BackgroundPain localization is one of the hallmarks for the choice of first-line treatment in neuropathic pain. This literature review has been conducted to provide an overview of the current knowledge regarding the etiology and pathophysiology of localized neuropathic pain (LNP), its assessment and the existing topical pharmacological treatments.Materials and methodsLiterature review was performed using Medline from 2010 to December 2016, and all studies involving LNP and treatments were examined. A multidisciplinary expert panel of five pain specialists in this article reports a consensus on topical approaches that may be recommended to alleviate LNP and on their advantages in clinical practice.ResultsSuccessive international recommendations have included topical 5% lidocaine and 8% capsaicin for LNP treatment. The expert panel considers that these compounds can be a first-line treatment for LNP, especially in elderly patients and patients with comorbidities and polypharmacy. Regulatory LNP indications should cover the whole range of LNP and not be restricted to specific etiologies or sites. Precautions for the use of plasters must be followed cautiously.ConclusionAlthough there is a real need for more randomized controlled trials for both drugs, publications clearly demonstrate excellent risk/benefit ratios, safety, tolerance and continued efficacy throughout long-term treatment. A major advantage of both plasters is that they have proven efficacy and may reduce the risk of adverse events such as cognitive impairment, confusion, somnolence, dizziness and constipation that are often associated with systemic neuropathic pain treatment and reduce the quality of life. Topical modalities also may be used in combination with other drugs and analgesics with limited drug–drug interactions.

MWA is feasible, safe, and effective in the management of painful refractory bone and soft tissue tumors. It may therefore be considered as a potential alternative to existing percutaneous ablation techniques in the management of bone and soft tissue tumors.

Background: Pudendal neuralgia (PN) is a very painful and often disabling condition in which pudendal nerve blocks play an important role in both the diagnosis and management of PN. Some previous reports have advocated the use of pudendal nerve infiltration (PNI) as a diagnostic test only. Objective: We aim to assess the outcomes of patients with typical refractory PN who underwent dual site computed tomography (CT)-guided pudendal nerve infiltration. Study Design: A bicentric, retrospective cohort analysis. Setting: An academic practice. Methods: Between 2002 and 2016, 385 PNIs were performed in 195 patients in the 2 units. Only patients suffering from typical clinical PN were included, and only the first infiltration in each patient was considered for analysis. Therefore, 95 patients who underwent 155 procedures were assessed. Pain was assessed using a visual analog scale (0–10) and self-reported estimated improvement (SRI), expressed as a percentage. Efficacy of the procedure was assessed at 1, 3, and 6 months after procedure follow-up, and clinical success was defined as a 50% decrease of the VAS score. All procedures were performed under CT guidance and on an outpatient basis. Dual site infiltration was performed in each case at both the ischial spine and intra-Alcock’s canal sites using a mixture of fast- and slow-acting anesthetic (1 mL lidocaine hydrochloride 1% and 2 mL ropivacaine chlorhydrate) along with a half dose of 1.5 mL of cortivazol (3.75 mg). Results: Clinical success at one month post-procedure was present in 63.2% of patients (60/95) with a mean VAS score of 2.07 (P < 0.05) and a mean SRI of 71%. At 3 months follow-up, clinical success was still present in 50.5% of patients (48/95) with a mean VAS score of 2.90/10 (P < 0.05) and a mean SRI of 62.3%. At 6 months follow-up, the efficacy rate decreased to 25.2% with a mean VAS score of 3.2/10 and SRI of 60%. Limitations: The retrospective aspect of the study is a limitation, as well as the lack of a control group. Conclusion: Dual site PNI under CT guidance may offer significant mid-term pain relief to a majority of patients suffering from typical refractory PN. Key words: Pudendal nerve, neuralgia, block, Alcock, CT, guidance

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Purpose Intravenous ketamine is often prescribed in severe neuropathic pain. Oral N -methyl-D-aspartate receptor (NMDAR) antagonists might prolong pain relief, reducing the frequency of ketamine infusions and hospital admissions. This clinical trial aimed at assessing whether oral dextromethorphan or memantine might prolong pain relief after intravenous ketamine. Patients and methods A multicenter randomized controlled clinical trial included 60 patients after ketamine infusion for refractory neuropathic pain. Dextromethorphan (90 mg/day), memantine (20 mg/day) or placebo was given for 12 weeks (n=20 each) after ketamine infusion. The primary endpoint was pain intensity at one month. Secondary endpoints included pain, sleep, anxiety, depression, cognitive function and quality of life evaluations up to 12 weeks. Results At 1 month, dextromethorphan maintained ketamine pain relief (Numeric Pain Scale: 4.01±1.87 to 4.05±2.61, p =0.53) and diminished pain paroxysms ( p =0.03) while pain intensity increased significantly with memantine and placebo ( p =0.04). At 3 months, pain remained lower than at inclusion ( p =0.001) and was not significantly different in the three groups. Significant benefits were observed on cognitive-affective domains and quality of life for dextromethorphan and memantine ( p <0.05). Conclusions Oral dextromethorphan given after ketamine infusion extends pain relief during one month and could help patients to better cope with pain. Future studies should include larger populations stratified on pharmacogenetics screening. Optimization of an oral drug that could extend ketamine antihyperalgesia, with fewer hospital admissions, remains a prime challenge in refractory neuropathic pain.