Effect of electroacupuncture on the cervicospinal P2X7 receptor/fractalkine/CX3CR1 signaling pathway in a rat neck-incision pain model

Increasing evidence supports that acupuncture intervention is an effective approach for intraoperative and postoperative pain. Neuron–microglia crosstalk, mediated by the purinergic P2X7 receptor (R)/fractalkine/CX3CR1 cascade in the spinal cord dorsal horn, plays a pivotal role in pain processing. However, its involvement in the analgesic effect of electroacupuncture (EA) remains unclear. In this study, a rat neck-incision pain model was established by making a longitudinal incision along the midline of the neck and subsequent repeated mechanical stimulation. EA stimulation was applied to bilateral LI18, LI4-PC6, or ST36-GB34. The thermal pain threshold, cervicospinal ATP concentration, expression levels of purinergic P2XR and P2YR subunits mRNAs, and fractalkine, CX3CR1 and p38 MAPK proteins, were detected separately. The neck incision induced strong thermal hyperalgesia and upregulation of spinal ATP within 48 h. No significant change was found in thermal hyperalgesia after a single session of EA intervention. However, a single session of EA dramatically enhanced the neck incision-induced upregulation of ATP and upregulated the expression of P2X7R, which was reversed by two sessions of EA. Two sessions of EA at bilateral LI18 or LI4-PC6 attenuated hyperalgesia significantly, accompanied with downregulation of P2X7R/fractalkine/ CX3CR1 signaling after three sessions of EA. EA stimulation of LI18 or LI4-PC6 alleviates thermal hyperalgesia in neck-incision pain rats, which may be associated with its effects in regulating the neck incision-induced increase of ATP and P2X7R and subsequently suppressing fractalkine/CX3CR1 signaling in the cervical spinal cord.     

The optimized acupuncture treatment for neck pain caused by cervical spondylosis: a study protocol of a multicentre randomized controlled trial

ABSTRACT: BACKGROUND: Neck pain is one of the chief complains of patients with cervical spondylosis (CS). Both in China and worldwide, acupuncture is a well-accepted and widely used complementary therapy for the management of neck pain caused by CS. In this paper, we present a protocol designed for a multi-centre, randomised, controlled trial to evaluate the effects of optimised acupuncture treatment for CS neck pain. The study aims to evaluate the effects of the optimised acupuncture treatment in real practice compared with sham and shallow acupuncture therapy. Methods/design This trial uses a multicentre, three-group, randomised, sham acupuncture and shallow acupuncture, controlled single-blind design. Nine hospitals are involved as trial centres. The sample size is calculated based on the formula for a three-group parallel design with a 0.05 significance level and a power of 0.9. A total of 105 cases in a single centre, and a total of 315 cases per each arm are required across all 9 centres. Patients who meet inclusion criteria are randomly assigned to receive optimised acupuncture treatment, sham acupuncture or shallow acupuncture by a computerised central randomisation system. The interventions last for 4 weeks with 8 to 10 treatments. The group allocations and interventions are concealed to patients and statisticians. The Northwick Park Neck Pain Questionnaire (NPQ) is used as the primary outcome measure, and the McGill Pain Questionnaire (MPQ) and The Short Form (36) Health Survey (SF-36) are applied as secondary outcome measures. The evaluation is performed at baseline, at the end of the intervention, and at the end of the first month and the third month during follow-up. The statistical analyses will include baseline data comparison and repeated measures of analysis of variance (ANOVA) for primary and secondary outcomes of group and time differences. Adverse events (AEs) will be reported if they occur. DISCUSSION: This trial is a multicentre randomised control trial (RCT) on the efficacy of acupuncture for CS neck pain and has a large sample size and central randomisation in China. It will strictly follow the CONSORT statement and STRICTA extension guideline to report high-quality study results. By setting the control groups as sham and shallow acupuncture, this study attempts to reveal the effects of real acupuncture versus placebo or non-classic acupuncture therapy and evaluate whether classic Chinese medical acupuncture is effective on CS neck pain. This study will provide evidence for the effects of acupuncture on CS neck pain. Trial Registration: Chinese Clinical Trial Registry: ChiCTR-TRC-00000184.     

One-stage bilateral radical neck dissection; indications and technique

Simultaneous bilateral radical neck dissection is an operation entailing acceptable risk if used in propertly selected cases. The procedure is indicated for patients with bilateral cervical lymph node metastases so situated that a two-stage radical neck dissection could not be done without cutting through cancer tissue. Such patients are those with intraoral or cervical visceral midline primary lesions or those in whom, either by direct extension or lymph node involvement, the submental and submaxillary triangles are solidly permeated with cancer. The operation is indicated only for cure; for prophylaxis or palliation, lesser or staged procedures would be more productive of better results with less morbidity and mortality.     

ONE-STAGE BILATERAL RADICAL NECK DISSECTION — Indications and Technique

Simultaneous bilateral radical neck dissection is an operation entailing acceptable risk if used in propertly selected cases. The procedure is indicated for patients with bilateral cervical lymph node metastases so situated that a two-stage radical neck dissection could not be done without cutting through cancer tissue. Such patients are those with intraoral or cervical visceral midline primary lesions or those in whom, either by direct extension or lymph node involvement, the submental and submaxillary triangles are solidly permeated with cancer. The operation is indicated only for cure; for prophylaxis or palliation, lesser or staged procedures would be more productive of better results with less morbidity and mortality.     

Carotidynia: a cause of neck and face pain.

Carotidynia is a form of vascular neck are face pain in which the vascular change occurs in the carotid artery in the neck. The disorder is not uncommon, and most patients have a prior history of migraine. They present with pain in the neck and face, and are often thought to have a disorder such as chronic sinusitis or trigeminal neuralgia. Diagnosis can be made from the type and location of the pain and the finding of a tender and swollen carotid artery on the same side. Carotidynia responds to the prophylactic medications used for migraine, often disappearing in weeks or months. In some patients the syndrome may become recurrent or chronic, with a variable response to medication.     

Comparison of Modic Changes in the Lumbar and Cervical Spine,in 3167 Patients with and without Spinal Pain

Background Context

There are few comparisons of Modic changes (MCs) in the lumbar and cervical spine.

Purpose

Compare the prevalence of MCs in the lumbar and cervical spine, and determine how MC prevalence depends on spinal pain, age, disc degeneration, spinal level, and the presence or absence of kyphosis.

Study Design

Retrospective clinical survey.

Materials and Methods

Magnetic resonance images (MRIs) were compared from five patient groups: 1. 1223 patients with low-back pain/radiculopathy only; 2. 1023 patients with neck pain/radiculopathy only; 3. 497 patients with concurrent low-back and neck symptoms; 4. 304 asymptomatic subjects with lumbar MRIs; and 5. 120 asymptomatic subjects with cervical MRIs.

Results

The prevalence of MCs was higher in those with spinal pain than in those without, both in the lumbar spine (21.0% vs 10.5%) and cervical spine (8.8% vs 3.3%). Type II MCs were most common and Type III were least common in all groups. The prevalence of lumbar MCs in people with back pain was little affected by the presence of concurrent neck pain, and the same was true for the prevalence of cervical MCs in people with neck pain with or without concurrent back pain. When symptomatic patients were reclassified into two groups (back pain, neck pain), the prevalence of lumbar MCs in people with back pain was greater than that of cervical MCs in people with neck pain. The prevalence of lumbar and cervical MCs increased with age, disc degeneration, (descending) spinal level, and increased kyphosis.

Conclusions

There is a significantly higher prevalence of MCs in patients with back and neck pain. The reported association with increased kyphosis (flat back) is novel.     

EMG scanning in the diagnosis of chronic pain

A surface EMG diagnostic protocol was developed to assess the neuromuscular/postural contributions to pain states. The EMG activity of the right and left aspects of 11 muscle groups were monitored while the patient was in the sitting and standing positions. The diagnostic protocol was evaluated by comparing the patterns of EMG activity in four diagnostic groups: headache only, neck/shoulder/upper back pain only, low back pain only, and mixed pain states. The results suggest that (1) bilateral levels of EMG activity in the frontalis and masseter groups are of primary importance for the headache patients, (2) the discrepancy between the right and left EMG activity in the lumbar and cervical paraspinal muscle groups are of primary importance for low back pain patients, (3) position (sit/stand) may provide important diagnostic information, and (4) the data appear to support the notion of a postural disturbance as a contributing factor in low back pain.     

Altered alignment of the shoulder girdle and cervical spine in patients with insidious onset neck pain and whiplash-associated disorder

Clinical theory suggests that altered alignment of the shoulder girdle has the potential to create or sustain symptomatic mechanical dysfunction in the cervical and thoracic spine. The alignment of the shoulder girdle is described by two clavicle rotations, i.e, elevation and retraction, and by three scapular rotations, i.e., upward rotation, internal rotation, and anterior tilt. Elevation and retraction have until now been assessed only in patients with neck pain. The aim of the study was to determine whether there is a pattern of altered alignment of the shoulder girdle and the cervical and thoracic spine in patients with neck pain. A three-dimensional device measured clavicle and scapular orientation, and cervical and thoracic alignment in patients with insidious onset neck pain (IONP) and whiplash-associated disorder (WAD). An asymptomatic control group was selected for baseline measurements. The symptomatic groups revealed a significantly reduced clavicle retraction and scapular upward rotation as well as decreased cranial angle. A difference was found between the symptomatic groups on the left side, whereas the WAD group revealed an increased scapular anterior tilt and the IONP group a decreased clavicle elevation. These changes may be an important mechanism for maintenance and recurrence or exacerbation of symptoms in patients with neck pain.     

Observing neck movements evokes an excitatory response in the sympathetic nervous system associated with fear of movement in patients with chronic neck pain

Abstract

The objective of this study was to evaluate the response of the sympathetic-excitatory nervous system in patients with chronic neck pain compared with a control group of asymptomatic subjects who underwent an intervention of watching activities involving movements in the neck region. Thirty participants were divided into two groups: patients with chronic neck pain (n?=?15) and the control group (n?=?15). The patients’ neck disability, fear of movement and catastrophism were assessed with a self-report. The recorded variables related to the autonomic nervous system were skin conductance and skin temperature. The ANOVA test revealed significant differences in the increase in skin conductance in the chronic neck pain group after observing the activities (both in the photographs and video) at the end of the observation and 5?minutes after the intervention (p?<?.01; d?>?0.80). There were no significant differences in skin temperature. Ultimately, the correlation analysis revealed a moderate positive correlation between kinesiophobia and skin conductance at 30?seconds (r?=?0.53) and at 60?seconds (r?=?0.52) of observing the activities in the video for the chronic neck pain group. Based on the results of the present study, we suggest that observing activities involving neck movements causes an activation of the sympathetic-excitatory nervous system in patients with chronic neck pain. These changes could be related to a fear of movement when faced with visual exposure to neck movements that could be interpreted as ‘harmful’ or ‘dangerous’.     

Neuromuscular adaptation in experimental and clinical neck pain.

The purpose of this brief review is to present evidence from experimental and clinical neck pain studies of pain-induced neuromuscular adaptations. It has been shown that clinical neck pain is associated with a substantial reorganization in the control strategies of cervical muscles during static and dynamic tasks. Experimental neck pain models allow local elicitation of nociceptive afferents, mimicking the sensory aspects of clinical pain, without major changes in muscle properties. These models may help understand the physiological mechanisms underlying the observations from clinical neck pain studies. The knowledge obtained from the interpretation of clinical findings with experimental pain models has relevance for the development of therapeutic interventions for the rehabilitation of patients with neck pain disorders.     

颈椎椎板切除融合术后轴性疼痛

目的：目前已证实颈椎椎板切除融合术是治疗多阶段的脊髓型颈椎病和后纵韧带骨化病的一种安全和有效的方法。然而,颈椎椎板切除融合术后经常发生颈部轴性疼痛。本研究的目的是观察C7棘突保留与否与颈椎椎板切除融合术后轴性疼痛的关系。方法：对2006年1月～2008年12月在我院行颈椎椎板切除融合术的67个病人进行回顾性分析。将这67个病人之中保留了C7棘突的29名病人称为A组,未保留C7棘突的38名病人称为B组,对两组病人的轴性症状、颈椎曲度和颈椎曲度指数（cervical curbature index,CCI）进行评估和比较。结果：在A组中有51.7%的病人发生了早期的轴性症状,10.3%的病人发生了晚期的轴性症状,B组分别为60.5%和42.1%。B组中42.1%的病人和A组中10.3%的病人在手术后晚期有轴性症状,A组的轴性疼痛发生率低于B组,有统计学意义（p=0.001）。结论：保留C7棘突可以降低颈椎椎板切除融合术后轴性症状的发生率。     

Chronic osteomyelitis of the clavicle

Osteomyelitis of the clavicle is an uncommon disease, but it should be considered in patients who present with pain, cellulitis, or drainage in the sternoclavicular area following head and neck surgery, irradiation, subclavian vein catheterization, or immunosuppression. An idiopathic presentation is possible. In contrast to primary osteomyelitis of the clavicle, which is occasionally seen in children, secondary osteomyelitis is quite rare. It is often mistaken for a fracture or a possible neoplasm on plain x-rays. Tomograms and CT scanning are confirmatory, and in early cases, technetium-99m bone scanning can be helpful. Treatment must include early, aggressive surgical debridement of all affected tissues, followed by wound coverage with a well-vascularized flap and perioperative antibiotics.     

Cervical helical axis characteristics and its center of rotation during active head and upper arm movements-comparisons of whiplash-associated disorders, non-specific neck pain and asymptomatic individuals

The helical axis model can be used to describe translation and rotation of spine segments. The aim of this study was to investigate the cervical helical axis and its center of rotation during fast head movements (side rotation and flexion/extension) and ball catching in patients with non-specific neck pain or pain due to whiplash injury as compared with matched controls. The aim was also to investigate correlations with neck pain intensity. A finite helical axis model with a time-varying window was used. The intersection point of the axis during different movement conditions was calculated. A repeated-measures ANOVA model was used to investigate the cervical helical axis and its rotation center for consecutive levels of 15 degrees during head movement. Irregularities in axis movement were derived using a zero-crossing approach. In addition, head, arm and upper body range of motion and velocity were observed. A general increase of axis irregularity that correlated to pain intensity was observed in the whiplash group. The rotation center was superiorly displaced in the non-specific neck pain group during side rotation, with the same tendency for the whiplash group. During ball catching, an anterior displacement (and a tendency to an inferior displacement) of the center of rotation and slower and more restricted upper body movements implied a changed movement strategy in neck pain patients, possibly as an attempt to stabilize the cervical spine during head movement.     

Muscle pain induces task-dependent changes in cervical agonist/antagonist activity.

This study examined the effect of experimental neck muscle pain on the EMG-force relationship of cervical agonist and antagonist muscles. Surface EMG signals were detected from the sternomastoid, splenius capitis, and upper trapezius muscles bilaterally from 14 healthy subjects during cervical flexion and extension contractions of linearly increasing force from 0 to 60% of the maximum voluntary contraction (MVC). Measurements were performed before and after injection of 0.5 ml hypertonic and isotonic saline into either the sternomastoid or splenius capitis in two experimental sessions. EMG average rectified value (ARV) of the sternomastoid, splenius capitis, and upper trapezius muscles and the muscle fiber conduction velocity (CV) of the sternomastoid muscle were estimated at 5% MVC force increments. During cervical flexion with injection of hypertonic saline in sternomastoid, ARV of sternomastoid was lower on the side of pain in the force range 25-60% MVC (P < 0.05) and was associated with a bilateral reduction of splenius capitis and upper trapezius ARV (P < 0.01). During cervical extension, injection of hypertonic saline in splenius capitis resulted in lower estimates of splenius capitis ARV on the painful side from 45 to 60% MVC (P < 0.05), which was associated with a bilateral increase in upper trapezius ARV estimates from 50 to 60% MVC (P < 0.001). However, no significant change was identified for estimates of sternomastoid ARV. Experimentally induced neck muscle pain resulted in task-dependent changes in cervical agonist/antagonist activity without modifications in muscle fiber CV.     

Tonsillolithiasis and orofacial pain

Tonsilloliths are rare calcified structures that usually result from chronic inflammation of the tonsils. Concretions show differences in size, shape and colour. They are usually asymptomatic but can be associated with halitosis, foreign body sensation, dysphagia and odynophagia, otalgia, and neck pain. A patient was referred because panoramic radiography performed by a general dentist revealed radiopaque shadows over the ascending rami of the mandible, located bilaterally: a solitary structure on the higher portion of the right side and two small structures on the left side. Paroxysmal attacks of orofacial pain and symptoms such as dysphagia and swallowing pain on the left side distributed within the tonsillar fossa and pharynx and the angle of the lower jaw were present. The computed tomography images revealed bilateral tonsilloliths. Clinically, there was no sign of inflammation, and the patient's past history revealed an approximately 2-year history of dysphagia, swallowing pain and left-sided neck pain. At the request of the patient, no surgical intervention was carried out. Glossopharyngeal neuralgia is a rare entity, and the aim of this report was to indicate the importance of tonsilloliths as a cause of orofacial pain.     

不同手术方式对分化型甲状腺癌患者预后的影响

目的：探讨不同手术方式对分化型甲状腺癌患者临床治疗的效果及其预后的影响。方法：回顾性分析了2005.02-2012.07入住我院的60例分化型甲状腺癌患者的临床资料,采用如下三种不同的治疗方式：甲状腺切除术联合双侧中央区颈淋巴结清扫手术;保留对侧喉返神经入喉处甲状腺组织的甲状腺次全切除术联合单侧改良颈淋巴结清扫手术;保留对侧喉返神经入喉之处甲状腺组织的甲状腺次全切除手术联合双侧改良颈淋巴结清扫手术。结果：（1）上述三组患者术后,患者的甲状旁腺的功能低下之间均存在显著的统计学差异（P〈0.01）,三组喉返神经损伤的发生率之间也存在显著的统计学差异（P〈0.01）;本组60例患者均获10-172个月（平均为93.5±10.2）的随访,上述三种手术方式下患者的癌症复发率分别为77.8%、4.5%及45.0%,三组具有显著的统计学差异（P〈0.01）;生化治愈率分别为27.8%、95.5%及50.0%;平均生存时间分别为（92.3±12.5）个月、（105.8±14.5）个月及（112.3±20.9）个月。（2）三组患者术后生存质量总得分分别为（122±9）、（118±8）及（125±9）分。结论：与甲状腺切除术联合双侧中央区颈淋巴结清扫手术进行对比,保留对侧喉返神经入喉处甲状腺组织的甲状腺次全切除术联合单侧改良颈淋巴结清扫手术与保留对侧喉返神经入喉之处甲状腺组织的甲状腺次全切除手术联合双侧改良颈淋巴结清扫手术在生存时期、术后生存质量两个方面不具显著性差异。     

Augmented Pain Processing in Primary and Secondary Somatosensory Cortex in Fibromyalgia: A Magnetoencephalography Study Using Intra-Epidermal Electrical Stimulation

The aim of this study was to investigate augmented pain processing in the cortical somatosensory system in patients with fibromyalgia (FM). Cortical evoked responses were recorded in FM (n = 19) and healthy subjects (n = 21) using magnetoencephalography after noxious intra-epidermal electrical stimulation (IES) of the hand dorsum (pain rating 6 on a numeric rating scale, perceptually-equivalent). In addition, healthy subjects were stimulated using the amplitude corresponding to the average stimulus intensity rated 6 in patients with FM (intensity-equivalent). Quantitative sensory testing was performed on the hand dorsum or thenar muscle (neutral site) and over the trapezius muscle (tender point), using IES (thresholds, ratings, temporal summation of pain, stimulus-response curve) and mechanical stimuli (threshold, ratings). Increased amplitude of cortical responses was found in patients with FM as compared to healthy subjects. These included the contralateral primary (S1) and bilateral secondary somatosensory cortices (S2) in response to intensity-equivalent stimuli and the contralateral S1 and S2 in response to perceptually-equivalent stimuli. The amplitude of the contralateral S2 response in patients with FM was positively correlated with average pain intensity over the last week. Quantitative sensory testing results showed that patients with FM were more sensitive to painful IES as well as to mechanical stimulation, regardless of whether the stimulation site was the hand or the trapezius muscle. Interestingly, the slope of the stimulus-response relationship as well as temporal summation of pain in response to IES was not different between groups. Together, these results suggest that the observed pain augmentation in response to IES in patients with FM could be due to sensitization or disinhibition of the cortical somatosensory system. Since the S2 has been shown to play a role in higher-order functions, further studies are needed to clarify the role of augmented S2 response in clinical characteristics of FM.     

Temperament of the Individual and Peculiarities of EEGs in Patients Suffering from Neurological Spinal Disorder-Induced Neck and Back Pain

Neurophysiology - Forty-seven patients suffering from neck and/or back pain were examined; their temperament was evaluated using the Eysenck Personality Questionnaire (EPQ); the pain syndromes in...     

Are chronic neck pain,scapular dyskinesis and altered scapulothoracic muscle activity interrelated?: A case-control study with surface and fine-wire EMG

ObjectivesThe function of the scapula is important in normal neck function and might be disturbed in patients with neck pain. The surrounding muscular system is important for the function of the scapula. To date, it is not clear if patients with idiopathic neck pain show altered activity of these scapulothoracic muscles. Therefore, the objective of this study was to investigate differences in deeper and superficial lying scapulothoracic muscle activity between patients with idiopathic neck pain and healthy controls during arm elevation, and to identify the influence of scapular dyskinesis on muscle activity.MethodsScapular dyskinesis was rated with the yes/no method. The deeper lying (Levator Scapulae, Pectoralis Minor (Pm) and Rhomboid major) and superficial lying (Trapezius and Serratus Anterior) scapulothoracic muscles’ activity was investigated with fine-wire and surface EMG, respectively, in 19 female subjects with idiopathic neck pain (age 28.3 ± 10.1 years, average duration of neck pain 45.6 ± 36.3 months) and 19 female healthy control subjects (age 29.3 ± 11.7 years) while performing scaption and towel wall slide. Possible interactions or differences between subject groups, scapular dyskinesis groups or phases of the task were studied with a linear mixed model.ResultsHigher Pm activity during the towel wallslide (p = 0.024, mean difference 8.8 ± 3.3% MVIC) was shown in patients with idiopathic neck pain in comparison with healthy controls. For the MT, a significant group 1 dyskinesis interaction effect was found during scaption which revealed that patients with neck pain and scapular dyskinesis showed lower Middle Trapezius (MT) activity in comparison with healthy controls with scapular dyskinesis (p = 0.029, mean difference 5.1 ± 2.2% MVIC).ConclusionsIn the presence of idiopathic neck pain, higher Pm activity during the towel wallslide was found. Patients with neck pain and scapular dyskinesis showed lower MT activity in comparison with healthy controls with scapular dyskinesis during scaption. Scapular dyskinesis did not have a significant influence on scapulothoracic muscle activity.     

An educational and physical program to reduce headache, neck/shoulder pain in a working community: a cluster-randomized controlled trial

Background

Noninvasive physical management is often prescribed for headache and neck pain. Systematic reviews, however, indicate that the evidence of its efficacy is limited. Our aim was to evaluate the effectiveness of a workplace educational and physical program in reducing headache and neck/shoulder pain.

Methodology/Principal Findings

Cluster-randomized controlled trial. All municipal workers of the City of Turin, Italy, were invited to participate. Those who agreed were randomly assigned, according to their departments, to the intervention group (IG) or to the control group and were given diaries for the daily recording of pain episodes for 1 month (baseline). Subsequently, only the IG (119 departments, 923 workers) began the physical and educational program, whereas the control group (117 departments, 990 workers) did not receive any intervention. All participants were again given diaries for the daily recording of pain episodes after 6 months of intervention. The primary outcome was the change in the frequency of headache (expressed as the proportion of subjects with a ≥50% reduction of frequency; responder rate); among the secondary outcomes there were the absolute reduction of the number of days per month with headache and neck/shoulder pain. Differences between the two groups were evaluated using mixed-effect regression models. The IG showed a higher responder rate [risk ratio, 95% confidence interval (CI)] for headache (1.58; 1.28 to 1.92) and for neck/shoulder pain (1.53; 1.27 to 1.82), and a larger reduction of the days per month (95% CI) with headache (−1.72; −2.40 to −1.04) and with neck/shoulder pain (−2.51; −3.56 to −1.47).

Conclusions

The program effectively reduced headache and neck/shoulder pain in a large working community and appears to be easily transferable to primary-care settings. Further trials are needed to investigate the program effectiveness in a clinical setting, for highly selected patients suffering from specific headache types.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00551980","term_id":"NCT00551980"}}NCT00551980