NRS-11 Scores Research Articles

Does selective intraoperative music reduce pain following abdominal wall reconstruction? A double-blind randomized controlled trial

PurposeAlthough intraoperative music is purported to mitigate postoperative pain after some procedures, its application has never been explored in abdominal wall reconstruction (AWR). We sought to determine whether intraoperative music would decrease early postoperative pain following AWR.MethodsWe conducted a placebo-controlled, patient-, surgeon-, and assessor-blinded, randomized controlled trial at a single center between June 2022 and July 2023 including 321 adult patients undergoing open AWR with retromuscular mesh. Patients received noise-canceling headphones and were randomized 1:1 to patient-selected music or silence after induction, stratified by preoperative chronic opioid use. All patients received multimodal pain control. The primary outcome was pain (NRS-11) at 24 ± 3 h. The primary outcome was analyzed by linear regression with pre-specified covariates (chronic opioid use, hernia width, operative time, myofascial release, anxiety disorder diagnosis, and preoperative STAI-6 score).Results178 patients were randomized to music, 164 of which were analyzed. 177 were randomized to silence, 157 of which were analyzed. At 24 ± 3 h postoperatively, there was no difference in the primary outcome of NRS-11 scores (5.18 ± 2.62 vs 5.27 ± 2.46, p = 0.75). After adjusting for prespecified covariates, the difference of NRS-11 scores at 24 ± 3 h between the music and silence groups remained insignificant (p = 0.83). There was no difference in NRS-11 or STAI-6 scores at 48 ± 3 and 72 ± 3 h, intraoperative sedation, or postoperative narcotic usage.ConclusionFor patients undergoing AWR, there was no benefit of intraoperative music over routine multimodal pain control for early postoperative pain reduction.Trial registrationClinicalTrials.gov: NCT05374096.

Normality analysis of numeric rating scale scores in patients with chronic axial spine pain before and after medial branch blocks: a multicenter study.

The statistical analysis typically used to compare pain before and after interventions assumes that scores are normally distributed. The present study evaluates whether numeric rating scale (NRS) scores, specifically NRS-11 scores, are indeed normally distributed in a clinically relevant cohort of adults with chronic axial spine pain before and after analgesic intervention. Retrospective review from 4 academic medical centers of prospectively collected data from a uniform pain diary administered to consecutive patients after they had undergone medial branch blocks. The pain diary assessed NRS-11 scores immediately before injection and at 12 different time points after injection up to 48 hours. D'Agostino-Pearson tests were used to test normality at all time points. One hundred fifty pain diaries were reviewed, and despite normally distributed pre-injection NRS-11 scores (K2 = 0.655, P = .72), all post-injection NRS-11 data were not normally distributed (K2 = 9.70- 17.62, P = .0001-.008). Although the results of parametric analyses of NRS-11 scores are commonly reported in pain research, some properties of the NRS-11 do not satisfy the assumptions required for these analyses. The data demonstrate non-normal distributions in post-intervention NRS-11 scores, thereby violating a key requisite for parametric analysis. We urge pain researchers to consider appropriate statistical analysis and reporting for non-normally distributed NRS-11 scores to ensure accurate interpretation and communication of these data. Practicing pain physicians should similarly recognize that parametric post-intervention pain score statistics might not accurately describe the data and should expect articles to utilize measures of normality to justify the selected statistical methods.

Pain Reduction and Changes in Serum Cortisol, Adrenocorticotropic Hormone, and Glucose Levels after Epidural Injections With Different Doses of Corticosteroid

BACKGROUND: An epidural steroid injection (ESI) effectively relieves acute lumbar discogenic radicular pain. Corticosteroids, a key ESI component, reduce pain by curbing inflammation and blocking pain signal transmission via C-fibers. While prior research confirms the efficacy of 40 mg and 80 mg methylprednisolone, the effectiveness of lower doses remains uncertain. OBJECTIVES: This trial aimed to compare the pain-relieving effects of ESI using varying methylprednisolone doses (10 mg, 20 mg, and 40 mg). Additionally, it sought to examine changes in fasting plasma glucose (FPG), serum cortisol, and serum adrenocorticotropic hormone (ACTH) levels across these groups. STUDY DESIGN: A prospective observational study. SETTING: Department of Pain Medicine, Affiliated Jinling Hospital, Medical School of Nanjing University, People’s Republic of China. METHODS: Ninety-three patients underwent a single epidural injection of methylprednisolone at different doses: 10 mg (n = 28), 20 mg (n = 32), and 40 mg (n = 33). We evaluated their Numeric Rating Scale (NRS-11) score and Oswestry Disability Index (ODI) score at preinjection and 7 days postinjection. We also measured FPG, serum cortisol, and ACTH levels at baseline and one day postinjection. RESULTS: Significant differences were observed in the likelihood of achieving substantial pain relief among the 3 groups at 7 days postinjection. Specifically, 10 mg vs 20 mg had an odds ratio (OR) of 6.546 (95% CI, 1.161 - 26.513, P = 0.008), and 10 mg vs 40 mg had an OR of 7.753 (95% CI, 1.98 - 30.353, P = 0.003). However, there was no significant difference between 40 mg and 20 mg, with an OR of 0.844 (95% CI, 0.239 - 2.987, P = 0.793) in Model 3. Additionally, the baseline NRS-11 score significantly predicted substantial pain relief, with an OR of 0.47 (95% CI, 0.287 - 0.768, P = 0.003). Furthermore, at 7 days postinjection, the ODI score was significantly lower in the 20 mg group (P = 0.007) and the 40 mg group (P < 0.001) compared to the 10 mg group. Moreover, the difference in serum cortisol and FPG between the 40 mg and 10 mg groups was more pronounced (P < 0.01), while the difference in ACTH was similar among all 3 groups (P = 0.191). LIMITATIONS: Potential selection bias and a short follow-up period may have influenced our study, and certain imaging results were omitted from the regression models. CONCLUSIONS: The effectiveness of ESI in relieving pain was found to be similar for both 20 mg and 40 mg doses, but with fewer changes in FPG and serum cortisol levels for the former (which were not statistically significant). As a result, it may be clinically viable to use a 20 mg dose for achieving short-term pain relief. Moreover, the baseline NRS-11 scores were found to be a reliable predictor of pain relief efficacy, with milder baseline pain intensity being associated with better pain relief outcomes. KEY WORDS: Epidural steroids, epidural injection, herniated disc, methylprednisolone, dose, cortisol, glucose, adrenocorticotropic hormone

Reliability and validity of the Dutch version of the Parents’ Postoperative Pain Measure (PPPM-Dv)

Background: Pain is often poorly managed in pediatric daycare surgery. The Parents’ Postoperative Pain Measure (PPPM) is available as parent report to rate children’s pain at home after surgery and is a reliable and well validated tool. Objectives: To establish the reliability and validity of the Dutch version of the Parents’ Postoperative Pain Measure (PPPM-Dv) to assess postoperative pain among children aged between 2 and 12 years during five postoperative days at home. Design: cross-sectional cohort study. Setting: ZNA Queen Paola’s Children’s Hospital. Methods: 120 children were included. Stratification was done according to age (2-5 and 6-12 years) and three surgical categories. Parents socioeconomic status (SES) and religion were registered. For all children, parents recorded pain using the PPPM-Dv and Numerical Rating Scale (NRS-11) twice daily for five days. Children between 6-12 years were asked to rate their experienced pain using the Faces Pain Scale-Revised (FPS-R). Results: From 120 children included 91 (76.6%) families completed pain diaries. Reliability across the five-day postoperative period, Cronbach’s α for PPPM-Dv was .70 to .90. Correlations between PPPM-Dv and NRS- 11/FPS-R were strong (.81 and .61). Using NRS-11(≥4) as binary classifier (yes/no), ROC analysis identified a PPPM-Dv score >2 as cut-off, with a sensitivity of 89% and specificity of 82%. With FPS-R (≥4) as binary classifier (yes/no), ROC analysis identified a PPPM-Dv score >2 as cut-off (sensitivity:88%; specificity:79%). PPPM-Dv scores decreased over time and followed a similar pattern as the NRS-11 and FPS-R scores. Generalized Estimation Equations (GEE) showed that higher PPPM-Dv scores were associated with a more painful surgical category and were independent of SES and religious affiliation. Conclusion: These data provide evidence for the reliability and validity of the PPPM-Dv. This can be a helpful tool to identify pain in children after daycare surgery at home in a Dutch speaking population. Trial registration: https://doi.org/10.1186/ISRCTN12813822

CTNI-79. PHASE 2 RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY OF THE ANTI-NERVE GROWTH FACTOR (NGF) ANTIBODY TANEZUMAB IN SUBJECTS WITH MODERATE TO SEVERE PAIN DUE TO SCHWANNOMATOSIS

Abstract INTRODUCTION Schwannomatosis (SWN) is a rare neurogenetic condition (prevalence 1:125,000) characterized by multiple schwannomas and severe chronic pain. Increased expression of nerve growth factor (NGF) has been identified in painful schwannomas. METHODS We conducted a single-institution, phase 2, randomized, double-blind, placebo-controlled trial of tanezumab, an anti-NGF antibody. Eligibility criteria included age ≥ 18; moderate-to-severe SWN-related pain; ability to discontinue NSAIDs; and absence of osteoarthritis. Participants were treated with tanezumab 10 mg SQ or placebo (double-blind treatment) followed by tanezumab 10 mg SQ (single-arm treatment). The primary endpoint was change in NRS-11 scores between days 1 and 57 (double-blind). Secondary endpoints included change in PROMIS-Pain Interference (PI) T-scores. RESULTS Nine subjects were enrolled (median age 44 years, 7 females). At baseline, mean NRS-11 score was 7.6 (SD 2.1) and mean PROMIS-PI T-score was 63.2 (SD 6.6). During double-blind treatment, four participants were randomized to receive tanezumab (early group) and five were randomized to placebo (delayed group). For the early group, the mean change in NRS-11 score was -2.5 (SD 4.5) after initial tanezumab and 0 (SD 0) with continued treatment. For the delayed group, the mean change in NRS-11 score was -0.4 (SD 2.1) with placebo and -1.4 (SD 1.9) after tanezumab. For the early group, the mean change in PROMIS-PI T-score was -6.2 (SD 10.9) after initial tanezumab and -0.4 (SD 2.0) with continued treatment. For the delayed group, the mean change in PROMIS-PI T-score was 1.1 (SD 2.9) after placebo and -3.3 (SD 4.1) after tanezumab. Discussion: For SWN patients with moderate-to-severe pain, addition of tanezumab was associated with decreases in pain intensity and pain interference. Although these changes reflect clinically meaningful differences per published literature, they were not statistically significant. This study was underpowered due to poor accrual and a larger study in this patient population is warranted.

Comparison of the Efficacy of Percutaneous Balloon Compression and Extracranial Non gasserian Ganglion Radiofrequency Thermocoagulation for Primary Multibranch Trigeminal Neuralgia

BACKGROUND: Both computed tomography-guided extracranial nongasserian ganglion radiofrequency thermocoagulation (RFT) and percutaneous balloon compression (PBC) have significant clinical efficacy in the treatment of trigeminal neuralgia, but a comparison of the efficacy of the 2 methods for pain in primary multibranch trigeminal neuralgia (TN) has not been studied clinically. OBJECTIVE: To compare the efficacy and safety of PBC with extracranial nongasserian ganglion RFT in the treatment of primary multibranch TN. STUDY DESIGN: This is a single-center, retrospective, observational study. SETTING: This study was conducted at the Pain Department of the Affiliated Hospital of Jiaxing College in Jiaxing, People’s Republic of China. METHODS: A total of 202 patients, including 112 patients in the RFT group and 90 patients in the PBC group, with multi-branch TN who visited the pain department of Jiaxing First Hospital for percutaneous minimally invasive surgery from April 2016 through June 2021 were retrospectively analyzed. Patients in both groups were followed-up regularly after surgery, and the Numeric Rating Scale, recurrence-free survival rate, Barrow Neurological Institute facial numbness score, and other postoperative complications were recorded before surgery (T0), immediately after surgery (T1) and at 3 months (T2), 6 months (T3), 12 months (T4), and 15 months (T5) postoperatively. RESULTS: All patients completed the operation successfully. No significant difference was found between the two groups in terms of gender, age, pain duration, preoperative Numeric Rating Scale (NRS-11), lateralization of pain and affected branches, and preoperative underlying disease (P > 0.05). There was a significant difference in preoperative and immediate postoperative NRS-11 scores between the 2 groups (P < 0.01). NRS-11 scores decreased at each time point (T1-T5) and were significantly different from preoperative scores (P < 0.001). Meanwhile, no significant difference was found in NRS-11 scores at T0, T1, and T2 between the RFT and PBC groups (P > 0.05). However, the differences were statistically significant at T3 (P < 0.05), T4 (P < 0.001), and T5 (P < 0.001). BNI-N scores decreased in both groups at T2, T3, T4, and T5 after surgery and were significantly different from preoperative scores (P < 0.05). BNI-N scores were significantly lower in the PBC group than in the RFT group at all time points (P < 0.05). In the long-term treatment of multibranch trigeminal neuralgia, the PBC group exhibited a lower recurrence rate than the RFT group. No severe complications or deaths were observed in either of the 2 groups. LIMITATIONS: A small sample size and being conducted at a single center are limitations of our study. CONCLUSION: Both RFT and PBC were effective in relieving primary multibranch TN, but patients in the PBC group had a lower recurrence-free survival rate, fewer complications, and a better safety profile. Follow-up studies with a larger patient sample held at multiple locations should be conducted. KEY WORDS: Radiofrequency thermocoagulation, percutaneous balloon compression, trigeminal neuralgia, extracranial nongasserian ganglion, multibranch pain

Effectiveness of Ultrasound-guided versus Anatomical Landmark-guided Genicular Nerve Block to Treat Chronic Knee Osteoarthritis: A Retrospective Cohort Study.

There is limited data on the relative effectiveness of different techniques used for administering genicular nerve block (GNB) for pain management of chronic knee osteoarthritis (OA) in the Malaysian population. This study aims to determine and compare the effectiveness of GNB administered using two pain management techniques?"anatomical landmark-guided (ALG) and ultrasound-guided (USG)?"for chronic knee OA in this population. This retrospective cohort study included 40 patients with chronic knee OA who received GNB, 20 of whom underwent treatment with the USG technique and the other 20 with the ALG technique. Pain, stiffness, and functional limitation scores were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index Questionnaire (WOMAC) and Numeric Rating Scale (NRS-11) at baseline and post-treatment day one, three weeks, and six weeks. Both groups reported a significant reduction in WOMAC and NRS-11 scores as per their feedback on day one, three weeks, and six weeks post-treatment. Greater reductions in WOMAC and NRS-11 scores were reported by patients who received GNB via USG than by ALG technique, the difference achieving statistical significance at six weeks after treatment (p =0.026). GNB administration using USG and ALG techniques are both effective in significantly reducing pain, stiffness, and functional limitation in patients suffering from chronic knee OA. Among the two techniques, USG appears to be more effective. Nevertheless, GNB guided by ALG continues to be a viable treatment modality, especially in healthcare settings with limited to no USG facilities.

Laser Treatment for Patients With Vulvodynia and Interstitial Cystitis/Bladder Pain Syndrome: A Case Series (The UNICORN-3 Study).

Introduction Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic pain disorder characterized by urgency, frequency of urination, and pelvic pain. Women with IC/BPS often experience sexual dysfunction, vulvodynia, and vaginal health issues. Combined erbium and neodymium yttrium aluminum garnet (YAG) laser treatments targeting the vagina and vulva have shown promise in improving symptoms. Our study aims to investigate the effectiveness of these combined laser treatments in women with IC/BPS and vulvodynia. Methods Women diagnosed with vulvodynia and IC/BPS underwent combined laser treatment using vaginal erbium:YAG laser (VEL) and neodymium:YAG laser (Nd:YAG). Various parameters were evaluated, including the vulvodynia test, numeric rating scale (NRS-11) for pain, interstitial cystitis symptom index and problem index (ICSI and ICPI), pelvic painand urgency/frequency symptom score (PUF), and mean urination volume/daily urination frequency in a three-day urination diary. Treatment was administered three times, with intervals of one month between each session, and follow-up evaluations were conducted at six and 12 months. All statistical analyses were designed and programmed by the AI chatbot GPT-4 (chatGPT-4). Results Fifteen female patients diagnosed with vulvodynia and IC/BPS were treated with three sessions of VEL + Nd:YAG. Significant improvements were observed in the vulvodynia test, NRS-11 scores, PUF, ICSI scores, ICPI scores, mean urination volume, and daily urination frequency at six and 12 months (p<0.01). Short-term improvements in IC/BPS pain scores correlated with improvements in the vulvodynia test (p=0.007), suggesting a synergistic effect. However, no significant correlations were found at 12 months. Conclusion Combined laser treatments targeting the vagina and vulva showed significant therapeutic effects in women with IC/BPS and vulvodynia. The addition of Nd:YAG to the VEL treatment enhanced outcomes. Short-term improvements in IC/BPS pain scores correlated with improvements in the vulvodynia test, indicating a synergistic effect. Long-term improvements in both vulvodynia and IC/BPS symptoms may occur independently.These findings highlight the importance of comprehensive approaches for treating coexisting vulvodynia and IC/BPS.

The Effectiveness of Intravenous lidocaine in Burn Pain Relief: A Randomized Double-Blind Controlled Trial

Objectives: Poor pain control in burn patients as a great public health problem disrupts the healing and rehabilitation process and results in several adverse outcomes. The aim of this study was to investigate the efficacy and safety of intravenous lidocaine in reducing the pain of burn injuries. Materials and Methods: From August 2014 to March 2015, 66 eligible burn patients participated in the study and were randomly divided into two groups of lidocaine (L) and placebo (P). In group L, lidocaine 2% was injected at a bolus dose of 1.5 mg/kg followed by infusion at the dosage of 1.5 mg/kg/h, and in group P, saline was administrated. Pain severity was measured during 24 hours at baseline and 1, 2, 4, 8, 12, 16, 20, 24 hours after intervention based on Numerical Rating Scale (NRS-11). Morphine consumption, Ramsay score, and side effects were also documented. Results: Finally the data from 60 patients were analyzed. Comparing baseline with 24 hours after intervention, NRS-11 scores decreased from 7.12±1.42 to 3.33±0.76 (P&lt;0.001) in group P and from 6.45±1.02 to 2.50±0.72 (P&lt;0.001) in group L. Moreover, the mean of NRS scores during 24 hours in the lidocaine group was significantly lower compared to the placebo group, 3.93±0.72 vs 4.73 ±1.14, (P=0.03). The mean amounts of morphine consumption in group L were significantly lower compared to group P, 14.41 ± 4.86 vs 21.07±6.86, (P=0.001). The mean of Ramsay score in group L was significantly lower compared to group P, 1.38±0.59 vs 1.45±0.6, (P=0.014). Conclusions: This study revealed that intravenous lidocaine was an effective and safe drug for pain reduction in burn patients.

Efficacy of Patient-Controlled Intravenous Analgesia with Esketamine for Herpes Zoster Associated with Breakthrough Pain

BACKGROUND: Some patients with herpes zoster (HZ) experience an intermittent spontaneous, short-lived and severe pain, which is called breakthrough pain (BTP). The effect of analgesic drugs and invasive procedures is not significant. Therefore, treatment of HZ associated with BTP is challenging. Esketamine is a new N-methyl-D-aspartate receptor antagonist, with enhanced analgesic effects. This study aimed to evaluate the efficacy and adverse reactions of patient-controlled intravenous analgesia (PCIA) with low-dose esketamine for HZ associated with BTP. OBJECTIVES: To evaluate the efficacy and adverse reactions of PCIA with low-dose esketamine for HZ associated with BTP. STUDY DESIGN: A retrospective, observational study. SETTING: The study was carried out in the Pain Department of the Affiliated Hospital of Jiaxing University in Jiaxing, China. METHODS: The clinical data of HZ associated with BTP treated by PCIA with low-dose esketamine at the Pain Department of the Affiliated Hospital of Jiaxing University, between October 2015 to October 2021, were collected retrospectively. The Numeric Rating Scale (NRS-11) scores of rest pain (RP) and BTP, frequency of BTP, Pittsburgh Sleep Quality Index (PSQI) score, and fasting blood glucose (FBG) were recorded and analyzed before treatment (T0) and on days one (T1) and 3 (T2), week one (T3), months one (T4), 3 (T5), and 6 (T6) after treatment. Adverse reactions during the treatment were recorded. RESULTS: Twenty-five patients treated by PCIA with low-dose esketamine were included finally. Compared with T0, the NRS-11 scores of RP at T2, T3, T4, T5, and T6 decreased significantly (P &lt; 0.05). The NRS-11 score of RP at T4 was significantly lower than that of T3 (P &lt; 0.001), but there was no statistical difference between T5 and T4 (P &gt; 0.05), the efficacy of esketamine in the treatment of RP was stable at one month after treatment. Likewise, compared with T0, the NRS-11 scores of BTP, frequency of BTP, and PSQI score decreased significantly at each time point after treatment (P &lt; 0.05). These at T5 were significantly lower than T4 (P &lt; 0.05), but there was no statistical difference between T6 and T5 (P &gt; 0.05), the efficacy of esketamine was stable at 3 months after treatment. FBG also decreased significantly at each time point after treatment (P &lt; 0.05), it tended to be normal and stable one month after treatment. All patients had mild symptoms of dizziness during treatment, and though a slight increase in noninvasive blood pressure (BP) was noted in all, the elevated BP did not exceed 30% of the baseline value. Four patients (16%) developed nausea without vomiting. There were no serious adverse reactions, such as respiratory depression. LIMITATIONS: The nonrandomized, single-center, small sample size, retrospective design is a major limitation of this study. CONCLUSIONS: PCIA with low-dose esketamine has a significant and long-term effect in the treatment of HZ associated with BTP. The RP was controlled, and the degree and frequency of BTP were significantly reduced after treatment, leading to improved quality of life. There were no serious adverse reactions worthy of clinical promotion. KEY WORDS: Patient-controlled intravenous analgesia, esketamine, herpes zoster, breakthrough pain

Efficacy of Pulsed Radiofrequency or Short-Term Spinal Cord Stimulation for Acute/Subacute Zoster-Related Pain: A Randomized, Double- Blinded, Controlled Trial

Postherpetic neuralgia (PHN) is the final stage of varicella zoster infection and a severe refractory neuropathic pain. Hence preventing transition of herpes zoster-related pain to PHN is a very important therapeutic principle for patients at an early stage, especially for older patients.Both pulsed radiofrequency (PRF) and short-term spinal cord stimulation (stSCS) have been proven to be effective to relieve acute/subacute zoster-related pain. However, which treatment could achieve better analgesic effects remains unclear. This study aimed to investigate the therapeutic efficacy and safety of PRF and stSCS in patients with acute/subacute zoster-related pain. Prospective, randomized, double-blinded study. Department of Pain Medicine, the First Affiliated Hospital of China Medical University. Ninety-six patients with acute/subacute zoster-related pain were equally randomized into 2 groups: PRF group and stSCS group. Patients in the different groups were treated with high-voltage, long-duration PRF or stSCS. The therapeutic effects were evaluated using a Numeric Rating Scale (NRS-11) and the 36-Item Short Form Health Survey (SF-36) at different time points. The average dose of pregabalin (mg/d) administrated at different time points was also recorded. The posttreatment NRS-11 scores in the 2 groups were significantly lower compared with baseline (P < 0.001). The NRS-11 scores in the stSCS group were significantly lower than those in the PRF group at 30 and 180 days after treatments (P < 0.05). The SF-36 scores of general health, social function, role-emotional, mental health, bodily pain, physical function, physical role, and vitality could be significantly improved at each time point after treatments in the 2 groups. Some SF-36 scores could be significantly improved at some time points in the stSCS group compared with the PRF group. The rescue drug (pregabalin) dosages were lower in the stSCS group than those in the PRF group at days 90 and 180 after treatments. There was no bleeding at the puncture site, infection, postoperative paresthesia, nerve injury, or any other serious adverse effects in either group. Single-center study, relatively small number of patients. PRF and stSCS are both effective and safe therapeutic alternatives for patients with acute/subacute zoster-related pain, however, stSCS could achieve more pain relief and improvement of life quality compared with PRF.

Patient-Reported Outcomes of Robotic vs Laparoscopic Ventral Hernia Repair With Intraperitoneal Mesh

Despite rapid adoption of the robotic platform for ventral hernia repair with intraperitoneal mesh in the United States, there is no level I evidence comparing it with the traditional laparoscopic approach. This randomized clinical trial sought to demonstrate a clinical benefit to the robotic approach.To determine whether robotic approach to ventral hernia repair with intraperitoneal mesh would result in less postoperative pain.A registry-based, single-blinded, prospective randomized clinical trial at the Cleveland Clinic Center for Abdominal Core Health, Cleveland, Ohio, completed between September 2017 and January 2020, with a minimum follow-up duration of 30 days. Two surgeons at 1 academic tertiary care hospital. Patients with primary or incisional midline ventral hernias of an anticipated width of 7 cm or less presenting in the elective setting and able to tolerate a minimally invasive repair.Patients were randomized to a standardized laparoscopic or robotic ventral hernia repair with fascial closure and intraperitoneal mesh.The trial was powered to detect a 30% difference in the Numerical Rating Scale (NRS-11) on the first postoperative day. Secondary end points included the Patient-Reported Outcomes Measurement Information System Pain Intensity short form (3a), hernia-specific quality of life, operative time, wound morbidity, recurrence, length of stay, and cost.Seventy-five patients completed their minimally invasive hernia repair: 36 laparoscopic and 39 robotic. Baseline demographics and hernia characteristics were comparable. Robotic operations had a longer median operative time (146 vs 94 minutes; P < .001). There were 2 visceral injuries in each cohort but no full-thickness enterotomies or unplanned reoperations. There were no significant differences in NRS-11 scores preoperatively or on postoperative days 0, 1, 7, or 30. Specifically, median NRS-11 scores on the first postoperative day were the same (5 vs 5; P = .61). Likewise, postoperative Patient-Reported Outcomes Measurement Information System 3a and hernia-specific quality-of-life scores, as well as length of stay and complication rates, were similar. The robotic platform adds cost (total cost ratio, 1.13 vs 0.97; P = .03), driven by the cost of additional operating room time (1.25 vs 0.85; P < .001).Laparoscopic and robotic ventral hernia repair with intraperitoneal mesh have comparable outcomes. The increased operative time and proportional cost of the robotic approach are not offset by a measurable clinical benefit.ClinicalTrials.gov Identifier: NCT03283982.

High-Voltage Intraarticular Pulsed Radiofrequency for Chronic Knee Pain Treatment: A Single-Center Retrospective Study

Background: Intraarticular pulsed radiofrequency (IAPRF) for the treatment of painful knee osteoarthritis (KOA) is a less invasive treatment method. It has fewer adverse effects and can quickly reduce KOA-related pain and improve knee joint dysfunction. Objectives: We compared the effectiveness of high- and low-voltage IAPRF for the treatment of chronic knee pain. Study Design: Retrospective comparative study design. Setting: This study took place at Shengjing Hospital of China Medical University. Methods: A total of 57 patients with KOA who were hospitalized between July 2018 and July 2019 were randomly allocated into the high-voltage (n = 29) and low-voltage (n = 28) IAPRF groups. IAPRF was performed under the guidance of computed tomography (CT). Numeric Rating Scale (NRS-11), Oxford Knee Score (OKS), degree of pain relief, global perceived effect, and side effects at baseline and 1 week, 2 weeks, 1 month, 3 months, and 6 months after the procedure were recorded and analyzed. Results: NRS-11 scores decreased significantly in both groups after the procedure, but gradually increased after the 6-month follow-up period. There was a significant difference in NRS-11 scores between the 2 groups at all follow-up periods postprocedure. OKS were similar between the 2 groups. Patients with pain relief rate 50% or greater at 1, 3, and 6 months after the procedure accounted for 72.41%, 72.41%, and 55.17% in the high-voltage group, and 46.43%, 46.43%, and 28.57% in the low-voltage group, respectively. The difference between the 2 groups was statistically significant. No significant adverse reactions were observed in the 2 groups, however, patient satisfaction in the high-voltage group was significantly higher compared with patients in the low-voltage group. Limitations: This study was a single-center retrospective study with a relatively small sample cohort and short follow-up period. Conclusions: CT-guided high-voltage IAPRF is more beneficial in reducing knee pain and improving knee function compared with low-voltage IAPRF. In addition, patients who received high-voltage IAPRF were more satisfied with their treatment. Key words: Pulsed radiofrequency, knee osteoarthritis, intraarticular, high voltage, Oxford Knee Score, Numeric Rating Scale

The Effect of Early Limited Activity after Bipedicular Percutaneous Vertebroplasty to Treat Acute Painful Osteoporotic Vertebral Compression Fractures

Although percutaneous vertebroplasty (PVP) can effectively relieve the pain for patients with acute osteoporotic vertebral compression fractures (OVCFs), many patients still complain of mild back pain in the early postoperative period. The aim of this study was to assess the effect of early limited activity (LA) on prognosis after bipedicular small-cement-volume (i.e., PVP) to treat single-segment acute OVCFs. A prospective study and retrospective observations were performed on 125 patients with a minimum of 1 year of follow-up. A university hospital orthopedics and pathology departments. All patients were allocated into an LA group (n = 64) and an unlimited activity group (ULA group, n = 61). Patients in the LA group were suggested to keep time of off-bed activity < 4 hours per day in the first 3 weeks postoperatively. Patients in the ULA group did not limit activity. The demographic, clinical, and radiologic outcomes were assessed, such as pain intensity Numeric Rating Scale (NRS-11) and vertebral height ratio (i.e., fractured vertebral height/adjacent nonfractured vertebral height). Based on outcomes following surgery, all patients were classified as responders (NRS-11 score 1-day postoperation < 50% of preoperative NRS-11 score) or low responders (NRS-11 score 1-day postoperation >= 50% of preoperative NRS-11 score). The demographic results and complications were similar. In the LA group, NRS-11 scores at 1 and 3 months postoperation respectively were 2.23 ± 0.42 and 1.46 ± 0.40, and corresponding scores respectively were 2.85 ± 0.80 and 1.73 ± 0.77 in the ULA group, and there was a difference in the 2 groups in both time points (P < 0.05). At 12 months postoperation, anterior and middle vertebral height ratio respectively were 78.42% ± 3.52% and 82.37% ± 3.49% in the LA group, which were higher than 76.87% ± 3.68% and 81.10% ± 3.31% in the ULA group (P < 0.05). Thirty-two cases were low responders. Among those, NRS-11 scores at 1 and 3 months postoperation respectively were 2.29 ± 0.45 and 1.53 ± 0.46 in the LA group, which were lower than 3.67 ± 0.80 and 2.56 ± 0.79 in the ULA group (P < 0.05), and at 12 months postoperation, anterior vertebral height ratio was 79.81% ± 3.25% in the LA group and 75.60% ± 3.50% in the ULA group (P < 0.05). First, some patients lacked the results of bone mineral density during follow-up; second, the limited time in our study was chosen from our previous working experience, which may lack an objective basis; third, NRS-11 is solely used as an indicator of clinical outcomes in our study; finally, our next studies can increase the sample size to improve the clinically difference. LA in the early period after PVP can help patients achieve more pain relief postoperatively and maintain better vertebral shape, especially for low responders. Osteoporotic vertebral compression fractures, percutaneous vertebroplasty, Numeric Rating Scale, vertebral height, responders, low responders, limited activity, complications.

Spinal Radiofrequency Ablation Combined with Cement Augmentation for Painful Spinal Vertebral Metastasis: A Single-Center Prospective Study

Background: The spine is the most common site of skeletal metastatic disease. Vertebral body metastases (VBM) can cause crippling pain, fractures, and spinal cord compression. Radiofrequency ablation (RFA) is a minimally invasive technique that has proven to be a safe method of targeted tissue destruction. Studies have shown that RFA combined with cement vertebral augmentation is safe and effective and has been associated with significant improvements in pain and quality of life. Objectives: The purpose of this study was continued evaluation of the safety and efficacy of this technique. Study Design: Prospective cohort. Setting: A single academic medical center. Methods: Patients undergoing RFA with cement vertebral augmentation for a painful thoracic or lumbar VBM were eligible for inclusion. Additional inclusion criteria included pain concordant with a metastatic lesion on cross-sectional imaging, aged 18 years or older, and considered candidates for spinal tumor ablation by the operating physician. Patients with vertebral metastatic disease in the cervical spine or patients with spinal cord compression from posterior tumor extension were excluded. Ablation within each VBM was performed using a bipolar radiofrequency probe with an extensible electrode and available articulation, permitting vertebral body navigation percutaneously. Patients were evaluated at baseline, 3 days, one week, one month, and 3 months using the Numeric Rating Scale (NRS-11) and Functional Assessment of Cancer Therapy-General 7 (FACT-G7) to assess pain and quality-of-life, respectively. A one-sample t test was performed, and 95% confidence intervals were calculated to assess changes in average NRS-11 and FACT-G7 scores. Results: A total of 30 patients met inclusion criteria and underwent RFA of one or more VBM. Patients with 13 different primary cancers types underwent treatment. Patients received RFA to either one (n = 26; 87%) or 2 vertebral body levels (n = 4; 13%). Of the 34 levels, 13 were thoracic vertebra (38%) and 21 were lumbar vertebra (62%). Average NRS-11 scores decreased from a baseline of 5.77 to 4.65 (3 days; P = 0.16), 3.33 (one week; P &lt; 0.01), 2.64 (one month; P &lt; 0.01), and 2.61 (3 months; P &lt; 0.01). FACT-G7 increased from a baseline average of 13.0 to 14.7 (3 days; P = 0.13), 14.69 (one week; P = 0.15), 14.04 (one month; P = 0.35), and 15.11 (3 months; P = 0.07). No major adverse events were reported. Limitations: A heterogeneous patient population, small sample size, and potential confounders of concurrent variable adjuvant therapies were limitations. Additionally, most patients received both cement augmentation and targeted RFA, making it difficult to distinguish independent analgesic benefits of the therapies. Conclusions: This study demonstrates that minimally invasive targeted RFA with cement augmentation of spinal metastatic lesions is an effective treatment for patients with VBM. Key words: Cancer, cancer pain, spinal metastasis, radiofrequency ablation, tumor ablation, cement augmentation

Exploring the Role of Chronic Pain Clinics: Potential for Opioid Reduction

The management of chronic nonmalignant pain with high-dose opioids has partially contributed to the current opioid epidemic, with some responsibility shared by chronic pain clinics. Traditionally, both primary care providers and patients used chronic pain clinics as a source for continued medical management of patients on high-dose opioids, often resulting in tolerance and escalating doses. Although opioids continue to be an important component of the management of some chronic pain conditions, improvement in function and comfort must be documented. Pain clinics are ideally suited for reducing opioid usage while improving pain and function with the use of a multimodal approach to pain management. We assessed whether the application of multimodal treatment directed by pain specialists in a pain clinic provides for improved function and reduced dosages of opioid analgesics. We evaluated the role of a pain clinic staffed by fellowship-trained pain physicians in reducing pain and opioid use in chronic nonmalignant pain patients. This study used a retrospective design. The research took place in an outpatient pain clinic in a tertiary referral center/teaching hospital. Of 1268 charts reviewed, 296 patients were on chronic opioids at the time of first evaluation. After a thorough evaluation, the patients were treated with nonopioid pharmacotherapy and interventional pain procedures as necessary. The data utilized from patients' latest follow-up visit included current pain level using the Numerical Rating Scale (NRS-11), opioid usage, and various functional parameters. NRS-11 scores decreased by 33.8% from 6.8 (± 0.1)/10 to 4.5 (± 0.2)/10. The pain frequency and number of pain episodes improved by 36.8 ± 2 and 36.2 ± 2.1, respectively. Additionally, the ability to sleep, work, and perform chores significantly improved. Total opioid use decreased by about 55.4% from 53.8 ± 4 to about 24 ± 2.8 MME/patient/day. This study is not a randomized prospective controlled study. The patients analyzed are still getting therapy and their pain status may change. Some opioids are underrepresented in the analyzed cohort. Finally, this study lacks in-depth stratification by type of pain, age, gender, and duration of opioid use. Chronic pain clinics can play a pivotal role in reducing opioid usage while improving pain and function in patients on chronic opioids. We wish to emphasize the importance of allocating resources toward nonopioid treatments that may improve the function and well-being of patients. Pain clinic, pain management, multimodal pain management, chronic pain, opioid reduction, improved pain, improved functional capacity.

Pain levels and typical symptoms of acute endodontic infections: a prospective, observational study.

BackgroundThis study aimed to identify key symptoms that could be associated with the diagnosis of acute forms of symptomatic apical periodontitis (SAP) and symptomatic irreversible pulpitis (SIP), and to identify a diagnostic algorithm based on these symptoms.MethodsIn this prospective, observational study 173 emergency patients diagnosed with acute pain of endodontic origin and no swelling or fistula were included. Patients were asked 11 specific questions from a checklist with a possible discerning value between acute SAP and acute SIP. Pain levels were recorded using the numeric rating scale (NRS-11). Subsequently, the painful tooth was diagnosed. Logistic regression was used to evaluate the checklist regarding its differentiation between SAP (N = 103) and SIP (N = 70). Moreover, a decision tree was constructed based on recursive partitioning to identify a hierarchy in differentiating symptoms.ResultsWith identical median NRS-11 scores of 8, the teeth diagnosed with acute SAP and SIP were severely painful. The decision tree analysis resulted in a tree with splits according to pain on cold, perceived tooth extrusion, and pain duration. The overall sensitivity of the tree to detect SAP based on key symptoms was 95 %, its specificity was 31 %.ConclusionsThe best indicator for SAP was a reported absence of pain to cold stimuli. In teeth that did have a history of pain triggered by cold stimuli, the decision tree correctly identified SAP in 72 % of the teeth that felt too high and had hurt for less than one week.

The impact of chronic pain—European patients’ perspective over 12 months

Background and methods Pain Study Tracking Ongoing Responses for a Year (PainSTORY) is a longitudinal study generating some quantitative and limited qualitative data concerning the experiences of individual patients with non-malignant chronic pain. Research was conducted across 13 European countries and a total of 294 patients completed the full evaluation process over 12 months. Adult patients (>18 years old) scoring >4 on an 11-point numeric pain rating scale (NRS-11) for most days during an average week were eligible. Four waves of interviews (W1–W4) were conducted over 12 months and information was recorded regarding pain levels, the impact of pain, pain treatment and treatment-associated side effects. Results At 3 months, 95% of respondents rated their worst pain level over the past week as >4. Most respondents had felt this pain level for ≥1 year, with 47% of patients reporting NRS-11 scores of 8–10 for >2 years. At 12 months, 93% of respondents still rated their worst pain level over the past week as >4. The overall net percentage of respondents with >4 pain intensity did not change substantially over 12 months of follow up. However, 40% (119/294) of patients felt their current pain level increased and 41% (121/294) felt their current pain level decreased during this time, with just 18% (53/294) of respondents reporting no change (1% of respondents not stated). At 3 months, 30% of respondents reported being managed by a pain specialist within the last 3 months, decreasing to 13% 9–12 months later. Patients were typically taking a combination of prescribed and non-prescribed medications; approximately 10% at W1 and 14% at 12 months were prescribed a strong opioid. Among those whose current pain level decreased over the year, a slightly lower proportion of patients were taking prescription medication (78%) at 12 months than in either the group with no change to their current pain level (85%), or the group whose pain level increased over the 12 month period (87%). Pain negatively affected quality of life, with respondents reporting difficulties with daily activities, including sleeping, walking, family and social interaction. Approximately half of respondents taking prescription medication reported suffering from ‘constipation and associated symptoms’. In spite of no change in pain intensity, 51% of patients were happy with their pain management at W4. Conclusions The heavy individual and societal burden of uncontrolled chronic pain is demonstrated in this study. This silent epidemic has not attracted the focus of attention that it deserves. Despite the significant negative impact on individual quality of life, patients evolve to a position where they believe that chronic pain is inevitable and untreatable. Implications It is clear that there is a real need for a coordinated response by healthcare providers and planners across European countries. Minimum standards of care should be developed and implemented at national level. Healthcare professionals and students of these disciplines must be educated to recognise, assess and manage pain within a reasonable timeframe. Patients who are not responding to standard measures must have rapid and easy access to a comprehensive, inter-disciplinary pain service.

The minimum clinically significant difference in Patient-Assigned 11-Point numeric pain scale scores for pain

Study objectives: The purpose of this study is to determine minimum clinically significant difference in patient-assigned, 11-point numeric rating scale (NRS-11) score for assessment of in adult emergency department (ED) patients. Methods: This prospective, observational study was approved by hospital institutional review board. A tertiary care academic ED served as study setting. ED patients presenting with consented and were enrolled in this study by an investigator or trained research assistant. Patients were asked to rate their on NRS-11, scale of 0 to 10, with 0 being no pain and 10 being the worst they could imagine on entry into study. Patients were asked to reevaluate their intensity every 20 minutes for 2 hours on NRS-11. Patients contrasted this with their intensity at previous evaluation. For contrast, patients were asked to choose 1 of following responses: a lot pain, a little pain, about same pain, a little pain, or a lot pain. The minimum clinically significant difference was defined as difference between scores when patient's was rated a little more or a little less severe. Results: Three hundred one patients were enrolled in study, and 1,192 comparisons were made. Of these comparisons, 187 were rated as a little pain, and 82 were rated as a little pain. The mean difference between current and preceding NRS-11 scores in these 269 comparisons was 1.41 (SD±1.05; 95% confidence interval [CI] 1.28 to 1.54). Conclusion: These findings suggest that minimum clinically significant difference in patient-assigned NRS-11 scores is 1.41 (SD±1.05; 95% CI 1.28 to 1.54). Studies that report change of than 1.41 points may indicate statistical significance, but findings may not have clinical significance. Additional research is needed to determine whether minimum clinically significant difference varies with age, race, or ethnicity.