Improvement In Pain Symptoms Research Articles

Tibial tubercle advancement osteotomy with bone allograft for patellofemoral arthritis: a retrospective cohort study of 50 knees

Forty consecutive patients (21 females and 19 males) in a single centre underwent 50 tibial tubercle advancement osteotomy procedures for patellofemoral arthritis between January 1993 and April 2007. Twenty knees with patellar maltracking also underwent medialisation of the tibial tubercle (6-12 mm) in addition to the standard 10-15 mm elevation. Femoral head bone allograft blocks were utilised in all cases, and all patients achieved bony union without further surgery. Forty-five knees had previously undergone arthroscopy, 18 with arthroscopic lateral releases. Ninety-four percentage of knees had sustained improvement in visual analogue pain scores (mean improvement of 37.4, P < 0.05) at a mean follow-up of 81 months (range 26-195 months), with 96% of patients still satisfied; and 92% of knees had sustained improvement in Shelbourne and Trumper anterior knee function scores (mean improvement of 39.8, P < 0.05). Overall clinical outcomes were rated excellent/good in 77%, fair in 35% and poor in 8% of knees. Two knees required arthroplasty surgery over the follow-up period (at 18 months and 8 years), and their anterior knee pain and function scores were not included in the analyses. Six knees (12%) suffered major complications: 1 temporary common peroneal neuropraxia; 2 intraoperative tibial metaphyseal fractures; and 3 tibial tuberosity fractures (at 8 days, 3 weeks and 3 months). Four knees (8%) suffered superficial wound infections, 31 knees had some numbness around the midline scar, 7 knees had scar pain lasting up to 12 months, and 22 knees (44%) experienced some discomfort relating to the metalwork, which was removed in all these cases. Tibial tubercle advancement osteotomy can be an effective treatment for anterior knee pain and for patients with arthroscopic evidence of patellar chondral damage. It can provide excellent/good long-term functional results in the majority of patients, with very high satisfaction levels and sustained improvement in pain symptoms. The use of femoral head bone allograft is both effective in obtaining bony union and by definition avoids the donor-site morbidity. Knees with patellar malalignment may also undergo individualised medialisation of the tibial tubercle such that the patella lies in the centre of the femoral trochlea, and may benefit from lateral trochleaplasty surgery in the presence of trochlear dysplasia. However, the major operative complication rate is high at 12%, and fracture of the tibial tubercle is associated with a poorer outcome. One can expect 10% of operated knees to have had some clinical deterioration in the patellofemoral joint by a mean follow-up of 93 months.

Preliminary assessment of the safety and efficacy of tanezumab in Japanese patients with moderate to severe osteoarthritis of the knee: a randomized, double-blind, dose-escalation, placebo-controlled study

To investigate the use of tanezumab, a humanized monoclonal antibody that inhibits nerve growth factor, for the treatment of moderate to severe osteoarthritis in Japanese patients. Patients received tanezumab 10, 25, 50, 100, 200μg/kg, or placebo and were followed for 92 or 120 days. Endpoints included the incidence of adverse events (AEs) and the change from baseline to week 8 in pain intensity and the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) subscales. Patients (n=83) were 69% female, age 44-73 years, with a Kellgren-Lawrence X-ray grade of 2-4. At week 8, compared with placebo, tanezumab 25, 100, and 200μg/kg improved index knee pain during walking (-18.5,-14.3, and-27.6, respectively), index knee pain in the past 24h (-19.1,-14.6, and-24.2, respectively), current index knee pain (-16.5,-10.9, and-22.8, respectively), and the WOMAC pain (-11.5,-9.6, and-18.8, respectively), physical function (-8.7,-9.5, and-17.6, respectively), and stiffness (-20.4,-11.2, and-10.2, respectively) subscales. Overall, seven patients reported AEs of abnormal peripheral sensation: allodynia (two in the tanezumab 200μg/kg group); paresthesia (two in the tanezumab 200μg/kg group), dysesthesia (one in the tanezumab 200μg/kg group); thermohypoesthesia (one in the tanezumab 100μg/kg group), and decreased vibratory sense (one in the placebo group). All of these AEs were mild to moderate in severity and transient in nature. Tanezumab was safe and generally well tolerated and may improve pain symptoms in Japanese patients with moderate to severe osteoarthritis of the knee. CLINICALTRIALS.GOV IDENTIFIER: NCT00669409.

Aromatase inhibition for refractory endometriosis-related chronic pelvic pain

To evaluate the use of an aromatase inhibitor for the treatment of endometriosis-related chronic pelvic pain. Retrospective analysis. Academic medical center outpatient reproductive endocrinology clinic. Sixteen patients with endometriosis and chronic pelvic pain who previously failed conventional medical and/or surgical therapy. Treatment with the aromatase inhibitor letrozole (2.5 mg/d) plus a gonadotropin suppressor (norethindrone acetate, 2.5 mg/d, or a combination oral contraceptive [OC]) for an average of 6 months. Pain scores were reported at each visit using a visual analogue scale from 0 to 10 (0: no pain, 10: maximum pain). Sixteen patients were treated with an aromatase inhibitor for 180 ± 31 days. The median pain score at the start of therapy was 7, and at the end of therapy it was 1.5. In the nine patients who were evaluated after discontinuing therapy, pain scores returned to pretreatment levels. We did not find any correlation between the length of treatment and the overall improvement in pain score. Letrozole plus a gonadotropin suppressor substantially improved pain symptoms in patients with endometriosis refractory to conventional therapies; however, pain recurred after treatment was completed.

Multidisciplinary pain education program (MPEP) for chronic pain patients: preliminary evidence for effectiveness and mechanisms of change

Objective:There is a need for effective brief interventions in chronic pain patients, and the identification of mechanisms of change.Method:In the present study, we tested the effectiveness of MPEP (Multidisciplinary Pain Education Program), a very brief, four-session cognitive-behaviorally based psycho-educational intervention for chronic pain using a pre-and post-test design. In addition, pre- to post-treatment change scores were calculated to investigate factors associated with change in pain. Participants of the study were 53 patients with chronic non-cancer pain. Primary outcome measures were (1) pain severity, (2) health perception, and (3) severity of depression. Secondary outcome measures included factors that have been implicated in the maintenance of chronic pain and that might be associated with worse treatment outcome: (1) catastrophizing, (2) kinesiophobia, and (3) action-proneness.Results:Findings provided preliminary evidence for the effectiveness of MPEP in that patients showed significant and clinically meaningful improvements in pain symptoms (F = 24.503, p < 0.001, d = 0.59) and action-proneness (F = 178.504, p < 0.001, d = 1.95), and small improvements in health perception (F = 7.116, p < 0.05, d = 0.30). Furthermore, results showed that changes in catastrophizing (β = −0.455, p = 0.001) and severity of depression (β = −0.300, p < 0.05) were independently and significantly associated with changes in pain. However, changes in health perception, kinesiophobia, and action-proneness were not significantly associated with changes in pain (β = 0.203, ns; β = 0.003, ns; and β = 0.154, ns, respectively). Importantly, duration of chronic pain was not related to treatment outcome (β = 0.070, ns).Conclusions:Overall, this study provides preliminary evidence for the effectiveness of MPEP and possible mechanisms through which MPEP is effective. Yet, further research is needed to investigate the efficacy of MPEP.

Percutaneous discectomy on lumbar radiculopathy related to disk herniation: Why under CT guidance? An open study of 100 consecutive patients

The primary objective of this study conducted on 100 patients is to demonstrate that performing CT-guided percutaneous discectomy for herniated disks results in a significant improvement in pain symptoms at several times (D1, D2, D7, 1 month, 3 months, 6 months). This objective assesses the effectiveness and feasibility of this technique under CT guidance in patients presenting documented lower back pain related to disk herniation that has not improved with appropriate medical treatment. The impact of various factors on the effectiveness of discectomy will also be evaluated. At 1 week, we notes a decrease in average VAS respectively of 71% and 67% in patients treated for posterolateral and foraminal herniated disks; the result for posteromedian herniated disks is only 45% in average decrease. At 6 months post op, 79% of lateralized herniated disks have a satisfactory result (≥ 70% decrease in pain as compared to initial pain), whereas post median herniated disks had a satisfactory result in only 50% of cases. Percutaneous fine needle discectomy probe under combined CT and fluoroscopic guidance is a minimally invasive spine surgery which should be considered as an alternative to surgery. This technique presents several advantages: the small diameter of the probe used (maximum 16 G or 1.5mm) allows a cutaneous incision of only a few millimeters, and a trans-canal approach can be possible; it also decreases the risk of ligamentary lesion and does not cause an osseous lesion of the posterior arc or of the adjacent muscular structures.

P03-399 - Somatization disorder treated with electro convulsive therapy

Electroconvulsive therapy (ECT) is predominantly being recommended for treatment of severe mood disorders and of catatonia. We report improvement with ECT in a patient suffering from somatization disorder.The patient, a 55-year-old man, suffered from intractable somatization disorder for more than thirty years. Numerous diagnostic and several futile surgical procedures had been performed in the past. On admission there had been no psychopharmacological therapy for one month. Subsequently treatment trials with duloxetine, mirtazapine, and venlafaxine were performed, but remained ineffective. Pregabalin lead to only slight amelioration of anxiety and no improvement of pain symptoms. After 3 months of unsuccessful clinical treatment, including pharmacotherapy, cognitive behavioral therapy, and regularly scheduled interdisciplinary medical consultations, ECT was first considered. A trial of right unilateral ECT was initiated. After five sessions the course had to be terminated due to severe ECT-related hypertension. During and following the ECT course, the patient reported rapid and significant improvement of somatic symptoms. In order to evaluate the effects of ECT the patient passed an assessment before and after the ECT (Hamilton Depression Rating Scale, Whiteley-Index, Quantification Inventory for Somatoform Syndroms, and an observer-rated version of the Screening for Somatoform Disorders). Assessment scores were in line with our clinical impression. Follow-up examination four months later showed no further change.Though somatic anxiety and hypochondriasis have been described to be negative predictors of successful remission with ECT, in our patient ECT has been particularly effective with regard to somatic symptoms of somatization disorder.

Six-month trial of Yoga Nidra in menstrual disorder patients: Effects on somatoform symptoms

Background:Yoga Nidra is a successful therapy for both recent and long-standing psychological disturbances of all kinds especially depression and high anxiety level and neurotic patterns.Objective:The purpose of the present work, therefore, was to conduct a preliminary randomized study of Yoga Nidra as a treatment in the patients of menstrual disorders with somatoform symptoms.Materials and Methods:Patients were recruited from Department of Obstetrics and Gynecology, CSM Medical University (erstwhile KGMU) Lucknow, Uttar Pradesh, India. One hundred and fifty female patients with menstrual disorders were randomly divided in to two groups 1- Intervention group: 75 subjects (Yoga Nidra intervention and medication) 2- control group: 75 subjects (without Yoga Nidra intervention only medication). Schedule for clinical assessment in neuropsychiatry tool was used.Results:There was significant improvement in pain symptoms (P<0.006), gastrointestinal symptoms (P<0.04), cardiovascular symptoms (P<0.02) and urogenital symptoms (P<0.005) after 6 months of Yoga Nidra therapy in Intervention group in comparison to control group.Conclusion:Yoga Nidra appears to be a promising intervention for psychosomatic problems. It is cost-effective and easy to implement. The results indicate that somatoform symptoms in patients with menstrual disorder can be decreased by learning and applying a program based on Yogic intervention (Yoga Nidra).

Outcomes of Surgical Management of Deep Infiltrating Endometriosis of the Ureter and Urinary Bladder

To report the outcomes of surgical management of urinary tract endometriosis and discuss the choice between conservative and radical surgery. We reviewed data concerning women managed for ureteral or bladder deep infiltrating endometriosis in 5 surgical departments participating in the CIRENDO prospective database. Preoperative data, surgical procedure data, and postoperative outcomes were analyzed. Data from 30 women pooled in the database showed 15 women presenting with ureteral endometriosis, 14 women with bladder nodules, and 1 with both types of lesions. Ureterolysis was performed in 14 cases; the ureter was satisfactorily freed in 10 of these. In 4 women over 40 years old, who were undergoing definitive amenorrhea, moderate postoperative ureteral stenosis was tolerated and later improved in 3 cases, while the fourth underwent secondary ureteral resection and ureterocystoneostomy. Primary ureterectomy was carried out in 4 women. Two cases of intrinsic ureteral endometriosis were found in 5 ureter specimens. Four complications were related to surgical procedures on ureteral nodules, and 2 complications followed the removal of bladder endometriosis. Delayed postoperative outcomes were favorable with a significant improvement in painful symptoms and an absence of unpleasant urinary complaints, except for one patient with prolonged bladder denervation. Conservative surgery, in association with postoperative amenorrhea, can be proposed in a majority of cases of urinary tract endometriosis. Although the outcomes are generally favorable, the risk of postoperative complications should not be overlooked, as surgery tends to be performed in conjunction with other complex procedures such as colorectal surgery.

Avaliação do tratamento de fissura anal crônica com isossorbida tópica a 1%

INTRODUÇÃO: Fissuras anais crônicas são úlceras benignas, dolorosas, profundas. Ocorrem devido a trauma das fezes, hipertonia esfincteriana e pobre vascularização. Cirurgia é mais efetiva, porém com efeitos adversos (incontinência anal). Terapia conservadora consegue decréscimo transitório da pressão de repouso, cicatrizando muitas lesões, sem dano muscular. MÉTODOS: Objetivando avaliar tratamento de fissuras crônicas com isossorbida (ISO) a 1% tópica, foi realizado um ensaio clínico, duplo-cego em pacientes do Serviço de Coloproctologia da Universidade Federal de Sergipe (UFS) - Aracaju, Sergipe, durante um ano. Foram estudados 24 pacientes: 14 no Grupo 1 - creme com ISO, e 10 no Grupo 2 - placebo. Avaliaram-se comportamento da pressão de repouso, melhora da dor e grau de cicatrização das feridas com e sem ISO. RESULTADOS: Resultados mostraram que a fissura acometeu mais mulheres, a constipação foi observada em 58,3%. Quanto à dor, obteve-se menor intensidade no Grupo 2, mas sem significância. A cicatrização ao fim de 60 dias foi igual nos dois grupos (50%). Quanto às médias de pressão de repouso com 30 e 60 dias, houve queda no padrão em ambos os grupos, porém sem significância. Observou-se que pacientes curados foram os de maior redução de pressão de repouso. CONCLUSÃO: Concluiu-se que a ISO não modificou o padrão de resposta manométrica; todavia, houve melhora clínica importante nos dois grupos, cuja taxa de cicatrização foi equivalente.

Endometriosis and estroprogestins: the chicken or the egg causality dilemma

Dysmenorrhea as a reason to initiate estroprogestins is significantly more common in women with endometriosis than in women without the disease. This might explain the previously reported mild association between endometriosis and past use of oral contraceptives.

Adhérences et douleurs pelvipérinéales chroniques

To analyse pathophysiology of adhesions and their link with chronic pelvic pain, as well as therapeutic and prevention options as reported in the literature. Review of articles and consensus conferences published on this topic in the Medline (Pubmed) database, selected according to their scientific relevance. Postoperative adhesions are responsible for a specific morbidity combining chronic pain, small bowel obstruction, infertility, and morbidity increase in the event of subsequent surgery. Chronic pains in previously operated on patients can be linked to postoperative adhesions. Ultrasonography and dynamic MRI can recognize intra abdominal adhesions, but cannot definitely link them to the painful symptoms. The prevention of adhesions is done firstly by respecting surgical rules concerning laparoscopic and open surgical approaches, and secondly by the use of anti-adhesion products. Pharmacological adhesion prevention systems decrease the frequency and extent of adhesions. Their efficiency has been proved by studies with substantial evidence levels. Patients suffering from potentially adhesion-induced chronic abdominal and pelvic pains can benefit from a laparoscopic adhesiolysis, which improved pain symptoms in more than 50% of patients, but exposes to the risk of complications, such as bowel injury. The decision to perform adhesiolysis should be taken for each patient individually, while taking in consideration the benefit-to-risk ratio. Adhesion relapse after adhesiolysis is a frequent phenomenon, but can be reduced by the use of anti-adhesion products.

Vaginal danazol in women with rectovaginal endometriosis and pain symptoms persisting after the insertion of the levonorgestrel-releasing intrauterine device

OBJECTIVE: To determine whether vaginal danazol improves pain symptoms caused by rectovaginal endometriosis persisting after the insertion of the Lng-IUD. DESIGN: Prospective study. MATERIALS AND METHODS: This study included women of reproductive age with rectovaginal endometriosis who had pain symptoms persisting after the insertion of the Lng-IUD. The patients were dissatisfied with the Lng-IUD when enrolled in the study. Vaginal danazol (100 mg/d) was self-administered for 6 months. Dysmenorrhea, deep dyspareunia, chronic pelvic pain and dyschezia were assessed before the insertion of the Lng-IUD and then every 3 months during therapy. The intensity of pain symptoms before and after administration of danazol was compared by paired t-test and signed rank test. RESULTS: Out of 16 women fitting the criteria for inclusion in the study, 13 (81.3%) accepted to participate. At the time of enrollment in the study, the patients had used the Lng-IUD for 8.2 (± 2.4) months. After 6-month treatment with vaginal danazol, 10 women (76.9%) were satisfied with the treatment; three women were dissatisfied. After 3-month treatment with vaginal danazol, there was a significant decrease in the intensity of dysmenorrhea (p < 0.001), chronic pelvic pain (p < 0.001) and deep dyspareunia (p = 0.010); there was a non-significant trend for a lower intensity of dyschezia (p = 0.098). After 6-month treatment with vaginal danazol, the intensity of dysmenorrhea (p < 0.001), chronic pelvic pain (p = 0.001) deep dyspareunia (p = 0.002) and dyschezia (p = 0.006) was significantly lower than before the administration of danazol. The following adverse effects were observed: seborrhea, oily hair or acne (n = 4), headache (n = 2), weight gain (n = 2), vaginal irritation (n = 1). 8 women (61.5%) continued the double-drug treatment after the completion of the study. CONCLUSION: In women with rectovaginal endometriosis, vaginal danazol decreases the severity of pain symptoms persisting after the insertion of the Lng-IUD.

Inherited multicentric osteolysis: case report of three siblings treated with bisphosphonate

Inherited Multicentric Osteolysis (IMO) is an uncommon familial condition of idiopathic pathophysiology causing bone osteolysis and dysplasia. These patients present with common rheumatologic complaints of pain, dysfunction and disability, and are often initially misdiagnosed as a chronic rheumatic disease of childhood such as juvenile idiopathic arthritis. We report a case of three siblings diagnosed with IMO. Diagnosis was made during childhood, with each sibling having different manifestations and course of disease. One had a previous history of bilateral hip dysplasia. Two had osteolysis of the foot, distal tibia and femur (lower limb bones), whilst one had osteolysis of the rib and unusual clavicular fractures. Unusually, all siblings appear to experience decreased pain sensation compared to norms. All siblings were treated with bisphosphonates and experienced a rapid improvement in pain symptoms, decreased analgesic requirements. Two had bone mineral density testing performed and both had increases post-bisphosphonate. In all three, there was subjective evidence of stabilisation of bone disease. Testing for matrix metalloproteinase-2 (MMP2) gene was negative.

Sacral neuromodulation as a treatment for neuropathic clitoral pain after abdominal hysterectomy

Sacral neuromodulation (SNM) may be beneficial in the treatment of patients with chronic pelvic pain, although it is not an FDA-approved indication. We present a case of a 51-year-old patient that presented with symptoms of lower urinary tract dysfunction and clitoral pain after an abdominal hysterectomy. Electrophysiological evaluation suggested a pudendal nerve lesion. After failure of conservative treatment, she was offered SNM as a treatment for her voiding symptoms. During test stimulation, she experienced only moderate improvement in voiding symptoms, but a striking improvement in pain symptoms. She underwent a two-stage implantation of a neurostimulator with a successful outcome after 6 months’ follow-up. The results of this report suggest that SNM may be effective in patients with neuropathic pelvic pain.

Clinical application of posterior paramedian approach in low back surgeries

To prospectively evaluate the clinical effects of posterior paramedian approach in nerve root decompression and reducing muscle damage in low back surgeries. Study group included 30 cases treated from January 2007 to May 2008, DDD 8 cases, spondylolisthesis 6 cases, LDH 11 cases, Low back surgery failure re-operation 5 cases. Based on the comprehensive understanding of modern spine anatomy, we abandoned laminectomy in our procedure, applied a mid-waist skin incision, dissect to the paraspinal muscles where you could easily reach the facets by separating between the multifidus and longissimus, enlarge the canal by performing resection along ligamentum flavum and the inner broader of the articular process, remove enough tissue till you could expose the traversing root and the disc space, this method could achieve a limited but precise and effective decompression with not taking out all of the articular process. Once the anatomy mark of the pedicle is located (usually would be at the central area of the incision), pedicle screws placement would be precise and easy without struggling with muscle traction. The following procedures would be Spondylolisthesis reduction, discectomy and interbody fusion. Post-op patients of study group all showed significant improvement of pain symptoms, VAS reduced from 7.14 + or - 1.8, pre-op to 1.39 + or - 0.72 post-op, narrowed disc space regained height, spondylolisthesis reached anatomic reduction, no complications such as pedicle screw misplacement and nerve root damage were found, the lumbar spine regained it's physiological lordosis structure. Significant difference is discovered (P < 0.001) in statistic study concerning the rate of intractable low back pain between pre-op and post-op. Applying low back surgery through posterior para-median approach could directly reach the inferior/superior facets and the "soft" structures of the spinal canal, expose the exact decompression region and anatomy mark of the pedicle in the central surgical field without strong retraction on the para-spinal muscles. This approach has the advantage of lowering the surgical difficulty of implantation, reducing the risk of nerve damage and is also a minimum invasive procedure. In many cases, laminectomy is unnecessary, leaving the lamina intact could preserve the physiological anatomy of the spine.

Fertility and clinical outcome after bowel resection in infertile women with endometriosis

Bowel resection for endometriosis improves pain symptoms and quality of life in symptomatic women. However, little is known about fertility after surgery, particularly after such treatment in women suffering from infertility. The aim of the present study was to evaluate post-operative fertility and long-term clinical outcome after laparoscopic colorectal resection for endometriosis in infertile women. This study reports clinical outcomes in 62 infertile women who underwent laparoscopic excision of endometriosis with segmental bowel resection performed for severe intestinal symptoms. Among women younger than 30 years trying to conceive spontaneously, the cumulative pregnancy rate was 58% and the cumulative pregnancy rate was 45% in those aged 30-34 years. The total pain recurrence was 9.7% (six cases) and endometriosis recurrence was diagnosed by ultrasound in 14.5% (nine cases) during the follow-up period. Four of these patients needed further surgery because of severe symptoms. The surgical treatment of bowel endometriosis seems to improve pain symptoms and patients' satisfaction rates, and it could also be indicated in infertile women.

Does Effective Management of Sleep Disorders Improve Pain Symptoms?

Co-morbid insomnia is a much more frequent problem than primary insomnia. In co-morbid insomnia, management of the underlying disease can improve sleep difficulty. Conversely, treating the sleep disorder may also improve the co-morbid condition. For example, patients with painful chronic illnesses are more likely to experience sleep disturbance than patients with non-painful illnesses. Moreover, there is evidence that insomnia further exacerbates pain in these illnesses. This suggests that a reciprocal relationship exists between pain and sleep, and that intervention targeted primarily at insomnia may improve pain. Treatment options for sleep disorders in the context of pain that have been assessed include cognitive behavioural therapy for insomnia and various pharmacological therapies. In randomized clinical trials, cognitive behavioural therapy significantly improved insomnia secondary to chronic pain compared with control therapy, but pain was only improved in patients in whom it was associated with pain disorders other than fibromyalgia. Of the pharmacological agents studied (zopiclone, zolpidem and triazolam), only triazolam improved both sleep and pain to a greater extent than placebo. Overall, clinical data supporting a cause-effect relationship between insomnia and pain are preliminary and are limited to several small trials. Further investigation is required to clarify the extent of the link between insomnia and pain and whether successfully managing insomnia secondary to pain improves pain symptoms. Areas of particular interest include investigation of the effect of sleep agents on analgesia and the effect of analgesics on sleep.

McGill Pain Questionnaire: A multi‐dimensional verbal scale assessing postoperative changes in pain symptoms associated with severe endometriosis

Objective evaluation of pelvic pain symptoms using a standard pain questionnaire is essential to assessing the treatment of endometriosis and related pain. To evaluate the McGill Pain Questionnaire (MPQ) as a multi-dimensional verbal scale in providing information about chronic pelvic pain associated with endometriosis, before and after laparoscopic surgery. Fifty-five women undergoing laparoscopy for severe endometriosis were asked to complete the MPQ before surgery and at the 6-month follow up. All patients presented with preoperative pain symptoms of variable severity. We obtained the pain indexes and studied their relation with: patients' characteristics (age, body mass index, parity, qualification, occupation); operative findings (number, site and size of endometriotic lesions and presence of pelvic adhesions); and postoperative evolution of variable MPQ pain indexes at the 6-month follow up. Median present pain index (PPI) (index of pain intensity), before surgical treatment was 3 (2-4): preoperative PPI was <2 in 25% of patients while 25% of patients had PPI > 4. Overall median PPI after surgical treatment was 1 (0-2): postoperative index of pain intensity was <1 in 50% of patients, >2 in 25% of patients while 25% of patients did not experience postoperative pain. Overall pain intensity significantly decreased after laparoscopic treatment of endometriosis (Wilcoxon test P < 0.0005). None of the patients' characteristics were found to be significantly correlated with the severity or improvement of preoperative pain at postoperative follow up (P > 0.05), and the intensity of preoperative pain was not correlated to any of the operative variables. There was a significant reduction in all individual MPQ pain indexes; however 18.2% of women did not show improvement of pain symptoms after laparoscopic surgery. An increasing endometrioma diameter was associated with a significant decrease in the difference in evaluative rank score of pain rating index between pain indexes at the 6-month follow up and preoperatively (P = 0.04, Spearman's rank correlation Rho = -0.277). MPQ appears to be useful as a multi-dimensional scale in describing patients' pain semiology and evaluating pain evolution after surgical treatment. However, due to the extreme variability of pain experience, MPQ results don't clarify the relationship between pain intensity and the severity of endometriosis.

Thorough Debridement Under Endoscopic Visualization With Bone Grafting and Stabilization for Femoral Head Osteonecrosis in Children

Osteonecrosis of the femoral head has become increasingly common after steroid therapy and as a consequence of improved survival in children with sickle cell anemia and leukemia. Multiple operative and nonoperative treatments have been explored in the pediatric patient population, and core decompression is a relatively safe and possibly effective option. To optimize core decompression further, we have tested a new technique involving thorough decompression of the osteonecrotic zone under endoscopic visualization (TDEV) combined with cancellous bone grafting and stabilization with a nail plate device. We retrospectively reviewed 16 hips in 13 patients (< or =20 years old) with femoral head osteonecrosis related to steroid treatment, sickle cell anemia, or leukemia. The Steinberg classification system was used to classify all cases. Each patient underwent TDEV, bone grafting, and stabilization of the grafting site. Patients were followed up postoperatively for changes in pain level, functional ability, and Steinberg radiologic stage. The mean follow-up was 28 months (range, 18-49 months). All patients in whom the procedure was successful had improvement in pain symptoms at latest follow-up, except for 1. Radiologically, all Steinberg stage II cases (B and C), except for 1, demonstrated good incorporation of graft without further progression of disease. Seven of the 8 patients that showed radiologic progression and deterioration of function or progressive symptoms had grade IIIB disease or higher at the time of procedure. Our initial results demonstrate that TDEV combined with cancellous bone grafting and stabilization produces encouraging early results for pediatric patients with lesions graded lower than Steinberg stage IIIB. Our findings were less optimistic for patients with higher-grade lesions. Our recommendation, therefore, is to use TDEV by trained surgeons for treatment of early-stage lesions, preferably less than Steinberg stage IIIB. Level IV, Therapeutic Study.

Brain Functional Changes and Duloxetine Treatment Response in Fibromyalgia: A Pilot Study

Serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressant medications may have efficacy in relieving pain associated with fibromyalgia syndrome (FMS), even in the absence of major depressive disorder (MDD). Current practice is to use a trial-and-error treatment strategy, often requiring 8-12 weeks to determine the effectiveness of a given pharmacological intervention. The ability to predict response to antidepressant medications would facilitate clinical management of FMS. Prior work in MDD has shown that the quantitative electroencephalographic (QEEG) cordance biomarker of brain functional changes early in the course of antidepressant treatment is related to later clinical response. We hypothesized that cordance might also predict response to antidepressant medications for symptoms of FMS. Twelve adults (9 females) meeting American College of Rheumatology criteria for FMS participated in a double-blind placebo-controlled treatment trial utilizing duloxetine 60 mg. QEEG cordance changes were examined over the first week of treatment. Primary clinical outcomes included change in average pain severity on the Brief Pain Inventory (BPI) and global improvement in pain on the Patient's Global Impressions of Improvement (PGI-I) scale at 12 weeks. Changes in left frontal QEEG cordance after the first week of duloxetine treatment significantly predicted BPI pain improvement (regression coefficient = 2.9, R(2) = 0.93, P = 0.008) and PGI-I global improvement (regression coefficient = 0.94, R(2) = 0.81, P = 0.04). This pilot study suggests that QEEG biomarkers may prove useful for predicting improvement in painful symptoms during SNRI treatment in FMS. Larger studies are needed to confirm this finding.