Lasting Pain Relief Research Articles

Predictors of patient satisfaction after surgery for grade 1 degenerative spondylolisthesis: a 5-year analysis of the Quality Outcomes Database.

Lumbar decompression and/or fusion surgery is a common operation for symptomatic lumbar spondylolisthesis refractory to conservative management. Multiyear follow-up of patient outcomes can be difficult to obtain but allows for identification of preoperative patient characteristics associated with durable pain relief, improved functional outcome, and higher patient satisfaction. A query of the Quality Outcomes Database (QOD) low-grade spondylolisthesis module for patients who underwent surgery for grade 1 lumbar spondylolisthesis (from July 2014 to June 2016 at the 12 highest-enrolling sites) was used to identify patient satisfaction, as measured with the North American Spine Society (NASS) questionnaire, which uses a scale of 1-4. Patients were considered satisfied if they had a score ≤ 2. Multivariable logistic regression was performed to identify baseline demographic and clinical predictors of long-term satisfaction 5 years after surgery. Of 573 eligible patients from a cohort of 608, patient satisfaction data were available for 81.2%. Satisfaction (NASS score of 1 or 2) was reported by 389 patients (83.7%) at 5-year follow-up. Satisfied patients were predominantly White and ambulation independent and had lower baseline BMI, lower back pain levels, lower Oswestry Disability Index (ODI) scores, and greater EQ-5D index scores at baseline when compared to the unsatisfied group. No significant differences in reoperation rates between groups were reported at 5 years. On multivariate analysis, patients who were independently ambulating at baseline had greater odds of long-term satisfaction (OR 1.12, p = 0.04). Patients who had higher 5-year ODI scores (OR 0.99, p < 0.01) and were uninsured (OR 0.43, p = 0.01) were less likely to report long-term satisfaction. Lumbar surgery for the treatment of grade 1 spondylolisthesis can provide lasting pain relief with high patient satisfaction. Baseline independent ambulation is associated with a higher long-term satisfaction rate after surgery. Higher ODI scores at 5-year follow-up and uninsured status are associated with lower postoperative long-term satisfaction.

Coccygectomy for refractory coccydynia, old-fashioned but effective procedure: A retrospective analysis.

Coccydynia, characterized by persistent pain in the coccygeal region, significantly impacts patients' quality of life. While various treatment modalities exist, including conservative measures and surgical interventions like coccygectomy, optimal management remains unclear. This retrospective cohort study aimed to compare the clinical outcomes, functional improvements, and quality of life in patients with chronic coccydynia undergoing either infiltrative treatment or coccygectomy. Data from patients treated at our institution from January 2018 to December 2022 were analyzed. Participants meeting inclusion criteria were divided into two groups: Group A underwent coccygectomy, while Group B received conservative therapy. Clinical assessments, radiographic evaluations, and patient-reported outcomes were collected preoperatively and at follow-up intervals. Of the 223 initially examined patients, 55 met inclusion criteria. Group A (n = 21) underwent coccygectomy, while Group B (n = 34) received conservative therapy. Both groups showed significant pain reduction post-intervention, with sustained improvement in Group A. Functional outcomes favoured Group A, with significant improvements in disability and quality of life measures. Complications were minimal, with only one case of superficial wound infection in Group A. Our findings suggest that coccygectomy provides superior and lasting pain relief, functional improvement, and quality of life improvement compared to conservative therapy. While complications were minimal, further research with larger cohorts is warranted to validate these results and explore long-term outcomes. Despite its historical association with complications, advancements in surgical techniques and perioperative care have led to improved outcomes and reduced complication rates. Thus, coccygectomy should be considered in the treatment algorithm for patients with debilitating coccydynia.

Botulinum toxin type a antinociceptive activity in trigeminal regions involves central transcytosis

ObjectiveBotulinum toxin type A (BoNT-A) provides lasting pain relief in patients with craniofacial pain conditions but the mechanisms of its antinociceptive activity remain unclear. Preclinical research revealed toxin axonal transport to the central afferent terminals, but it is unknown if its central effects involve transsynaptic traffic to the higher-order synapses. To answer this, we examined the contribution of central BoNT-A transcytosis to its action in experimental orofacial pain. Material and methods:Male Wistar rats, 3–4 months old, were injected with BoNT-A (7 U/kg) unilaterally into the vibrissal pad. To investigate the possible contribution of toxin's transcytosis, BoNT-A-neutralizing antiserum (5 IU) was applied intracisternally. Antinocicepive BoNT-A action was assessed by duration of nocifensive behaviors and c-Fos activation in the trigeminal nucleus caudalis (TNC) following bilateral or unilateral formalin (2.5%) application into the vibrissal pad. Additionally, cleaved synaptosomal-associated protein of 25 kDa (cl-SNAP-25) immunoreactivity was analyzed in the bilateral TNC. Results:Unilaterally injected BoNT-A reduced the nocifensive behaviors and bilateral c-Fos activation induced by formalin, which was accompanied by the toxin's enzymatic activity on both sides of the TNC. BoNT-A antinociceptive or enzymatic activities were prevented by the specific neutralizing antitoxin. BoNT-A contralateral action occurred independently from ipsilateral side nociception or contralateral trigeminal nerve-mediated axonal traffic. ConclusionHerein, we demonstrate that antinociceptive action of pericranially administered BoNT-A involves transsynaptic transport to second order synapses and contralateral trigeminal nociceptive nuclei. These results reveal more complex central toxin activity, necessary to explain its clinical effectiveness in the trigeminal region-related pain states.

Bipolar radiofrequency ablation lesion areas and confluence: An exvivo study and technical report.

Radiofrequency ablation (RFA) has been used for nearly 100 years, treating an array of medical conditions including chronic pain. Radiofrequency (RF) energy depolarizes and repolarizes tissues adjacent to a probe producing heat and causing direct thermal injury. When positioned adjacent to neural structures, it leads to neural tissue injury and cell death interrupting pain signaling with the ultimate goal of providing lasting pain relief. Today, RFA is commonly used to treat cervical, thoracic, and lumbar zygapophyseal joints, sacroiliac joint, and more recently large peripheral joint-mediated pain. There are several applications of RFA systems, including bipolar, conventional thermal, cooled, protruding, and pulsed. As yet, no study has determined the best technical practice for bipolar RFA. This exvivo study examines RFA lesion midpoint (LMP) area and lesion confluence comparing three different commonly used gauge (g) probes (18-g, 20-g, and 22-g) with 10-mm active tips at various interprobe distances (IPD) to guide best technical practices for its clinical application. Bipolar RFA lesions were generated in preservative-free chicken breast specimens using three different gauge probes (18-g, 20-g, and 22-g) with 10-mm active tips at various IPD (6, 8, 10, 12, 14, 16, and 18 mm). RF was applied for 105 s (15-s ramp time) at 80°C for each lesion at both room and human physiological temperature. The specimen tissues were dissected through the lesion to obtain a length, width, and depth, which were used to calculate the LMP area (mm2 ). The LMP areas of each thermal ablation were investigated using visualization and descriptive analysis. The Kruskal-Wallis test was performed to compare LMP areas between the two temperature groups and the three different gauge probe subgroups at the various IPDs. Of the 36 RF lesions (14: 18-g, 12: 20-g, and 10: 22-g) performed, 24 demonstrated lesion confluence. The average time to reach 80°C was 16-17 s; therefore, the average time of RF-energy delivery (at goal temperature) was 88-89 s despite varying needle size or IPD. Comparing the 25 and 37°C groups, 18-g probes produced mean LMP areas of 73.7 and 79.2 mm2 , respectively; 20-g probes produced mean LMP areas of 66 and 66.8 mm2 , respectively; 22-g probes produced mean LMP areas of 56.6 and 59.7 mm2 , respectively. There was no statistical evidence to state a difference regarding LMP area between temperature groups; however, the 18-g probes produced consistently larger LMP areas in the 37°C compared to 25°C specimen groups at each IPD. Lesion confluence was lost for 18-g, 20-g, and 22-g probes at IPD of 14, 12, and 10 mm, respectively, in both 25 and 37°C groups. LMP area was similar between 6 and 8 mm IPD in all of the three-gauge groups; however, there was a significant drop in LMP area from 8 mm IPD to 10 mm and greater. The 18-g, 20-g, and 22-g probes all demonstrated a sharp decline in LMP area when increasing the IPD from 8 to 10 mm. This exvivo technical study evaluated bipolar RFA LMP areas and lesion confluence, and determined the recommended IPD of 18-g, 20-g, and 22-g probes to be less than 12, 10, and 8 mm, respectively, for best clinical practice. Placing bipolar probes at an IPD greater than 14, 12, and 10 mm, respectively, risks the loss of lesion confluence and failure to produce a clinically significant treatment response due to lack of nerve capture. In clinical practice, the use of injectate may produce larger lesions than demonstrated in this study. Additionally, invivo factors may impact ablation zone size and ablation patterns. As there are a paucity of studies comparing various RFA applications and conventional RFA needles are least expensive, it is possible that bipolar conventional RFA is more cost-effective than other techniques.

Evaluation of Total Hip Arthroplasty Performed from a Lateral Approach as Optimal Treatment for Femoral Neck Fractures in Elderly, Active Patients

Background. The aim of the study was to evaluate total hip arthroplasty in terms of clinical and functional outcomes, rate of complications and hospitalization, as a treatment of choice for displaced femoral neck fractures.Materials and methods.We retrospectively reviewed the data of 526 patients with THA operated on in our department between January 2017 and December 2021. Clinical examinations, functional outcome assessment and radiographic evaluation were performed during follow-up. Patients were evaluated at the following time points: postoperatively at 3 days, 6 weeks, 12 weeks and 1 year, and we recorded surgery related data, complications, Visual Analogue Scale pain score, Harris Hip Score, the Western Ontario McMaster Osteoarthritis Index, and range of motion. Results. Low intraoperative blood loss, short surgical time, short hospitalization, early mobilization of the patient and a good range of motion testify that the modified direct lateral approach is a valuable procedure for the patients with THA. A VAS score evaluated at 3 days and 6 weeks indicated a very good overall postoperative experience. The HHS and Womac scores were evaluated at 6 weeks, 12 weeks and 1 year and showed excellent results. Conclusion. THA for active patients with a displaced fracture of the femoral neck is an excellent treatment option which provides lasting pain relief, a high level of function and very low rates of reoperation.

A comparison of pulsed radiofrequency and radiofrequency denervation for lumbar facet joint pain

BackgroundLumbar facet joint pain is a common disorder. The main symptom is chronic lumbar pain, which can reduce quality of life. Radiofrequency has often been used to treat lumbar facet joint pain. However, the effectiveness of this technique has been controversial. This study was conducted to compare the effectiveness of pulsed radiofrequency (PRF) and radiofrequency denervation (RD) for lumbar facet joint pain.MethodsOne hundred and forty-two patients with lumbar facet joint pain were allocated to two treatment groups: PRF group (N = 72) and RD group (N = 70). Patients enrolled in the study were assessed using a visual analogue scale (VAS), Roland-Morris questionnaire (RMQ), Oswestry disability index (ODI) and Short-Form 36 (SF-36) questionnaire before therapy, 3 months and 12 months later.ResultsThere were no significant differences in VAS, RMQ score, ODI score and SF-36 score at 3 months (p > 0.05). Significant differences in pain control were observed in both groups at 12 months (3.09 ± 1.72 vs. 2.37 ± 1.22, p = 0.006). There was a significant difference in RMQ score (11.58 ± 3.58 vs. 8.17 ± 2.34, p < 0.001) and ODI score (43.65 ± 11.01 vs. 35.42 ± 11.32, p < 0.001) at 12 months. The total SF-36 score was higher in the RD group than in the PRF group at 12 months (58.45 ± 6.97 vs. 69.36 ± 6.43, p < 0.001). In terms of complications, skin numbness occurred in three patients. Mild pain such as burning and pinking at the puncture site in two patients. One patient experienced a decrease in back muscle strength and back muscle fatigue. These complications disappeared in 3 weeks without any treatment. There were no serious adverse events in the PRF group.ConclusionRadiofrequency is an effective and safe treatment option for patients with lumbar facet joint pain. RD could provide good and lasting pain relief, with significant improvement in lumbar function and quality of life at long-term follow-up.

Abstract OT3-20-01: Ketamine Analgesia for Long Lasting Pain Relief after Surgery (KALPAS) Study

Abstract Background: Post-mastectomy pain syndrome (PMPS) affects up to 60% of women undergoing mastectomy. Standard perioperative multimodal analgesia remains only moderately effective in preventing PMPS, and many patients continue to rely on opioids for their chronic pain. In the context of the opioid overdose crisis, alternative interventions are urgently needed. Ketamine targets risks factors for PMPS including acute pain and negative mood, making it an ideal candidate for the prevention of PMPS. Trial Design: This is a multisite, three-arm, double-blind, RCT to test the effectiveness of ketamine in reducing PMPS in women undergoing mastectomy for oncologic indication. Arm 1 consists of continuous perioperative ketamine infusion that begins during surgery and continues for 2 hours in the post-anesthesia care unit (PACU). Arm 2 consists of a single-dose of ketamine in the PACU given over 50-60 minutes. Arm 3 consists of placebo. Standard surgical and postsurgical care remain unchanged across all arms. Eligibility Criteria: Inclusion criteria are: women ≥18 years of age undergoing total mastectomy for oncologic indication +/- lymph node dissection and +/- immediate or delayed reconstruction with no distant metastases. Exclusion criteria include: (1) history of cognitive impairment (2) past ketamine or phencyclidine misuse or abuse, (3) schizophrenia or history of psychosis, (4) history of post-traumatic stress disorder, (5) known sensitivity or allergy to ketamine, (6) liver or renal sufficiency, (7) uncontrolled hypertension, chest pain, cardiac arrhythmia, stroke, head trauma, intracranial mass or hemorrhage, glaucoma, porphyria, uncontrolled thyroid disease, or other contraindication to ketamine, (8) lamotrigine alfentanil, physostigmine, or 4-aminopyridine use, (9) currently pregnant, (10) body mass index greater than 35, (11) non-English or non-Spanish speaker, (12) currently participating in another pain interventional trial, (13) patient has started or undergone hormone therapy for gender transition into male, or (14) patient is scheduled for bilateral (or greater) flap reconstruction. Specific Aims: The primary outcome is pain intensity on the Brief Pain Inventory short form scale at the surgical site three months after mastectomy. Secondary outcomes include pain severity and interference at the surgical site, incidence of PMPS, anxiety, and depression over 12 months after surgery. Tertiary outcomes include neuropathic symptoms, fatigue, sleep, physical function, and opioid use. Statistical Methods: We will test the differences in the primary outcome between 1) the continuous ketamine infusion and the control; and 2) the single-dose ketamine and the control, each at 0.025 significance level (adjusted for multiple comparisons using the Bonferroni correction), based on the two-sample t-tests (allowing unequal variances) if outcome variables are approximately normal, or Wilcoxon’s rank-sum tests otherwise. Accrual: The target accrual for this study is ~750. Recruitment began January 2022. Recruitment is expected to be complete by October 2025. As of July 14, 2022, 43 participants have been enrolled across all sites. If interested in the KALPAS Study, please contact kalpas@nyulangone.org, jing.wang@nyulangone.org, or lisa.doan@nyulangone.org This research is supported by the National Institutes of Health through the NIH HEAL Initiative under UH3CA261067. It is also supported by the NCATS Trial Innovation Network under award numbers U24TR001608 (CCC), U24TR001597 (DCC), U24TR001609 (SSC), U24TR001579 (RIC) Citation Format: Lisa Doan, Raven Perez, Jeana Chun, Randy Cuevas, Pabel Miah, Amber Guth, Karen Hiotis, Freya Schnabel, Michele Curatolo, Robert Edwards, Hyung Park, John Rotrosen, Deborah Axelrod, Jing Wang. Ketamine Analgesia for Long Lasting Pain Relief after Surgery (KALPAS) Study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr OT3-20-01.

Effect of Hypnosis in Adolescents: A Narrative Review

Background: More than half of reproductive-age women experience dysmenorrhea, which can reduce their quality of life. The treatment options for dysmenorrhea are medications and alternative therapies. The tendency to use alternative therapies, such as hypnotherapy has increased. Objectives: This study aimed to carry out a narrative review to evaluate the effect of hypnosis on dysmenorrhea in adolescents. Methods: EMBASE, Web of Science, Scopus, Google Scholar, PubMed, Cochrane library ProQuest and clinicaltrials.gov were searched up to 2021 using the following keywords “dysmenorrhea”, “hypnosis”. The quality of studies was assessed by Cochrane collaboration’s tool and the risk of bias in the non-randomized studies of interventions (ROBINS-I) tool. Results: Nine studies with a sample size of 5203 participants were included. The hypnosis intervention similar to drug therapy was effective in reducing the intensity of dysmenorrhea and improving the women’s quality of life. Dysmenorrhea pain scores in hypnosis and drug therapy groups were significantly lower than those at baseline, but pain scores in the drug therapy group were significantly lower than in the hypnosis group. Conclusions: Hypnosis can provide lasting pain relief compared to NSAIDs. Therefore, it is recommended that hypnosis as a complementary or alternative therapy reduce the intensity of dysmenorrhea in adolescents.

Surgery for chronic pancreatitis and different methods of surgeries

Objectives: Chronic pancreatitis, a benign inflammatory process of the pancreas resulting in exocrine and endocrine in sufficiency. Pain is the most devastating symptom, for which patient seeks medical advice. Even though these problems are addressed medically, surgery is indicated in many cases of intractable pain. Methods: Thirty- patients who are managed surgically during November 2018 to October 2020 at our institute. Data is collected and analyzed. Various surgical procedures for chronic pancreatitis and their indications are noted. Pain relief, improvement of exocrine and endocrine in sufficiency and improvement of quality of life are studied. Results: Various operative procedures are done including intra operative Celiac plexus block in some. Puestow’s, Frey’s and Whipples PD are done in these patients, which are selected according to the pathological anatomy. We observed long lasting pain relief is observed in 90% of our patients. In two of the patient’s surgery was done in acute condition with edematous pancreas. In these cases, intra operative celiac plexus block was added. Conclusions: Surgery is effective in Chronic Pancreatitis with intractable pain and better results can be obtained with selection of procedure tailor made to the patient. Exocrine and endocrine functions may become better in some patients.

Long-term outcomes of trapeziectomy with Gore-Tex® ligament reconstruction for trapezio-metacarpal osteoarthritis

BackgroundTrapezio-metacarpal osteoarthritis is a common condition for which the reference standard treatment after failure of non-operative measures is trapeziectomy. Several techniques have been devised to avoid proximal migration of the first metacarpal bone (M1) with impingement on the scaphoid bone. We have developed a Gore-Tex® ligament reconstruction technique that avoids potential complications of tendon harvesting. The objective of this study was to assess the long-term outcomes of this technique. HypothesisTrapeziectomy with Gore-Tex® ligament reconstruction is a reliable option for providing lasting pain relief in patients with trapezio-metacarpal osteoarthritis. Materials and methodsWe conducted an observational, single-centre, single-surgeon, retrospective cohort study in consecutive patients managed by primary trapeziectomy. We excluded patients with revision trapeziectomy or less than 10 years’ follow-up. The primary outcome was event-free survival, defined as absence of revision surgery and of a numerical rating scale score for pain above 3/10. The secondary criteria were clinical tolerance of the Gore-Tex® implant and radiological changes. The patients were assessed at last follow-up either in person or during a teleconsultation. ResultsOf 78 included joints, 54 were assessed during patient visits and 24 by teleconsultation. At 10 years, the event-free survival rate was 91.3%, and 60.3% of patients were free of pain. Evidence of osteolysis was visible in 24% of patients. No patient experienced clinical intolerance of the Gore-Tex® implant. The mean Disabilities of Arm, Shoulder and Hand score was 25.5. Metacarpo-phalangeal hyperextension was significantly increased, to 30.6°, and the mean trapezial space ratio was significantly decreased, to 39.1% of the baseline value. ConclusionLong-term event-free survival was high. Functional outcomes and pain were similar to previous reports. Trapeziectomy with Gore-Tex® ligament reconstruction obviates the need for tendon harvesting. Osteolysis developed in some patients but did not correlate with clinical intolerance. Long-term clinical and radiological monitoring is in order after Gore-Tex® implantation. Level of evidenceIV, Observational, single-centre, single-surgeon, retrospective cohort study.

Selective Expression of a SNARE-Cleaving Protease in Peripheral Sensory Neurons Attenuates Pain-Related Gene Transcription and Neuropeptide Release.

Chronic pain is a leading health and socioeconomic problem and an unmet need exists for long-lasting analgesics. SNAREs (soluble N-ethylmaleimide-sensitive factor attachment protein receptors) are required for neuropeptide release and noxious signal transducer surface trafficking, thus, selective expression of the SNARE-cleaving light-chain protease of botulinum neurotoxin A (LCA) in peripheral sensory neurons could alleviate chronic pain. However, a safety concern to this approach is the lack of a sensory neuronal promoter to prevent the expression of LCA in the central nervous system. Towards this, we exploit the unique characteristics of Pirt (phosphoinositide-interacting regulator of TRP), which is expressed in peripheral nociceptive neurons. For the first time, we identified a Pirt promoter element and cloned it into a lentiviral vector driving transgene expression selectively in peripheral sensory neurons. Pirt promoter driven-LCA expression yielded rapid and concentration-dependent cleavage of SNAP-25 in cultured sensory neurons. Moreover, the transcripts of pain-related genes (TAC1, tachykinin precursor 1; CALCB, calcitonin gene-related peptide 2; HTR3A, 5-hydroxytryptamine receptor 3A; NPY2R, neuropeptide Y receptor Y2; GPR52, G protein-coupled receptor 52; SCN9A, sodium voltage-gated channel alpha subunit 9; TRPV1 and TRPA1, transient receptor potential cation channel subfamily V member 1 and subfamily A member 1) in pro-inflammatory cytokines stimulated sensory neurons were downregulated by viral mediated expression of LCA. Furthermore, viral expression of LCA yielded long-lasting inhibition of pain mediator release. Thus, we show that the engineered Pirt-LCA virus may provide a novel means for long lasting pain relief.

Denervation of the proximal interphalangeal joint: Results from 54 cases in 42 patients

IntroductionArthropathy of the proximal interphalangeal joint (PIP) is common. Joint denervation is a symptomatic treatment. It relieves pain by cutting the afferent nerve branches without altering joint biomechanics, and is indicated in painful arthropathy with conserved range of motion. The objective of this study was to evaluate clinical outcome in PIP denervation and the sustainability of results. HypothesisDenervation is an effective intervention in painful PIP arthropathy with functional range of motion, showing lasting benefit. Patients and methodsA single-center retrospective study included all patients with painful PIP arthropathy with functional range of motion treated by denervation between January 2005 and September 2018 and evaluated by an independent examiner. Joint stiffness was an exclusion criterion. 54 consecutive denervation procedures were performed in 42 patients (41 women, 1 man) with a mean age of 66.5 years (range, 44–78 years). There were 11 inflammatory and 43 degenerative arthropathies. ResultsThe 42 patients were evaluated in consultation or contacted by telephone, with a mean follow-up of 51 months (range, 4–168 months). Mean VAS pain score was 7.5/10 (range, 5–10) before the procedure and 1.1/10 (range, 0-8) at last follow-up. Patients considered their joint cured or improved in 78% of cases whatever the etiology (42 cases/54), and in 86% of cases of degenerative arthropathy (37 cases/43). 32 patients were satisfied or very satisfied with the intervention (76% of cases). Active range of motion was improved in 16 cases, unchanged in 33 and impaired in 5. There were 7 denervation failures, which led to surgical treatment by fusion (2 cases) or joint replacement (5 cases); 5 of these cases concerned arthropathy of inflammatory origin. ConclusionDenervation is an effective treatment for painful PIP osteoarthritis, providing lasting pain relief while conserving range of motion. Level of evidenceIV; retrospective study.

Does total wrist denervation give reliable long-term results? Survival curve with an average follow-up of 8.2 years

IntroductionPain is the main reason why patients consult for degenerative and posttraumatic wrist conditions. While the many surgical techniques make choosing the appropriate procedure difficult, total wrist denervation, which has an “analgesic” aim, remains an accessible therapeutic solution to treat this symptomatology. Nevertheless, long-term results remain controversial, and few studies have focused on the survival of this procedure. HypothesisTotal wrist denervation provides lasting pain relief. Patients and methodsThis was a single center, single operator (DLN), retrospective observational study. We analyzed 63 wrists. The mean age at the time of the procedure was 53.7 years. We verified the primary endpoint for survival, which included no further analgesic procedures and no significant residual pain (NRS≤3). Patient satisfaction and the quality of the wrist function were also assessed. ResultsThe mean follow-up was 8.2 years. Some of the patients (12.7%) did not respond to treatment. We reported 1 neuroma of the superficial sensory branch of the radial nerve, 2 CRPS and 11 revision surgeries. We observed that the treatment became less effective over time. The median survival was 8.8 years. The survival rate of the procedure fell to 13.5% at the last follow-up. The mean residual pain was 3.4 on a numerical rating scale and the mean DASH score was 23.5. The mean satisfaction level, on a scale from 0 to 10, was 7.3 and most patients (79.6%) would undergo this procedure again. DiscussionSurvival of the total wrist denervation at the last follow-up was low in our study. Even though the treatment became less effective over time, the quality of the wrist function remained satisfactory and similar to the different studies previously published on the subject. There were very few complications and revisions. ConclusionTotal wrist denervation therefore remains an interesting surgical solution for patients with chronic wrist pain as it preserves mobility. Level of EvidenceIV; Single center, single operator retrospective observational study.

Secretome of human adipose-derived mesenchymal stem cell relieves pain and neuroinflammation independently of the route of administration in experimental osteoarthritis

ObjectiveTreatment of pain associated with osteoarthritis (OA) is unsatisfactory and innovative approaches are needed. The secretome from human adipose-derived mesenchymal stem cells (hASC-Conditioned Medium, CM) has been successfully used to relieve painful symptoms in models of chronic pain. The aim of this study was to explore the efficacy of the hASC-CM to control pain and neuroinflammation in an animal model of OA. MethodsOA was induced in mice by intra-articular monosodium-iodoacetate (MIA) injection. Thermal hyperalgesia and mechanical allodynia were assessed. Once hypersensitivity was established (7 days after MIA), hASC-CM was injected by IA, IPL and IV route and its effect monitored over time. Neuroinflammation in nerve, dorsal root ganglia and spinal cord was evaluated measuring proinflammatory markers and mediators by RT-qPCR. Protein content analysis of secretome by Mass Spectrometry was performed. ResultsA single injection with hASC-CM induced a fast and long lasting antihyperalgesic and antiallodynic effect. The IV route of administration appeared to be the most efficacious although all the treatments were effective. The effect on pain correlated with the ability of hASC-CM to reduce the neuroinflammatory condition in both the peripheral and central nervous system. Furthermore, the secretome analysis revealed 101 factors associated with immune regulation. ConclusionWe suggest that hASC-CM is a valid treatment option for controlling OA-related hypersensitivity, exerting a rapid and long lasting pain relief. The mechanisms underpinning its effects are likely linked to the positive modulation of neuroinflammation in peripheral and central nervous system that sustains peripheral and central sensitization.

Matrix-Induced Autologous Chondrocyte Implantation (MACI) Grafting for Osteochondral Lesions of the Talus.

Matrix-induced autologous chondrocyte implantation (MACI) is an established treatment method for larger joints and has shown promising results in the ankle as well. We present a series of patients after ankle MACI with long-term follow-up of clinical and radiological outcomes. We present the follow-up of 15 patients who underwent MACI grafting from August 2003 to February 2006. The mean follow-up was 12.9 years. Clinical evaluations were conducted using the American Orthopaedic Foot & Ankle Society (AOFAS), Foot and Ankle Activity Measurement (FAAM), and visual analog scale (VAS) scoring systems and the magnetic resonance observation of cartilage repair tissue (MOCART) scoring system for radiological evaluation. The mean size of the talar osteochondral defects was 204 mm2. We found a significant improvement in mean AOFAS score from 60 preoperatively to a mean of 84 at 12 years postoperatively. The 12-year FAAM score for Activities of Daily Living was 89% (range, 62%-99%). The mean 12-year MOCART score was 65 points (range, 30-100 points) with significant agreement between assessors (P < .001). However, the MOCART scores did not correlate with the FAAM scores (P = .86). Considering our long-term follow-up, we believe MACI is a reliable treatment method for talar osteochondral defects providing lasting pain relief and satisfying clinical results. However, with an equivalent outcome, but at higher costs, and the requirement for 2 operative procedures, the results do not seem to be superior to other established methods. The clinical utility of the MOCART score requires further scrutiny since we were not able to show any correlation between the score and clinical outcome. Level IV, case series.

Endoscopic rhizotomy for chronic lumbar zygapophysial joint pain

BackgroundChronic lumbar zygapophysial joint pain is a common cause of chronic low back pain. Percutaneous radiofrequency ablation (RFA) is one of the effective management options; however, the results from the traditional RFA need to be improved in certain cases. The aim of this study is to investigate the effect of percutaneous radiofrequency ablation under endoscopic guidance (ERFA) for chronic low back pain secondary to facet joint arthritis.MethodsThis is a prospective study enrolled 60 patients. The cases were randomized into two groups: 30 patients in the control group underwent traditional percutaneous radiofrequency ablation, others underwent ERFA. The lumbar visual analog scale (VAS), MacNab score, and postoperative complications were used to evaluate the outcomes. All outcome assessments were performed at postoperative 1 day, 1 month, 3 months, 6 months, and 12 months.ResultsThere was no difference between the two groups in preoperative VAS (P > 0.05). VAS scores, except the postoperative first day, in all other postoperative time points were significantly lower than preoperative values each in both groups (P < 0.05). There was no significant difference between the two groups in VAS at 1 day, 1 month, and 3 months after surgery (P > 0.05). However, the EFRA demonstrated significant benefits at the time points of 3 months and 6 months (P > 0.05). The MacNab scores of 1-year follow-up in the ERFA group were higher than that in the control group (P < 0.05). The incidence of complications in the ERFA group was significantly less than that in the control group (P < 0.05).ConclusionsERFA may achieve more accurate and definite denervation on the nerves, which leads to longer lasting pain relief.

Vertebral Compression Fractures Treated in Acute by Instrumented Kyphoplasty: Early and Mid-Term Clinical and Radiological Results.

The treatment of traumatic low-degree vertebral compression fracture remains in a wide range between functional treatment, bracing, vertebroplasty, kyphoplasty, and even surgical fixation. The objective was to assess the innovation of instrumented kyphoplasty and to report the early and mid-term functional and radiological results. This study is a retrospective review of patients enrolled from 2012 to 2017. 104 consecutive endovertebral implantations of instrumented kyphoplasty were reviewed for the study. There were 56 women and 48 men. 93 of 104 patients were evaluated, of whom 27 were evaluated only by retrospective medical record review and 66 with follow-up visit. Clinical parameters were the pain rating scale (VAS) and the Oswestry score questionnaire. The radiological parameters were the vertebral kyphosis, vertebral height, lumbar lordosis, and adjacent disc degeneration (UCLA scale). Statistical correlations between before/after surgery/last follow-up were performed. The average follow-up was 26.7 months (3 to 55). The average VAS decreased from 8.2 to 3.2 the day after surgery, allowing immediate standup. The average Oswestry score was 14.6 at follow-up. The average vertebral kyphosis decreased from 12.9° to 6.5° post-op and stabilized at 8.0° at the last follow-up, corresponding to 28% gain on vertebral height. The lumbar lordosis was restored (+6.6°). Adjacent disc degeneration increased by 1 UCLA grade in 17 patients (16.3%) at follow-up. The instrumented kyphoplasty in acute led to immediate and lasting pain relief, with no bracing or bed rest, short stay in hospital, and quick return to daily life including professional activities. The good clinical results were associated to a stable radiological restoration of the vertebral anatomy.

Efficacy of Adductor Canal Block With Liposomal Bupivacaine: A Randomized Prospective Clinical Trial.

This study compared the postoperative analgesic efficacy of liposomal bupivacaine as a single-administration adductor canal block (ACB) vs periarticular injection (PAI) for pain control after total knee arthroplasty (TKA). From May 2016 to June 2017, a total of 70 unilateral TKA patients were randomized into 2 groups: PAI (extended-release bupivacaine 266 mg [20-mL vial] with 20 mL of 0.5% bupivacaine hydrochloride and normal saline to a total volume of 120 mL) and ACB (subsartorial saphenous nerve using extended-release bupivacaine 266 mg [20-mL vial]). All patents underwent spinal anesthesia with comprehensive preemptive and postoperative multi-modal pain protocol. All opioids administered were converted to morphine equivalents. Pain was recorded at 4 to 12 hours on the day of surgery, and on postoperative days 1, 2, and 3. Patients and investigators other than the surgeon and anesthesiologist were blinded to the study. The difference in pain scores between the PAI and ACB groups was not statistically significant during the first 12 hours (day 0) after surgery or on postoperative day 1 (5.31 vs 4.26, P=.091). However, on postoperative day 3, the mean pain score increased in the ACB group and decreased in the PAI group (4.8 vs 1.83, P=.037). There was no statistically significant difference between the 2 groups regarding the accumulative daily converted morphine equivalent consumption or total consumption. Although the PAI group demonstrated longer lasting pain relief than the ACB group for the duration of the study, other outcomes were similar between the 2 groups. [Orthopedics. 2020; 43(1):e47-e53.].

Mechanical Diagnosis and Therapy and Morton's Neuroma: A Case Report.

Purpose: Morton's neuroma (MN) is a neuralgia involving the common plantar digital nerves of the metatarsal region. Evidence-based treatment options for this condition are sparse, and physiotherapy's usefulness is limited. Client Description: A woman aged 44 years was referred to physiotherapy for left forefoot pain lasting 3 months. The podiatrist diagnosed MN using ultrasonography. Examination found positive squeeze test, painful interphalangeals and metatarsal heads, and painful metatarsophalangeal joint (MPJ) extension. Intervention: Repeated flexion of MPJ digit II relieved the patient's pain. She was treated six times over 3 months to progress treatment, achieve longer lasting pain relief, and recover function to full pain-free status, including running. Measures and Outcome: The patient's pain reduced after treatment from a variable 2-7 out of 10 on the Numeric Pain Rating Scale to 0 out of 10. After two sessions, the patient's Lower Extremity Functional Scale score improved, from 56 out of 80 to 70 out of 80, and by discharge, it was 73 out of 80. At 6-month follow-up, the patient was still running pain-free. Implications: This article describes the rapid and lasting improvement in chronic forefoot pain associated with MN after mechanical diagnosis and therapy assessment and treatment. Finding new, effective, conservative interventions is important for this condition because so few evidence-supported treatments exist. The findings from this case report demonstrate the benefit derived from exercise-based treatment and may indicate a role for physiotherapy in managing MN.

Urgent care peripheral nerve blocks for refractory trigeminal neuralgia

ObjectiveAfter medication failure, patients with refractory trigeminal neuralgia (TGN) often present urgently and seek more potent or invasive therapies such as opioids or surgical options. Peripheral nerve blocks, safe and simple, may offer extended pain relief prior to opioid use or more invasive ganglion level procedures. MethodsWe report a retrospective case-series (urgent care, at a large urban medical center, over a 2 year period) of nine patients with intractable primary TGN who underwent peripheral trigeminal nerve blocks after failing conservative medical therapy. After antiseptic skin preparation, a 30 g needle was inserted localizing to the supraorbital, infraorbital, and mental foramens. 0.5 mL of 0.25% bupivicaine:1% lidocaine was injected locally at all three foramens. Then, 1 mL of the above was injected in the region of the auriculotemporal nerve (see Video 1). All injections were done on the side with TGN pain. ResultsAll nine patients experienced immediate pain relief of >50% with 7 of 9 being completely pain free or just mild paresthesia. Six of nine patients had lasting pain relief (1–8 months); three patients reporting pain now tolerable with adjunct medication and two patients were completely pain free. ConclusionsThe treatment paradigm for TGN remains unclear when a patient fails conservative medical therapy. In this case series, many patients achieved rapid and sustained TGN pain relief with peripheral trigeminal nerve blocks. This modality should be considered as a potential therapeutic option in the ED or urgent care setting.