sixth day after the symptom onset led to the diagnosis of herpes zoster.Interventions:Antiviral agent of valacyclovir (1000 mg t.i.d.) was administered for 7 days.Outcomes:The patient recovered from motor weaknesses by 2 weeks from the onset of the symptom. Mild degree post-herpetic neuralgia recovered by 2 months.Lessons:A high index of suspicion is necessary to differentiate early herpes zoster radiculitis before the appearance of vesicular rash from compressive radiculopathy. In L2–3 ipsilateral radiating pain along the dermatome or myotome, the absence of reverse Straight Leg Raise sign may be a possible factor in differentiating herpes zoster radiculitis from compressive radiculopathy.     

Treatment of glossopharyngeal neuralgia by carbamazepine.

An elderly woman who presented with Adams-Stokes attacks that were preceded by paroxysms of neuralgia was successfully treated with carbamazepine. Ventricular asystole was provoked by pharyngeal pain and coincided with loss of consciousness. Vagal reflexes are probably responsible for the bradycardia that causes the cardiac symptoms of glossopharyngeal neuralgia. Carbamazepine (600 mg/day) abolished the pharyngeal pain and associated cardiovascular manifestations in this patient for at least ten months.     

Treatment of glossopharyngeal neuralgia by carbamazepine

An elderly woman who presented with Adams-Stokes attacks that were preceded by paroxysms of neuralgia was successfully treated with carbamazepine. Ventricular asystole was provoked by pharyngeal pain and coincided with loss of consciousness. Vagal reflexes are probably responsible for the bradycardia that causes the cardiac symptoms of glossopharyngeal neuralgia. Carbamazepine (600 mg/day) abolished the pharyngeal pain and associated cardiovascular manifestations in this patient for at least ten months.