Early Pain Reduction Research Articles

Response to duloxetine in patients with knee pain due to osteoarthritis: an exploratory post hoc analysis of a Japanese Phase III randomized study.

PurposeTo assess whether patients with knee osteoarthritis pain who have early pain reduction or treatment-related adverse events of special interest (TR-AESIs; constipation, decreased appetite, malaise, nausea, somnolence, thirst) with duloxetine treatment are more likely to have later improvements in pain and quality of life (QOL) relative to placebo than patients without these early indicators.Patients and methodsThis was a post hoc analysis of 14-week randomized trial of Japanese patients with knee osteoarthritis pain (Brief Pain Inventory [BPI]-Severity average pain score ≥4) receiving duloxetine 60 mg/day (n=177 analyzed) or placebo (n=176). Primary trial outcome was change from baseline in BPI-Severity average pain at Week 14. Subgroups included early pain reduction (≥30%, 10%–30%, or <10% decrease in BPI-Severity average pain at Week 4) and early TR-AESIs (with/without TR-AESIs by Week 2). Measures included changes from baseline in BPI-Severity average pain, QOL (BPI-Interference, Western Ontario and McMaster Universities Osteoarthritis Index), Patient Global Impression of Improvement (PGI-I), and response rate (proportion achieving ≥30% or ≥50% pain reduction at Week 14).ResultsThe ≥30% early pain reduction subgroup (n=93) had significantly greater improvements in pain, QOL, and PGI-I and higher ≥30% and ≥50% response rates than placebo; the 10%–30% (n=45) and the <10% (n=33) pain reduction subgroups did not show the same (except 10%–30% group: PGI-I at Week 10 and some QOL at Weeks 10 and/or 14). Both TR-AESI subgroups (with, n=52; without, n=125) had significantly greater improvements in pain, PGI-I, and most QOL measures and higher response rates than placebo.ConclusionEarly efficacy responses to duloxetine treatment, but not early TR-AESIs, may predict later pain reduction and QOL improvements in Japanese patients with knee osteoarthritis pain.ClinicalTrials.govNCT02248480.

Minimally invasive anterior muscle-sparing versus a transgluteal approach for hemiarthroplasty in femoral neck fractures-a prospective randomised controlled trial including 190 elderly patients

BackgroundThe relevance of femoral neck fractures (FNFs) increases with the ageing of numerous societies, injury-related decline is observed in many patients. Treatment strategies have evolved towards primary joint replacement, but the impact of different approaches remains a matter of debate. The aim of this trial was to evaluate the benefit of an anterior minimally-invasive (AMIS) compared to a lateral Hardinge (LAT) approach for hemiarthroplasty in these oftentimes frail patients.MethodsFour hundred thirty-nine patients were screened during the 44-months trial, aiming at the evaluation of 150 patients > 60 yrs. of age. Eligible patients were randomised using an online-tool with completely random assignment. As primary endpoint, early mobility, a predictor for long-term outcomes, was evaluated at 3 weeks via the “Timed up and go” test (TUG). Secondary endpoints included the Functional Independence Measure (FIM), pain, complications, one-year mobility and mortality.ResultsA total of 190 patients were randomised; both groups were comparable at baseline, with a predominance for frailty-associated factors in the AMIS-group. At 3 weeks, 146 patients were assessed for the primary outcome. There was a reduction in the median duration of TUG performance of 21.5% (CI [− 41.2,4.7], p = 0.104) in the AMIS-arm (i.e., improved mobility). This reduction was more pronounced in patients with signs of frailty or cognitive impairment. FIM scores increased on average by 6.7 points (CI [0.5–12.8], p = 0.037), pain measured on a 10-point visual analogue scale decreased on average by 0.7 points (CI: [− 1.4,0.0], p = 0.064). The requirement for blood transfusion was lower in the AMIS- group, the rate of complications comparable, with a higher rate of soft tissue complications in the LAT-group. The mortality was higher in the AMIS-group.ConclusionThese results, similar to previous reports, support the concept that in elderly patients at risk of frailty, the AMIS approach for hemiarthroplasty can be beneficial, since early mobilisation and pain reduction potentially reduce deconditioning, morbidity and loss of independence. The results are, however, influenced by a plethora of factors. Only improvements in every aspect of the therapeutic chain can lead to optimisation of treatment and improve outcomes in this growing patient population.Trial registrationwww.clinicaltrials.gov: NCT01408693 (registered August 3rd 2011).

Effect of Bupivacaine on Postoperative Pain after Laparoscopic Cholecystectomy.

To determine whether intraoperative local injection of 0.5% bupivacaine around port sites would decrease early postoperative pain after laparoscopic cholecystectomy, and the use of intravenous opioid analgesics postoperatively. Randomised controlled trial. Department of Surgery, Khyber Teaching Hospital, Peshawar, from July 2016 to June 2017. Patients who underwent laparoscopic cholecystectomy were divided into two groups. Group A had instillation of 20 ml of 0.5% Inj. bupivacaine at the end of procedure into port sites and group B had no bupivacaine injection at trocar sites. Both groups had postoperative intravenous ketorolac 30 mg three times daily and intravenous opioid analgesics on demand. Pain was assessed 2 hours after recovery from general anesthesia, and at 6, 12 and 24 hours through visual analog scale 0-10. One hundred and twenty patients completed this study with 60 patients in each group. A significant difference in mean postoperative pain scores was observed at 2 and 6 hours after surgery between the groups. Pain scores at 2 and 6 hours after surgery were 3.97 +1.327 and 3.02 ±1.08 in group A, while it was 4.65 +1.448 and 4.72 ±1.277 in group B with p-values of 0.008 and 0.005, respectively. There was no significant difference in mean postoperative pain scores at 12 and 24 hours between the groups, with pain scores of 3.72 ±0.78 and 3.75 ±0.95 (p=0.488 and 0.744, respectively). However, there was a significant difference in opioid analgesics use in first 24 hours with less analgesics use in bupivacaine injected group. Injecting 0.5% bupivacaine at trocar sites during laparoscopic cholecystectomy offers significant reduction in early postoperative pain.

Relationship between arthroscopic findings of synovitis and levels of tumour necrosis factor-alpha and matrix metalloproteinases in synovial lavage fluid from patients with unilateral high mandibular condyle fractures.

Arthrocentesis has an effect of washing out inflammatory products that accumulate in the joint compartment of a dysfunctional temporomandibular joint (TMJ). The procedure removes inflammatory cytokines, which are pain-causing substances, for early reduction of TMJ pain and quick recovery of jaw function, thus increasing the possibility of a successful rehabilitation. The aim of this study was to investigate the relationship between arthroscopy synovitis grade in patients with unilateral high condylar fractures and concentrations of the pro-inflammatory cytokines tumour necrosis factor (TNF)-alpha as well as of matrix metalloproteinases (MMPs) in washed-out synovial fluid (SF) samples obtained from those patients. A total of 26 patients with unilateral high condylar fractures who underwent arthrocentesis for a therapeutic purpose were examined. SF samples were collected before performing arthroscopy to determine synovitis grade. The detection rates and concentrations of TNF-alpha and MMPs were determined, and their association with synovitis grade was analysed. TNF-alpha was detected in 23 and MMP-3 in 22 of the TMJs. There was a correlation between synovitis grade and concentration of TNF-alpha in the fracture group. Furthermore, the concentrations of TNF-alpha and MMP-3 were significantly higher as compared to the control group, comprised of TMJs on the non-fracture side of the same patients, while a correlation was also noted between TNF-alpha concentration and synovitis grade in the fracture group. The present findings may provide a biological/biochemical rationale for arthrocentesis as a reasonable treatment modality for high condylar fractures.

Mesenchymal stem cell secretome reduces pain and subchondral bone alterations in a mouse osteoarthritis model

Purpose: Mesenchymal stem cells (MSCs) represent a promising biological therapeutic option as an OA modifying treatment and have shown clinical improvement. Next to their differentiation potential into several lineages, they have the ability to influence their environment by secreting trophic mediators. These secreted factors could possibly counteract inflammatory and catabolic processes and attract endogenous repair cells. By using the MSC secretome as an OA treatment instead of the MSCs themselves, the possibilities to provide a more standardized and affordable therapeutic option would be largely increased. Together with a decrease of legal and safety issues, this would greatly enhance the clinical applicability of cell-based treatment as a true disease modifying anti-osteoarthritic drug. Aim of our study was to explore the anti-osteoarthritic effects of MSC secretome on pain, subchondral bone changes, cartilage damage, synovial thickness and synovial macrophage subtypes in a mouse osteoarthritis model. Methods: For the production of MSC Conditioned Medium (MSC-CM), human bone marrow derived MSCs from 3 donors were stimulated with IFNγ and TNFα (50 ng/mL each). After 24 hours of stimulation, medium was replaced by αMem without Phenol Red containing 0.05% BSA. This medium was collected after 24 hours, concentrated using 3k cut-off filters, frozen and designated MSC-CM. OA was induced unilaterally in 54 male C57/Bl6 mice by two intra-articular collagenase injections (collagenase-induced osteoarthritis model). After 7 days, mice were randomly assigned to 3 consecutive injections with 20.000 MSCs, MSC-CM from 20.000 MSCs or medium only (control). Weight distribution over the left and right hind limbs was evaluated as an indicator of pain using an incapitance tester. Other outcome measures were evaluated by histology at 5 and 21 days after treatment. Results: Seven days after induction of OA (day 0), 41.2 6.3% of weight was distributed on the affected limb, indicating pain when compared to before OA (Fig. 1, P<0.0001). We observed an early normalization in weight bearing in MSC-CM injected animals at day 7 compared to day 0, indicating early pain reduction (P = 0.001). Moreover, mice that received MSC-CM displayed significantly less pain compared to the medium control at day 7 (P = 0.001). OA induction lead to loss of subchondral bone tissue in the medial tibia plateau, 5 days after the first collagenase injection. (Fig. 2, P = 0.003). The percentage of subchondral bone in the MSC-CM treated group as well as the MSC treated group was not statistically different from the healthy control group, indicating amelioration of OA related decrease of subchondral bone volume. No treatment effects were seen on cartilage damage, synovial inflammation or the presence of iNOS, CD206, or CD163 positive macrophages (Fig. 3A–C). Conclusions: In this study, we found that injection of human MSC secretome resulted in an early pain reduction and amelioration of early subchondral bone changes, in a comparable manner to injection of MSCs themselves. Possibly, these two aspects are related, since subchondral bone marrow edema or bone marrow lesions have clinically been shown to be correlated with patients perceived degree of pain. Synovitis is another OA feature which has clinically been related to pain. We did not find a treatment effect on synovial thickness or macrophage phenotype in our study. Additional studies are warranted to further unravel the mechanisms behind the therapeutic effects of MSCs and their secretome. This way, we can evolve this biological approach towards a true disease modifying anti-osteoarthritic drug, in which the use of secretome would greatly enhance the standardization, affordability and clinical translatability.

206 (PB-107) - Early reduction of pain, heaviness and paresthesia following combined decongestive therapy in patients with breast cancer-related lymphedema

206 (PB-107) - Early reduction of pain, heaviness and paresthesia following combined decongestive therapy in patients with breast cancer-related lymphedema

Effect of zoledronic-acid and alendronate on bone oedema and pain in spontaneous osteonecrosis of the knee: a new paradigm in medical management

ObjectiveThe aim of this study was to determine the effect of combined zoledronic acid and alendronate therapy on bone oedema and knee pain in cases of spontaneous osteonecrosis of knee. We report our experience with this treatment. MethodsWe report a retrospective case series of 11 patients with MRI-confirmed spontaneous osteonecrosis of knee. Patients were treated with a single dose of intravenous 5mg zoledronic acid paired along with 35mg twice weekly oral alendronate, for 16 weeks. The visual analogue scale scores were noted before starting the therapy, at eight weeks, and at 16 weeks of follow-up. The size of bone marrow oedema adjacent to the lesion was measured on T2-weighted MRI coronal images at the start of therapy and at 16 weeks. ResultsThe average visual analogue scale score at 0 weeks was 7.72 vs. 0.81 at 16 weeks of therapy; the difference being significant (p=0.03). The mean bone marrow involvement at 0 weeks was 80%, which reduced to 11.81% at 16 weeks of therapy. The change was statistically significant (p=0.03). ConclusionOur data shows that the combination therapy gives early pain relief and reduction of bone oedema, and is safe, effective and well-tolerated for a painful disease entity like spontaneous osteonecrosis of knee.

Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation – A case report of a 4-year-old girl

Background and purposeThe purpose of this case report is to describe a multimodal pain therapeutic concept including the adjunct use of pregabalin in a 4.5 year-old child after forefoot amputation.Phantom limb pain and sensation is a complex pain syndrome that is difficult to treat and prevent. 70–75% of all children develop such a pain syndrome after amputation. We describe here a paediatric patient who underwent forefoot amputation following traumatic foot injury and received multimodal pain therapy including pregabalin. MethodsA 4.5 year-old otherwise healthy girl suffered severe injuries of the right foot and lower leg during a motor vehicle accident. Due to development of severe necrosis, forefoot amputation had to be performed during the hospital stay. ResultsInitial pain therapy included paracetamol, ibuprofen, metamizol, morphine and fentanyl. With mounting pain and anxiety, regional anaesthesia of the distal sciatic nerve was administered in combination with a ketamine and morphine patient controlled analgesia pump (PCA). The peripheral blockade of the distal sciatic nerve was placed with the guidance of ultrasound and nerve stimulator. The PCA concept included a continuous basal rate combined with a bolus function. Although the regional anaesthesia was well positioned and functioning, there was inadequate pain control. The pain was described by the patient as short, highly intense and sharp sensations with intensity on the visual analogue scale (VAS) of 10 (out of 10). Furthermore, she suffered from anxiety episodes and sleep disturbance. The medical team decided to treat with pregabalin to resolve these issues while awaiting amputation (Lisfranc line). She received psychological counselling as adjunct treatment. This multimodal concept enabled an early and efficient pain reduction pre- and post-amputation and allowed for the possibility of a hospital discharge without any opioid pain medication. ConclusionThe multimodal pain therapy including pregabalin was well tolerated, safe and highly effective in this case of traumatic limb injury and subsequent amputation. The use of pregabalin allowed significant pain and anxiety reduction for the patient. ImplicationsPregabalin is frequently used in adult patients for severe complex pain syndromes. There are only few reports of such adjunct medication (pregabalin) in paediatric pain syndromes. These reports focus mainly on the paediatric oncologic population. The case reported here encourages physicians to consider adjunct medications when treating complex pain, which are well established in the adult population. The benefits of such therapy in complex pain and anxiety can be extended to the paediatric population in select cases. Of course, one must always take into account that many routine medications used in children are well established but are off-label use. The authors are well aware of this problem and have conducted a critical literature review prior to pregabalin administration, including the search for randomized trials examining safety and tolerability. The parents or legal guardians of a minor must be thoroughly informed and consent to such a constellation of medical treatment.

Response to duloxetine in chronic low back pain: exploratory post hoc analysis of a Japanese Phase III randomized study.

PurposeDuloxetine is efficacious for chronic low back pain (CLBP). This post hoc analysis of a Japanese randomized, placebo-controlled trial (ClinicalTrials.gov, NCT01855919) assessed whether patients with CLBP with early pain reduction or treatment-related adverse events of special interest (TR-AESIs; nausea, somnolence, constipation) have enhanced responses to duloxetine.Patients and methodsPatients (N = 456) with CLBP for ≥6 months and Brief Pain Inventory (BPI) average pain severity score of ≥4 were randomized (1:1) to duloxetine 60 mg/day or placebo for 14 weeks. Primary outcome was change from baseline in BPI average pain severity score (pain reduction). Subgroup analyses included early pain reduction (≥30%, 10%–30%, or <10% at Week 4) and early TR-AESIs (with or without TR-AESIs by Week 2). Measures included changes from baseline in BPI average pain severity score and BPI Interference scores (quality of life; QOL), and response rate (≥30% or ≥50% pain reduction at Week 14).ResultsPatients with ≥30% early pain reduction (n = 108) or early TR-AESIs (n = 50) had significantly greater improvements in pain and QOL than placebo-treated patients (n = 226), whereas patients with 10%–30% (n = 63) or <10% (n = 48) pain reduction did not; patients without early TR-AESIs (n = 180) had significant improvements in pain at Week 14. Response rates (≥30%/≥50% pain reduction) were 94.4%/82.4%, 66.7%/49.2%, and 25.0%/18.8% for patients with ≥30%, 10%–30%, and <10% early pain reduction, respectively, 74.0%/64.0% for patients with early TR-AESIs, 67.2%/54.4% for patients without early TR-AESIs, and 52.2%/39.4% for placebo.ConclusionEarly pain reduction or TR-AESIs may predict which CLBP patients are most likely to respond to duloxetine with improvements in pain and QOL.

Duloxetine 60 mg for chronic low back pain: post hoc responder analysis of double-blind, placebo-controlled trials.

IntroductionDuloxetine has demonstrated efficacy in chronic low back pain (CLBP). We examined the predictors of response to duloxetine for CLBP.Patients and methodsThis was a post hoc analysis of pooled data from 4 double-blind, ran-domized, placebo-controlled trials of duloxetine (60 mg/day for 12–14 weeks) in adult patients with CLBP. Primary outcome was proportion of patients with ≥30% reduction in Brief Pain Inventory (BPI) average pain (“pain reduction”) at 12–14 weeks. The proportion of patients with ≥30% and ≥50% (secondary outcome) pain reduction in duloxetine and placebo groups was compared. Variables for responder analyses were early improvement (≥15% pain reduction at Week 2), sex, age, baseline BPI average pain score, duration of CLBP, and number of painful body sites according to the Michigan Body Map (≥2 vs 1 [isolated CLBP]; 1 trial); relative risk (RR) and 95% confidence interval (CI) were calculated.ResultsCompared with placebo (n = 653), a greater proportion of duloxetine-treated patients (n = 642) achieved ≥30% (59.7% vs 47.8%; P < 0.001) and ≥50% pain reduction (48.6% vs 35.1%; P < 0.001). Among duloxetine-treated patients, early improvement was associated with greater likelihood of ≥30% (RR [95% CI], 2.91 [2.30–3.67]) or ≥50% (3.24 [2.44–4.31]) pain reduction. Women were slightly more likely than men to achieve ≥30% (RR [95% CI], 1.14 [1.00–1.30]) or ≥50% (1.17 [0.99–1.38]) pain reduction. Response rates were similar between age, CLBP duration, and baseline BPI average pain score subgroups. Patients with ≥2 painful sites were more likely to respond to duloxetine 60 mg relative to placebo than patients with isolated CLBP (RR, duloxetine vs placebo [95% CI]: ≥30% reduction, ≥2 painful sites 1.40 [1.18–1.66], isolated CLBP 1.07 [0.78–1.48]; ≥50% reduction, ≥2 painful sites 1.51 [1.20–1.89], isolated CLBP 1.23 [0.81–1.88]).ConclusionEarly pain reduction was indicative of overall response. Patients with multiple painful sites had more benefit from duloxetine than patients with isolated CLBP.

Platelet rich fibrin in the management of established dry socket.

ObjectivesDry socket may occur secondary to the removal of any tooth. However, most dry socket cases develop in the third molar region. Dry socket is multifactorial in nature and has been treated using various modalities with varying success rates. This study assessed the efficacy of platelet rich fibrin (PRF) in established dry socket.Materials and MethodsTen patients of either sex aged from 41 to 64 years with established dry socket according to established criteria were treated using PRF. Evaluation was performed by observing the reduction of pain using visual analogue scale, analgesic tablet use over the follow-up period, and healing parameters.ResultsPain was reduced on the first day in all patients with decreased analgesic use. Pain was drastically reduced during follow-up on the first, second, third, and seventh days with a fall in pain score of 0 to 1 after the first day alone. The pain scores of all patients decreased to 1 by the first day except in one patient, and the scores decreased to 0 in all patients after 48 hours. Total analgesic intake ranged from 2 to 6 tablets (aceclofenac 100 mg per tablet) over the follow-up period of 7 days. Healing was satisfactory in all patients by the end of the seventh day.ConclusionPRF showed early pain reduction in established dry socket with minimal analgesic intake. No patients had allergic reactions to PRF as it is derived from the patient's own blood. PRF showed good wound healing. Our study suggests that PRF should be considered as a treatment modality for established dry socket.

Effect of Physiotherapy on Pain and Recovery of Physical Function after Total Knee Arthroplasty: One Month Follow-up

Objective: To investigate the effect of physiotherapy on pain and recovery of physical function after total knee arthroplasty (TKA). Methods: 80 patients (male 29, female 51) in the age group of 48–80 years (mean 63.28, SD 9.44) undergone TKA (bilateral 50, unilateral 30) participated in the prospective interventional study. All the participants received daily inpatient physiotherapy and outpatient physiotherapy sessions 4 days a week for 3 weeks. Pain and physical function were assessed at preoperatively, 1 week, and 1 month post-operatively by visual analogue scale (VAS) and lower extremity functional scale (LEFS), respectively. The data was analysed using repeated measures analysis of variance. Results: VAS score at 1-week after surgery was 4.38 (SD 0.99) vs. 2.13 (SD 1.35) at 1-month (p Conclusions: A regime of physical therapy program provides early pain reduction and improvement of function after TKA at 1-month post-operatively.

Modulation of serum BDNF levels in postherpetic neuralgia following pulsed radiofrequency of intercostal nerve and pregabalin.

To study the modulation of serum BDNF levels following integrated multimodal intervention in postherpetic neuralgia (PHN). A randomized, double-blind controlled study was undertaken among patients of thoracic PHN where 30 patients received pregabalin with pulsed radiofrequency and 30 controls received pregabalin with sham treatment. Pain intensity (visual analog scale) was reduced earlier in intervention group (15.3 ± 5.7 at the fourth week) compared with control group (16.3 ± 6.6 at the eighth week). Serum BDNF level increased with time in both the groups with overall increase more pronounced in intervention group. Integrated multimodal therapy using minimally invasive pulsed radiofrequency and pregabalin in PHN was effective in early pain reduction with elevated serum BDNF levels.

The Effectiveness of Phalleria macrocarpa Bioactive Fraction in Alleviating Endometriosis and/or Adenomyosis Related Pain

The overexpression of estrogen receptor-beta (ER-s) and the cyclooxygenase-2 (COX-2) enzyme coupled with the absence of expression of progesterone receptors (PR) is critical to thepathogenesis of endometriosis and adenomyosis associated pain.n DLBS1442, a novel bioactiveextract of Phaleria macrocarpa, exerts its action by downregulating the overexpressed ER-s andCOX-2 products and up-regulating PR gene expression. This pilot study was conducted to evaluatethe effectiveness of DLBS1442 treatment in alleviating endometriosis- and/or adenomyosis-relatedpain. Ten endometriosis and/or adenomyosis patients were recruited consecutively at YasminClinic Dr. Cipto Mangunkusumo General Hospital in January - March 2013. Pain associated withmenses, including pre-menstrual pain, dysmenorrhea, dyschezia and dysuria, was measuredusing the visual analog scale (VAS) at each of the next three menstrual cycles. Patients reportingone or more pain symptoms with a VAS score = 4 were given 100 mg of DLBS1442 three timesdaily for 12 weeks. VAS score reduction was noted in the first post-treatment menstrual cycle(approximately 5.3 weeks after treatment initiation) and VAS scores continued to decline overthe final two cycles. DLBS1442 was effective in alleviating endometriosis- and/ or adenomyosisrelatedpain, as demonstrated by early pain reduction as evaluated using the VAS.

Identification and management of the ilio-inguinal and ilio-hypogastric nerves in open inguinal hernia repair: benefits of self-gripping mesh.

A large randomized, multicenter European study recently reported a reduction in early pain after open inguinal surgery when self-gripping mesh was used compared with sutured Lichtenstein repair. This secondary exploratory study is focused on the influence of nerve identification and handling on post-operative pain. Post-operative VAS pain data and Surgical Pain Scores (SPS) from 507 patients included in this study were analyzed according to whether inguinal nerves were preserved or resected during surgery to investigate whether identification and peri-operative nerve handling impact post-operative pain. Preservation of the ilio-hypogastric nerve during Lichtenstein mesh repair with suture fixation was associated with significantly more post-operative pain compared with resection at each follow-up (p≤0.003). This difference was not significant with self-gripping mesh repair. The decrease from baseline in post-operative VAS and SPS scores were significantly greater after self-gripping mesh repair compared to Lichtenstein repair at 1year, but only when the ilio-hypogastric nerve was preserved (VAS scores, p=0.009; SPS scores, p=0.015). No such difference was observed with the ilio-inguinal nerve. When self-gripping mesh was used, preservation of the ilio-hypogastric nerve was associated with significantly greater decreases in post-operative pain (change in VAS score from baseline) compared with Lichtenstein repair at each follow-up (p≤0.018). The ilio-hypogastric nerve is in danger of being traumatized during Lichtenstein mesh repair with suture fixation. The use of self-gripping mesh was shown to reduce the level of post-operative pain when the ilio-hypogastric nerve was preserved. Resection of the ilio-hypogastric nerve during Lichtenstein repair eliminates this difference.

Antidepressant Drugs for Prevention of Acute and Chronic Postsurgical Pain

Wong, Karen*; Phelan, Rachel*; Kalso, Eija†; Galvin, Imelda*; Goldstein, David*; Raja, Srinivasa‡; Gilron, Ian§ Author Information

Aerosolized local anaesthetic to reduce postoperative pain.

McDermott et al. present a well-conducted randomised controlled trial to assess the effects of aerosolized intraperitoneal anaesthesia on postoperative pain following laparoscopic procedures [1]. This group and others have previously reported that shoulder tip pain following laparoscopic surgery may be experienced by a considerable proportion of patients, and this can delay postoperative progress [2, 3]. The ability to deliver a pre-emptive analgesic effect offers the opportunity to reduce postoperative analgesic requirement, facilitate earlier hospital discharge, reduce costs and ultimately improve the patient experience. In the present study, McDermott et al. used a novel device called the AeroSurge , which the group had previously shown to be safe and effective at delivering intraperitoneal aerosolized anaesthetic [4]. The group inserted the AeroSurge device through a 10-mm port and attached to a CO2 pump, filling the peritoneal cavity with aerosolized ropivacaine (treatment group) or normal saline (control). The theory being that by delivering aerosolized anaesthetic to the peritoneal cavity, the stimulation of pain receptors caused by insufflation that results in shoulder tip pain may be reduced. Other randomised controlled trials using a similar aerosolized approach have been encouraging, demonstrating reduced pain scores following laparoscopic cholecystectomy [5, 6]. McDermott et al. included two very different, but common, laparoscopic procedures: cholecystectomy and Nissen fundoplication. While the inclusion of these two procedures has facilitated achievement of the recruitment target (determined by their pre-trial power calculation), the variability in length of procedure, port positioning, size of trocars, and technical aspects (such as the potential for pneumomediastinum with fundoplication) limits interpretation of the results. While overall no benefit to the primary outcome measure (shoulder tip pain at 6 h) was demonstrated, subgroup analysis suggested that there was a reduction in early postoperative pain following laparoscopic cholecystectomy. While the study is underpowered for demonstration of benefit in this subgroup, the results are encouraging when taken in the context of previous studies which also demonstrate benefit using a similar approach [5, 6]. Ultimately effective reduction of postoperative pain is likely to require a multimodal approach. Other techniques which have been shown to be of benefit in this setting include low pressure pneumoperitoneum, pulmonary recruitment manoeuvres and peritoneal infiltration of local anaesthetic [7–9]. Techniques such as subdiaphragmatic normal saline irrigation and drain placement to minimise postoperative pneumoperitoneum have not proved so effective [10, 11]. By determining the most appropriate surgical indications and optimising the administration regimen, aerosolized intraperitoneal anaesthesia may have a role in improving the postoperative experience of patients undergoing laparoscopic surgery.

Comparing parecoxib and ketorolac as preemptive analgesia in patients undergoing posterior lumbar spinal fusion: a prospective randomized double-blinded placebo-controlled trial.

BackgroundPoor postoperative pain control is frequently associated with complications and delayed discharge from a hospital. Preemptive analgesia is one of the methods suggested for reducing postoperative pain. Opioids are effective for pain control, but there known addictive properties make physicians cautious about using them. Parecoxib and ketorolac are potent non-opioid NSAIDs that are attractive alternative drugs to opioids to avoid opioid-related side effects. However, there are no good head-to-head comparisons between these two drugs in the aspect of preemptive analgesic effects in lumbar spinal fusion surgery. This study aimed to compare the efficacy in terms of postoperative pain control and safety of parecoxib with ketorolac as preemptive analgesia in posterior lumbar spinal fusion patients.MethodsA prospective, double-blinded randomized controlled trial was carried out in patients undergoing posterior lumbar spinal fusion, who were randomized into 3 groups (n = 32). Parecoxib, ketorolac or a placebo was given to each patient via injection around 30 minutes prior to incision. The efficacy of postoperative pain control was assessed by a verbal numerical rating score (0–10). And various postoperative things were monitored for analysis, such as total opioid consumption, complications, and estimated blood loss.ResultsBoth the ketorolac and parecoxib groups showed significantly better early postoperative pain reduction at the postanesthesia care unit (PACU) than the control group (p < 0.05). There were no differences between the pain scores of ketorolac and parecoxib at any time points. Complications and bleeding were not significantly different between all three groups.ConclusionsPreemptive analgesia using both ketorolac and parecoxib showed a significantly better early postoperative pain control in the PACU than the control group in patients undergoing lumbar spinal fusion.Trial registrationClinicalTrials.gov NCT01859585. Registered 15 May 2013.

Antidepressant drugs for prevention of acute and chronic postsurgical pain: early evidence and recommended future directions.

This review evaluates trials of antidepressants for acute and chronic postsurgical pain. Trials were systematically identified using predefined inclusion and exclusion criteria. Extracted data included the following: pain at rest and with movement, adverse effects, and other outcomes. Fifteen studies (985 participants) of early postoperative pain evaluated amitriptyline (three trials), bicifadine (two trials), desipramine (three trials), duloxetine (one trial), fluoxetine (one trial), fluradoline (one trial), tryptophan (four trials), and venlafaxine (one trial). Three studies (565 participants) of chronic postoperative pain prevention evaluated duloxetine (one trial), escitalopram (one trial), and venlafaxine (one trial). Heterogeneity because of differences in drug, dosing regimen, outcomes, and/or surgical procedure precluded any meta-analyses. Superiority to placebo was reported in 8 of 15 trials for early pain reduction and 1 of 3 trials for chronic pain reduction. The majority of positive trials did not report sufficient data to estimate treatment effect sizes. Many studies had inadequate size, safety evaluation/reporting, procedure specificity, and movement-evoked pain assessment. There is currently insufficient evidence to support the clinical use of antidepressants-beyond controlled investigations-for treatment of acute, or prevention of chronic, postoperative pain. Multiple positive trials suggest the therapeutic potential of antidepressants, which need to be replicated. Other nontrial evidence suggests potential safety concerns of perioperative antidepressant use. Future studies are needed to better define the risk-benefit ratio of antidepressants in postoperative pain management. Higher-quality trials should optimize dosing, timing and duration of antidepressant treatment, trial size, patient selection, safety evaluation and reporting, procedure specificity, and assessment of movement-evoked pain relevant to postoperative functional recovery.

SAT0344 Intravenous Bisphosphonate Reduces Rapidly Pain in Complex Regional Pain Syndrome (CRPS)

BackgroundThe treatment of CRPS remains controversial, but multidisciplinary and interdisciplinary approaches is mandatory to prevent long-standing or permanent disability. Bisphosphonates, apart from their antiresorptive activity, have been shown to have...