Median Visual Analog Scale Pain Score Research Articles

Efficacy of Piriformis Block Using Intravenous Steroids with Bupivacaine versus Botox in Piriformis Syndrome

Background: Piriformis syndrome, a condition that affects predominantly females, leads to significant morbidity and impacts the quality of life. Despite its prevalence, it remains underdiagnosed, especially in the developed world. Treatment options include physiotherapy, painkillers, massage, heat, corticosteroids, local anesthetics, and botulinum toxin. However, comparative analysis of combination therapy versus botulinum toxin alone is limited. Objective: To compare the efficacy of intravenous steroids combined with bupivacaine versus botulinum toxin (Botox) injections in the treatment of piriformis syndrome. Methods: This quasi-experimental study was conducted at the Department of Anesthesiology, Combined Military Hospital, from January 2022 to December 2022, following ethical approval. The study included 100 patients diagnosed with piriformis syndrome, divided into two groups: Group L (n=50) received 10 ml of 0.25% bupivacaine with 40 mg of methylprednisolone, and Group B (n=50) received 100 U of botulinum toxin type A diluted in 10 ml distilled water. Standard monitoring was applied, and injections were performed under ultrasound guidance with the patients in the prone position. Pain scores were assessed using the Visual Analog Scale (VAS) at 24 hours, 72 hours, 7 days, and 28 days post-procedure. Patient satisfaction was measured using a 5-point Likert scale at 28 days. Data were analyzed using t-tests and chi-square tests, with significance set at p<0.05. Results: The mean age was 36 ± 3.35 years in Group L and 35.82 ± 3.42 years in Group B (p=0.297). The mean weight was 75.82 ± 5.23 kg in Group L and 77.64 ± 4.47 kg in Group B (p=0.066). Before the procedure, both groups had a median VAS pain score of 7.0. At 24 hours, the median pain score was 4.0 in Group L and 5.0 in Group B (p=0.292). At 72 hours, Group L had a median pain score of 3.0 compared to 4.0 in Group B (p=0.010). At 7 days, the scores were 2.0 and 3.0 respectively (p=0.013), and at 28 days, they were 2.0 and 3.0 respectively (p=0.013). The median satisfaction score at 28 days was 1.0 in Group L and 2.0 in Group B (p=0.043). Conclusion: Combination therapy with local anesthetics and steroids is superior to botulinum toxin in reducing pain and improving patient satisfaction in piriformis syndrome. This approach should be considered the first-choice treatment.

Improvement in Clinical and Radiographic Outcomes After Isolated Realignment Surgery in Patients With Large Cystic Osteochondral Lesion of the Talar Shoulder and Concurrent Malalignment.

Malalignment has been suggested as a predisposing factor for the development of osteochondral lesions of the talus (OLTs). To evaluate the clinical and radiographic outcomes of realignment surgery in patients with a large cystic OLT of the talar shoulder and concurrent malalignment of the foot and ankle. Case series; Level of evidence, 4. The authors reviewed consecutive patients with large cystic OLTs (diameter, >10 mm) of the talar shoulder and concurrent malalignment of the foot and ankle who underwent realignment surgery between September 2013 and April 2021. The type of realignment procedure was determined based on patient symptoms and findings on plain radiographs and weightbearing computed tomography. Clinical improvement was assessed using pre- and postoperative Foot Function Index (FFI) scores and the visual analog scale (VAS) for pain. The OLT location was categorized according to Raikin zone, and the OLT area and volume were measured and compared pre- and postoperatively. The comparative analysis was performed using the Wilcoxon signed-rank test. In total, 27 ankles in 27 patients (mean age, 34.4 ± 11.9 years) were included in the analysis. There were 25 patients with a medial lesion (zone 4 [n = 19], zone 7 [n = 5], and zone 1 [n = 1]), and 2 patients with a lateral lesion (zone 6). Despite OLT location, patients' symptoms varied; 15 (55.6%) patients reported both medial- and lateral-sided pain, 10 (37%) reported lateral-sided pain, and 2 (7%) reported medial-sided pain. Supramalleolar osteotomy was performed in 18 patients, while foot and hindfoot correction without supramalleolar osteotomy was performed in 9 patients. Postoperatively, both the median FFI (from 44.4 [interquartile range (IQR), 35.7-52.2] to 9.1 [IQR, 5.2-13.9]) and median VAS pain score (from 6 [IQR, 5-6] to 1 [IQR, 1-2]) improved significantly (P < .0001 for both), and the median lesion size (from 25.8 mm2 [IQR, 19.3-45.2 mm2] to 13.8 mm2 [IQR, 6.8-26.5 mm2]) and median volume (from 2226.8 mm3 [IQR, 1311-3104 mm3] to 1326.5 mm3 [IQR, 714-2100 mm3]) decreased significantly (P < .0001 for both). During the mean follow-up of 4.1 ± 2.1 years, no subsequent surgery for OLT was necessary. The results suggest that realignment procedures can improve the symptoms and radiographic profile of OLTs in patients with large cystic OLTs of the talar shoulder and malalignment of the foot and ankle.

Percutaneous CT-Guided Microwave Ablation for the Treatment of Osteoid Osteomas: A Single Center Experience

Rationale and ObjectivesThe aim of the current study was to evaluate the feasibility and effectiveness of CT-guided microwave ablation (MWA) in the treatment of osteoid osteomas (OO). Materials and methodsData from 59 consecutive patients who underwent percutaneous CT-MWA for OO treatment were examined in the current retrospective study. The period of this study spanned from January 2021 to May 2023 at a single institution. The study involved an evaluation of clinical and radiological characteristics, procedural data, Visual Analog Scale (VAS) pain scores, complication incidences, as well as clinical and technical success rates. Statistical analyses were performed by using the Wilcoxon test with Bonferroni correction, Friedman, Spearman, Mann-Whitney U test. Results59 patients with an average age of 17.31±8.53 years underwent CT-guided MWA for the treatment of OO. The procedure demonstrated a high success rate, with 96.6% of cases achieving both technical and clinical success. However, recurrence was observed in two patients (3.4%) at the three-month follow-up. These cases were successfully managed with a second MWA procedure. The median VAS pain scores reported by the patients was significantly improved post-procedure: from 8.64 ± 1.14 before treatment to 0.63 ± 0.98 in the first month, 0.41 ± 1.02 in the third month, and 0.15 ± 0.45 in the sixth month. Only one patient (1.7%) experienced a minor complication; no major complications were recorded in this study. ConclusionCT-guided percutaneous MWA is a minimally invasive and a highly effective and safe approach for the treatment of OO.

V11-10 ANATOMIC TRANSPERINEAL PUDENDAL NERVE BLOCK BEFORE PENILE PROSTHESIS PLACEMENT TO REDUCE IMMEDIATE POSTOPERATIVE PAIN - DESCRIPTION AND OUTCOMES

You have accessJournal of UrologyCME1 Apr 2023V11-10 ANATOMIC TRANSPERINEAL PUDENDAL NERVE BLOCK BEFORE PENILE PROSTHESIS PLACEMENT TO REDUCE IMMEDIATE POSTOPERATIVE PAIN - DESCRIPTION AND OUTCOMES Kieran Lewis, Raevti Bole, Jacquelyn Booher, Lydia Deangelo, Gwendolyn Fuller, Ly Hoang Roberts, Petar Bajic, and Scott Lundy Kieran LewisKieran Lewis More articles by this author , Raevti BoleRaevti Bole More articles by this author , Jacquelyn BooherJacquelyn Booher More articles by this author , Lydia DeangeloLydia Deangelo More articles by this author , Gwendolyn FullerGwendolyn Fuller More articles by this author , Ly Hoang RobertsLy Hoang Roberts More articles by this author , Petar BajicPetar Bajic More articles by this author , and Scott LundyScott Lundy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003337.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inflatable penile prosthesis (IPP) is the gold standard surgery for refractory erectile dysfunction, though patients can experience significant pain in the postoperative period. Historically, this pain has been managed with opioid medication, which presents additional risk to patients. Pudendal nerve block (PNB) has long been used for intraoperative pain management in IPP, though knowledge of its impact in the postoperative period is limited. Recently, a multimodal analgesic regimen that included a PNB was shown to reduce pain and opioid use following IPP when compared to opioid medication alone. In this video abstract, we describe a simple and safe pudendal nerve block to reduce postoperative pain in patients undergoing IPP. METHODS: We retrospectively reviewed 10 patients who underwent a transperineal PNB prior to IPP at our institution. To explore its safety, we documented intraoperative complications and 90-day postop complications. We also documented immediate postop pain using the visual analog scale (VAS), immediate postop opioid administration, and patient-reported pain at the first follow-up visit. Our PNB is a single component of an ERAS protocol, which utilizes pre and postoperative gabapentin, meloxicam, and acetaminophen, in addition to intracavernosal lidocaine. RESULTS: Of the 10 patients we reviewed, 0/10 experienced intraoperative complications and in the 90-day period following surgery 0/10 experienced postop complications. The median VAS pain score in the immediate postop period was 2 (IQR=0 – 3), with 5/10 patients receiving fentanyl for pain control in the PACU. Patients that received fentanyl were on average given two 50mcg doses and had a median VAS pain score of 5 prior to the first dose. 9/10 patients reported no pain at first follow-up, with just a single patient reporting mild pain along the scrotum. CONCLUSIONS: In this video abstract, we demonstrate a safe and effective transperineal pudendal nerve block to minimize pain and reduce opioid use in patients following IPP implantation. Our PNB adds minimal pre-op time, does not require ultrasound, and has a low risk of possible complications. For quality control, we reviewed 10 patients who received a PNB before IPP. None of these patients experienced intraoperative or postop complications, demonstrating the safety of the procedure. Additionally, patients reported minimal pain in the immediate postop period and at first follow-up, once again demonstrating the safety and potential efficacy of the nerve block. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1001 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kieran Lewis More articles by this author Raevti Bole More articles by this author Jacquelyn Booher More articles by this author Lydia Deangelo More articles by this author Gwendolyn Fuller More articles by this author Ly Hoang Roberts More articles by this author Petar Bajic More articles by this author Scott Lundy More articles by this author Expand All Advertisement PDF downloadLoading ...

Nebulized dexmedetomidine versus neostigmine/atropine for treating post-dural puncture headache after cesarean section: a double-blind randomized controlled trial.

Post-dural puncture headache (PDPH) is one of the most common complications of neuraxial anesthesia after an accidental dural puncture. This study aimed to test non-interventional alternatives to treat PDPH. Our goals were to compare the effectiveness of nebulized dexmedetomidine (DEX) versus neostigmine/atropine in the conservative management of PDPH. A randomized double-blind controlled study of ninety (90) women divided into three equal groups: group C (given nebulization of saline 0.9% placebo in four mL), group N (given nebulization of 20 µ/kg neostigmine and 10 µ/kg atropine diluted in four mL normal saline), and group D (given nebulization of dexmedetomidine 1 µg/kg diluted in four mL normal saline). Nebulization was done twice daily for three days, and a Visual Analogue Scale pain score (VAS) was recorded for seventy-two hours after the intervention for the three groups with a VAS Score equal or less than three being the cutoff value. VAS was significantly decreased in dexmedetomidine, and neostigmine/atropine groups compared to the control group at six hours (median VAS: 5, 2, and 2 for groups C, N, and D respectively [P=0.001]). There was a significant difference in VAS trends between the three groups (at six, twelve, twenty-four, thirty-six, and forty-eight hours [P=0.001], and at seventy-two hours [P=0.003]). No patients in group D, but one patient in group N and seven patients in group C needed an epidural blood patch. Nebulized dexmedetomidine and neostigmine/atropine had a rapid effect on relieving PDPH after cesarean section.

The use of intrathecal morphine for acute postoperative pain in lower limb arthroplasty surgery: a survey of practice at an academic hospital

Background and purpose of the studyIntrathecal morphine (ITM) provides optimal postoperative analgesia in patients who are scheduled for total knee and hip operation with spinal anaesthesia. However, the ideal dose at which maximal analgesic effect occurs with minimal side effects is not known. This study aimed to describe the use of two doses of ITM and side effect profile in patients undergoing elective hip and knee arthroplasty.MethodsThis was a prospective, descriptive, and contextual study conducted on patients who had total hip and knee replacement at Chris Hani Baragwanath Academic Hospital from 1 September to 30 November 2020. The sample size consisted of 66 patients who were 18 years and older, American Society of Anaesthesiology (ASA) classification 1–3, patients who had received either 100 mcg or 150 mcg ITM dose under spinal anaesthesia and sent to the ward postoperatively. Visual Analogue Scale (VAS) score was used to assess pain in the first 24 h, consumption of rescue analgesia and reported side effects were documented.ResultsThere was no relationship between age, weight, ASA classification or type of surgery and VAS score classification groups. Patients who received 100 mcg ITM had a higher median VAS pain score 2 (1–5) compared to those who received 150 mcg ITM 1 (0–2), p = 0.01. The need for rescue analgesia between the two groups was marginally less in the 150 mcg ITM group (p = 0.098). There was no difference in the rate of side effects between the 100 mcg ITM group [12 (41%)] and the 150 mcg ITM group [17 (59%)], p = 0.92. Rescue analgesia was marginally different between groups, p = 0.09. There were no real differences in the VAS pain scores between the total knee and total hip surgeries. None of the patients experienced clinically significant respiratory depression.ConclusionThe 150 mcg ITM dose provided good analgesic effects with longer duration of action and comparable side effect profile to the 100 mcg ITM dose. This dose was not associated with development of respiratory depression and can therefore be administered safely to patients who are discharged to the ward postoperatively in a resource constraint environment.

The L-shaped tunnel technique showed favourable outcomes similar to those of the Y-graft technique in anatomic lateral ankle ligament reconstruction.

To compare the mid- to long-term clinical and radiological outcomes of the confluent L-shaped tunnel technique with the Y-graft technique for anatomic lateral ankle ligament reconstruction. This retrospective study involved 41 patients who underwent lateral ankle ligament reconstruction between 2013 and 2018. Based on the tunnel direction and tendon fixation method at the fibula side, patients were divided into two groups, with 17 patients in the L-shaped tunnel group and 24 patients in the Y-graft group. The American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) pain score, Tegner score, and Karlsson score were evaluated and compared preoperatively and at follow-up. Anterior talar translation and talar tilt at stress radiographs, postoperative sprain recurrence, range of motion (ROM) restriction, sensory disturbance, etc., were also collected and compared. The mean follow-up times were 72 and 42months for the L-shaped group and Y-graft group, respectively. The median VAS pain score, Tegner score, AOFAS score, Karlsson score significantly improved from a preoperative level in both groups (all with p < 0.01). No significant difference was found between the two groups regarding the changes from preoperatively to postoperatively except for the VAS pain score reduction (1.58 ± 1.58 in the L-shaped group vs. 2.53 ± 1.29 in the Y-graft group, p = 0.035). The incidence of flexion-extension ROM restriction (≥ 5°) was significantly higher in the Y-graft group (41.2%) than in the L-shaped group (12.5%) (p = 0.035). Both the confluent L-shaped tunnel technique and the Y-graft technique significantly improved symptoms, ankle function, and radiographic outcomes in patients with chronic lateral ankle instability (CLAI) at mid- to long-term follow-up. The confluent L-shaped tunnel technique resulted in lower rates of flexion-extension ROM restriction, while the Y-graft technique showed better VAS pain reduction. This result could provide further evidence for the surgical treatment of CLAI. III.

Osteoid Osteoma: Percutaneous CT-guided Cryoablation Is a Safe, Effective, and Durable Treatment Option in Adults.

Background Cryoablation is playing an increasing role in the percutaneous treatment of bone tumors. However, despite its potential advantages over heat-based ablation techniques, the clinical safety and efficacy of cryoablation have not been established for osteoid osteoma treatment. Purpose To evaluate percutaneous CT-guided cryoablation for the treatment of osteoid osteoma in young patients and adults. Materials and Methods This retrospective study reviewed data from 50 consecutive patients who underwent percutaneous CT-guided cryoablation for the treatment of osteoid osteoma between January 2013 and June 2019 in a single institution. In 30 of 50 patients (60%), the procedure was carried out with the patient under local anesthesia and conscious sedation, with the cryoprobe covering the lesion from an extraosseous position, avoiding direct penetration of the nidus. Clinical and radiologic features, procedure-related data, visual analog scale (VAS) pain scores, complications, and overall success rate were evaluated. Statistical analyses were performed by using the nonparametric Friedman test and Wilcoxon signed rank test for repeated measures. Results Fifty patients (median age, 24 years; interquartile range [IQR], 19-38 years; 31 men) underwent CT-guided cryoablation for the treatment of osteoid osteoma, with a 96% (48 of 50 patients) overall clinical success rate. Of the two patients without clinical success, one patient had incomplete pain relief and the other experienced a recurrence of osteoid osteoma at 11 months, which was successfully treated with a second cryoablation procedure. The median VAS pain score was 8 (IQR, 7-8) before the procedure and 0 (IQR, 0-1; P < .001) after the procedure at both primary (6 weeks) and secondary (18-90 months) follow-up. Three of the 50 patients had minor complications (6%); no major complications were reported. Conclusion Osteoid osteoma was safely, effectively, and durably treated with CT-guided percutaneous cryoablation. In the majority of patients, treatment could be performed without general anesthesia, with the cryosphere covering the nidus from an extraosseous position. © RSNA, 2021.

P68. Racial disparities in presenting physical functionality and mental distress characteristics of patients undergoing spine surgery

<h3>BACKGROUND CONTEXT</h3> When considering severity of presentation, patient-reported outcomes (PROs) have become increasingly emphasized in orthopedic surgery as surrogates for quality of care. Additionally, PROs provide insight into the severity of an illness or injury and its impact on a patient's life and may also be predictors of treatment outcomes and patient satisfaction. The literature suggests that Black and other minority patients undergoing spine surgery are more likely to present with lower baseline PROs (bodily pain, physical functioning), worse symptom severity, and greater pain compared to white patients. <h3>PURPOSE</h3> To examine racial disparities in functional and mental health impairment, measured by PROMIS scores for mental health and physical impairment, upon indication for spine surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective Chart Review of patient reported scores on presentation for spinal surgery. <h3>PATIENT SAMPLE</h3> Patients between November 2018 and August 2019 who received 1-2 segment cervical decompression and fusion, 1-2 segment cervical or thoracic laminotomy, 1-2 segment lumbar laminotomy, 1-2 level lumbar interbody fusion, or arthrodesis to correct long, spinal deformity but limited to 8 segments or fewer. <h3>OUTCOME MEASURES</h3> Patient-Reported Outcome Measurement Information System (PROMIS) Global Physical Health (GPH) score, a PROMIS Global Mental Health (GPH) score, and a Visual Analog Scale (VAS) pain score at the time of presentation. <h3>METHODS</h3> Chi Square analysis, one-way analysis of variance (ANOVA), and Kruskal-Wallis analyses were used to determine if race, socioeconomic status of a patient's community, and procedure type had an effect on the degree of physical impairment, overall pain, or mental distress of a presenting patient. Bonferroni-corrected post hoc t tests and Dunn's post hoc nonparametric test for multiple comparisons were conducted after obtaining significant ANOVA, or Kruskal-Wallis results, respectively. <h3>RESULTS</h3> The overall study sample predominantly self-identified as racially White (73.5%), and males comprised 49.8% of the total cohort. At the time of presentation for spine surgery, patients presented with an average Visual Analog Scale (VAS) pain score of 5.84 (95% C.I: 5.66-6.03), a median PROMIS mental health score of 12 (IQR: 9-15), and a median PROMIS physical health score of 11 (IQR: 8-13). Notably, there was no difference in the presenting pain score by the Visual Analog Scale among patients who underwent the five different procedures (PANOVA = 0.9749) When compared to White patients undergoing the same procedure, Black/African-American patients had median VAS pain scores that were 16.7% higher, indicating greater pain, among those undergoing cervical decompression and fusion (P= 0.047) as well as lumbar interbody fusion (P=0.0167). Black/African-American patients had median VAS pain scores that were 60% higher among those undergoing cervical/thoracic laminotomy (P=0.0005), lumbar laminotomy (P<0.0001), and arthrodesis for spinal deformity (P=0.0012) when compared to White patients undergoing the same procedure. Additionally, Black/African-American patients had lower median PROMIS mental scores among those undergoing cervical/thoracic laminotomy (P=0.0012), lumbar laminotomy (P=0.0195), and lumbar interbody fusion (P=0.0208). Black/African-American patients had lower median PROMIS physical scores among those undergoing cervical decompression and fusion (P=0.0028), cervical or thoracic laminotomy (P=0.0024), lumbar laminotomy (P<0.0001), lumbar interbody fusion (P=0.0100), and arthrodesis to correct long, spinal deformity (P=0.0261). <h3>CONCLUSIONS</h3> These findings suggest that racial disparities exist in patients' presentation for spine surgery. Likely causes include disparities in household income, characteristics of a patient's neighborhood, and a patient's access to health care. Our findings refute any notions or misconceptions held by both medical professionals and laypersons that Black/African-American patients are more immune to pain and impairment when compared to White patients. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Enhanced recovery after cystectomy in patients with preoperative narcotic use.

The aim of this study was to evaluate the outcomes of radical cystectomy with an enhanced recovery after surgery (ERAS) protocol in patients with a history of chronic preoperative narcotic use compared to narcotic-naive patients. We identified 553 patients who underwent open radical cystectomy with ERAS. Preoperative narcotic use was identified in 34 patients who were then matched to 68 narcotic-naive patients. Postoperative outcomes, opioid use, and visual analog scale (VAS) pain scores were analyzed and compared. All routes of opioid use were recorded and converted to a morphine equivalent dose (MED). Patients with preoperative narcotic use reported higher median VAS pain scores per day (postoperative day [POD1]: 5.2 vs. 3.9, p=0.003; POD2: 5.1 vs. 3.6, p<0.001; POD3: 4.6 vs. 3.8, p=0.004) and used significantly more opioids (median MED) per day (POD1: 13.2 vs. 10.0, p=0.02; POD2: 11.3 vs. 6.4, p=0.003; POD3: 10.2 vs. 5.0, p=0.005) following surgery. Preoperative narcotic users were noted to have a significantly higher incidence of 90-day re-admissions (41.2% vs. 20.6%, p=0.03). There was no difference in median hospital stay (4 vs. 4 days, p=0.6), 30-or 90-day complications (64.7% vs. 60.3%, p=0.8 and 82.4% vs. 75.0%, p=0.4, respectively) or gastrointestinal complications (29.4% vs. 26.5%, p=0.8), including postoperative ileus (11.8% vs. 20.6%, p=0.2). Patients with preoperative narcotic exposure report higher pain scores and require more opioid use following radical cystectomy with ERAS and are more likely to be re-admitted within 90 days. However, there was no observed difference in hospital stay or complications.

The effectiveness of PROLOTHERAPY for recalcitrant Medial TIBIAL Stress Syndrome: a prospective consecutive CASE series

BackgroundMedial tibial stress syndrome (MTSS) is one of the most common lower leg injuries in sporting populations. It accounts for between 6 and 16% of all running injuries, and up to 53% of lower leg injuries in military recruits. Various treatment modalities are available with varying degrees of success. In recalcitrant cases, surgery is often the only option.ObjectiveTo evaluate whether ultrasound-guided injection of 15% dextrose for treatment of recalcitrant MTSS decreases pain and facilitates a return to desired activity levels for those who may otherwise be considering surgery or giving up the sport.MethodThe study design was a prospective consecutive case series involving eighteen patients: fifteen male and three female; (mean age = 31.2 years) with recalcitrant MTSS. They were referred from sports injury clinics across the UK, having failed all available conservative treatment.InterventionAn ultrasound-guided sub-periosteal injection of 15% dextrose was administered by the same clinician (NP) along the length of the symptomatic area. Typically, 1 mL of solution was injected per cm of the symptomatic area.Main outcome measuresPain was assessed using a 10-cm visual analog scale (VAS) at baseline, short-term, medium-term (mean 18 weeks), and long-term (mean 52 weeks) follow-up. Symptom resolution and return to activity were measured using a Likert scale at medium and long-term follow-up. Statistical analyses were performed using SPSS for Mac version 19.0.0 (IBM, New York, NY, US). The Shapiro-Wilk test was used to evaluate the normality of the distribution of data. Friedman’s non-parametric test was used to compare the within-patient treatment response over time. Post-hoc Wilcoxon signed-rank tests with Bonferroni corrections were performed to determine VAS average pain response to treatment over five paired periods.ResultsPatients reported a significant (p < 0.01) reduction in median VAS pain score at medium and long-term follow-up compared to baseline. Median improvement per patient was 4.5/10. Patients rated their condition as ‘much improved’ at medium-term follow-up and the median return to sports score was ‘returned to desired but not pre-injury level’ at medium-term and long-term follow-up. No adverse events were reported.ConclusionsUltrasound-guided 15% dextrose prolotherapy injection has a significant medium-term effect on pain in MTSS. This benefit may be maintained long-term; however, more robust trials are required to validate these findings in the absence of controls.Clinical relevanceClinicians should consider the use of ultrasound-guided injection of 15% dextrose as a viable treatment option to reduce pain and aid return to activity for patients with recalcitrant MTSS.

Short-Term Effects of Early Postoperative Celecoxib Administration for Pain, Sleep Quality, and Range of Motion After Total Knee Arthroplasty: A Randomized Controlled Trial

BackgroundWe hypothesized that early postoperative administration of celecoxib would reduce pain scores and improve sleep quality and active range of motion after total knee arthroplasty (TKA) under general anesthesia. MethodsPatients in the celecoxib group received 400 mg of celecoxib 2 hours after TKA, followed 6 hours later by 200 mg of celecoxib. Patients in the control group received 400 mg of celecoxib the second day after surgery. Patients in both group had access to patient-controlled analgesia fentanyl. The primary outcome measure was the patient-reported visual analog scale (VAS) pain score the second day after TKA. The secondary outcome measure was sleep quality (days 1, 2, and 7 postoperatively). Active knee joint range of motion was assessed on days 2 and 7 postoperatively, and VAS pain scores were evaluated on postoperative days 1 to 7. Total fentanyl consumption was also assessed. ResultsCompared to the control group, the celecoxib group had significantly lower median VAS pain scores on postoperative days 1 and 2, significantly less nocturnal awakening (in minutes) and frequency of body motion, and better sleep efficacy on postoperative day 1. The celecoxib group also had a significantly better median flexion angle (°) on postoperative days 2 and 7, and lower cumulative fentanyl consumption. ConclusionEarly administration of celecoxib after TKA was associated with significantly reduced early VAS pain scores and improved sleep quality and active knee flexion angles. Thus, the early administration of celecoxib after TKA under general anesthesia may reduce pain and improve sleep quality and functional recovery. Levels of EvidenceLevel II, therapeutic study. Trial RegistrationUMIN-CTR 000014624 (July 23, 2014).

Evaluating the User Preference and Level of Insulin Self-Administration Adherence in Young Patients With Type 1 Diabetes: Experience With Two Insulin Pen Needle Lengths.

BackgroundSelecting the appropriate insulin pen needle is important to reduce pain and injection-related adverse events like insulin leakage. It also helps to improve medication adherence and glycemic control in patients with type 1 diabetes mellitus (T1DM).ObjectiveThis study aimed to compare the 6-mm and 8-mm 32.5-gauge insulin pen needles in terms of glycemic control, pain score, user preference, medication adherence, and injection adverse events in patients with T1DM.MethodsWe conducted a prospective cohort study of 62 patients with T1DM. All patients constituted an experimental group initially and then changed the length of the needle to be part of a self-control group. The glycemic control, visual analog scale (VAS) pain score, Morisky Medication Adherence Scale (MMAS) score, needle attribute score, and injection-related adverse events were measured for all patients with both lengths of needles. Patients were assessed at the baseline visit and followed up for three months. Statistical comparisons were done by the chi-squared test, paired t-test, and paired Wilcoxon test when appropriate with a two-tailed alpha level below 0.05 indicating statistical significance.ResultsWith the NanoPass® 32.5-gauge, 6-mm needle (Terumo Corp., Tokyo, Japan), patients had significantly lower glycated hemoglobin (HbA1c) compared to 8-mm needles (7.9% vs. 8.3%; p<0.001). The proportions of patients who reported no hypoglycemic episodes were 22/62 and 9/62, with the 6-mm and 8-mm needles, respectively. The 6-mm needles were better in terms of the following parameters compared to 8-mm needles: mean needle attribute scores (36.7 vs. 24.2; p<0.001), median VAS pain scores (20 vs. 55; p<0.001), insulin leakage (6/62 vs. 20/62; p=0.002), and the MMAS score (4.9 vs. 3.4; p<0.001).ConclusionThis study provided an overview of the safety, adherence, pain score, and glycemic control relating to the 6-mm and 8-mm insulin needle lengths. Insulin injections using the NanoPass 32.5-gauge, 6-mm needle were associated with lower pain score, higher patient adherence, fewer adverse events, and better glycemic control compared to the 8-mm needle. Therefore, we recommend the use of the NanoPass 6-mm needle for patients with T1DM. Further studies are needed to confirm these findings in patients with type 2 diabetes mellitus (T2DM).

P1328EFFECTIVENESS OF MUSIC FOR ALLEVIATING PAIN DURING HAEMODIALYSIS ACCESS CANNULATION: A MULTI-FACILITY, SINGLE-BLIND, RANDOMISED CONTROLLED TRIAL

Abstract Background and Aims Repeated needle pain during haemodialysis (HD) access cannulations is a serious problem for HD patients. Although the efficacy of music for alleviating pain and anxiety is well established, there is insufficient scientific evidence related to its effectiveness in alleviating pain during access cannulations during HD. This study aimed to investigate the effects of music on reducing pain during access cannulating in HD patients. Method A prospective, multi-facility, single-blind, crossover, randomised controlled trial was conducted. The intervention included listening to Mozart and a white-noise control condition. Patients were randomly allocated to either an ‘Early-group’ or a ‘Later-group’. All patients who underwent cannulation wore headphones without sound in the first and third weeks (No-sound period). The Early-group received cannulation while listening to Mozart’s Sonata for Two Pianos in D major (K.448) during the second week (Music period), and white noise during the fourth week (White noise period). The Later-group received cannulation while listening to white noise first, followed by Mozart in the fourth week. During each period, the music or no-music protocol started 8 minutes prior to the cannulation, and participants finished listening after HD began. The Visual Analogue Scale (VAS) was used to measure pain and anxiety during cannulation and the VAS scores for pain and anxiety were compared for the music and no-music settings. We evaluated the ratio of outcome measures between the music and white noise periods with the repeated measure mixed effect regression. We analysed the effects according to the intention-to-treat principle. Two-sided-significance-level was set at 0.05. Results In total, one hundred and twenty-one patients were enrolled in this study, across four facilities. The median age was 64 years, and there were 84 males (69.4%). Sixty-five patients (53.7%) used analgesics for alleviating pain. The median VAS pain score was 28 and VAS anxiety score was 19 in No-sound period. The Mozart music setting had a 12.2% (95% confidence interval (CI): 2.3 to 21.1, p=0.017) lower VAS score than the white noise setting. On the other hand, there was no significant difference in the VAS anxiety score between the two groups, that is the Mozart music setting had a 7.96% (95% CI: -4.70 to 18.4, p=0.172) reduction compared to the white noise setting. Conclusion We examined the effects of Mozart’s music on alleviating pain using scientific methods. The music appears to reduce pain of access cannulation in HD patients. Although the trial assessed the effects of music using a single musical composition, the study did not clarify the effects of music on the physical, emotional, and cognitive status of patients. Further studies in this direction are required.

Contralateral limb improvement after unilateral iliac vein stenting argues against simultaneous bilateral stenting

ObjectiveSymptoms of chronic venous insufficiency secondary to obstructive iliofemoral disease are often bilateral. The impact of iliofemoral stenting of the more symptomatic lower extremity on clinical outcomes in the less affected contralateral extremity is not clear. Such benefit, secondary to offloading of collaterals, may potentially be of the magnitude that the contralateral extremity does not require intervention. MethodsA retrospective review of contemporaneously entered electronic medical record data of 368 patients/limbs with initial unilateral iliocaval stents (240 left and 128 right) placed during a 3-year period from 2015 to 2017 was performed. Patients who underwent simultaneous bilateral stenting or had occlusive disease were excluded. Of the remainder, the impact of stenting on contralateral leg symptoms was evaluated by analyzing visual analog scale (VAS) pain score (1-10), grade of swelling (1-3), and Venous Clinical Severity Score (VCSS). The duration of any improvement and need for intervention on the contralateral side were also appraised. Kaplan-Meier analysis was used to assess stent patency after intervention, whereas paired t-tests were used to examine clinical outcomes. ResultsOf the 368 limbs that underwent stenting with a combination of a Wallstent (Boston Scientific, Marlborough, Mass) with a Z stent (Cook Medical, Bloomington, Ind) for stenotic lesions, 304 patients (89 men and 215 women) had contralateral symptoms (200 left and 104 right). The cause was post-thrombotic syndrome in 229 limbs and May-Thurner syndrome or nonthrombotic iliac vein lesion in 75 limbs. In this contralateral group, at 12 months, the VAS pain score improved from 5 to 0 (P < .0001), the grade of swelling went from 3 to 1 (P < .0001), and VCSS went from 5 to 3 (P < .0001) after stenting of the ipsilateral side. During the median follow-up of 20 months, 15 contralateral limbs underwent stenting. Median time to stenting of the contralateral limb after ipsilateral stenting was 9 months. The median VAS pain score, grade of swelling, and VCSS in this group before stenting were 6.5, 2, and 5 compared with 0 (P < .0001), 1 (P = .27), and 3 (P = .0021), respectively, in those members of the contralateral group who did not require stenting. Primary and primary assisted patencies at 12 months after contralateral stenting were 78% and 100%, respectively. There were no stent occlusions after contralateral stenting. ConclusionsPatients with bilateral obstructive iliofemoral venous lesions often experience improvement of the contralateral limb symptoms (95%) after stenting of the worse ipsilateral limb. Only 15 of 304 (5%) symptomatic contralateral limbs had to undergo stenting during the follow-up period because of a worsening clinical picture. Based on this, a staged approach to iliofemoral stenting in patients with bilateral symptoms focusing initially on the more symptomatic limb is suggested.

Ropivacaine versus placebo on postoperative analgesia and chronic pain following third molar extraction: A Prospective Randomized Controlled Study

PurposeThe present study aimed at assessing the efficiency of ropivacaine on post-operative pain for extraction of third molars. MethodsIn a single centre, prospective, parallel, double blind randomised trial, patients scheduled for removal of all four third molars, ASA I–III patients<65 year-old patients were included. After intubation under general anesthesia (using intravenous remifentanil and propofol), for each of the third molars, 2mL of ropivacaine (7.5mg/mL) or placebo (0.9% saline solution) was injected into the vestibular capsule (total: 8mL) before extraction. At the end of surgery, similar analgesia was injected for both groups (intravenous paracetamol 1g and ketoprofene 100mg). The primary outcome was postoperative pain assessed by Visual Analog Scale (VAS). Postoperative consumption of analgesics (morphine titration in post-operative care unit when VAS>3/10, followed by oral tramadol 50mg after discharge), patient satisfaction, chronic pain (1–3 month), time in PACU and total hospitalization time were also recorded. ResultsA total of 50 patients were analysed in each group with similar characteristics (ropivacaine vs. control, for age (years) 18 [17–21] vs. 18 [17–21], for sex (female) 33 (66%) vs. 25 (50%), and BMI (kg/m2): 20 [19–23] vs. 21 [19–23]). Area Under the Curve for VAS pain (0 to 4h) was lower for Ropivacaine group: 0.43 [0.19–0.66] vs. 0.63 [0.43–0.87], P=0.005. Use of morphine in PACU (8 vs. 18, P=0.02) and median length of stay in ambulatory setting (5 vs. 6h, P=0.03) were reduced in Ropivacaine vs. Placebo group. At days 1 and 4, VAS of pain was higher in Ropivacaine group (respectively 4 vs. 2, P=0.006 and 3 vs. 2, P=0.05). At month 1 and 3, pain and DN4 score were similar between groups, with a median VAS pain score at 0 for both groups (P=0.42). No difference was observed for patient satisfaction and adverse events. ConclusionsRopivacaine provides an immediate efficient pain relief after extraction of third molars without benefit after discharge. ClinicalTrial registrationNCT01541059.

Shoulder Pain Among Patients With Amyotrophic Lateral Sclerosis: A Case Series.

Evidence has demonstrated that shoulder pain constitutes a functional impairment for patients with amyotrophic lateral sclerosis (ALS). No studies have yet examined the efficacy of scapular mobilization of the painful shoulder among patients with ALS. Our retrospective case series evaluated the effects of scapular mobilization on pain and shoulder motion among patients with ALS. Retrospective case series over 2 yr. A multidisciplinary outpatient clinic at an academic medical institution. Twenty-eight patients with ALS who had shoulder pain and range of motion (ROM) limitations. Patients were excluded if information on visual analog scale (VAS) score for pain and shoulder ROM was not available. Scapular mobilization, ROM, and caregiver education. All patients also received standard occupational therapy treatment for this patient population. The primary outcome was VAS shoulder pain scores; the secondary outcome was shoulder flexion ROM. The median VAS pain score was 2 before treatment and 0 after treatment, with a significant median reduction of 2. Median shoulder flexion ROM was 100° before mobilization treatment and 130° after treatment, with a significant median increase of 25°. The results provide strong evidence that both VAS pain score and shoulder ROM noticeably improve after mobilization treatment. Occupational therapists can effectively promote shoulder care techniques such as scapular mobilization to both patients and care providers to reduce pain and improve quality of life for patients with ALS.

Comparing the Efficacy of IV Ibuprofen and Ketorolac in the Management of Postoperative Pain Following Arthroscopic Knee Surgery. A Randomized Double-Blind Active Comparator Pilot Study.

Introduction: Acute postoperative pain following knee arthroscopy is common in orthopedic surgeries. Managing pain postoperatively combines usage of opioids and non-steroidal anti-inflammatory drugs. The aim of this clinical study was to assess the efficacy of two different analgesic treatment regimens: intravenous (IV) ibuprofen and IV ketorolac for the treatment of postoperative pain pertaining to arthroscopic knee surgery.Methods: This was a single center, randomized, double-blind, parallel, active comparator clinical pilot study. Subjects were randomized to receive either IV ibuprofen, administered as two 800 mg doses or IV ketorolac, administered as a single 30 mg dose. Subjects in the ibuprofen group received 800 mg of IV ibuprofen within 2 h prior to surgery and a repeated second dose 4 h after the initial dose if they had not been discharged. Subjects in the ketorolac group received IV ketorolac 30 mg at the end of surgery, as per the manufacturer's recommendations. Pain assessments and opioid consumption data were collected up to 24 h postoperatively.Results: Of 53 randomized subjects, 51 completed the study. There were 20 subjects in the ibuprofen group and 31 subjects in the ketorolac group. The median (IQR) visual analog scale (VAS) pain score at resting upon post-anesthesia care unit (PACU) arrival was 33 (12, 52) vs. 9 (2, 25) (p = 0.0064) for the ketorolac and ibuprofen group, respectively. The median (IQR) visual analog scale (VAS) pain score at movement upon PACU arrival was 38 (20, 61) vs. 15 (6, 31) (p = 0.0018) for the ketorolac and ibuprofen group, respectively. Median VAS pain scores during movement taken at subsequent 30 min intervals in the ibuprofen group were less than half that of those reported in the ketorolac group for up to 90 min after arriving in PACU. The median VAS pain scores at rest and movement in the course of 120 min−24 h after PACU arrival was not statistically significant in both groups. Rescue opioid medication during PACU stay was required in 55.0% (N = 11) and 83.9% (N = 26), with a mean amount of narcotic consumption (oral morphine conversion) of 5.53 ± 5.89 mg vs. 19.92 ± 15.63 mg for the ibuprofen and ketorolac group, respectively (P < 0.001). However, opioid consumption during the first 24 h after PACU discharge was not statistically significant (p-value = 0.637). The mean time to first rescue medication was 77.62 ± 33.03 and 55.78 ± 35.37 for the ibuprofen and ketorolac group, respectively (p-value = 0.0456). There were no significant differences in patient satisfaction and documented adverse events during the first 24 h.Conclusion: This pilot study showed that the use of preemptive IV ibuprofen 800 mg could be considered to reduce postoperative pain and opioid consumption. Future prospective clinical trials using similar regimens should be conducted in order to gain a better understanding of how to best provide perioperative analgesic regimens.Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT01650519.

Clinical Outcomes Following the Latarjet Procedure in Contact and Collision Athletes.

Few studies have evaluated the success of the Latarjet procedure for recurrent anterior glenohumeral instability in the contact or collision athlete. The purpose of this study was to evaluate the return-to-sport and functional results of the Latarjet procedure in this select group. One hundred and nine consecutive contact or collision athletes (112 shoulders) treated with an open Latarjet procedure for recurrent anterior glenohumeral instability were retrospectively identified. Seventy-three shoulders in 73 patients (67%) were evaluated at a mean follow-up of 52 months (range, 24 to 120 months). The average age at surgery was 25.8 years (range, 15 to 54 years). The primary outcomes were the scores on the Western Ontario Shoulder Instability Index (WOSI), the American Shoulder and Elbow Surgeons (ASES) questionnaire, a visual analog scale (VAS) for pain, and return to sport. Predictors of return to sport were analyzed. Six (8%) of the 73 patients experienced ≥1 postoperative dislocations. Ten additional patients (14%) experienced a perception of instability without a dislocation. The median postoperative WOSI and ASES scores were 382 (range, 0 to 2,016) and 93.3 (range, 21.7 to 100), respectively. The median postoperative VAS pain score was 0 (range, 0 to 10). Forty-nine percent (36) of the 73 patients returned to their preoperative sports level, 14% (10) decreased their activity level in the same sport, 12% (9) changed sports, and 25% (18) decreased their level of activity and changed sports or stopped participating in sports altogether. Patients with ≥2 stabilization procedures prior to the Latarjet procedure demonstrated a lower likelihood of returning to their original sport (p = 0.019; relative risk = 2.84; 95% confidence interval = 1.34 to 6.06). The percentage of glenoid bone loss showed no association with the return-to-sport rate (p = 0.507). The outcome of the Latarjet procedure in high-risk contact or collision athletes is variable. Patients who have fewer prior stabilization surgical procedures are more likely to successfully return to their original sport. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

New Pain Management Procedure after Total Knee Arthroplasty: Gonyautoxins are Safe and Effective after A Single Intra-Articular Infiltration

Objective To evaluate the effect of a single intraarticular dose of Gonyautoxins for pain control after Total Knee Arthroplasty (TKA). Subjects 30 consecutive patients with osteoarthritis with Kellgren &amp; Lawrence level of two or more, who required TKA, were enrolled. Methods Subjects receive a single intra-articular infiltration of 40 µg dose of Gonyautoxins, immediately after TKA wound closure. The pain was measured with the Visual Analog Scale (VAS). Additionally, the range of motion at 12, 36, and 60 hours and hospital stay length were recorded. Results were compared to the 2014 TKA cohort. Results 25 patients (83.33%) achieved successful pain management. All patients achieved complete flexion ≥90° 60 hours after surgery and 24 patients achieved full extension before hospital discharge. The median VAS pain score for each evaluation period was ≥2. The 25 Gonyautoxins treated patients who achieved successful pain management had a median VAS pain score of 0 after 36 and 60 hours. Conclusions Gonyautoxins are safe and effective in pain management after TKA when used as a single intra-articular dose. This protocol shows adequate pain control in TKA, reducing discharge to 3 days and greater range of motion, improving the post-operated patient experience.