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Altered lumbar multifidus (LM) activation has been found in populations with non-specific chronic low back pain (NSCLBP).

Opioids are commonly prescribed beyond what is necessary to adequately manage postoperative pain, increasing the likelihood of chronic opioid use, pill diversion, and misuse. We sought to assess opioid utilization and patient-reported outcomes (PROs) in patients undergoing ventral hernia repair (VHR) following the implementation of a patient-tailored opioid prescribing guideline.

The interest in Para athletes' health continues to increase. Still, there are few studies that have evaluated health parameters beyond injury and illness in this athlete population.

Patients with severe burn injuries often require split thickness skin grafting to expedite wound healing with the thigh being a common donor site. Uncontrolled pain is associated with increased opioid consumption, longer lengths of stay, and delay in functional recovery. Peripheral nerve blocks are increasing in popularity although supportive literature is limited, and techniques vary. The purpose of this case series is to assess the safety, feasibility, and clinical efficacy of a recently demonstrated novel continuous LAM (lateral, anterior, medial) femoral cutaneous block technique in a larger cohort. The study was a dual IRB approved, observational case series from a single verified burn center. The electronic health record was retrospectively reviewed for patients admitted between June 2018 to May 2021 who had the continuous LAM block performed for donor site pain by the acute pain service team. Demographics were reported with descriptive statistics and morphine milligram equivalents (MME) were analyzed via Friedman analysis of variance. Forty-seven patients had a total of 53 blocks placed, where 2 patients received the LAM block on two separate occasions and 4 patients had bilateral LAM blocks placed. Most were African American males, but mechanism of injury varied. Over half had a neurologic (17 %) or psychiatric history (34 %) outside of substance use. Almost three-quarters had a history of substance use with 17 % being opioids, and a quarter had a history of polysubstance use. Median day from admission to LAM was 7 (2.5, 11.5) with a median duration of 4 (3, 5) days. Temperature and pressure sensation were reduced at the donor site. Quadricep strength remained intact, and median day until first ambulation after LAM placement was 2 (1, 3) days. Pain was adequately controlled, and there were no significant adverse events associated with the block. There was a significant reduction in MME after block placement (p < 0.001). Continuous peripheral nerve blocks offer an advantageous means of analgesia, while reducing potential adverse events associated with opioids or multimodal regimens. The novel LAM technique reduced sensation and pain without inhibiting early ambulation, and patients were able to fully participate in their rehabilitation.

In this issue of Anesthesia & Analgesia, Lim and colleagues offer a scoping review of the available literature encompassing opioid use disorder (OUD) in pregnant patients. As discussed in their review, opioid use and abuse in pregnant patients have increased four-fold in the past decade. As such, these patients can present significant challenges with respect to pain management during labor and delivery. A baseline habituation to opioids can render patients resistant to conventional pain management plans. Those who are additionally prescribed opioid agonist-antagonists or other maintenance medications for OUD such as buprenorphine or methadone have even more complex pharmacologic considerations that make pain management unpredictable. As detailed in their analysis, there is a paucity of literature surrounding optimal management strategies in this population of patients. Reports are increasing over time, however, most publications are of lower tier evidence, with very few randomized trials and systematic reviews to inform practitioners. It becomes plainly evident that this is an area of clinical science that demands greater attention. Specific areas of focus elaborated by the authors include: better characterization of opioid selection and dosing in managing labor analgesia, effectiveness of different regional anesthetic techniques, non-pharmacologic management, and psycho-social support for these patients. The reader is strongly encouraged to review the cited article for an in-depth understanding of the concepts summarized in this infographic.

Headache is a commonly encountered symptom in urgent care and the emergency department. Headache syndromes are classified a primary headache and do not require neuroimaging; however, patients should be assessed at each encounter for changes in their headache symptoms. This case highlights a patient who was suffering from a new headache type, characterized as different from her previous attacks and unyielding to her current acute and preventive treatment methods. The patient was sent for neuroimaging and found to have a mass within her sella turcica that required surgical intervention and removal. Assessing headache patients for red flag symptoms can uncover significant alterations in the patient's symptomatology and indicate a need for further evaluation. By evaluating for red flag symptoms, clinicians can ensure the delivery of high-quality care and better health care outcomes for patients with headache disease.

Cardiac cephalalgia is an unusual condition that occurs during an episode of myocardial ischemia. Information about cardiac cephalalgia is scarce and its characteristics and physiopathology remain unclear. Our aim is to provide a narrative review of clinical characteristics and physiopathology of cardiac cephalalgia and to evaluate the current diagnostic criteria.  METHODS: A search through PubMed was undertaken for studies on cardiac cephalalgia published until 20 September 2022. We summarized the literature and provide a comprehensive review of the headache characteristics and possible mechanisms. We also evaluated current International Classification of Headache Disorders third edition diagnostic criteria based on prior reported cases.  RESULTS: In total, 88 cases were found. Headache characteristics were variable. Occipital location and throbbing pain were the most frequently reported. Headache was accompanied in most cases by cardiac symptoms. Criterion B was fulfilled by 98% of cases, criterion C1 by 72%, and criteria C2a and C2b by 37 and 93.2%, respectively. Regarding headache features described in diagnostic criterion C3, 'moderate to severe intensity', 'accompanied by nausea', 'not accompanied by photophobia or phonophobia' and 'aggravated by exertion', were reported in 75, 31, 55 and 55% of cases, respectively.

Galcanezumab, a humanized monoclonal antibody against calcitonin gene-related peptide, is a preventive migraine treatment. In global, randomized, placebo-controlled trials, galcanezumab reduced migraine headache severity and the frequency of migraine headaches associated with nausea and/or vomiting, photophobia and phonophobia, prodromal symptoms, or aura. We report secondary analyses from a Japanese phase 2 trial that assessed the effect of galcanezumab on migraine headache severity, frequency of migraine-associated symptoms, and frequency of migraine headaches during menstrual periods in Japanese patients with episodic migraine.

While high-frequency transcranial magnetic stimulation (HF-rTMS) is now included in the armamentarium to treat chronic neuropathic pain (NP), direct-current anodal stimulation (a-tDCS) to the same cortical targets may represent a valuable alternative in terms of feasibility and cost. Here we performed a head-to-head, randomized, single-blinded, cross-over comparison of HF-rTMS versus a-tDCS over the motor cortex in 56 patients with drug-resistant NP, who received 5 daily sessions of each procedure, with a washout of at least 4 weeks. Daily scores of pain, sleep, and fatigue were obtained during 5 consecutive weeks, and functional magnetic resonance imaging (fMRI) to a motor task was performed in a subgroup of 31 patients. The percentage of responders, defined by a reduction in pain scores of > 2 SDs from pre-stimulus levels, was similar to both techniques (42.0% vs. 42.3%), while the magnitude of "best pain relief" was significantly skewed towards rTMS. Mean pain ratings in responders decreased by 32.6% (rTMS) and 29.6% (tDCS), with half of them being sensitive to only one technique. Movement-related fMRI showed significant activations in motor and premotor areas, which did not change after 5 days of stimulation, and did not discriminate responders from non-responders. Both HF-rTMS and a-tDCS showed efficacy at 1 month in drug-resistant NP, with magnitude of relief slightly favoring rTMS. Since a significant proportion of patients responded to one procedure only, both modalities should be tested before declaring a patient as unresponsive.