Health Professionals Musings August 2014


Magnetic Resonance Imaging Contribution for Diagnosing Symptomatic Neurovascular Contact in Classical Trigeminal Neuralgia: A Blinded Case-Controlled Study and Meta-Analysis. Antonini et al, Pain, 2014 Vol 155, pp 1464-71

This study from Rome looked at 24 patients with classical trigeminal neuralgia and a similar number of age matched health controls with independent analysis of the MRI scan by blinded neuro-radiologists. They showed that either trigeminal nerve root entry zone neurovascular contact or anatomical changes of the trigeminal nerve (such as atrophy, dislocation, distortion, flattening or indentation) produced odds ratios of 10 or more for the patient being symptoms with classical trigeminal neuralgia. This study enhances the selection criteria for patients to be considered for microvascular decompression by including trigeminal nerve root abnormalities as being equally a predictor.

Psycho-Social Factors and Risk of Chronic Widespread Pain: An Eleven Year Follow-up Study – The HUNT Study, Pain 2014, VOl 155 pp 1555 – 1561 Mandal et al.

This study from Trondheim in Norway looked at 19000 individuals without chronic widespread pain who were assessed initially between 1995 to 1997 and then again in 2006 to 2008. They found that after eleven years, 12% developed chronic widespread pain. The risk factors for this were anxiety, depression, smoking history, body weight outside of the normal range (high or low), sleeping problems (one or more of non-restorative sleep, difficulty initiating sleep or difficulty maintaining sleep). The only protective variable was eight times or more per month of alcohol intake.

This study replicates a number of other studies that have shown a similar combination of mood disorder, obesity, sleep disorder and smoking as being risk factors for chronic widespread pain. The implication of this across a societal level is to improve health status by elimination of these risk factors on the basis of reasonable suspicion that they are causative rather than associative.

5835 musings Spinal Cord Stimulation and Pain Relief in Painful Diabetic Peripheral Neuropathy: A Prospective Two Centre Randomised Controlled Trial, Slangen et al, Diabetes Care 2014, Sept 11.

This study from Holland was of 36 patients, 22 received spinal cord stimulation with best medication treatment and 14 patients received best medical treatment only. Treatment success was defined as at least 50% pain relief or “very much improved” for pain and sleep on the patient global impression of change scale at six months. Treatment success was found in 7% of the best medical treatment patients and 59% of the spinal cord stimulation plus best medical treatment patients. Pain relief during the day was reported by zero % by the best medical treatment group and 41% in the spinal cord stimulation group.

Spinal Cord Stimulation in Patients with Painful Diabetic Neuropathy: A Multicentre Randomise Clinical Trial, Pan 2014, August 29th

This European study looked at 40 patients with spinal cord stimulation and 20 patients in a control group. At six months, the visual analogue scale went from 6.7 at baseline to 6.7 at six months in the control group and the VAS for pain intensity went from 7.3 in the spinal cord stimulation group to 3.1 at six months. There was a significant improvement in quality of life outcomes in the spinal cord stimulation group only in addition.

These two studies together are of almost 100 patients and both show significant improvement with spinal cord stimulation with no significant improvement with continued best medical practice. These studies would be amenable to meta-analysis. It is now appropriate to confirm that patients with refractory painful diabetic neuropathic pain are suitable candidates to be considered for spinal cord stimulation to improve their pain, sleep and quality of life.

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