Maximum Pain Research Articles

Arthrocentesis of Temporomandibular Joints—A Clinical Comparative Study

The objective of this study was to compare single-needle arthrocentesis with the conventional two-needle arthrocentesis, as well as the additional intracapsular injection of hyaluronic acid or platelet-rich fibrin. A total of 96 patients with established osteoarthritis (OA) (n = 48) or with internal de-arrangement (DD) (n = 48) were assigned single-needle arthrocentesis with distension of the joint or conventional two-needle arthrocentesis with or without intracapsular injection of the medication (hyaluronic acid (HA) or platelet-rich plasma (PRP)) performed every month over a period of 6 months. The maximum mouth opening and pain, as measured by the visual analog scale (VAS), were compared. Each group exhibited significant improvement, i.e., a decrease in pain and an increase in mouth opening. The single-puncture technique provided similar pain reduction as the two-needle approach but provided significantly better results in terms of maximum mouth opening. The reduction in pain was similar when comparing the OA and DD cohorts; however, patients with disc displacement achieved significantly better mouth opening than OA. Intracapsular application of medication contributed to a significant decrease in pain in both HA and PRP groups, with platelet-rich fibrin being significantly superior to HA in terms of mouth opening improvement.

Human dorsal root ganglia are either preserved or completely lost after deafferentation by brachial plexus injury

BackgroundPlexus injury results in lifelong suffering from flaccid paralysis, sensory loss, and intractable pain. For this clinical problem, regenerative medicine concepts set high expectations. However, it is largely unknown how dorsal root ganglia (DRG) are affected by accidental deafferentation. MethodsHere, we phenotyped DRG of a clinically and MRI-characterised cohort of 13 patients with plexus injury. Avulsed DRG were collected during reconstructive nerve surgery. For control, we used DRG from forensic autopsy. The cellular composition of the DRG was analysed in histopathological slices with multicolour high-resolution immunohistochemistry, tile microscopy, and deep-learning-based bioimage analysis. We then sequenced the bulk RNA of corresponding DRG slices. ResultsIn about half of the patients we found loss of the typical DRG units consisting of neurones and satellite glial cells. The DRG cells were replaced by mesodermal/connective tissue. In the remaining patients, the cellular units were well preserved. Preoperative plexus MRI neurography was not able to distinguish the two types. Patients with ‘neuronal preservation’ had less maximum pain than patients with ‘neuronal loss’. Arm function improved after nerve reconstruction, but severe pain persisted. Transcriptome analysis of preserved DRGs revealed expression of subtype-specific sensory neurone marker genes, but downregulation of neuronal attributes. Furthermore, they showed signs of ongoing inflammation and connective tissue remodelling. ConclusionsPatients with plexus injury separate into two groups with either neuronal preservation or neuronal loss. The former could benefit from anti-inflammatory therapy. For the latter, studies should explore mechanisms of neuronal loss especially for regenerative approaches. Clinical trial registrationDRKS00017266.

Exploring the relationship between pain intensity, self-management of pain and pain self-efficacy on post-operative pain on day 5 after cesarean section: A cross-sectional study in Mie prefecture in Japan.

Pain self-management among women who begin child-rearing after a cesarean section (CS) has not been ascertained. This study aimed to explore the relationship among pain intensity, self-management, and self-efficacy on post-operative day (POD) 5 after CS in postpartum women. A cross-sectional online survey was conducted on POD5 after CS. Participants were recruited through convenience sampling in Mie Prefecture, Japan, from August 2023 to April 2024. Pain was assessed using a numerical rating scale (NRS), both during activity and at rest, with higher scores indicating greater pain. Pain self-efficacy was assessed using the Japanese version of the Pain Self-Efficacy Questionnaire (PSEQ-J), and pain self-management was investigated. SPSS version 29.0 was used for data analysis, and p<0.05 was set as the significance level. Data from 124 participants (valid response rate: 73.8%) were analyzed. The median (IQR) of the NRS was 4.5 (3-6) during activity and 2.0 (1-4) at rest. There were significant differences according to method of oral analgesia during activity (p<0.049) and at rest (p<0.015). Multiple regression analysis revealed that NRS scores at maximum pain after CS significantly influenced pain on POD5. However, the number of oral analgesics and PSEQ-J scores were not influenced (during activity: R2=0.21, p<0.001, at rest: R2=0.12, p<0.001). Pain intensity during activity on POD5 was moderate and required pain-management. Acute post-operative pain-management was related to pain intensity on POD5, suggesting the importance of early post-operative pain control. Future studies are needed to examine the association between pain self-efficacy and other psychological factors.

Attitudes and Experiences of Patients Regarding Gender-Specific Aspects of Pain Management.

Biological, pharmacological, and socio-cultural aspects influence gender-specific effects in pain management. Gender-specific aspects of pain management were assessed in a rural outpatient center via semi-structured patient interview: (i) general gender aspects (total population) from 1 = "fully disagree" to 5 = "fully agree"; and (ii) individual pain (matched pairs) via numeric analog scale (NAS) from 0 = "no pain" to 10 = "maximum pain". Patient charts were assessed for pain management (WHO-ladder). In total, 113 patients were enrolled (59.18 [SD: 12.76] years, 46% female, 54% male, 0% diverse), and 42 were matched into female-male pairs. (i) Women and men agreed that men and women should be treated equally despite biological differences (median: 5 [women] vs. 5 [men]; p = 0.789). As a reason for gender-specific aspects, "medication concentration" was reported more frequently by women (p = 0.038) and "no answer" by men (p = 0.014). (ii) Mean value (SD) of pain (NAS) was 4.0 (SD 2.3) for women and 3.3 (SD 2.6) for men (p = 0.215) with a positive correlation between pain management escalation (WHO-ladder) and the pain score (NAS) only in men (r = 0.704, p = 0.001). Women rather reported an influence of adverse drug reactions on treatment contentment than men (p = 0.042). Although patients pleaded for gender-independent equal treatment, gender-specific differences in pain therapy were found.

Machine learning approach to predict postoperative pain after spinal morphine administration during caesarean delivery

BackgroundA major barrier to optimal pain management is the difficulty in predicting and assessing patients at high risk for significant pain across multiple locations within the institution in a timely manner. This is compounded by the fragmented display of clinical information on enterprise clinical platform, which further hinders delay the reviews and hence the increased risk of untreated pain. We evaluated and compared the predictive performance of six modelling techniques in predicting significant pain, defined as the maximum pain score of 3 or more on movement at the 13th to 24th hour after spinal morphine administration during caesarean delivery. MethodsWe retrieved medical records from women who underwent caesarean delivery and received postoperative spinal morphine in a single specialist maternity hospital in Singapore between Aug 2019 and Aug 2022. We extracted 120 clinical variables from the medical records of eligible patients and further selected 23 to improve algorithm accuracies. The dataset was split randomly, with 80 % of patients (n = 5248) used for training the models, and 20 % (n = 1313) reserved for validation. ResultsThe study cohort comprised 6561 patients with an incidence of significant postoperative pain of 7.9 %. Ridge regression demonstrated the best performance with both the full (AUC: 0.649) and selected (AUC: 0.719) feature sets. By reducing the number of features, Ridge regression, LASSO, Elastic net, and XGBoost showed similar in AUC (0.704–0.719), sensitivity (0.644–0.695), specificity (0.644–0.705), positive predictive value (0.155–0.179), and negative predictive value (0.949–0.955) in predicting significant postoperative pain. These were attributed to the top three variables, mainly the last recorded postoperative pain score (on movement) before the prediction point, mean and standard deviation of the hourly maximum postoperative pain score (at rest) at 0th to 12th hour. ConclusionsFuture research will aim to refine these models and explore their implementation in clinical settings to enhance real-time pain management and risk stratification for women after caesarean delivery.

A Propensity Score-Weighted Analysis of Short-Term Corticosteroid Therapy for Refractory Pain Following Spontaneous Subarachnoid Hemorrhage.

Corticosteroids are prescribed for refractory headache in patients with spontaneous subarachnoid hemorrhage (SAH) despite limited supporting evidence. We hypothesized that a short course of corticosteroids would reduce pain. We reviewed all patients who received corticosteroids for refractory headache following spontaneous SAH within our institutional database. Pain was measured by a numeric rating scale (NRS) every 2h. The primary outcome was maximum daily NRS score; secondary outcomes were the mean daily NRS score and daily opioid consumption. Propensity scores were developed using potential predictors of corticosteroid use, including age, sex, pretreatment 24-h pain burden, and the number of analgesics being used to control pain. Inverse probability treatment weighting (IPTW) was used to balance baseline covariate distributions between patients receiving corticosteroids and control patients. Generalized estimating equations were used to analyze longitudinal NRS scores and oral morphine equivalents based on the weighted cohort. A total of 213 patients were included. The mean age was 55 (SD 13) years, and 141 of 213 (66%) were female. Of 213 patients, 195 (92%) had a low clinical grade (i.e., Hunt-Hess grades 1-3). Seventy patients were prescribed corticosteroids on postbleed day 5 (SD 3.3) on average, with an average of 26 (SD 10)mg of dexamethasone over 48h. Patients receiving corticosteroids and controls were well balanced on baseline predictors of treatment status. After IPTW, we found that corticosteroid therapy reduced the daily maximum pain NRS score by 0.59 (SE = 0.39, p = 0.12), 0.96 (SE = 0.42, p = 0.02), and 0.91 (SE = 0.46, p = 0.048) on days 1-3, respectively, after adjusting for control effects. The mean daily pain NRS score and daily opioid use were nonsignificantly reduced in the 3days following corticosteroid initiation after adjusting for control effects. Short-term corticosteroids only slightly reduced maximum pain severity after spontaneous SAH. Other analgesic strategies are required to manage refractory pain in this population.

The analgesic effect of continuous adductor canal block combined with popliteal plexus block for total knee arthroplasty: a randomized controlled trial

This study aimed to confirm the hypothesis that continuous ACB (CACB) combined with a popliteal plexus block (PPB) can improve posterior knee pain, reduce nalbuphine consumption, and shorten the length of hospital stay. Patients who underwent TKA were allocated to the CACB + sham block (SHAM) or CACB + PPB groups. The primary outcome was the maximum pain score originating from the posterior knee within 4 h after TKA. Secondary outcomes included the maximum pain score originating from the posterior and anterior knees within 72 h after TKA, range of motion on postoperative day (POD) 1–3, postoperative nalbuphine consumption within 72 h of surgery, length of hospital stay, and complications. The maximum pain score of the posterior knee was lower in the CACB + PPB group than in the CACB + SHAM group within 0–12 h after surgery. Nalbuphine consumption within 24 h after surgery was lower in the CACB + PPB group than in the CACB + SHAM group. The range of motion was better in the CACB + PPB group than in the CACB + SHAM group on POD1 and 2. The length of hospital stay was shorter in the CACB + PPB group than in the CACB + SHAM group. The incidence of clinical significant nausea and vomiting was lower in the CACB + PPB group than in the CACB + SHAM group. This study found that PPB combined with CACB could relieve pain in the posterior knee within at least 12 h after TKA, reduce nalbuphine consumption within 24 h after TKA, improve the range of motion on POD1 and 2, and shorten the length of hospital stay for patients who underwent TKA.

Optimizing pediatric tonsillectomy outcomes with an opioid sparing anesthesia protocol: Learning and continuously improving with real-world data.

This quality improvement initiative is a continued pursuit to optimize outcomes by iteratively improving our opioid sparing anesthesia protocol for tonsillectomy with or without adenoidectomy at our pediatric ambulatory surgical center through data driven Plan-Do-Study-Act cycles. From 1/2015 through 12/2023, our standardized tonsillectomy protocol underwent nine procedure-specific perioperative Plan-Do-Study-Act cycles, three procedure-specific postoperative prescription Plan-Do-Study-Act cycles, and four general ambulatory surgical center enhanced recovery Plan-Do-Study-Act cycles. We analyzed data from the medical record using statistical process control charts. The primary outcome measure was the percent of patients requiring intravenous opioid in the post anesthesia care unit. Secondary outcomes included maximum post anesthesia care unit pain score, the percent of patients requiring treatment for nausea and/or vomiting in the post anesthesia care unit, and the number of postoperative opioid prescription dosages. Balancing measures were average post anesthesia care unit length of stay, percent of patients with prolonged Post Anesthesia Care Unit length of stay (>120 min), and 30-day reoperation rate. A total of 5654 tonsillectomy with or without adenoidectomy cases were performed at our ambulatory surgical center from 2015 to 2023. The incidence of intravenous opioid administered in the post anesthesia care unit initially rose with opioid free anesthesia launch, but subsequently decreased below the target of 10%. Maximum post anesthesia care unit pain scores rose from mean 3.6 to 4.5, but subsequently returned to the baseline of 3.5, while the incidence of postoperative nausea and/or vomiting improved. The average post anesthesia care unit length of stay increased by 10 min with opioid free anesthesia; however, prolonged post anesthesia care unit stay and 30-day reoperation rates were unchanged. The continued refinement of our opioid sparing anesthesia protocol has led to reduced perioperative and home opioid use, stable maximum post anesthesia care unit pain scores, and improved postoperative nausea and vomiting rates, with only a slight increase in mean post anesthesia care unit length of stay.

Lidocaine patches after cesarean sections: a randomized control trial

ObjectivesLidocaine patches are a common topical analgesic therapy but have not been thoroughly investigated in the surgical or obstetric literature. We sought to investigate the impact of adding topical lidocaine patches to routine postcesarean pain management on patients’ postcesarean pain scores and opioid use. Study DesignThis is a prospective randomized subject-blinded controlled trial of patients undergoing cesarean delivery at a single institution. Individuals were excluded if they had three or more cesarean sections (CS), abdominoplasty, history of abdominal hernia repair with mesh, active polysubstance use, or history of opiate use disorder with current medication-assisted treatment. Patients were randomized via a 1:1 randomization scheme to a placebo patch or lidocaine patch. Baseline maternal characteristics were collected. The primary outcome was mean visual analog pain scores (0–10). Our secondary outcome was total morphine equivalents used over the postoperative hospital stay. Pre- and poststudy surveys were performed to evaluate subject's prior analgesia use (including opioids) and patient experience in the study. ResultsA total of 100 patients were randomized and 93 had complete data for analysis (46 placebo group, 47 treatment group). Groups had similar baseline characteristics (age, BMI, ethnicity, surgical time, and estimated blood loss). Mean maximum postoperative pain score by visual analog scale did not differ between placebo or lidocaine patch groups on postoperative day (POD) 1 (P=.3), day 2 (P=.9), day 3 (P=.07), or day 4 (P=.09). Mean postoperative pain score by visual analog scale did not differ between placebo or lidocaine patch groups on POD 1 (P=.7), day 2 (P=.6), day 3 (P=.2), or day 4 (P=.5). In the poststudy survey, 0% of the respondents in the lidocaine patch group reported disruption of their care and 63% reported desired use of lidocaine patch in the future. ConclusionThe addition of lidocaine patches did not significantly decrease the maximum or average postoperative pain scores via visual analog scale after CS. More research is needed into nonopioid pain management strategies in the postoperative period in obstetric care.

The Impact of Depression and Anxiety Comorbidities on Acute Postoperative Pain After DIEP Flap Breast Reconstruction.

Depression and anxiety have a complex association with opioid dependence, though their impact on acute postoperative pain is unclear. The present study investigated the impact of depression and anxiety on acute postoperative pain and opioid requirements following deep inferior epigastric perforator (DIEP) flap breast reconstruction. Patients receiving DIEP flap breast reconstruction were retrospectively identified from 2019 to 2023. Patients were classified into the psychiatric comorbidity (PC) group based on a history of depression or anxiety diagnoses, or the control group. Pain (0-10 Numerical Rating Scale [NRS]) scores and cumulative inpatient opioid requirements (in morphine milli-equivalents [MMEs]) were compared between groups. Linear regression analysis assessed the association of psychiatric comorbidities with pain outcomes. In total, 557 patients were included, of which 11.4% reported a psychiatric history. The PC group was younger (50.0 vs. 52.7 years, p = 0.032) and more frequently reported current marijuana use (15.6% vs. 4.3%, p = 0.001) and former smoking (51.6% vs. 24.5%, p < 0.001). The PC group had higher mean (2.5 vs. 2.0, p < 0.001) and maximum pain scores (8.6 vs. 7.8, p = 0.003) than the control group, which corresponded to higher opioid requirements (256 vs. 223 MMEs, p = 0.041). Psychiatric comorbidities were associated with higher average and maximum pain scores (p < 0.01) while current marijuana use was associated with higher opioid requirements (p = 0.033). Patients with depression or anxiety comorbidities tended to have greater acute postoperative pain and opioid consumption. Marijuana use was also more prevalent, potentially exacerbating pain outcomes, and risk of opioid dependence. These findings will inform patient discussions and targeted interventions to mitigate opioid misuse.

Enhancing Postoperative Analgesia After Cesarean Section: Insights Into Transversus Abdominis Plane Block, Intrathecal Opioids, and Other Analgesic Techniques.

Cesarean section (CS) is associated with moderate to severe pain that may delay recovery and interfere with the mother's ability to take care of the newborn. This clinical study aimed to evaluate different analgesic protocols for postoperative pain management after CS. The study included 300 parturients scheduled for CS and classified into five equal groups as follows: general anesthesia (GA group), GA plus transversus abdominis plane (TAP) block (GA+TAP group), spinal anesthesia (SA) plus intrathecal fentanyl (ITF group), SA plus fentanyl + TAP block (ITF+TAP group), and SA plus intrathecal morphine (ITM group). Multimodal analgesia was added to all groups in the form of paracetamol 1 g/6 hours intravenously (IV), lornoxicam (8 mg/8 hours/IV), in addition to rescue opioid analgesia (morphine or oxycodone 4 mg/IV) upon the patient's request. Primary outcomes included pain assessments by numerical rating scale (NRS), worst and least pain scores, and time in maximum pain. Secondary outcomes included time to first request of analgesia, total opioid consumption, patient request for additional analgesia, function, and satisfaction scores. Possible side effects and neonatal Apgar scores were recorded at five and 10 minutes. The results showed a significant difference between the study groups regarding pain relief. The best pain relief, lowest worst pain, least pain, and total opioid consumption were reported by the ITM group, followed by ITF+TAP, GA+TAP, then SA, and GA groups (p < 0.05). The lower percentage of time in the worst pain and the longest time to the first request of analgesia were reported with ITM and ITF+TAP groups followed by the ITF group and GA+TAP group. In contrast, the longest time spent in the worst pain and the shortest duration until the first request of analgesia was observed in the GA group (p < 0.05). The best function scores were observed with ITF+TAP and then ITM, while the highest satisfaction scores were reported with ITM, ITF+TAP followed by SA and GA+TAP, and the lowest scores were observed in the GA group (p < 0.001 and p < 0.005, respectively). Side effects such as itching, nausea, and vomiting were significantly higher in the ITM group when compared to the other groups (p < 0.05). There were no significant differences between the study groups regarding the Apgar scores at five and 10 minutes (p = 0.271 and 0.760). Bilateral TAP block has the potential to effectively enhance postoperative analgesia and reduce the need for systemic opioids after both GA and SA. Compared to ITF, ITM provides a higher quality and longer duration of analgesia with minimal analgesic-related side effects. Further studies to find an optimal analgesic protocol with few to no side effects are warranted.

Uncontrolled chronic pain: can a pain consultation in primary care be a solution?

Chronic pain is one of the most frequent medical problems in Portuguese primary health care. These patients significantly show poorer functioning capabilities and quality of life than the general population. The importance of improving the quality of life in patients suffering from chronic pain is paramount, and a holistic approach must be implemented. However, proper pain evaluation and management may be time-consuming in a routine primary health care consultation. Given the significant impact of this disease, we initiated a dedicated consultation for patients with chronic pain in our primary health care unit. A complete evaluation is performed, and, among other questionaries, the Brief Pain Inventory is applied to evaluate pain impact on functioning at the first appointment and re-evaluated after six months of follow-up. In the first six months, 31 patients with uncontrolled pain were referred by their family physicians to this consultation. Non-pharmacological strategies were strongly recommended alongside pharmacological therapies. Although this consultation is relatively recent, our patients with longer follow-ups showed improvement in both maximum and minimum pain levels and substantial improvement in all the measured interferences in the Brief Pain Inventory. Even though there is literature that thoroughly describes the impact of pain on patients’ quality of life, there is much to be done to change this problem. Since family physicians know their patients and their contexts well, they are in a privileged position to manage this problem, and a specific pain consultation in primary health care can be one of the best services for managing pain.

Are Extracorporeal Shock Waves Just a Therapeutic Tool?

Focused extracorporeal shock wave therapy (ESWT) has been successfully used to treat musculoskeletal conditions, but ESWT stimulates nociceptors, causing pain deep in the tissue during treatment. The occurrence of pain during ESWT is a side effect, but it can help identify painful sites and assess minimum (MiTI) and maximum (MaTI) pain thresholds to ESWT pressure stimuli. This topic has received limited attention in literature. This observational study describes a specific approach to using ESWT to study pain in 71 patients. The approach proposes moving the ESWT transducer head of the device over the entire joint surface, progressively increasing the energy level until the patient experiences pain. In the study, MiTI and MaTI were 0.218 ± 0.090 and 0.416 ± 0.165 mJ/mm2 in the affected joint and 0.282 ± 0.128 and 0.501 ± 0.174 mJ/mm2 in the contralateral homologous healthy joint, being significantly lower in the affected joint (MiTI: p < 0.001 and MaTI: p = 0.003, respectively). ESWT induced pain in 94.37% of the sites with the highest subjective pain and in a greater number of sites (204) than digital pressure (123) (p < 0.001). All sites with digital pressure pain also had ESWT pain. These results suggest that the ESWT device may be useful in investigating pain in musculoskeletal conditions and tailoring therapy.

Efficacy of dextrose prolotherapy for temporomandibular joint hypermobility: A systematic review and meta-analysis

ABSTRACT Objective We reviewed the efficacy of dextrose prolotherapy versus placebo and other active interventions, like autologous blood injection (ABI) and botulinum toxin (BTX), in improving the outcomes of temporomandibular joint (TMJ) hypermobility. Methods We searched PubMed, the Cochrane CENTRAL library, Embase, Scopus, and Web of Science databases to identify randomized controlled trials (RCTs) . Maximal mouth opening (MMO), pain, and frequency of dislocations were analyzed. Results Eight RCTs were included. In comparison with placebo, dextrose prolotherapy was associated with significantly reduced pain and MMO. Comparison of dextrose with ABI revealed no significant difference in MMO. Qualitative analysis showed no significant difference in outcomes in patients who received dextrose prolotherapy and BTX. Conclusions Low-quality evidence suggests that dextrose prolotherapy may reduce MMO and improve pain scores compared to placebo in patients with TMJ hypermobility. Low-quality evidence also suggests that there may be minimal difference in outcomes between dextrose vs ABI and BTX.

Exploring the Potential of Electronic Patient-Generated Health Data for Evaluating Treatment Response to Intramuscular Steroids in Rheumatoid Arthritis: Case Series.

Mobile health devices are increasingly available, presenting exciting opportunities to remotely collect high-frequency, electronic patient-generated health data (ePGHD). This novel data type may provide detailed insights into disease activity outside usual clinical settings. Assessing treatment responses, which can be hampered by the infrequency of appointments and recall bias, is a promising, novel application of ePGHD. Drugs with short treatment effects, such as intramuscular steroid injections, illustrate the challenge, as patients are unlikely to accurately recall treatment responses at follow-ups, which often occur several months later. Retrospective assessment means that responses may be over- or underestimated. High-frequency ePGHD, such as daily, app-collected, patient-reported symptoms between clinic appointments, may bridge this gap. However, the potential of ePGHD remains untapped due to the absence of established definitions for treatment response using ePGHD or established methodological approaches for analyzing this type of data. This study aims to explore the feasibility of evaluating treatment responses to intramuscular steroid therapy in a case series of patients with rheumatoid arthritis tracking daily symptoms using a smartphone app. We report a case series of patients who collected ePGHD through the REmote Monitoring Of Rheumatoid Arthritis (REMORA) smartphone app for daily remote symptom tracking. Symptoms were tracked on a 0-10 scale. We described the patients' longitudinal pain scores before and after intramuscular steroid injections. The baseline pain score was calculated as the mean pain score in the 10 days prior to the injection. This was compared to the pain scores in the days following the injection. "Response" was defined as any improvement from the baseline score on the first day following the injection. The response end time was defined as the first date when the pain score exceeded the pre-steroid baseline. We included 6 patients who, between them, received 9 steroid injections. Average pre-injection pain scores ranged from 3.3 to 9.3. Using our definitions, 7 injections demonstrated a response. Among the responders, the duration of response ranged from 1 to 54 days (median 9, IQR 7-41), average pain score improvement ranged from 0.1 to 5.3 (median 3.3, IQR 2.2-4.0), and maximum pain score improvement ranged from 0.1 to 7.0 (median 4.3, IQR 1.7 to 6.0). This case series demonstrates the feasibility of using ePGHD to evaluate treatment response and is an important exploratory step toward developing more robust methodological approaches for analysis of this novel data type. Issues highlighted by our analysis include the importance of accounting for one-off data points, varying response start times, and confounders such as other medications. Future analysis of ePGHD across a larger population is required to address issues highlighted by our analysis and to develop meaningful consensus definitions for treatment response in time-series data.

Short-term outcomes of da Vinci SP versus Xi for rectal cancer surgery: a propensity score matching analysis of two tertiary center cohorts.

This study compares the perioperative outcomes of robotic rectal cancer surgery between da Vinci single-port (SP) system, the most recent system allowing minimally invasive surgery with reduced ports, and the da Vinci Xi system. Patients who underwent robotic surgery for rectal adenocarcinoma from January 2016 to September 2023 at two tertiary referral centers were included. A retrospective analysis was conducted to compare key parameters between patient cohorts before and after propensity score matching. A total of 378 patients (SP, 65 vs. Xi, 313) were analyzed. The SP group comprised a higher proportion of females (44.6% vs. 28.4%; p = 0.016) and a higher tumor location (8.25cm vs. 6.71cm from the anal verge; p < 0.001) than did the Xi group. SP surgery promoted a shorter total incision length (4.9 cm vs. 9.2 cm; p < 0.001), lower maximum pain scores (5 vs. 7; p < 0.001), and shorter hospital stay (6 vs. 7days; p < 0.001) than did Xi surgery. Operation time (175 vs. 182min; p = 0.829) and postoperative complications (9.2% vs. 12.1%; p = 0.650) did not significantly differ between the groups. Lower lying rectal tumors were more frequently treated using the Xi system than the SP system, promoting a higher diverting stoma rate (13.8% vs. 45.4%; p < 0.001) and a lower anastomosis level (4.6cm vs. 3.3cm; p < 0.001). After 1:1 matching, SP maintained its advantages over Xi in terms of incision length (p < 0.001), maximum pain scores (p = 0.001), and hospital stay (p < 0.001). Overall postoperative complication rates were similar between both groups (10.8% vs. 12.3%; p = 0.777). The da Vinci SP system continues to offer minimal invasive benefits in rectal cancer surgery. However, the Xi system's instrument diversity provides a certain advantage, particularly in cases involving low-lying rectal tumors. Tailoring robotic approaches based on individual patient characteristics remains pivotal for optimizing outcomes of rectal cancer surgery.

CT-guided infiltration of the ischiofemoral space in young patients with ischiofemoral impingement is an effective diagnostic tool.

To present our technique of diagnostic CT-guided ischiofemoral space injection and report on pain response, complications, and associated imaging findings in young patients with ischiofemoral impingement (IFI). Retrospective case series of patients with a clinical diagnosis of IFI that underwent CT-guided IFS injection with local anesthetic in a prone position with the feet in maximum internal rotation between 06/2019 and 04/2021. The response was evaluated using maximum subjective pain evaluation on a 0-10 visual analog scale (VAS) during a standardized pre- and postinterventional clinical examination. Patient charts and radiographic imaging data were reviewed to report associated imaging findings and subsequent surgeries. Eleven patients (13 hips, 9 females) with a median age of 31 years (interquartile range; IQR: 25-37 years) were included. Median baseline VAS was 7 points (IQR: 5-8) with a pain reduction of 5 points (IQR: 5-7 points, p = 0.001) after the injection. One patient reported transient ischial nerve paresthesia, otherwise, no complications occurred. Quadratus femoris muscle edema was present in 85% (11 of 13 hips). Excessively high femoral torsion (11/13 hips, 85%) and cam deformities (8/13 hips, 62%) were the most common osseous deformities. Eight of 13 hips (62%) underwent subsequent surgery for IFI. CT-guided diagnostic injection of the ischiofemoral space is safe and feasible. In young IFI patients, diagnostic IFS injections have the potential to improve the differential diagnosis of hip pain and to inform decision-making with regard to a possible benefit of joint-preserving hip surgery. In young patients with hip pain, diagnosis of IFI can be challenging due to concomitant pathologies. Furthermore, surgical treatment in these patients is controversial. In this context, CT-guided diagnostic infiltrations of the ischiofemoral space may facilitate not only the initial diagnosis of IFI, but could also improve surgical decision-making. CT-guided diagnostic injection of local anesthetic in the ischiofemoral space is safe. In young patients with IFI, it leads to subjective pain reduction. In young patients with concomitant osseous deformities, it may improve surgical decision-making.

Postoperative pain after parotid surgery-comparison between superficial/total parotidectomy and extracapsular dissection: a prospective observational study.

To evaluate postoperative pain and discomfort after parotid surgery with regard to different surgical approaches. This clinical study was carried out at a single tertiary referral center (2021-2022) and included 2 groups of adult patients (mean age 56.6 ± 12.7 vs. 53.4 ± 14.1years) following elective parotid surgery due to a parotid tumor of any entity.The first group (SP/TP group) consisted of 31 patients after superficial parotidectomy (SP) or total parotidectomy (TP) (n = 31). The second group (ECD group) included all patients who had undergone extracapsular dissection (ECD) (n = 51). Primary endpoints comprised pain on ambulation as well as maximum and minimum pain (NRS 0-10) on the first three postoperative days (PODs). A neuropathic pain component (evaluated on POD 1 and 3), the analgesic score (collected from the patient file on POD 1-3), treatment-related side-effects/pain-associated impairments, and patient satisfaction (all measured on the 1st POD) were defined as secondary endpoints. Patients were surveyed using the standardized and validated "Quality Improvement in Postoperative Pain Treatment" (QUIPS) questionnaire and the painDETECT® questionnaire. Comparisons were performed using independent t tests, Wilcoxon tests, and χ2 tests, and the respective effect sizes were calculated. Looking at the first postoperative day, patients of both groups (SP/TP vs. ECD) reported comparable pain on ambulation (2.8 ± 2.0 vs. 2.6 ± 1.8; p = 0.628, r = 0.063), maximum (3.5 ± 2.2 vs. 3.5 ± 2.3; p = 0.992, r = 0.002) and minimum pain (1.1 ± 1.04 vs. 1.0 ± 1.2; p = 0.206, r = 0.157). Furthermore, there were no significant differences in pain-related restrictions or pain medication requirement. The patients in both groups were equally satisfied with their pain therapy (p = 0.282, R = 0.135). The sum score of the painDETECT® questionnaire delivered clearly negative (< 12) results on average (POD1: 6.81; POD3: 6.59); no significant difference between the groups was found (p = 0.991, R2 < .001). Neither surgical technique on the parotid gland was significantly superior to the other in terms of postoperative pain perception. Overall, postoperative pain can be classified as mild to moderate following parotid surgery. A neuropathic pain component could be excluded for the acute postoperative phase. The study was registered in the German Registry for Clinical Studies (DRKS) (application No.: DRKS00016520).

Hip Surgery is Not More Painful Than Spine Surgery in Children With Cerebral Palsy.

Posterior spinal fusion (PSF) and hip reconstruction are commonly indicated surgeries in children with cerebral palsy (CP), particularly those functioning at GMFCS levels IV and V. These are large and often painful procedures, and previous literature suggests that hip surgery is more painful than spine surgery in this patient population. The purpose of this study is to investigate pain scores and opioid use following hip and spine surgery in a large cohort of children with CP, including many patients who have undergone both types of surgery. A retrospective chart review was performed to identify children with CP who underwent hip reconstruction and/or PSF at a tertiary children's hospital between 2004 and 2022. Charts were reviewed for demographic data, pain scores, pain medication usage, duration of hospital stay, and complications. Data were collected for 200 patients (101 male, 99 female) who met inclusion criteria. Eighty-seven patients underwent hip reconstruction, 62 spinal fusion, and 51 both hip and spine surgery asynchronously. Median (interquartile range) age at the time of surgery was significantly older for spinal fusion compared with hip surgery [13.1 (4.9) vs. 8.1 (5.7) y, P <0.0001]. Length of stay was significantly longer after PSF, with a median of 6 (4) days compared with 2 (1) days after hip surgery ( P <0.0001). Both maximum and average daily pain scores were similar following hip and spine surgery, with the exception that average pain scores for hip surgery were slightly higher on postoperative day 1, hip=1.73 vs. spine=1.0 ( P <0.0001). The amount of opioids used, expressed as morphine milligram equivalents (MME)/kg were similar in the hip and spine surgery groups; however, it was significantly lower in the hip surgery group on postoperative day 0, hip=0.06 versus spine=0.17 ( P <0.0001). For the 51 patients who underwent both hip and spine surgery, the amount of opioids used mirrored that for the entire group (similar MME/kg, though only statistically significantly less on POD 0 and 3), and pain scores were not significantly different between the 2 groups except in 2 circumstances. The 2 exceptions in these 51 patients both demonstrated lower pain scores in patients after hip surgery, including lower maximum pain scores on POD 1 ( P =0.041), and lower average pain scores on POD3 ( P =0.043). This is the largest series to date comparing postoperative pain in children with CP after hip and spine surgery, including 51 of 200 patients who underwent both types of surgery. The results of this study demonstrate that hip surgery is not more painful than spine surgery in children with CP, and conflict with the traditional belief that hip surgery is more painful. This is important information for health care providers when counseling patients and families regarding these surgeries in children with CP. Level 3.

Ropivacaine and magnesium sulfate in sciatic nerve block at the popliteal level: randomized double-blind study.

Following surgical procedures, over 80% of patients experience acute pain, with half of them expressing dissatisfaction with pain relief. The modern approach to surgical treatment and pain management increasingly relies on implementing multimodal analgesia, which includes the use of adjuvants in addition to long-acting local anesthetics (such as ropivacaine). This double-blind randomized study evaluated the analgesic effect of magnesium sulfate added to ropivacaine in the sciatic nerve block at the popliteal level for bunion correction surgery. In this double-blind study, fifty patients were enrolled and randomized in a 1:1 ratio to receive ropivacaine and MgSO<inf>4</inf> 200 mg or ropivacaine and physiological solution. The primary endpoint was the duration of sensory block. A statistically significant difference was observed in the onset time for sensory block (9.2 minutes vs. 21.8 minutes, P<0.001) and its duration (18.2 hours vs. 13.9 hours, P<0.001) between the two groups. Between 12 and 24 hours postoperatively, the maximum NRS pain scores in the magnesium group were lower than those in the control group (IQR [range]) 2 (2-3.8 [0-6.5]) vs. 6.7 (5.6-7.9 [2.7-9.2], P<0.001). The need for additional opioids after 12-24 hours was significantly higher in patients in the physiological solution group compared to those in the magnesium group. Our results suggest that magnesium added to the local anesthetic extends sensory block duration, reduces postoperative pain, improves the quality of analgesia, decreases the need for additional opioids. Further studies are needed to confirm these preliminary findings.