Visual Analog Scale Pain Levels Research Articles

Prospective study of superior cluneal nerve disorder as a potential cause of low back pain and leg symptoms.

BackgroundEntrapment of the superior cluneal nerve (SCN) in an osteofibrous tunnel has been reported as a cause of low back pain (LBP). However, there are few reports on the prevalence of SCN disorder and there are several reports only on favorable outcomes of treatment of SCN disorder on LBP. The purposes of this prospective study were to investigate the prevalence of SCN disorder and to characterize clinical manifestations of this clinical entity.MethodsA total of 834 patients suffering from LBP and/or leg symptoms were enrolled in this study. Diagnostic criteria for suspected SCN disorder were that the maximally tender point was on the posterior iliac crest 70 mm from the midline and that palpation of the tender point reproduced the chief complaint. When patients met both criteria, a nerve block injection was performed. At the initial evaluation, LBP and leg symptoms were assessed by visual analog scale (VAS) score. At 15 min and 1 week after the injection, VAS pain levels were recorded. If insufficient pain decrease or recurrence of pain was observed, injections were repeated weekly up to three times. Surgery was done under microscopy. Operative findings of the SCN and outcomes were recorded.ResultsOf the 834 patients, 113 (14%) met the criteria and were given nerve block injections. Of these, 54 (49%) had leg symptoms. Before injection, the mean VAS score was 68.6 ± 19.2 mm. At 1 week after injection, the mean VAS score significantly decreased to 45.2 ± 28.8 mm (p < 0.05). Ninety-six of the 113 patients (85%) experienced more than a 20 mm decrease of the VAS score following three injections and 77 patients (68%) experienced more than a 50% decrease in the VAS score. Surgery was performed in 19 patients who had intractable symptoms. Complete and almost complete relief of leg symptoms were obtained in five of these surgical patients.ConclusionsSCN disorder is not a rare clinical entity and should be considered as a cause of chronic LBP or leg pain. Approximately 50% of SCN disorder patients had leg symptoms.Electronic supplementary materialThe online version of this article (doi:10.1186/s13018-014-0139-7) contains supplementary material, which is available to authorized users.

Locking plate fixation combined with iliac crest bone autologous graft for proximal humerus comminuted fracture.

Although the use of an intramedullary fibular allograft together with locking plate fixation can provide additional medial support and prevent varus malalignment in displaced proximal humeral fractures with promising results, the fibular autograft donor site often sustains significant trauma and cannot restore the articular surface of comminuted fractures. The aim of this study was to evaluate the clinical and radiographic outcomes of a locking plate and crest bone autologous graft for treating proximal humerus comminuted fractures. We assessed the functional outcomes and complication rates in 40 patients with proximal humerus comminuted fractures. Eighteen patients were treated with a locking plate and an autologous crest bone graft (experimental group), and 22 were treated with only the locking plate and no bone graft (control group). Postoperative assessments included radiographic imaging, range of motion analysis, pain level based on the visual analogue scale (VAS), and the SF-36 (Short Form (36) Health Survey), as well as whether patients could return to their previous occupation. All fractures healed both clinically and radiologically in the experimental group. There was no more than 2 mm collapse of the humeral head, and no osteonecrosis or screw penetration of the articular surface. In contrast, two patients had a nonunion in the control group, and they eventually accepted total shoulder replacements. The average time from surgery to radiographic union was significantly shorter in the experimental group ((4.66±1.63) months) compared with the control group ((5.98±1.57) months) (P < 0.05). For the experimental versus controls groups, the mean shoulder active flexion (148.00±18.59 vs. 121.73±17.20) degrees, extension (49.00±2.22 vs. 42.06±2.06) degrees, internal rotation (45.00±5.61 vs. 35.00±3.55) degrees, external rotation (64.00±9.17 vs. 52.14±5.73) degrees, and abduction (138.00±28.78 vs. 105.95±15.66) degrees were all significantly higher (all P < 0.001). The median SF-36 in the experimental group ((88.00±5.71) points) was significantly higher than that of the control group ((69.45±9.45) points; P < 0.001). The median VAS pain level (mean rank, 10.50) in the experimental group was lower than that (mean rank, 47.19) of the control group (P < 0.001). All but one patient (17 of 18, 94.4%) in the experimental group returned to their previous activities or occupations, and that one patient changed to a different occupation because of slight restrictions to activities. On the other hand, four patients could not return to their previous activities or occupations in the control group. Locking plate fixation combined with an iliac crest bone graft is an effective technique for treating proximal humerus comminuted fractures.

Two cases of opioid rotation applied to patients with chronic pain

Two cases of opioid rotation applied to patients with chronic pain

Locking plate and fibular allograft augmentation in unstable fractures of proximal humerus

The use of an intramedullary fibular allograft together with a locking plate fixation has been recently described in biomechanical studies to provide additional medial support and prevent varus malalignment for displaced proximal humeral fractures with promising results. The aim of this study was to evaluate the clinical and radiographic outcome of a locking plate with fibular allograft augmentation in unstable humeral fractures. We prospectively assessed the functional outcome and complications in 17 patients with proximal humeral fractures with disrupted medial column, treated with a locking plate and a fibular strut graft. The median patient age was 62 years. Postoperative assessments included radiographic imaging, range of motion, pain according to the visual analogue scale (VAS), Short Form (SF36) Health Survey, Constant-Murley and Disabilities of the Arm, Shoulder and Hand (DASH) shoulder scores as well as return to previous occupation and complications. No patients were lost to follow-up and no major complications were recorded. There was no collapse of the humeral head more than 2mm, osteonecrosis or screw penetration of the articular surface. All fractures healed clinically and radiographically. After an average follow-up of 13 months, the mean Constant score was 79 points. The mean active flexion was 149°; extension, 47°; internal rotation, 40°; external rotation, 65°; and abduction, 135°. The median VAS pain level was 1 point. The median DASH score was 33 points, and the median SF36 was 83 points. Locking plate with fibular graft augmentation is a safe and promising technique to support the humeral head and maintain reduction in the proximal humeral fracture with medial comminution.

Analgesic tolerance without demonstrable opioid-induced hyperalgesia: A double-blinded, randomized, placebo-controlled trial of sustained-release morphine for treatment of chronic nonradicular low-back pain

Although often successful in acute settings, long-term use of opioid pain medications may be accompanied by waning levels of analgesic response not readily attributable to advancing underlying disease, necessitating dose escalation to attain pain relief. Analgesic tolerance, and more recently opioid-induced hyperalgesia, have been invoked to explain such declines in opioid effectiveness over time. Because both phenomena result in inadequate analgesia, they are difficult to distinguish in a clinical setting. Patients with otherwise uncomplicated low-back pain were titrated to comfort or dose-limiting side effects in a prospective, randomized, double-blind, placebo-controlled clinical trial using sustained-release morphine or weight-matched placebo capsules for 1month. A total of 103 patients completed the study, with an average end titration dose of 78mgmorphine/d. After 1month, the morphine-treated patients developed tolerance to the analgesic effects of remifentanil, but did not develop opioid-induced hyperalgesia. On average, these patients experienced a 42% reduction in analgesic potency. The morphine-treated patients experienced clinically relevant improvements in pain relief, as shown by a 44% reduction in average visual analogue scale pain levels and a 31% improvement in functional ability. The differences in visual analogue scale pain levels (P=.003) and self-reported disability (P=.03) between both treatment groups were statistically significant. After 1month of oral morphine therapy, patients with chronic low-back pain developed tolerance but not opioid-induced hyperalgesia. Improvements in pain and functional ability were observed.

Are Psychoactive Substance (Opioid)‐Dependent Chronic Pain Patients Hyperalgesic?

One indirect line of evidence for opioid-induced hyperalgesia (OIH) in humans is decreased pain thresholds (PTREs) and tolerances (PTOLs) in opioid addicts on opioids. There are a number of such studies in opioid maintained addicts, but no such studies in chronic pain patients (CPPs) with current opioid addiction. The objective of this study was to determine if this group demonstrates hyperalgesia. CPPs were subdivided into those with psychoactive substance (opioid dependence) (PSOD) (n=38) (addicted) and those taking opioids but without PSOD (n=198) (not addicted). A group of opioid-free non-CPPs served as a control group (n=36). PTREs/PTOLs were determined in each group by pressure pain stimulation in both the right and left index fingers. PTREs/PTOLs were compared by analysis of variance among the three groups controlling for sex/age and by analysis of covariance between the PSOD CPPs and non-PSOD CPPs controlling for duration of pain and visual analog scale pain level over the last 24 hours. The PSOD and non-PSOD CPPs had significantly lower PTREs and PTOLs vs. the control group, ie, were hyperalgesic. However, they were not significantly different from each other. This study contributes to the human OIH literature. However, because of the potential confounders in this study, the issue of OIH in humans remains unresolved.

Randomized Double-Blind Placebo-Controlled Clinical Trial Testing Ketorolac Tromethamine for Reducing the Pain and Discomfort Experienced during Mammography.

Abstract OBJECTIVE: To study the possibility of reducing the pain and discomfort experienced during mammography, by means of using an analgesic as premedication. PATIENTS AND METHODS: This was a randomized double-blind placebo-controlled clinical trial testing ketorolac tromethamine for reducing the pain and discomfort experienced during mammography. There were 308 participants in the study, who all signed a free and informed consent statement. Of these, 153 patients (group 1) received 10 mg of ketorolac tromethamine orally and 155 (group 2) received placebo orally, 60 minutes before undergoing mammographic examination. After taking the medication and while waiting to undergo the procedure, the patients themselves filled out a form asking about personal data and possible factors relating to pain and discomfort while undergoing mammography. After the examination, the patients subjectively assessed the pain and discomfort experienced during the examination using a visual analog scale (VAS) graded from zero to ten. The statistical analysis consisted of characterizing the groups using absolute and relative frequencies and comparing the dependent and independent variables between the groups using the chi-squared association test, with Yates correction when necessary. RESULTS: The mean VAS pain level presented by the patients was 3.36 and the median was 2.90. It was observed that 51 (16.6%) of the patients did not present any pain, 106 (34.4%) presented mild pain, 94 (30.5%) moderate pain, 40 (13%) severe pain and 17 (5.5%) intolerable pain. With regard to discomfort, 68 (54.9%) reported tolerable discomfort, 63 (20.5%) a lot of discomfort and 8 (2.6%) intolerable discomfort. Among the factors related to pain, only the presence of previous mastalgia was significant (p &amp;lt; 0.05). Somnolence was the adverse event most present: 2.6 and 5.8% in the ketorolac and placebo groups, respectively. CONCLUSIONS: The use of 10 mg of ketorolac tromethamine did not have any influence regarding reduction of the pain and discomfort experienced by the patients during mammography, when compared with placebo. Among the factors studied, the only one associated with greater possibility of pain and discomfort while undergoing mammography was a history of mastalgia. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4014.

Cell Carriers as the Next Generation of Cell Therapy for Cartilage Repair

Background: Since the first patient was implanted with autologous cultured chondrocytes more than 20 years ago, new variations of cell therapies for cartilage repair have appeared. Autologous chondrocyte implantation, a first-generation cell therapy, uses suspended autologous cultured chondrocytes in combination with a periosteal patch. Collagen-covered autologous cultured chondrocyte implantation, a second-generation cell therapy, uses suspended cultured chondrocytes with a collagen type I/III membrane. Today’s demand for transarthroscopic procedures has resulted in the development of third-generation cell therapies that deliver autologous cultured chondrocytes using cell carriers or cell-seeded scaffolds. Purpose: To review the current evidence of the matrix-induced autologous chondrocyte implantation procedure, the most widely used carrier system to date. Also discussed are the characteristics of type I/III collagen membranes, behavior of cells associated with the membrane, surgical technique, rehabilitation, clinical outcomes, and quality of repair tissue. Study Design: Systematic review. Methods: Relevant publications were identified by searching Medline from its inception (1949) to December 2007; peer-reviewed publications of preclinical and clinical cell behavior, manufacturing process, surgical technique, and rehabilitation protocols were identified. Preclinical and clinical studies were included if they contained primary data and used a type I/III collagen membrane. Results: Data from these studies demonstrate that patients treated with matrix-induced autologous chondrocyte implantation have an overall improvement in clinical outcomes. Reduced visual analog scale pain levels (range, 1.7-5.32 points) and improvements in the modified Cincinnati (range, 3.8-34.2 points), Lysholm-Gillquist (range, 23.09-47.6 points), Tegner-Lysholm (range, 1.39-3.9 points), and International Knee Documentation Classification scale (P <.05) were observed. Patients had good-quality (hyaline-like) repair tissue as assessed by arthroscopic evaluation (including International Cartilage Repair Society score), magnetic resonance imaging, and histology, as well as a low incidence of postoperative complications. Conclusion: The findings suggest that matrix-induced autologous chondrocyte implantation is a promising third-generation cell therapy for the repair of symptomatic, full-thickness articular cartilage defects.

Likelihood ratio methodology to identify predictors of treatment outcome in temporomandibular joint arthralgia patients

The purpose of this prospective, cohort study of patients with temporomandibular joint (TMJ) pain was to develop rules to predict treatment outcome related to occlusal stabilization splints. The study comprised 119 patients with a unilateral Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) axis I diagnosis of arthralgia. Visual analog scale (VAS) pain level of function was assessed before stabilization splint therapy and compared with the respective 2-month and 6-month follow-up findings. Magnetic resonance (MR) images were obtained immediately before treatment to establish the presence or absence of disk displacement, osteoarthrosis, effusion, and bone marrow edema. Treatment outcome (success or failure) was categorized based on changes in the VAS pain level after 6 months. Sixty-five (55%) subjects were categorized as treatment success, 17 (14%) as treatment failures, and 37 (31%) as somewhat improved. After using univariate analyis to determine the association between potential clinical and MR imaging predictor variables and treatment outcome status, preliminary prediction rules were developed for prediction of success (positive LR, 10.8; 95% confidence interval [CI], 0.6-188.1) and failure (negative LR, 0.05; CI, 0.0-0.8). The most important variables were time since pain onset, basic VAS pain level, change in VAS level at 2-month follow-up, and clinical diagnoses of disk displacement with and without reduction. Outcome following use of occlusal stabilization splints may be predicted from variables collected from self-report and physical examination. Predictive modeling may provide clinicians with the opportunity to identify "at-risk" patients early and initiate alternative treatment approaches.

Clinical factors affecting the outcome of arthrocentesis and hydraulic distension of the temporomandibular joint

Significant psychosocial distress and substantial cost are associated with the diagnosis and management of chronic temporomandibular joint (TMJ) pain conditions. Successful intervention based on identified risk factors has potential functional and financial benefits. Arthrocentesis and hydraulic distension of the TMJ has been described as an effective modality in the treatment of patients demonstrating clinical findings consistent with the diagnosis of disc displacement without reduction. The purpose of this study was to investigate whether clinical variables such as age, gender, time since pain onset (TSO), visual analog scale (VAS) pain level, and mandibular range of motion (ROM) may predict treatment outcomes of arthrocentesis and hydraulic distension of the TMJ. The study comprised 64 consecutive patients presenting with TMJ pain, who were diagnosed with a unilateral clinical TMJ disorder of "TMJ pain associated with an internal derangement (ID) type III (disc displacement without reduction)." TMJ pain level of function and mandibular range of motion were assessed initially and then compared with the respective 2-month follow-up findings after arthrocentesis and hydraulic distension. Outcome criteria of success included an absence of signs and symptoms characteristic of a diagnosis of ID type III. A multiple logistic regression analysis of pretreatment data was used to compute the odds ratio for variables of age, gender, TSO, VAS pain level, and ROM for successful outcomes (n = 34) vs nonsuccessful (n = 30) outcomes. At 2-months follow-up, clinical evaluation showed a significant reduction in TMJ pain during function (P < .001), a significant reduction in clinical diagnoses of TMJ disorders (P < .001), and a significant increase in mandibular range of motion (P < .001). For the outcome criteria of "absence of ID type III," there was a significant difference between the clinical outcome groups for the variables of age (P = .029) and VAS pain level (P < .001). Significant increase in benefit of a successful outcome occurred with an age of < or = 25 years (11.8 odds ratio; P = .044), a VAS pain level of > 75 mm (6.5 odds ratio; P = .026), and an ROM of < 25 mm (6.9 odds ratio; P = .029). Clinical variables predicted TMJ "ID type III and pain" patients who went on to show successful treatment outcomes of arthrocentesis and hydraulic distension. Predictive modeling may provide clinicians with the opportunity to identify "at-benefit" patients early and initiate specific treatments.

Surgical and clinical results with the PDN prosthetic disc-nucleus device.

The PDN prosthetic disc-nucleus device has been in use for 6 years, both in clinical trials and through commercial sale. Surgical and clinical data for the device have been collected and analyzed to help determine the strengths and limitations of the implant. The shape of the device has been found to be an important element in predicting surgical success, with wedge and rectangular devices being the most stable. The patient's disc dimensions are also critically important. Data indicate that patients with a disc height of less than 5 mm should be excluded from surgery. Moreover, the anterior-posterior (AP) diameter of the disc endplates must be 37 mm or more in order to properly situate two devices within the disc--patients with a smaller AP diameter should receive only a single device. Body mass and overall patient weight are also good predictors of surgical success. If the patient's body mass index is 30 or greater, then the patient should not receive the implants. Complications related to the PDN implant have included migration of the device and endplate remodeling in some patients. This endplate remodeling has usually been mild, and has occurred in response to the change in load distribution. In a few cases there has been more pronounced remodeling with a loss of disc height. To minimize endplate remodeling, the PDN hydrogel has been reformulated to be softer, absorbing 80% of its weight in water. Subsequent to implementing changes in device design and patient selection, and with the introduction of the ALPA (Anterior-Lateral transPsoatic Approach) technique for implanting the devices, there has been an increase in surgical success with a concomitant reduction in the number of revision surgeries. The current surgical success rate for patients implanted from 1999 through 2001 is 88%. Clinical results are also very encouraging, with marked decreases in Oswestry and visual analog scale pain levels, and disc height also shows improvement and stabilization.

Douleur aiguë intense en médecine d’urgence. Les clefs d’une analgésie efficace

Objective: To measure severe acute pain (SAP) frequency, to describe SAP management and to bring to view the conditions of analgesia success in emergency medicine. Design: Multicentre prospective survey: 7 days in Emergency Departments (ED), 30 days in Mobile Intensive Care Units (MICU). Multivariate analysis to measure the independent effect on pain relief of factors identified by Chi squared test. Setting: All of 6 ED and 8 MICU of a French region. Patients: Over 15 years of age. Main outcome measures: Pain intensity was assessed with Visual Analog Scale (VAS) before and after ED or MICU management. SAP group (defined by initial VAS score > 40 mm) was analyzed for pain relief (defined by final VAS score ≤ 40 mm). Influence on pain relief through pain aetiology, initial pain intensity, treatment delay and opioid use was analyzed. Results: 1,082 fulfilled medical forms for 3,419 eligible patients. SAP frequency was estimated 36% (CI 95 = 34-38%) in ED and 29% (CI 95 = 25-33%) in MICU. SAP ( n = 368) was often persistent : 45% (CI 95 = 43-47%) after discharge from ED and 26% (CI 95 = 22-30%) after MICU intervention. The prognostic factors of pain control success revealed by Chi squared test were: MICU (vs ED), treatment delay ≤ 3 hours (vs > 3 hours), opioid use (vs non opioid use) and VAS pain level ≤ 70 mm (vs > 70 mm). The last 3 factors were confirmed by multivariate analysis. Treatment delay, opioid use, and pain level were found to be determinants of efficient analgesia for SAP. Conclusion: Despite the high frequency of SAP in ED and MICU, pain control is not satisfying. Opioid use and early treatment are determinant in analgesia efficiency for SAP and should be therefore encouraged to improve pain relief in emergency medicine.

Clonazepam open clinical treatment trial for myofascial syndrome associated chronic pain.

A number of case reports and nonplacebo controlled studies have documented the efficacy of clonazepam (Klonopin) in the treatment of a number of chronic pain syndromes including lancinating and neuropathic/deafferentation pain. There are, however, no data on the efficacy of clonazepam for chronic pain (CP) associated with myofascial pain syndrome (MFPS). Therefore, we wish to report the results of an open clinical treatment trial of clonazepam for CP associated with MFPS. Forty-six patients with chronic pain (PWCP) and a diagnosis of MFPS were recruited into a clonazepam pain treatment open clinical trial. At entrance and completion of the study the patients completed a 10-cm visual analog scale (VAS) requesting them to rate their pain over the last 24 hours. Clonazepam was titrated upwards from 0.5 mg per day, at 0.5 mg increments, every 2 days. These patients rated their perceived pain relief daily on a 3-point rating scale: none, partial, total. Once a patient claimed partial pain relief clonazepam increases were stopped. Patients who complained of intolerable side effects before partial pain relief were withdrawn from the study. For a subgroup of patients claiming partial pain relief, clonazepam serum levels were determined. Because of the reported efficacy of clonazepam for neuropathic/deafferentation type of pain, patients with this diagnosis were withdrawn from the partial response group. Statistical analyses were performed on this remaining patient group with myofascial pain syndrome without a secondary diagnosis of neuropathic/deafferentation pain and partially responsive to clonazepam. Descriptive statistics were calculated for this group. Drop in pain level from entrance to partial response was tested for statistical significance via t test. In addition, 17 independent variables such as presence of trigger points, presence of burning pain etc, were utilized in a regression analysis, with drop in pain level as the dependent variable. A Pearson correlation analysis was first performed in order to determine which of the independent variables significantly correlated with decrease in pain level. Independent variables having a Pearson r of.3687 or greater were selected for the regression procedure. Multidisciplinary pain facility. Patients with chronic pain with a diagnosis of MFPS and without neuropathic/deafferentation pain. Of the 46 patients entered into the study, 9 were not titrated to partial pain relief because of intolerable sedation and 9 had a diagnosis of neuropathic/deafferentation pain. For the remaining group (n = 28), mean drop in VAS pain level from beginning of the study to partial response was 2.78 (SD = 1.94). This was statistically significant (t = 5.49, P <.001). Mean clonazepam dosage to reach partial response was 2.41 (SD = 1.62) mg/day and the mean dosage per kilogram body weight per day was 0.04 (SD = 0.03) mg. Mean clonazepam serum level was 30.58 (SD = 24.53) microg/L. Decrease in pain level was associated with the presence of the following independent variables: trigger points (r =.451); range of motion restriction (r =.653); non anatomical sensory abnormalities (r =.370); chronic low back pain (r =.451); and burning pain (r =.482). In the regression analysis, restricted range of motion and presence of burning pain accounted for 42% and 16% of the variance respectfully. Clonazepam may have an antinociceptive effect for pain associated with myofascial pain syndrome.

Conscious Pain Mapping by Laparoscopy in Women With Chronic Pelvic Pain

In Brief Objective To evaluate the findings and outcomes of laparoscopic conscious pain mapping in women with unsuccessfully treated chronic pelvic pain. Methods Fifty consecutive women with at least one prior procedure for chronic pelvic pain had conscious pain mapping. Operative findings and clinical outcomes were documented. Preoperative and postoperative pain levels were evaluated using visual analog scales. Results Conscious pain mapping was successful in 35 cases (70%). Twenty-nine patients had 42 specific positive sites, and six patients had diffuse visceroperitoneal pelvic tenderness. Adhesions and endometriosis accounted for 45% of positive lesions or sites. About half of women with endometriosis or adhesions mapped pain specifically to those lesions. For endometriosis, histologic but not visual diagnosis predicted positive mapping. Specific viscera accounted for 36% of positively mapped sites. Diagnoses of chronic visceral pain syndrome were suggested by the findings in 16 (46%) patients whose mapping was successful. Mean ± standard deviation visual analog scale pain levels were 8.7 ± 1.2 preoperatively and 5.5 ± 3.7 postoperatively. Twenty-two women (44%) had decreased pain postoperatively and eight (16%) were pain-free. Conclusion Conscious pain mapping can be done with reasonable success in women with prior surgical evaluations and treatments for chronic pelvic pain. Chronic visceral pain syndrome, adhesions, and endometriosis were the most common diagnoses. Laparoscopic conscious pain mapping might be useful for evaluating women with unsuccessfully treated chronic pelvic pain.

Conscious pain mapping by laparoscopy in women with chronic pelvic pain

Objective: To evaluate the findings and outcomes of laparoscopic conscious pain mapping in women with unsuccessfully treated chronic pelvic pain. Methods: Fifty consecutive women with at least one prior procedure for chronic pelvic pain had conscious pain mapping. Operative findings and clinical outcomes were documented. Preoperative and postoperative pain levels were evaluated using visual analog scales. Results: Conscious pain mapping was successful in 35 cases (70%). Twenty-nine patients had 42 specific positive sites, and six patients had diffuse visceroperitoneal pelvic tenderness. Adhesions and endometriosis accounted for 45% of positive lesions or sites. About half of women with endometriosis or adhesions mapped pain specifically to those lesions. For endometriosis, histologic but not visual diagnosis predicted positive mapping. Specific viscera accounted for 36% of positively mapped sites. Diagnoses of chronic visceral pain syndrome were suggested by the findings in 16 (46%) patients whose mapping was successful. Mean ± standard deviation visual analog scale pain levels were 8.7 ± 1.2 preoperatively and 5.5 ± 3.7 postoperatively. Twenty-two women (44%) had decreased pain postoperatively and eight (16%) were pain-free. Conclusion: Conscious pain mapping can be done with reasonable success in women with prior surgical evaluations and treatments for chronic pelvic pain. Chronic visceral pain syndrome, adhesions, and endometriosis were the most common diagnoses.

Transcervical or intraperitoneal analgesia for laparoscopic tubal sterilization: a randomized controlled trial

Objective: To test the effectiveness of analgesia administered transcervically through a uterine manipulator compared with direct topical application to the fallopian tubes for relief of postoperative pain after interval laparoscopic tubal sterilization. Methods: Sixty-one women who had laparoscopic sterilization were enrolled in a randomized, double-masked clinical trial comparing analgesia with 75 mg of bupivacaine administered through a uterine manipulator with 75 mg of bupivacaine applied directly to the fallopian tubes through a secondary trocar. Results were evaluated using visual analog scale pain levels, time of administration of analgesics, total analgesics required, and recovery room times. We calculated that a sample size of 60 women would detect a 30% difference in pain levels with a power of 80% at a significance level of .05. Results: In the 59 women who completed the study, there were no differences in the two groups in pain levels, amounts of medications used, or times to administration of postoperative analgesia. Mean recovery room time was shorter in the group given analgesia transcervically, but that difference was not statistically significant. Conclusion: There were no significant differences in postoperative pain relief between transcervical administration and topical application of analgesia for laparoscopic tubal sterilization.