Complete Pain Research Articles

CASE SERIES: CHALLENGES AND OUTCOMES OF TLIF PROCEDURES IN A PERIPHERAL HOSPITAL IN BHARATPUR, RAJASTHAN

Objective: Chronic back pain, particularly from degenerative spinal conditions, significantly impacts patient quality of life, especially in regions with limited healthcare resources, such as rural Rajasthan. Transforaminal Lumbar Interbody Fusion (TLIF) has been recognized for its efficacy in treating severe spinal degeneration and instability. This case series examines the application of TLIF in a peripheral hospital setting, assessing its challenges and outcomes in such environments. Methods: This study included three patients aged 34 to 75, who underwent TLIF at a peripheral hospital in Bharatpur, Rajasthan, from February to July 2024. Detailed preoperative and postoperative evaluations were conducted, focusing on pain levels and functional mobility. Follow-ups were performed at the first, second, and fourth weeks post-surgery to monitor recovery and assess surgical success. Results: All patients reported significant improvements in pain and mobility by the first-month follow-up. The 34 y old female experienced complete pain relief and returned to full activities by four weeks. The 75 y old female and 65 y old male also showed considerable improvements in pain and function, with no severe complications noted during or after surgery. Conclusion: TLIF can be effectively implemented in peripheral hospital settings with outcomes comparable to those in higher-resource environments. This case series demonstrates the feasibility and significant benefits of advanced spinal surgeries in resource-limited settings, highlighting the potential for expanding such sophisticated interventions to improve healthcare accessibility and patient outcomes in rural areas.

Pain Remission Following Delayed Targeted Muscle Reinnervation in Amputees.

Targeted muscle reinnervation (TMR) has demonstrated efficacy for treatment of neuropathic pain. This study aims to identify patients for whom delayed TMR may be most effective and to identify associated factors for favorable pain outcomes in this patient population. An analysis was conducted on prospectively enrolled amputee patients who underwent delayed TMR at a tertiary care center from 2017 to 2024. Data on demographics, comorbidities, surgical details, and pain outcomes were collected. Patient reported pain severity on a 0-10 scale was prospectively collected. The main pain outcome was pain remission (achieving the minimally clinically important difference (MCID)). Additionally, sustained mild pain (pain score ≤ 3/10 for ≥ 3 months), and pain disappearance (pain score 0/10 for ≥ 3 months) were assessed. Multivariable regression analyses identified factors influencing pain outcomes. Out of 101 patients included in this study, 64 patients (63.4%) achieved pain remission within a two-year post-operative period, and 37 patients (36.6%) did not. Sustained mild pain, which could be achieved in addition to pain remission, was achieved by 45.8% of patients, with 17.8% of these achieving complete pain disappearance. Patients achieving pain remission demonstrated lower pain over the entire post-operative trajectory (p < 0.001). Lower pre-operative pain scores, absence of depression, no pre-operative opioid use, lower Elixhauser Comorbidity Index, and distal amputation levels were correlated with favorable outcomes following delayed TMR (p < 0.05). Pre-operative pain severity, psychiatric comorbidities, and opioid use significantly influenced pain outcomes, emphasizing the need for comprehensive patient assessment. These findings will help with patient stratification and pre-operative counseling to support patients who are best suitable for delayed TMR surgery.

Evaluation of Cold and Electric Pulp Tests for Assessing the Success of Inferior Alveolar Nerve Block for Mandibular First Molars diagnosed with Symptomatic Irreversible Pulpitis

IntroductionFear of dentistry, often due to past painful experiences, is a significant barrier preventing patients from visiting dentists. Achieving effective pain control, especially during root canal treatments, is crucial. However, inferior alveolar nerve blocks (IANB) have a low success rate, influenced by factors such as anxiety, anatomical variations, and technique limitations, leading to anesthesia failure. Although numerous studies have examined the cold test and EPT in assessing the success of local anesthesia, no standardized method has been established. This study evaluated the effectiveness of electric pulp test (EPT) and cold tests in assessing the depth of anesthesia in patients with symptomatic irreversible pulpitis (SIP) in the mandibular first molar teeth. MethodsA cross-sectional study was conducted on 50 patients with SIP who met the inclusion criteria and exhibited lip numbness. Following the administration of the IANB and confirmation of lip numbness, cold tests and EPT were performed on all patients. Subsequently, the preparation of the access cavity (gold standard test) was initiated, and patients' responses during cavity preparation were recorded as either "presence of pain or discomfort" or "absence of pain or discomfort," indicating IANB failure and success, respectively. Sensitivity (SN), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratios (LR-/+), and accuracy (AC) with 95% confidence intervals (CI) were calculated for each test separately as well as for sequential testing. ResultsIANB failure was determined in 56% of the patients. A comparative analysis of diagnostic tests (cold test and EPT) showed no significant difference in SN, NPV, and AC; however, the cold test had higher SP, PPV, and LR+. Combining cold test and EPT evaluations improved SN, NPV, PPV, and LR-, but SP and AC were similar to EPT alone. No correlation was found between IANB success and patient age, sex, or initial pain. ConclusionsDespite evidence of lip numbness, a significant number of IANBs failed in cases of painful pulpitis. A positive result from the cold test strongly indicated anesthesia failure. The findings of the current study suggested that when the cold test yielded a negative result, further evaluation with EPT was necessary to confirm anesthetic success and ensure complete pain control.

Microvascular Decompression for Trigeminal Neuralgia Secondary to Vertebrobasilar Dolichoectasia: Review of the Literature and Illustrative Case.

Classical trigeminal neuralgia (TN) is a chronic pain disorder characterized by severe, unilateral facial pain, often resulting from vasculonervous conflict. A less common cause of TN is vertebrobasilar dolichoectasia (VBD). Microvascular decompression (MVD) is the preferred surgical intervention for TN, but in case of VBD, the surgical procedure is more complex due to the aberrant vascular anatomy. This study aims to review the evidence on MVD for VBD-induced TN, and analyze operative challenges, efficacy, and postoperative outcomes. An illustrative case is also presented. We report on the case of a 62-year-old male with a 7-year history of right-sided TN affecting the maxillary (V2) and mandibular (V3) territories. The patient underwent MVD using the interposition technique, where Teflon sponges were placed between the basilar artery and the nerve. Postoperatively, the patient experienced complete pain relief without neurological deficits. At 12 months follow-up, the patient remained pain-free and off medications. We performed an extensive literature review using PubMed, Scopus, and Web of Sciences, highlighting the most relevant studies and findings on the topic. The literature review showed that, while MVD is effective in providing long-term pain relief in VBD-induced TN, the choice between interposition and transposition techniques remains debated. Interposition is easier to perform but may inadvertently increase nerve compression in some cases, whereas transposition offers more definitive decompression but carries higher technical risks. Our case and the available literature highlight the importance of individualized treatment planning in achieving optimal outcomes for patients with VBD-induced TN. Further research is needed to refine surgical techniques and minimize complications in this subset of TN patients.

Randomized phase III study comparing re-irradiation stereotactic body radiotherapy and conventional radiotherapy for painful spinal metastases: Japan Clinical Oncology Group study JCOG2211 (RESCORE study).

Bone metastases are often associated with pain and can occur in various types of cancer, significantly affecting patients' quality of life. Despite the high response rates to initial conventional radiotherapy in patients with painful spinal metastases, recurrence and inadequate response still occur. Thus, the development of a highly effective strategy for pain recurrence is crucial to improving the quality of life in patients with advanced metastatic cancer. This randomized phase III trial aims to confirm the superiority of re-irradiation with stereotactic body radiotherapy (24Gy in 2 fractions) over conventional radiotherapy (8Gy in a single fraction) in achieving a complete pain response at 12weeks in patients with previously irradiated painful spinal metastases. A total of 158 patients from 33 hospitals will be enrolled in Japan over 3.5years. This trial has been registered in the Japan Registry of Clinical Trials as jRCTs1030240172 (https://jrct.niph.go.jp/latest-detail/jRCT1030240172).

Extent and pattern of symptom relief following surgical castration in patients with advanced prostate cancer treated at a tertiary referral hospital in Tanzania: a prospective cohort study

BackgroundAdvanced prostate cancer leads to many symptoms, notably bone pain and lower urinary tract symptoms (LUTs); however, the degree and duration of pain relief, changes in LUTs severity and underlying factors associated with the extent of symptom relief remain inadequately understood. Surgical castration has proven effective in relieving both bone pain and urinary symptoms for metastatic prostate cancer patients.ObjectiveTo determine the extent and pattern of symptom relief in advanced prostate cancer patients following surgical castration at Muhimbili National Hospital (MNH).MethodsWe conducted a prospective cohort study for a period of 6 months involving men with advanced Prostate cancer (PCa) undergoing surgical castration at MNH and followed them for 30 days. The international prostate symptoms score tool was used to assess changes in LUTs, and the pain rating scale was used for assessing changes in bone pain symptoms before and after surgery. Logistic regression model was used to determine factors associated with complete bone pain relief.ResultsA total of 210 participants with a mean age of 72.3 years were recruited. The LUTS score showed a decrease of 7.1 points after surgical castration (95% CI: 6.4 to 7.7, p < 0.001). The bone pain score showed an absolute decrease of 39.8% (95% CI: 34.7 to 44.9, p < 0.001) after surgical castration, with more than half of the patients (111, 52.9%) reporting bone pain relief within the first two weeks. Among the factors associated with greater pain relief were being in a marital union (aOR 2.73, 95% CI: 1.26 to 5.89, p < 0.011). Normal BMI was also linked to pain relief in bivariate analysis (OR 1.92, 95% CI: 1.03 to 3.61, p < 0.035). Additionally, patients with severe bone pain before surgical castration were more likely to achieve complete pain relief compared to those with mild or moderate pain (odds ratio 8.32, 95% CI: 3.63 to 19.1, p < 0.001).ConclusionSurgical castration improves both bone pain and lower urinary tract symptoms in patients with advanced prostate cancer. Notably, patients experiencing severe bone pain reported resolution of bone pain symptoms within the first and second weeks, respectively, indicating the prompt effectiveness of the surgery on these symptoms.

Spinal Neuromodulation for Peripheral Arterial Disease of Lower Extremities: A Ten-Year Retrospective Analysis.

This long-term retrospective study evaluated the survival and amputation outcome of subjects who received neuromodulation therapy for the management of peripheral arterial disease (PAD). The study reviews the health data of a single cohort of 51 patients who received spinal neuromodulation (spinal cord stimulation [SCS] or dorsal root ganglion stimulation [DRG-S]) for PAD from 2007 to 2022 in a single German center. Survival rate and major amputation rate were determined. Pain, quality of life, walking distance, and opioid usage were assessed before implantation (baseline), one, six, and 12 months (M) after implantation, and then annually (during a follow-up visit). Implant-related complications also were documented. In total, 51 patients (37 men [mean age 68.9± 10.2 years], 14 women [mean age (68.7± 14.6 years]) underwent SCS (n= 49) or DRG-S (n= 2) implantation owing to persistent ischemic pain. The follow-up mean years± SD is 4.04± 2.73. At baseline, patients were classified as Rutherford's category 3 (n= 23), category 4 (n= 15) or category 5 (n= 9). At 24 M, 42 of 47 patients did not require a major amputation after the implant. All the patients reported nearly complete pain relief from pain at rest. A total of 75% of patients were able to walk >200 m, and 87% of patients who used opioids at baseline were off this medication at 24 M. Overall, 93% of patients reported an improvement in their overall health assessment. These improved outcomes were sustained through years three to 10 for patients who have reported outcomes. Our single-center data support the efficacy of spinal neuromodulation for improvements in limb salvage, pain relief, mobility, and quality of life. The data also show that neuromodulative therapy has a long-term therapeutic effect in patients with chronic limb pain with Rutherford category 3, 4, and 5 PAD.

Motor improvement and spasms recovery with high-frequency 10kHz spinal cord stimulation in a patient with spastic tetraparesis: beyond pain relief.

To describe the clinical outcomes beyond pain relief of high-frequency spinal cord stimulation at 10kHz (10kHz SCS) in a patient with cervical myelopathy and drug-resistant chronic neuropathic pain with spastic tetraparesis. A patient with C3-C6 myelomalacia and spastic tetraparesis previously treated with decompressive laminectomy underwent implantation of 10kHz SCS for pain management through a trial procedure followed by permanent implantation. Due to the presence of epidural fibrotic scar tissue in the area of the previous C3-C6 laminectomy, the leads could not be implanted at the cervical level; therefore, the leads were positioned at the thoracic level. Data were collected during routine follow-up visits up to 15 months after implantation. Since the trialing phase and during all follow-up visits, along with complete pain relief in the lower limbs, a recovery from spasms was observed with an improvement in motor function. The patient recovered from a sensation of stiffness and difficulty in movement, with a significant decrease in muscle tone, regaining confidence in walking, and no longer needing assistance even for long walking distances. Although all disabling and painful symptomatology in the upper limbs instead did not ameliorate, the Oswestry Disability Index (ODI) score decreased from 50% at baseline to 6%. To our knowledge, recovery from spasms and motor improvement in a spastic tetraparesis patient has never been reported before with 10kHz SCS and possibly this new stimulation paradigm may overcome some performance limitations of traditional low-frequency SCS (LF-SCS). Treatment eliminated spasms at the lower limbs but not at the upper ones, thus suggesting that the location of the epidural leads could affect outcomes.

Stereotactic radiosurgery for patients with spinal metastases from prostate cancer.

Spinal metastases may result in intractable pain, neurological deficit, and vertebral body collapse. There are only a few studies describing outcomes following spine stereotactic radiosurgery (SRS) specifically for prostate cancer metastases. A prospectively collected database of patients with prostate cancer spinal metastases treated at the University of Pittsburgh Medical Center from 2003 to 2023 was analyzed. The primary outcome was local control (LC). Secondary outcomes were overall survival (OS), pain resolution, and adverse radiation effects (AREs). Thirty-seven patients and 51 lesions were identified. Fifteen lesions (29%) were previously resected and 34 lesions (67%) were previously irradiated. The median tumor volume was 37.0cc (range: 2.9-263.3). A majority of lesions (71%) were treated in a single fraction (median 20Gy, range: 14-22.5); multi-fractionated treatment consisted of 21-30Gy in 2-5 fractions. Median follow-up was 12 months (range: 1-146). The 6-month, 1-year, and 2-year LC rates were 97%, 91%, and 91%, respectively. No tested prognostic factors were associated with LC, including hormone sensitivity. The 6-month, 1-year, and 2-year OS rates were 71%, 56%, and 32%; age > 70 years (p = 0.048) and tumor volume > 30cc (p = 0.03) were associated with inferior rates of OS. Complete or partial pain response was observed in 58% of patients. There were 8 instances (16%) of AREs, 2 of which were vertebral compression fractures (4%). Radiosurgery as a primary or adjuvant treatment modality for prostate cancer spinal metastases confers durable LC and moderate pain relief with minimal toxicity. Further studies are warranted to optimize management in this patient population.

A rare case of total hip replacement in an 11-year-old female: rehabilitation goals and challenges - a case report

This case report describes a unique pediatric patient, the first and youngest in India, who underwent total hip replacement (THR) for right ankylosed hip. Patient presented with preoperative musculoskeletal deformities, posing challenges for postoperative rehabilitation. This 11-year-old female presented with non-traumatic insidious right hip pain, limping, right hip flexion and abduction deformity. Patient was diagnosed with idiopathic chondrolysis of the hip through exclusion and clinico-radiological findings. Patient underwent surgery for ceramic-on-ceramic THR. Fusion of triradiate cartilage and epiphysis and Risser’s skeletal maturity staging were confirmed. Postoperative examination revealed right hip flexion and abduction deformity resulting in pelvic obliquity, which led to limb length discrepancy and functional scoliosis. There was increased anterior pelvic tilt, altering the gait pattern. Adhering to THR restrictions, rehabilitation strategies were tailored to restore normal pelvic orientation and address deformities through manual stretching of right hip abductor, tensor fascia latae, iliopsoas and rectus femoris. A left-sided shoe raise was also given. Lumbar segmental muscle activation, pelvic floor muscle training and gait training were crucial parts of the rehabilitation protocol. At ten-week, prodigious outcomes were achieved in the form of complete pain relief, complete correction of abduction and flexion deformity, normal pelvic alignment in the frontal plane and independent, stable full weight-bearing ambulation after two years of disabling ordeal suffering. However, minimal compensation of the anterior pelvic tilt persisted. Rehabilitation of this challenging patient with multiple deformities achieved excellent outcomes at ten-week post-rehabilitation. Thus, a tailored meticulous rehabilitation program can significantly improve quality of life.

Clinical and patient reported treatment outcomes of livedoid vasculopathy: A systematic review

Abstract Livedoid vasculopathy (LV) is a rare condition affecting the lower extremities, often linked to hypercoagulable states or vascular disorders, and despite increasing treatment options, patients frequently experience suboptimal outcomes. Our systematic review of 44 studies, involving 216 patients, found that Rivaroxaban was the most common treatment, with complete (n=18, 31%) or partial (n=40, 68%) ulcer healing and complete pain resolution in the 19% reported, while IVIG also showed promise, though results were mixed. The review highlights the need for further research to identify optimal treatments for LV and establish a standard of care for future clinical trials.

Clinical application of ultrasound in thoracic medial branch block and thoracic cooled-radiofrequency ablation: Case report and literature review

Introduction: Radiofrequency ablation is a procedure used to alleviate pain by destroying nerves with by radiofrequency-generated heat. Traditionally, radiofrequency ablation is preceded by diagnostic medial branch block injections, both guided by fluoroscopy. Fluoroscopic visualization of the superolateral aspect of the thoracic transverse process, where thoracic medial branch nerves occur, can be challenging due to anatomical complexities, especially in obese patients. We present a novel technique in which ultrasound was utilized in conjunction with fluoroscopy to perform medial branch block and radiofrequency ablation of the thoracic medial branch nerves. Case Report: First, two diagnostic thoracic medial branch nerve blocks were performed under ultrasound guidance. For the subsequent radiofrequency ablation, spinal needles were first advanced under ultrasound guidance to the target thoracic medial branch nerves. The position of those spinal needles was then used to guide the placement of cooled radiofrequency ablation probes using fluoroscopy. The patient reported 100% pain relief following the procedures. Discussion: We found that the addition of ultrasound allowed us to overcome the challenge of visualizing the superolateral aspect of thoracic transverse process under fluoroscopy alone. Direct ultrasound visualization allowed us to accurately and safely perform a thoracic medial branch block and radiofrequency ablation in a patient with poor fluoroscopic anatomy, as demonstrated by the patient’s complete pain relief after both medial branch block and radiofrequency ablation. We also theorize that our novel technique allows the provider to directly visualize the pleura, which could reduce the risk of severe pneumothorax associated with thoracic medial branch block and cooled radiofrequency ablation.

Efficacy and Safety Profile of Gamma Knife Radiosurgery in Classic and Idiopathic Trigeminal Neuralgia

BackgroundTrigeminal neuralgia is a debilitating disease, with severe recurrent paroxysms of shock-like facial pain. Although pharmacotherapy may suffice in the majority of cases, a proportion of patients require surgical treatment. Gamma knife radiosurgery (GKRS) represents a potential non-invasive alternative to surgery in these patients. MethodsWe retrospectively analysed all patients that underwent GKRS for classic/idiopathic TN between 2013 and 2023. Pain prior to GKRS was graded per the Barrow Neurological Institute (BNI) pain score, which was also used to define outcomes. “Complete pain relief (CPR)” was defined as a BNI pain score of I or II, while “Adequate pain relief (APR)” was defined as a BNI pain score of III, and “Failure” as a BNI score of IV or V. ResultsThe mean age of 70 patients (50 females and 20 males) was 47.4 ± 12.4 years. The mean follow-up was 51.3 ± 16.2 months. Although initial pain relief was achieved in 64 patients (91.4%), recurrence of pain at the latest follow-up occurred in 10 patients (14.3%). Overall, 41 patients (58.6%) achieved CPR, while 13 patients (18.6%) achieved APR. Multivariate analysis revealed that multiple prior failed procedures for TN predicted failure of pain relief. ConclusionGKRS is effective among patients with classic/idiopathic TN, with complete pain relief in 58.6% of patients, and adequate pain relief in 18.6% of patients. The most frequent complication is facial hypesthesia, affecting 38.6% of patients. Multiple prior failed procedures for TN significantly predict failure of pain relief at latest follow-up.

A Comparative Study of the Effect of Pericapsular Nerve Block (PENG) and Ultrasound-guided Fascia Iliaca Blocks on Postoperative Pain of Intertrochanteric Fractures

Background: Previous anesthesia blocks often failed to provide complete pain relief and were associated with weakness in the lower limbs, which hindered the essential mobility of patients undergoing hip surgery. Recently, the pericapsular nerve group block (PENG) has emerged as a promising alternative for managing postoperative pain following hip fracture surgery. Objectives: This study aimed to compare pain reduction between the pericapsular nerve group block (PENG) and the fascia iliaca compartment block (FICB) in patients who underwent intertrochanteric hip surgery. Methods: This randomized, double-blind clinical trial included 41 patients who were randomly assigned to either the pericapsular block group (PENG) or the ultrasound-guided (FICB). The primary outcome was pain relief, assessed using the postoperative Visual Analog Scale (VAS) score. Secondary outcomes included the dose of morphine consumed, the time of first morphine request, patient satisfaction with analgesia, and complications. Results: There was no significant difference between the PENG and FICB groups in terms of pain scores at any of the studied intervals (P-value &gt; 0.05). The dose of morphine consumed and the time to the first morphine request were similar for both methods, with no significant difference (P-value &gt; 0.05). The complication rates were 15% for the PENG group and 8.3% for the FICB group, with no significant difference observed (P-value &gt; 0.05). Conclusions: Both pericapsular and fascia iliaca blocks effectively reduced postoperative pain in patients undergoing intertrochanteric fracture surgery. Additionally, both methods were well tolerated by patients with no significant complications. However, there was no evidence to suggest that PENG is superior to FICB in terms of pain reduction.

Renal autotransplant as a definitive treatment for nutcracker syndrome: A multicenter retrospective study

ObjectiveNutcracker syndrome is a rare condition that involves mechanical compression of the left renal vein, leading to chronic and debilitating left flank pain. The etiology of the pain is misdiagnosed frequently, and patients usually require long-term opioid use to manage their pain. Multiple therapeutic options for nutcracker syndrome have been described in the literature but the reports are limited by small numbers of patients, and the lack of convincing data demonstrating consistently improved outcomes. Here we report the largest series to date of patients undergoing renal autotransplantation for the treatment of nutcracker syndrome. MethodsWe performed a multicenter retrospective cohort review of patients 105 patients with nutcracker syndrome who underwent renal autotransplantation as a primary or salvage therapy. ResultsDuring the overall study period, 93.1% of patients treated with autotransplantation had durable, complete flank pain relief at 12 months with both open and robotic surgical approach. After autotransplantation, a statistically significant decrease in the percentage of patients using opioids from 48.6% to 17.0% was demonstrated at 12 months. In those patients using opioids before autotransplantation, a statistically significant decrease in morphine milligram equivalents was demonstrated from an alarming 68.9 ± 15.0 per day to 25.0 ± 11.02 morphine milligram equivalents per day. ConclusionsOur findings suggest that renal autotransplantation, as a primary treatment or a salvage treatment, in patients with nutcracker syndrome provides durable pain relief and a marked decrease in chronic opioid use regardless of surgical approach.

Temporary halo fixation and radiotherapy as alternative to long-construct spondylodesis in patients with multiple unstable cervical metastases

Background and purposeCurrently no minimally invasive surgical treatment exists to provide immediate stability for unstable cervical/cervicothoracic metastases. Long-construct spondylodesis carries a high complication risk and has severe impact on residual range of motion. This study explores temporary halo fixation and radiotherapy as an alternative to long-construct cervical spondylodesis. Materials and methodsThis retrospective cohort study included twenty patients with multiple unstable cervical metastases treated between 2013–2023. All patients underwent halo fixation for an intended duration of three months to allow for safe reossification of lytic lesions following radiotherapy, with a dose fractionation scheme best suited to the histological origin of the tumor. ResultsImmobilization with halo fixation lasted a median 83 days (range, 41–132 days). Radiotherapy started on average 7 days after halo fixation (range, −35–118 days). The median pain score at baseline was 8, and was 0 at halo removal and at last follow-up. All patients had no or minor neurological deficits at baseline and did not develop new neurological deficits. At halo removal, 17/18 patients showed radiographic evidence of reossification. The majority of patients experienced minor limitations or had full range of motion of the neck at last follow-up. ConclusionPatients with multiple unstable cervical metastases treated with halo fixation and radiotherapy showed complete pain response or substantial pain reduction, reossification of the vertebrae and a, mostly, preserved range of motion. In selected neurologically intact patients, this treatment might be a patient-friendly alternative to fixation. Prospective evaluation of this treatment combination is needed.

Long-term clinical outcomes of extracorporeal shockwave lithotripsy and endoscopic retrograde cholangiopancreatography for pancreatic duct stone treatment in patients with chronic pancreatitis.

Extracorporeal shock wave lithotripsy for pancreatic stones (P-ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferred therapeutic approaches for painful chronic pancreatitis (CP) with pancreatic stones. This study aimed to report the short- and long-term outcomes following P-ESWL and ERCP in a large cohort with CP. Patients with painful CP and pancreatic stones >5 mm in size, who underwent P-ESWL and subsequent ERCP between March 2011 and June 2018, were included in this retrospective-prospective mixed observational study. The total stone clearance rates were recorded. All patients were followed up until the end of March 2024, with the visual analogue scale (VAS) for pain, pain type, quality-of-life scores and other relevant information recorded. A total of 2071 patients underwent P-ESWL, and 93.1% of them subsequently underwent ERCP during the study period. Patients were followed up for an average of 11.8 years from the onset of CP and 6.7 years from the first P-ESWL procedure. Complete stone clearance was achieved in 73.7% of the patients. At the end of the follow-up period, 70.1% of the patients achieved complete pain remission. Significant pain type conversion and lower VAS scores were observed in the patients after treatment. Quality-of-life scores and body mass indices increased after P-ESWL and ERCP. P-ESWL and ERCP are effective and minimally invasive treatments for pancreatic stones in patients with painful CP. Most patients achieved complete pain relief, and pain-type conversion was common after treatment. (ClinicalTrials.gov: NCT05916547).

Rectus Sheath Blocks for Umbilical Hernia Reductions in the Emergency Department: A Case Series.

Rectus sheath blocks have been used for decades in the operating room for analgesia following umbilical surgical procedures. We present the first reported case series of a rectus sheath block used in the emergency department (ED) for the reduction of an umbilical hernia. Four patients presented to the ED for painful, non-reducible umbilical hernias. An ultrasound-guided bilateral rectus sheath block was used in all four patients with complete pain relief and an easy hernia reduction. Rectus sheath blocks are an excellent addition to a multimodal analgesic regimen in periumbilical pain and painful procedures. This block is easy to perform and implement for pain control in umbilical hernias in an ED setting.

Outcomes of cooled radiofrequency ablation of cervical nerves for the treatment of chronic pain.

Chronic pain, defined as pain persisting for more than 3-6 months, has a mean one-year prevalence in the United States of 25.8% and is one of the most frequent reasons adults seek medical care. Treatment options include physical therapy, analgesics, anticonvulsants, exercise, and muscle relaxants. Even with conventional treatment modalities, in a subset of patients, pain may persist. Cooled radiofrequency ablation (c-RFA), a minimally invasive therapy, employs thermal energy generated by electrical currents to disrupt the transmission of pain stimuli along nociceptive pathways. This leads to an attenuation of pain impulses, primarily through nerve tissue necrosis. The potential of c-RFA to alleviate chronic pain for patients who struggle to find relief elsewhere accentuates the importance of rigorously investigating its outcomes. This study investigates whether patients receiving c-RFA for relief of chronic neck pain caused by cervical facet joint arthropathy experience a reduction in pain scores, the length of this reduction in pain scores, and the magnitude of this reduction in pain. This study was a retrospective analysis of data extracted from UW-Health Electronic Medical Health records (EMR), encompassing cervical c-RFA procedures performed from 2015 through 2022. Patient data were obtained, including diagnosis, pre-operative pain score, post-operative pain score, duration of relief, patient age, sex, and BMI. A two-tailed paired t-test was used to statistically analyze the pre-operative and post-operative pain scores, in which a p-value ≤0.05 was considered significant. A total of 450 cervical c-RFA procedures were reviewed, 152 were excluded due to absent pre- or post-op pain scores. 298 were included in the analysis, comprising 203 unique patients: 129 females and 74 males with an average age of 56.03 ± 12.76 and a BMI of 28.76 ± 6.05. Improvement of pain symptoms was reported in 85.23% (n = 263), 6% (n = 19) reported complete pain remission, 8.72% (n = 26) reported no change, and 3.02% (n = 9) reported worsening symptoms. Patients reported an average pre-operative pain score of 6.15 (M = 6.15, SD = 1.55) and an average post-operative pain score of 3.64 (M = 3.64, SD = 2.09) this achieved significance (p < 0.0001). Of the 85.23% (n = 263) charts that noted improvement, there is an average of 48.04% ± 26.53 reduction from their pre-operative pain scores. The average duration of relief lasted 6.67 ± 4.84 months. This study supports the potential efficacy of c-RFA as a minimally invasive treatment for chronic neck pain secondary to cervical facet joint arthropathy refractory to conventional treatment measures, demonstrating significant relief for a substantial length of time. Due to chronic pain's detrimental effect on one's quality of life, finding effective treatment options is essential, especially for those refractory to conventional treatments.

Cystoductojejunostomy for pseudocyst associated with chronic pancreatitis

Pseudocyst is frequently associated with chronic pancreatitis (CP). We describe our experience of managing seven patients for pseudocyst associated with CP by bile duct preserving pancreatic head resection (BDPPHR) and cystoductojejunostomy. 88 patients were operated on for chronic pancreatitis between April 2021 till May 2023 out of which 7 patients underwent BDPPHR and cystoductojejunostomy for pseudocyst associated with CP. Key steps of surgery include meticulous dissection with exposure of the pancreatic head to tail, head excision up to the posterior capsule with laying open of the pancreatic duct till the tail and reconstruction incorporating pancreatic duct (PD) and pseudocyst to a single loop of jejunum. All seven patients were successfully treated with BDPPHR and cystoductojejunostomy. Mean operative time and mean blood loss was 478 minutes and 450 ml respectively. Mean hospital stay was 4.5 days. On follow-up at a one-year minimum, all patients had complete pain relief. In patients with pseudocyst associated with CP, surgery preferably needs to address both the pseudocyst and the underlying chronic pancreatitis to improve the quality of life. A combined anastomosis to the PD and cyst may be termed as cystoductojejunostomy.