Degree Of Pain Improvement Research Articles

(131) Microsurgical Denervation of the Spermatic Cord for Chronic Scrotal Pain: Results from a Prospective Case Series

Abstract Introduction Microsurgical spermatic cord denervation (MSCD) is one of the lines of management of chronic scrotal pain refractory to conservative lines of therapy, however, it has not been fully adopted by different centres. Other procedures such as epididymectomy, orchidectomy and vasectomy reversal are being offered instead. Objective To evaluate the safety and efficacy of microsurgical denervation of the spermatic cord in the management of chronic scrotal pain refractory to conservative lines of therapy. Methods Twenty consecutive patients were prospectively enrolled for MSCD over a 24-month period. These patients underwent MSCD after exclusion of any correctable cause of chronic scrotal pain (CSP) and/or poor response to medical treatment. Efficacy of the technique was evaluated by the degree of pain improvement using the Visual Analogue Scale (VAS). Safety was assessed by reporting any intra- or post-operative complications. Results The mean age of the studied population was 51.7 (36–78) years. The mean pain duration was 4.2 (1–20) years. In 8 patients (40%), the aetiology of the chronic pain was idiopathic, 5 patients (25%) the pain occurred after previous scrotal surgery (vasectomy in 2 patients, AUS in 2 and an epididymal cyst excision in 1 patient), 4 patients (20%) post scrotal trauma and 3 patients (15%) post epididymo-orchitis. Ten patients (50%) had complete pain resolution, 8 (40%) had a partial resolution of their pain, the pain remained the same in a one patient (5%), and one patient (5%) had resolution of the scrotal pain but developed pain at the incision site following MSCD. The VAS pain score significantly improved from a mean of 9.7 to 3.7 postoperatively. (p=0.0029). No significant complications have been encountered in this case series. Conclusions Microsurgical denervation of the spermatic cord is a safe and reliable option that should be more widely adopted to treat men with chronic scrotal pain refractory to conservative treatment. Disclosure No.

CLINICAL SIGNIFICANCE OF THE TRADITIONAL JAPANESE MEDICINE, KEISHIKA-SHAKUYAKU-TO, IN ABDOMINAL SPASTIC PAIN

Primary goal: To assess the usefulness of Kampo for the outpatient treatment of abdominal spastic pain.Research Design: Retrospective studyMethodology: A total of 85 patients with symptoms of abdominal spasmodic pain and diarrhea of unknown cause, including the patients with contraindications for anticholinergic drugs, were included in the study. The patient was administered oral Keishika-Shakuyaku-to (TJ-60: 7.5 g/day) to treat spastic pain and diarrhea. The degree of improvement in pain was evaluated using a numerical rating scale at the start of treatment and 3 months later and used as an indicator of continuation.Main outcomes and Results: Therapeutic effects were seen in 77.6% (66/85) of the included patients with the level of pain decreasing by over 50% 3 months after the first treatment. Additionally, no side effects from oral administration or adverse events leading to drug discontinuation were observed.Conclusions: Kampo, Keishika-Shakuyaku-to was found to reduce abdominal pain and diarrhea of unknown cause and could be used safely without causing significant side effects even in patients with contraindications for anticholinergic drugs.

Defining Clinically Significant Outcomes for Revision Arthroscopic Rotator Cuff Repair (230)

Objectives:While clinically significant outcomes including Minimal Clinically Important Difference (MCID), Substantial Clinical Benefit (SCB), and Patient Acceptable Symptom State (PASS) have been defined in primary rotator cuff repair (RCR), these values have not been established in revision RCR. Revision cases may be associated with lower absolute improvement compared to primary cases, and outcomes should therefore be assessed against revision-specific clinically significant differences. The purpose of this study was to define clinically significant outcomes in American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Constant scores, and to investigate factors associated with achievement of significant improvement following revision arthroscopic RCR. We hypothesized that MCID, SCB, and PASS values would be lower than those reported for primary RCR patients.Methods:A retrospective review of revision RCRs from July 2014 through June 2019 was performed. Patients who did not complete any patient reported outcomes (PROs) and those who underwent superior capsular reconstructions were excluded; graft augmentations were included. MCID was calculated with the distribution-based method, whereas SCB and PASS were calculated using anchor-based methodology from postoperative PRO scores. The SCB was determined by comparing the PRO scores of the substantial improvement and control patient cohorts, and PASS was determined by comparing the PRO scores of patients responding as satisfied and unsatisfied with their postoperative outcome. Receiver operating characteristic (ROC) curves and area under the curve (AUC) analysis were used to calculate optimal threshold scores corresponding to achievement of the SCB and PASS. Optimal thresholds were determined through maximization of sensitivity and specificity via Youden’s index. This process was repeated for each questionnaire (ASES, SANE, and Constant). Wilcoxon signed-rank paired tests were used to assess improvement in PRO scores from baseline. Threshold analysis to determine if any preoperative PRO scores were sufficiently predictive of achieving the MCID, SCB, or PASS were performed.Results:A total of 97 patients were identified and 54 patients (51 anchor responses) answered 1-year PROs. All PROs demonstrated significant increases from baseline to 1-year postoperatively (all P < 0.001). There was a gain of 22.4, 19.9, and 5.7 points for ASES, SANE, and Constant from baseline, respectively. MCID was 13.7, 14.1, and 4.2 for ASES, SANE, and Constant, respectively (Table 1). Values for SCB using the physical function and pain anchors, and PASS using the satisfaction anchor are demonstrated in Table 1. For physical function improvement, 26 patients (51.0%) had some degree of improvement, 15 patients (29.4%) had no change or negligible change in their status, and 10 patients (19.6%) were worse based on the anchor question. For the pain anchor, 24 patients (47.1%) had some degree of pain improvement, 16 patients (31.4%) had no change or negligible change in their status, and 11 patients (21.6%) were worse. Preoperative PRO score thresholds that were predictive of achieving MCID, SCB, and PASS are presented in Table 2. There were no significant effects of sex on attaining any clinically significant outcome, but a greater age was associated with a higher likelihood of achieving SCB (r = 0.299, p = 0.043) on Constant. BMI was negatively correlated with achieving SCB on SANE (r = -0.383, p = 0.009), while WC status was negatively correlated with achievement of SCB (13.3% WC vs 58.9% non-WC, p = 0.005) and PASS (13.3% WC vs 58.9% non-WC, p = 0.029) on SANE.Conclusions:In this study, we defined MCID, SCB, and PASS values at 1-year for ASES, SANE, and Constant in patients undergoing revision RCR. Our MCID values were higher for ASES but lower for SANE and Constant compared to prior studies on clinically significant outcomes in primary RCR. Our findings suggest different clinical thresholds should be used in the revision RCR population.

Prospective Study of Outcome of Minimally Invasive Open Discectomy in Single Level Lumber Disc Herniation

AIMS: To study the functional outcome, incidence, degree of pain improvement, neurological improvement and complication following Minimal invasive open lumbar discectomy in single level lumbar disc herniation. METHOD: This prospective study was carried out at Department of Orthopedics of UCMS-TH between November 2016 to July 2017 with symptomatic lumbar disc herniation with failed conservative treatment and who have fulfilled the inclusion criteria were enrolled into this study. Evaluations of the patients were done post-operatively at fourteen post operative day, one month and three months. At each assessment detail clinical and neurological examination was done with ODI and VAS assessment Results: In our study sample size was 30 in which the mean age was 41.7 years ranging from 20 to 65 years. Among 30 patients, 18 were male and 12 were female. 17 patients (56.7%) were of self employed group, 8 patients (26.7%)were housewife,2 patients (6.7%) were farmer,2 patients (6.7%) were public servant and 1 patients (3.3%) was ex army . Average blood loss was 93.9 ml. minimum 70 ml to maximum 120 ml. The mean operative time duration was 90 minutes, minimum 58 to maximum 120 minutes. Pre operative mean ODI score was 46.06, one month mean ODI was 33.73 and on three month mean ODI was 22.93.Mean for VAS for leg pain pre operatively was 7.43, one month follow up score was 5.06 and lastly three month score was 3.43. One patient had dura tear as intra-operative and two patients had discitis as late complication. Conclusion: Minimal invasive open discectomy is best treatment for symptomatic lumber disc herniation who had failed conservative treatment in our locality and developing country like Nepal.

Gamma knife radiosurgery on the trigeminal ganglion for idiopathic trigeminal neuralgia: Results and review of the literature.

Background:In the present study, we evaluate the results of gamma knife surgery (GKS) for the treatment of trigeminal neuralgia (TN) using the trigeminal ganglion (TG’) and the adjacent fibers of trigeminal nerve as a target.Methods:From February 2013 to July 2017, we treated 30 cases of TN with GKS. In this group, all patients had an idiopathic typical TN. The radiosurgical target was conformed through two isocenters, 8 and 4 mm at the cavum de Meckel. The maximum dose was 86 Gy using the isodose line of 50%. The median age of the patients was 58.5 (range 28–94) years old, and the median time from diagnosis to GKS was 94 months (range 13–480 months). The median follow-up was 28.5 (range 12–49) months. Clinical outcomes were analyzed. Univariate and multivariate analyses were performed to evaluate factors that correlated with a favorable, pain-free outcome.Results:The mean time to relief of pain was 7 (range 1–40) days. The percentage of patients with significant pain relief was 93.3%. Relapse in pain was noted in four patients at 3, 16, 19, and 36 months. Nine patients were treated in acute status. Fourteen patients had intense pain between 1 and 7 days before the procedure. Among those with the recurrence of their symptoms, one patient had a microvascular decompression. Multivariate regression adjusted for age and sex suggests that, by 40 months, 70% of the patients treated with radiosurgery will remain pain free. At the last follow-up, GKS resulted in pain relief in 86.6% of patients. Our analysis suggests that, using this technique, we can expect that approximately 70% of patients with TN will have some degree of pain improvement at 3 years’ post radiosurgery.Conclusions:GKS on TG appears to be a reasonable treatment option with short latency period, minor collateral effects, and high percentage of pain control. The mechanism of action of radiosurgery could be related to the inactivation of the satellite glial cells in the TG.

Palliative Radiation Therapy for Bone Metastases in Neuroendocrine Neoplasms

PurposeBone metastases are reported in 10% to 12% of patients with neuroendocrine neoplasms (NENs) and can lead to pain and skeletal-related events (SREs), resulting in diminished quality of life and functional status. In other solid tumors with bone metastases, radiation therapy (RT) is an established treatment approach for SREs, yet few data are available in NENs historically considered to be radioresistant. We hypothesize that RT is effective for pain and other SREs in NENs and aimed to delineate any differences in pain palliation and time until progression of pain between different fractionation and dosing schedules of RT. Methods and MaterialsWe retrospectively reviewed 686 records of patients with NENs treated at the institution between 2011 and 2018 and identified 28 (4.1%) patients treated with RT for 61 cases of SREs. The primary endpoint was change in patient reported pain scores after RT. ResultsAll 28 patients experienced bone pain. Nineteen sites were treated with a single fraction (doses of 800-1800 cGy) and 42 sites with fractionated regimens (doses of 900-3750 cGy over 3-15 fractions). In 55 of 61 cases (90%), patients experienced improvement in pain after RT. The median time to recurrence or progression of pain was 3.5 months. Significant differences were found between primary site and change in performance status (P = .024), sex, and reported magnitude of pain score decrease after RT (P = .025). There were no differences in the time to the progression of pain, change in performance status, and degree of improvement in pain based on age, chemotherapy received during RT, or radiation site. Outcomes were similar for patients who received single-fraction versus fractionated regimens (P = .545) and between those receiving palliative versus ablative RT regimens (P = .812). ConclusionsAlthough the majority of cases in this NEN cohort benefited from RT, additional studies on the use of RT in the treatment of painful bone metastases are warranted.

Usefulness of K-Point Injection for the Nonspecific Neck Pain in So-Called K-Point Syndrome.

BackgroundShoichi Kokubun introduced his successful experience with local anesthetic injection at the occipital insertion of the sternocleidomastoid muscle in K-point syndrome. The purpose of this study was to evaluate the short-term and long-term effectiveness of K-point injection and investigate factors affecting treatment results.MethodsK-point injection was performed in 58 patients with K-point syndrome at Yeungnam University Medical Center. The syndrome was associated with cervical whiplash injury in 10 patients and was of nonspecific origin in the rest. One milliliter of 2% lidocaine mixed with 1 milliliter of dexamethasone was injected in 50 patients and 2 milliliters of 1% lidocaine alone in the rest. Initially, the severity of local tenderness at the K-point and other tender points was examined and the degree of immediate pain relief effect was assessed within 1 hour after injection. Early effect within 1 month after the injection and current effect were evaluated in 27 patients using a modified Kim's questionnaire with regard to the duration of improvement, degree of improvement in pain and daily living activities, and satisfaction.ResultsOf the total 58 patients, 44 (75.8%) apparently had immediate pain relief after K-point injection. The only factor associated with successful immediate pain relief was the whiplash injury associated with traffic accident (TA). The early pain control effect was associated with the immediate effect. The current effect was associated with the early effect alone. Satisfaction with the K-point injection was related to early successful pain relief.ConclusionsK-point injection would be useful for early pain relief in nonspecific neck pain syndrome so called K-point syndrome, but not for current pain relief. Especially, it was very effective for early pain control in the whiplash injury associated with TA.

MP25-14 THE TREATMENT OF CHRONIC ORCHALGIA WITH TMRTM: SUBSTANTIAL PAIN REDUCTION WITH DURABLE RESULTS

You have accessJournal of UrologyInfections/Inflammation of the Genitourinary Tract: Prostate & Genitalia1 Apr 2015MP25-14 THE TREATMENT OF CHRONIC ORCHALGIA WITH TMRTM: SUBSTANTIAL PAIN REDUCTION WITH DURABLE RESULTS Daniel H. Shin, and Aaron Spitz Daniel H. ShinDaniel H. Shin More articles by this author , and Aaron SpitzAaron Spitz More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1217AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Chronic orchalgia is a common urological complaint with treatments ranging from medication to denervation and orchiectomy. Here we report our five year experience in the treatment of chronic orchalgia with Therapeutic Magnetic Resonance (TMRTM), an FDA approved device for the treatment of pain. With TMRTM, an electric current is applied for 10-20 minutes directly to the skin overlying the spermatic cord via two metal probes positioned on opposite sides of the scrotum, reportedly altering nerve cell ion conduction and the sensation of pain. METHODS Men with chronic orchalgia who had failed conservative management and were treated with TMRTM were identified and contacted. Demographic and pain data were collected and results were analyzed with T-test and one-way ANOVA to determine statistical difference. Patients reported pain levels using the numerical (zero-ten) pain scale, which has been validated to correspond measurably to severity of painful stimuli. RESULTS Forty-nine patients met criteria. Mean age was 50 years (range 22-82). Forty-five percent reported left testicular pain, 25% right testicular pain, and 29% bilateral. Mean duration of pain prior to TMRTM was 84 months (range 3-408). Etiology was 39% post-surgical (vasectomy, varicocelectomy, and hernia surgery), 28% idiopathic, and 20% associated with anatomic abnormality such as varicocele or epididymal cyst. Mean pain level prior to treatment (baseline) was 5.7 (range 1-10, n=36). After treatment, mean nadir pain level was 39% lower than baseline (3.5, range 0-8, n = 26, p < 0.005). On followup, mean reported pain level was 58% lower than baseline (2.4, range 0-7, n = 24, p < 0.005). Mean number of treatments received was 3.2 (range 1-14). Mean years since treatment to the followup was 2.75 years (range 0.5-4.9 years). No adverse effects were reported from treatment. There were no significant differences in degree of pain improvement when patients were stratified by etiology of orchalgia. CONCLUSIONS TMRTM represents an effective treatment for chronic orchalgia, with substantial reductions in reported pain levels, durable response, and no reported side effects. Limitations to our study include a small sample size, lack of a control group, and reliance of post-treatment pain data on patient recall. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e290 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel H. Shin More articles by this author Aaron Spitz More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

(481) What degree of improvement in pain and function constitutes a clinically meaningful improvement in shoulder impingement syndrome?

(481) What degree of improvement in pain and function constitutes a clinically meaningful improvement in shoulder impingement syndrome?

Efficacy of Combined Treatment with Medial Branch Radiofrequency Neurotomy and Steroid Block in Lumbar Facet Joint Arthropathy

PurposeTo evaluate the long-term efficacy of combined radiofrequency (RF) neurotomy and steroid nerve block in patients with lumbar facet joint arthropathy. Materials and MethodsCombined RF neurotomy and steroid nerve block was performed in 34 patients with chronic paravertebral low back pain. The diagnosis was confirmed by comparative double diagnostic block of the medial branch with bupivacaine and lidocaine. Under fluoroscopy, RF thermal ablation of the medial branch was performed (at RF needle tip temperature 85°C for 90 seconds), three times for each target nerve. At the end of the procedure, 20 mg of methylprednisolone acetate (sustained-release preparation) was infiltrated on each ablated nerve. Outcome variable was the degree of improvement in pain using visual analog scale (VAS) and numerical rating scale (NRS). Improvement in the quality of life was assessed using the Roland-Morris (RM) questionnaire. The procedure was repeated in cases of unbearable pain (>5 VAS score). ResultsPatients had a mean VAS score of 8.6 before the procedure. Thereafter, VAS score was 0.91 immediately after the procedure and 3.0, 2.8, 3.7, and 3.6 at 1 month, 2 months, 6 months, and 1 year. NRS showed pain relief after the procedure of 85%, 65%, 78%, 62%, and 59.5% at the same time points. RM score was 18 before the procedure, 7.6 at 6 months after the procedure, and 8.5 at 1 year after the procedure. No major complication was noted except local pain in all patients and numbness of the back in six patients after the procedure. ConclusionsCombined RF neurotomy and steroid nerve block produced substantial improvement in terms of long-term pain relief and quality of life.

Octreotide in Palliative Treatment of Hepatic Metastases: Is it Effective for Clinical Stabilization?

Octreotide in Palliative Treatment of Hepatic Metastases: Is it Effective for Clinical Stabilization?

Gamma knife surgery for trigeminal neuralgia: outcomes and prognostic factors

Microvascular decompression (MVD) and percutaneous ablation surgery have historically been the treatments of choice for medically refractory trigeminal neuralgia (TN). Gamma knife surgery (GKS) has been used as an alternative, minimally invasive treatment in TN. In the present study, the authors evaluated the long-term results of GKS in the treatment of TN. From 1996 to 2003, 151 cases of TN were treated with GKS. In this group, radiosurgery was performed once in 136 patients, twice in 14 patients, and three times in one patient. The types of TN were as follows: 122 patients with typical TN, three with atypical TN, four with multiple sclerosis-associated TN, and seven with TN and a history of a cavernous sinus tumor. In each case, the chosen radiosurgical target was located 2 to 4 mm anterior to the entry of the trigeminal nerve into the pons. The maximal radiation doses ranged from 50 to 90 Gy. The median age of the patients was 68 years (range 22-90 years), and the median time from diagnosis to GKS was 72 months (range 1-276 months). The median follow up was 19 months (range 2-96 months). Clinical outcomes and postradiosurgical magnetic resonance (MR) imaging studies were analyzed. Univariate and multivariate analyses were performed to evaluate factors that correlated with a favorable, pain-free outcome. The mean time to relief of pain was 24 days (range 1-180 days). Forty-seven, 45, and 34% of patients were pain free without medication at the 1-, 2-, and 3-year follow ups, respectively. Ninety, 77, and 70% of patients experienced some improvement in pain at the 1-, 2-, and 3-year follow ups, respectively. Thirty-three (27%) of 122 patients with initial improvement subsequently experienced pain recurrence a median of 12 months (range 2-34 months) post-GKS. Among those whose symptoms recurred, 14 patients underwent additional GKS, six MVD, four glycerol injection, and one patient a percutaneous radiofrequency rhizotomy. Twelve patients (9%) suffered the onset of new facial numbness post-GKS. Changes on MR images post-GKS were noted in nine patients (7%). On univariate analysis, right-sided neuralgia (p = 0.0002) and a previous neurectomy (p = 0.04) correlated with a pain-free outcome; on multivariate analysis, both rightsided neuralgia (p = 0.032) and patient age (p = 0.05) were statistically significant. New onset of facial numbness following GKS correlated with undergoing more than one GKS (p = 0.002). At the last follow up, GKS effected pain relief in 44% of patients. Some degree of pain improvement at 3 years post-GKS was noted in 70% of patients with TN. Although less effective than MVD, GKS remains a reasonable treatment option for those unwilling or unable to undergo more invasive surgical approaches and offers a low risk of side effects.

What decline in pain intensity is meaningful to patients with acute pain?

Despite widespread use of the 0–10 numeric rating scale (NRS) of pain intensity, relatively little is known about the meaning of decreases in pain intensity assessed by means of this scale to patients. We aimed to establish the meaning to patients of declines in pain intensity and percent pain reduction. Upon arrival to the postanesthesia care unit, postsurgical patients rated their baseline pain intensity on both a 0–10 NRS and on a 4-point verbal scale. Patients whose NRS was higher than 4/10 received intravenous opioids until their pain intensity declined to 4/10 or lower. During opioid titration, patients were asked every 10 min to rate pain intensity on a NRS and to indicate the degree of pain improvement on a 5-point Likert scale from ‘no improvement’ to ‘complete pain relief’. Seven hundred adult patients were enrolled. For patients with moderate pain, a decrease of 1.3 units (20% reduction) corresponded to ‘minimal’ improvement, a decrease of 2.4 (35% reduction) to ‘much’ improvement, a decrease of 3.5 units (45% reduction) corresponded to ‘very much’ improvement. For patients with severe pain, the decrease in NRS pain score and the percentage of pain relief had to be larger to obtain similar degrees of pain relief. The change in pain intensity that is meaningful to patients increases as the severity of their baseline pain increases. The present findings are applicable in the clinical setting and research arena to assess treatment efficacy.

Evaluation of Capsaicin's Use in Analgesic Medicine

ABSTRACT Capsaicin, trans-methyl N-vanillyl-nonenamide, is the major pungent compound derived from the hot pepper plant. Regular and cumulative topical applications of capsaicin cream has been shown to produce analgesic effects in many painful medical conditions. This effect is mediated by a neuronal mechanism which involves the depletion of substance P from C-fiber sensory neurons. The elucidation of a receptor-mediated mechanism at the vanilloid receptor has further explained the biochemical events observed with capsaicin use. Use of capsaicin in the therapeutic setting is desirable due to its non-narcotic non-steroidal properties. Toxcity symptoms are evident only in large doses. This review includes research on capsaicin's use as an analgesic in three painful medical conditions: postherpetic neuralgia, osteoarthri-tis and postmastectomy pain syndrome. All report some degree of improvement in pain with capsacin use. Although only a small sample of medical conditions are represented here, a variety of o...

THE ILIZAROV METHOD IN NONUNION, MALUNION AND INFECTION OF FRACTURES

We have reviewed a series of 56 consecutive patients treated by the Ilizarov circular fixator for various combinations of nonunion, malunion and infection of fractures. We used segmental excision, distraction osteogenesis and gradual correction of the deformity as appropriate. Treatment was effective in eliminating 40 out of 46 nonunions and all 22 infections. There were two cases of refracture some months after removal of the frame, both of which healed securely in a second frame. Correction of malunion was good in the coronal plane but there was a tendency to anterior angulation, often occurring in the regenerate bone rather than at the original fracture site, after removal of the frame. This was associated with very slow maturation of regenerate bone in some patients, occurring largely, but not exclusively, in those who smoked heavily. Patients expressed high levels of satisfaction with the outcome, despite relatively modest improvements in pain and function, presumably because their longstanding and intractable nonunion had been treated. None the less, the degree of satisfaction correlated strongly with the degree of improvement in pain and function. We emphasise the importance of a multidisciplinary team in the assessment and support of patients undergoing long and demanding treatment. The Ilizarov method is valuable, but research is needed to overcome the problems of delayed maturation of the regenerate and slow or insecure healing of the docking site.