Surgical removal of impacted lower third molars is a common oral surgical procedure, generally followed by moderate to severe postoperative pain. Transdermal drug delivery as a concept offers interesting possibilities for postoperative pain control. The aim of this study was to evaluate the efficacy of transdermal system with fentanyl in relieving pain following impacted lower third molar surgery.Seventeen patients with bilateral impacted lower third molars were included in this preliminary study. For postoperative pain control, patients randomly received a fentanyl patch plus placebo tablet after the first operation and regular (placebo) patch and an analgesic, after the second operation. Analgesia was evaluated during first 24 hours postoperatively according to patients’ reports about time of first pain appearance and additional analgesic consumption. Pain severity was rated using a 10 cm long visual analogue scale (VAS).p<0.05). Duration of postoperative analgesia was significantly higher with FTS when compared to control treatment (p<0.05).Intensity of postoperative pain and postoperative analgesic consumption were significantly lower after the Fentanyl Transdermal System (FTS) was applied (Based on the results of this preliminary study, transdermal system with fentanyl significantly reduced postoperative pain after third molar surgery.Key words:Analgesia, fentanyl, transdermal administration, third molar surgery, acute pain, postoperative care. Removal of impacted lower third molars is one of the most frequently performed oral surgical procedures. Regardless the difficulty of the procedure itself, it is still so often accompanied with postoperative pain that is usually used as a model for studying analgesic properties of several drugs or physical means ,2. DespiTransdermal drug delivery is not a new concept, but with interesting possibilities for postoperative pain control. Fentanyl was patented for use in a transdermal patch since 1984, and it has proven to be extremely effective in the treatment of severe chronic pain  and, intThe aim of this preliminary report was to present possible efficacy of transdermal Fentanyl application for managing postoperative pain after lower third molar surgery.The present preliminary study was carried out at the Clinic of Oral surgery, School of Dental Medicine, University of Belgrade. After study approval by the local Ethics Committee , 17 adult patients aged between 18 and 36 years, having bilaterally impacted lower third molars indicated for surgical removal, entered the study. Following thorough information, all patients subscribed the informed consent. Ethical approval ,Ethics Committee of Faculty of Dental Medicine, University of Belgrade; No. 36/10.Randomization was accomplished using envelope containing random number of tooth and postoperative pain control protocol. Both, the operator and patients were blinded to the use of FTS.- Inclusion criteria- Bilaterally identical position of impacted lower third molars;- Good physical and mental condition (ASA I);- Absence of infection (pericoronitis) or trauma prior to surgery.- Exclusion criteria- A history of allergy to the drugs used in the present study;- A recent use of anti-inflammatory or antimicrobial drugs;- The condition of being pregnant or lactating;- Alcohol or narcotics abusers;- Lack of compliance.The lower third molars were evaluated on the panoramic radiographs in order to confirm symmetrical position on both sides. Preoperative measurements included: mouth opening dimension, taken as the maximum distance between upper and lower central incisors, and facial cheek diameter, evaluated by measuring a distance between two reference points: tragus and pogonion. All the measurements were performed by a ruler and recorded as to the nearest mm.- Surgical procedureIn each patient, surgical extractions of bilateral impacted lower third molars were done in separate visits, the interval between surgeries being approximately two weeks. In order to avoid bias in manual skill, all surgical procedures were done by the same surgeon (first author). All the procedures were performed in local anesthesia using 2% lidocaine chloride with adrenaline 1:80.000 , without any premedication or use of sedation during surgery. After raising a mucoperiosteal flap from the buccal aspect, a round bur with sterile saline irrigation was used to remove bone over the impacted tooth. If needed, sectioning of the crown and roots was performed before removing the tooth. The extraction wound was inspected and irrigated with sterile saline solution before suturing with a 4-0 suture. All the data concerning surgery were recorded, including the duration of surgery from the incision to placement of the last interrupted suture.- Postoperative regimen and measurementsPostoperative pain control regimens were randomly divided into two groups (FTS and control group). After the first operation, as the FTS group, all the patients received a transdermal patch containing Fentanyl  and a placebo tablet postoperatively. After the second operation, patients received a regular (placebo) patch and an analgesic tablet - a non-steroid anti-inflammatory drug , orally once daily, representing a control regimen. Patients were advised to take an additional analgesic tablet as soon as their pain reached a moderate level, recording the exact moment of taking additional analgesic, so that we could count the elapsed time till the occurrence of pain. After each operation, patients were instructed to record the number of tablets used.Concerning antimicrobial therapy, all the patients were given amoxicillin 500 mg every 8 h orally for 5 days and advised to use chlorhexidine mouth rinse twice daily starting on the day after each operation for 10 following days. The patients were given usual postoperative instructions.Each patient was evaluated at the follow-up control 24 hours postoperatively. Postoperative pain was evaluated using a 100 mm long visual analogue scale (VAS) with verbal descriptors “no pain” at the left end of the scale and “extremely severe pain” at the right end. The same examiner who assessed the patients preoperatively performed clinical measurements during follow-up examinations. Trismus and facial edema, measured as stated previously, were recorded as the differences between preoperative (baseline) and postoperative (after 24 hours) values.- Statistical analysisp-values <0.05.Statistical analysis was performed using the Statistical Package for Social Sciences . The normality of the data was evaluated using Shapiro–Wilk test. Differences between two protocols were analyzed by Wilcoxon signed rank test for paired samples and the paired t-test, depending on data normality. Categorical variables were analyzed by χ2 test. Statistical differences between groups were accepted for Data from 17 patients  were included in the study, the mean age being 22.8 ± 4.2 years. There was no statistically significant difference between study groups with regard to duration of surgery in both sessions . A postoWith respect to pain evaluation by the VAS, there was a statistically significant difference between the FTS and the control group after 24 hours . HoweverThe impact that postoperative pain, among other postoperative sequels, has on patient quality of life after lower third molar surgery is undoubted. Of all the symptoms associated with this procedure, postoperative pain is one that patients apprise as the most inconvenient. In the literature, there are many articles regarding control of postoperative pain using various analgesics over time and comparing their efficacy. Theoretically, FTS could be an ideal drug for patients who are unable to eat due to severe trismus, swelling and especially for patients with gastrointestinal problems such as ulcer.Although the efficacy of FTS has already been proven in the treatment of chronic cancer pain -10, therAdverse events due to transdermal fentanyl use can be divided into three categories based largely on the intent of use: appropriate therapeutic use, inappropriate therapeutic use (misuse), and abuse. Abuse is defined as the intentional inappropriate use of the transdermal device, or its contents, for purposes other than those for which the transdermal device was intended or prescribed . This isThe recipient site on the skin that is most appropriate for application of FTS and its condition should also been discussed. The average skin thickness of the human body is 40 μm, but it ranges between 20 and 80 μm based on location, race, age, and gender, among other factors. In skin samples from 8 individuals, there was a >50% difference in the permeability of fentanyl . Skin suAlso, following application of a transdermal fentanyl device to broken skin, blood fentanyl concentrations can rise 5-fold . In our Recently, Fentanyl Iontophoretic Transdermal System (fentanyl ITS) was introduced as a system that has been approved especially for the management of acute, moderate-to-severe postoperative pain . FentanyIn conclusion, it can be stated that this preliminary report found FTS to be very effective in relieving postoperative pain after lower third molar surgery, with excellent tolerability. However, future clinical trials are necessary, with sufficient sample size and use of fentanyl ITS, regarding possible standard use of opioids for control of acute pain after oral surgery.


Osteoarthritis is the most degenerative joint disease. The aim was to investigate the effects of ultrasound using mineral water or aqua sonic gel on severity of knee pain, measured by the visual analog scale and the Western Ontario and McMaster Universities Arthritis Index (WOMAC).Thirty women with bilateral osteoarthritis of the knee were assigned to two groups: ultrasound with mineral water  or with aqua sonic gel . Both groups underwent 4 weeks intervention, three per week. The participants were assessed using the visual analog scale and the WOMAC. Tests were performed before and after interventions.Both groups had significantly reduced pain and improved WOMAC compared with preintervention values.The ultrasound with mineral water group had more pronounced improvement at p-value < 0.001.Ultrasound with mineral water is preferable in treatment of knee OA. Knee pain is terrible for the patient and affects the locomotor activity of the person. Our study compares an ultrasonic device with traditional gel for the treatment of knee pain versus an ultrasonic device with mineral water from natural source. We compared treatment results after 1-month treatment period on the pain and the physical function of these patients. Our results demonstrated that treatment with ultrasound with mineral water showed superior patient improvement in terms of pain and physical function. Osteoarthritis (OA) is one of the most common chronic and degenerative joint diseases . The joiOA is a disease of multiple dimensions characterized by deterioration of the articular surface of the joint. OA presents with pain, deformity, muscle atrophy, progressive loss of independence and decrease in functional capability . Risk faAppropriate treatment modalities for all individuals with knee OA included biomechanical interventions, intra-articular corticosteroids, exercise (land based and water based), self management and education. For specific clinical subphenotypes recommended treatments were balneotherapy and pharmacological drugs but, uncertain appropriateness for specific clinical subphenotypes acupuncture and ultrasound Therapeutic modalities in treating OA are mainly directed at symptom relief and other treatment options, including both nonpharmacological and pharmacological measures. Physiotherapy is one of the recommended nonpharmacological options in patients with OA .One of the most common physical agents used within physiotherapy practice, ultrasound therapy is based on the application of high-frequency sound waves to body tissues in order to obtain mechanical or thermal effects. These effects are intended to enhance soft tissue healing, increase blood flow and metabolic activity and decrease inflammatory response and decrease pain .Ultrasound treatment modalities have been proven to promote repair of full-thickness articular cartilage defects, have resulted in formation of hyaline cartilage life repair tissue at the sites of defects, softened and dissipated condensed fibrous connective tissue and delayed progression of early OA .Ultrasound may be administered in either continuous or pulsed mode. Pulsed ultrasound produces nonthermal effects and is used to aid in the reduction of inflammation, whereas continuous ultrasound generates thermal effects to alleviate pain .When ultrasound is used with specific medicaments to enhance transdermal absorption of a compound, significant amounts of the compound are absorbed by the subcutaneous circulation .Balneotherapy is defined as the use of baths (in tubs or pools) containing thermal and/or mineral water from natural springs or drilled wells . The maiSpa therapy is one of the most commonly used nonpharmacological approaches for OA in many European and Middle Eastern countries. It comprises a broad spectrum of therapeutic modalities including hydrotherapy, balneotherapy, mud-pack therapy, physiotherapy and exercise .For patients with knee osteoarthritis a short-term 3 weeks of spa therapy with home exercises and usual pharmacological treatments offers benefit after 6 months compared with exercises and usual treatment alone .Mineral water has been used for a long time in the alleviation of musculoskeletal pain. The beneficial effects of balneotherapy were studied and proven in a variety of rheumatological diseases in past decades. In osteoarthritis of the knee, pain and musculoskeletal dysfunction improved in the short to medium terms .In Israel, increased serum concentrations of bromine, rubidium, calcium and zinc were noted in patients with psoriasis after bathing in the Dead Sea. Whether these chemicals have any biologic effect is not known. There are data, however, that indicate that sulfur can be absorbed through the skin and may have analgesic effects .Beneficial effects of a cycle of sulphate–bicarbonate–calcium mineral water baths have been shown for the pain management, functional capacity and quality of the life parameters in patients with knee OA .The aim of this study was to investigate the effects of 12 sessions of pulsed ultrasound with mineral water versus that with aqua sonic gel on severity of knee pain and evaluation of perceived health and physical function using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) in women with bilateral osteoarthritis of the knee.We hypothesized that there will be greater improvement in severity of knee pain and perceived physical function in the group treated with pulsed ultrasound and natural mineral water than in that treated with pulsed ultrasound and aqua sonic gel.The procedures followed were in accordance with the ethical standards of the committee on human experimentation of Cairo University. The trial was registered by number: NTR 334.This was a controlled randomized single-blinded assessor study. The block randomization list was kept by individuals who had no contact with the investigator, who assigned patients to their randomization treatment.Patients with osteoarthritis of the knee were recruited from an orthopedic clinic, evaluated and informed about the objective and experimental procedures of the study. Thirty women with bilateral OA of the knee completed all the procedures. Exclusion criteria included any rheumatic disease , unilateral OA of the knee, neurological disorders, cognitive limitations or endocrine disease. These also included patients who had undergone arthroscopy or treatment with intra-articular hyaluronic acid during previous 6 months or who had been treated with intra-articular corticosteroids during the past 3 months. Inclusion criteria included female sex, bilateral OA of the knee, Kellgren–Lawrence scores of 2 and 3 on radiologic evaluation , age ranParticipants were randomized into two groups: group 1 received ultrasonic treatments with mineral water (n = 15) and group 2 received ultrasonic treatments with aqua sonic gel (n = 15). These physiotherapy treatments were performed three-times per week for 4 weeks. The patients' characteristics are presented in The study was conducted at a clinic in the spa center. Design was organized into four steps: medical and physical examination; preintervention evaluations; treatment; postintervention evaluations. Participants underwent detailed medical examination (performed by an orthopedist) and OA diagnostic evaluation . One day before and after treatment, participants were evaluated for perceived health and physical function using the WOMAC questionnaire ,20, and 2 power, applied with a 5-cm diameter applicator . The area of treatment was cleaned to permit an effective skin applicator coupling. For group 1 we used the indirect ultrasound applications, degassed water because it is less expensive [All patients completed 4 weeks of treatment (12 sessions). The ultrasonic protocol for each group consisted of pulsed ultrasonic waves of 1 MHz frequency and 1 W/cmxpensive . Group 1Knee pain was assessed using the VAS. The VAS consists of a 10-cm line, with the extreme left indicating ‘no pain’ or ‘0’ and the extreme right indicating ‘unbearable pain’ or ‘10’. The patients were instructed to use the scale to indicate their current level of pain. The values (in centimeters) were recorded for the statistical analysis.The WOMAC osteoarthritis index was used as a subjective measure of perceived health and physical function.The WOMAC osteoarthritis index is a three-part questionnaire, completed by the patients themselves and consisting of 24 questions revealing clinically important symptoms in the areas of pain (5 questions), stiffness (2 questions) and physical function (17 questions) for patients with OA of the hip and/or the knee ,15. In tThe WOMAC questionnaire has been proven to show moderate to high validity in many studies .Power analysis  determined that a sample size of 15 patients in each group was needed to demonstrate a 10-mm difference in improvement in the patient's assessment of pain (using 0–100-mm VAS) between the both groups, with standard deviation of 22 mm.The data were analyzed using the Statistical Package for the Social Sciences version 16 software for windows . Data were represented as mean and ± SD. All variables presented normal distributions according to Kolmogorov–Smirnov tests. Paired t-sample t-tests were used to compare pre- and post-treatment changes in each group. Student's T-tests were used to compare both groups. The results were considered to be statistically significant at p < 0.05.All participants completed 12 treatment sessions  represenOA of the knee is considered to be the fourth highest cause of disability in women and is responsible for the deterioration of quality of life and functional ability . EvidencTo our knowledge, this is the first study that examines the therapeutic effects of mineral water in combination with ultrasound compared with the traditional method of using aqua gel and ultrasound in the treatment of OA of the knee.Mineral baths seem to be more beneficial to quality of life when compared with an absence of pain treatments and/or analgesic intake. It was presumed that most mineral ingredients are absorbed through the skin into systemic circulation. This mechanism has not been confirmed so far .In this present study, significant beneficial effects on pain and functional capacity in patients with OA of the knee were demonstrated using mineral water with ultrasound. All evaluation parameters were significantly reduced after the treatment. A significant difference, superior to that of the group in which aqua gel was used with ultrasound, was observed. Our results have shown that using mineral water with ultrasound improves pain and total WOMAC scores.In this study we proposed that the absorption of the components of mineral water is enhanced by ultrasound, resulting in benefits additional to those of conventional therapeutic ultrasound using aqua gel, however effective both treatment methods are.Ultrasound is one of the deep heating modalities used in physical therapy. Therapeutic ultrasound is generated by a transducer that converts electrical energy to ultrasound by using the piezoelectric principle . AlthougIn our study, we used mineral water (containing cations and anions) with ultrasound for one group, and ultrasound with aqua gel in another group. Therapeutic ultrasound administration enhances percutaneous penetration of topical diclofenac gel . We propOur results have shown that using mineral water with ultrasound treatment may be useful alongside pharmacological therapy, and may represent an alternative option to patients with OA of the knee and who are susceptible to drug-related side effects.-2), is dominant. Sulfur, which can be absorbed into the body through the skin, has a known antioxidant effect in the cellular level. The antioxidant effect of sulfurous mineral water protects cartilage tissue against the oxidative damage in osteoarthritis [It is difficult to separately analyze the effect of each component of mineral water. Spa water, which contains high sulfide ions (Srthritis .The efficacy is probably the result of a combination of factors covering ultrasound and chemical effects of the mineral water.We used the pulsed ultrasound in our study because pulsed ultrasound with greater probability of being the preferred mode, is more effective in both pain relief and function improvement, whereas the continuous ultrasound could only be considered as a pain relief treatment in the management of knee OA . In our Our sample is homogeneous because we recruited only women with bilateral OA of the knee.The main limitations of this study are: the small number of patients; the short period of treatment of 1 month and 12 sessions; the absence of follow-up after the treatment and that it did not include any quality of life outcome. Other, more objective outcome variables should be included in the study protocol, such as range of motion at the knee joint, among others.Ultrasound treatment is effective for reducing pain and improving WOMAC scores. However, ultrasound treatment with mineral water is superior to ultrasound treatment with aqua gel. The results of the present study may encourage subsequent researchers with larger patient populations and the ability to follow-up to verify therapeutic effects and to assess the biological effects of mineral water with ultrasound on the clinical status of patients with OA of the knee.Mineral water and ultrasound may be useful and may represent an alternative treatment in patients with OA with a high risk to drugs side effects. We can extract from the active ingredient composition of the water ointment to be used with the ultrasound and may be also extract drugs to be used in treatment of the knee OA.Ultrasound treatment with the mineral water was superior in treatment of bilateral knee osteoarthritis in female patients after 12 sessions of treatment.The superiority was determined at pain measured by visual analog scale.The superiority was also determined at the Western Ontario and McMaster Universities osteoarthritis index.


To analyze the association between the OHIP-14 and the different subtypes making up the clinical and psychological axis obtained using the RDC/TMD.407 patients treated at the TMD unit of the Andalusian Healthcare Service were administered the Spanish version of the Research Diagnostic Criteria for Temporomandibular Disorders questionnaire (RDC/TMD), together with the Oral Health Impact Profile questionnaire (OHIP-14). The degree of association between the patients’ score in the OHIP-14 and the clinical and biopsychosocial variables was analyzed through bivariate and multivariate analyses, specifically through linear regression.p<0.05) was observed with the following variables: Axis I, jaw disability checklist, depression, somatization, perceived pain duration, and pain interference with activities of daily living.89.4% of the treated patients were women, while 10.6% were men, with an average age of 42.08 ± 14.9 years. The mean score and standard deviation for the OHIP-14 was 20.57 ± 10.73. A significant association . The term temporomandibular disorders (TMD) includes a wide range of pathologies, whose signs and symptoms involve the temporomandibular joints, the muscles that control them or both . The siget al.  has been standardized, which are based on a dual axis that makes it possible to obtain clinical sub-types in these patients , either individually or in groups. The second axis, or biopsychosocial axis, allows using a series of items such as pain intensity, graded chronic pain scale, and psychological variables , providing a comprehensive approach to the possible etiological causes.Applying and introducing the RDC/TMD criteria, with their high specificity and reliability, allowed us throughout the last two decades to standardize the different clinical subtypes , as wellThe lack of items reflecting the qualitative perception of these patients’ health was perhaps the main handicap of the RDC/TMD in the beginning; however, this was overcome during the last decade by incorporating questionnaires measuring patients’ self-perceived health, which made up for that lack .et al. , which belongs to the public Andalusian Healthcare Service. Before being examined, the patients were informed about the study’s protocols and were asked for express permission to fill out the questionnaire. This questionnaire complied with the norms previously established by the ethics committee of the Reina Sofia Teaching Hospital. Eight patients who refused to undergo the examination or to fill out the questionnaire were excluded from the study. The remaining 407 patients were examined by a specialist with 27 years of experience in TMD, and filled out the questionnaire between January 2011 and November 2012.It is worth mentioning that the main limitation of our study was the lack of a control group to allow us to compare the variability of results among patients with no pathology. The possible bias in assessment and interpretation was corrected by having coauthors unconnected to the clinical aspects of the examination of patients analyze the data.The criteria for inclusion were being 18 or over  and having reported some of the following signs or symptoms: pain in the jaw or the TMJs; limited or restricted range of motion when opening or closing the mouth, or in lateral excursions; and/or joint sounds, with or without pain.Apart from the refusal to take part in the study or to sign the informed consent form, the following exclusion criteria were also applied: patients who suffered some kind of systemic rheumatic disease , or neurological or autoimmune diseases; patients who had undergone TMJ surgery or head and neck radiation treatment in the two months prior to the study; patients who had suffered head and neck trauma in the two months prior to the study; pregnant patients; patients treated with narcotic analgesics, muscle relaxants or corticosteroids whose treatment could not be suspended one week prior to the study; patients who had been treated with antidepressants or NSAIDs at least in the three days prior to the study; and drug-dependent patients.et al.  was also calculated, as it is usually described in the literature . It was It is also important to note that the pain duration variable was divided into two groups, one made up of patients who reported having suffered from pain for less than a year, and another group made up of patients who reported having had pain for one year or more. These groups were formed empirically on the basis of a hierarchical segmentation analysis where the dependent variable was the OHIP-14 score and the independent variable was pain duration measured in months. This empirical analysis allowed us to statistically discriminate those groups which differed in relation to the dependent variable. More precisely, it provided an appropriate number of groups and established the cutoff point taking into account the statistical differences observed in the empirical evidence.As regards the statistical analyses carried out to achieve our objective, we first performed a contrast of means between the OHIP-14 scores and the analyzed variables . After that, a hierarchical segmentation analysis of the variables GPCS and Axis I was performed, with the aim of empirically observing for which categories of such variables their association to the OHIP-14 variable was more significant Figs. .As may be observed in Figure Finally, we performed a linear regression analysis, using the OHIP-14 indicator as the dependent variable and the variables that were found to be statistically significant in the bivariate analysis as explanatory variables.We tested for collinearity between the independent variables and, in order to avoid it, we analyzed the partial correlations and the indicators of collinearity, thus decreasing the number of variables that were ultimately included in the model. High collinearity was the reason to exclude the somatization variable from the regression model. The data were analyzed using the statistical software package SPSS, version 15.The sample was made up of 365 women (89.7%) with a mean age of 42.15 ± 14.63 (mean ± standard deviation), and 42 men (10.3%) with an average age of 41.48 ± 17.28. This representation corresponds to a 8.4 W:M ratio. The age range is from 18 to 83 years.The distribution of the mean scores and standard deviations for each indicator are shown in Figure Beginning with the descriptive values of some variables, the score obtained from the mean and the standard deviation of the OHIP-14 was 20.57 ± 10.73 (mean ± standard deviation), thus with a 95% CI (19.52 – 21.61).The jaw disability variable, in turn, obtains a mean score of 0.33, with scores ranging from a minimum of 0 to a maximum of 1. The pain interference with activities of daily living indicator interpreted as the “degree of disability associated to pain” is made up of each patient’s pain intensity variable, together with the variable measuring the disability generated by that pain in each of the activities the patient performs. The former reveals an average score of 1.78, with a 95% CI range (1.71-1.86), which would mean that 95% of the sample shows pain intensity scores above 50 points in the VAS scale, but they do not report disability in their daily activities.Depression, measured by a 0-4 scale, shows an average score of 1.33, with a CI range between 1.25-1.41, which may be interpreted as a severe degree of depression, since, according to the RDC/TMD International Consortium, depression is considered severe when the average score is over 1.105.The average score for the pain duration variable was 1.59, with a CI range between 1.55-1.64. If we take into account that the scores for this variable are: 1, whether the patient has had pain for a period of less than 12 months, and 2, whether the pain duration is more than one year, we note that the average score is slightly over the midpoint, which means that the patients who have been having pain for more than one year slightly outnumber those who have had pain for a shorter period of time.In the relation between the OHIP-14 variable and pain duration, we have noted that there is a clear difference in the scores of both subgroups, as the patients reporting pain for more than one year obtain a score 6.6 points higher in the OHIP-14 than those who report pain for less than one year.As regards the relation between the OHIP-14 with the Axis I variable , it may be observed that the OHIP scores for the muscular subgroups associated to arthralgia and those muscular pathologies accompanied by arthralgia and discopathy are the ones with a worse perception of their oral health, followed, with 6 points less, by the rest of patients.p ≤ 0.05), as is the case in the rest of the studied variables.As far as the Axis II or biopsychosocial axis is concerned, two variables were taken into account: the depression variable and the jaw disability variable, both with a high significance value , which assume that these patients suffer from disability, show a OHIP-14 mean score 20 points higher than that of the patients who do not report pain intensity or disability as a consequence of such pain. These results would be in line with those obtained by Alajbeg v , who reps. study , there iThe difference of mean scores in the pain duration variable was 6.5, with a Fisher’s value of 39.7. This may be interpreted as most patients having a worse perception of their oral health-related quality of life in accordance with the duration of their painful pathology. This large difference reveals that, as suggested by several authors ,24, the If we analyze the relationship between the OHIP-14 mean scores and each of the combined subgroups comprising the clinical axis or Axis I of the RDC/TMD, we observe a clear preponderance of patients with myofascial pain associated to other subtypes, while the patients with discopathies or arthropathies with no muscular involvement have a better perception of their oral health. Just like in our case, other authors like Barros  observe Likewise, a worse self-perception of their oral health has been widely reported in patients with TMD who also have a psychosomatic pathology like depression , with hiLooking at these results, we can conclude that those patients with more pain intensity, linked to a higher disability to develop their professional and personal lives, have a worse perception of their oral health, which even worsens in accordance with the duration of the pathology.We would also like to highlight that, within the different categories the temporomandibular disorders are broken down into, those patients with a muscular pathology accompanied by arthralgia perceive their oral health-related quality of life significantly worse than the rest of patients, which may be accounted for by the fact that these patients are the ones with the highest pain intensity. Regarding the psychological variables, both depression and jaw disability seem to be associated with a worsening in the oral health related quality of life.


Burning Mouth Syndrome (BMS) is a chronic pain condition characterized by persistent intraoral burning without related objective findings and unknown etiology that affects elderly females mostly. There is no satisfactory treatment for BMS. We aimed to observe the long-term efficacy of high velanfaxine doses combined with systemic and topical administered clonazepam in a particular subgroup of BMS patients who do not respond to current clinical management.Eight  out of 14 BMS patients fulfilled the inclusion criteria and were treated with venlafaxine (300 mg/d) and clonazepam (5 mg/d) for 35.4 ± 12.1 (mean ± SD) months. The average duration of the symptoms at baseline was 4.3 ± 1.4 years and the overall mean daily pain intensity score was 8.6 ± 1.3 (VAS); pain was in tongue and within the oral mucosa, accompanying by oral and facial dysesthesia. In five patients tasting was abnormal. All patients had positive history of concomitant primary headache. The average score of Hamilton Rating scale for Anxiety and Depression was 21 ± 4.2, and 26.1 ± 2.9, respectively. Previous ineffective treatments include anticonvulsants and anti-depressants. All patients responded (more than 50% decrease in VAS) after three months treatment (mean VAS 3.2 ± 2.2) with no remarkable adverse events.BMS deserves bottomless psychiatric evaluation and management when current available treatments fail. Treatment with venlafaxine combined with topical and systemic clonazepam may be effective in refractory BMS cases but further investigation in a large-scale controlled study is needed to confirm these results. P < 0.001). The highest prevalence was in women aged 70 through 79 years . Mean (SD) age at BMS diagnosis was 59.4 (15.1) years  [BMS is a chronic pain condition characterized by persistent intraoral burning without related objective findings and unknown etiology that predominantly affects elderly females. Previously used terms include stomatodynia, or glossodynia when confined to the tongue (based on the Greek words stoma that means mouth and glossa that means tongue). The condition has been recently recognized in the current International Classification for Headache Disorders (ICHD-III beta) as an intraoral burning or dysaesthetic sensation, recurring daily for more than 2 h per day over more than 3 months, without clinically evident causative lesions. Oral mucosa should appear normal with normal sensory testing . How pre0 years) , as well0 years) . In some0 years) .There is no satisfactory treatment for BMS. The most widely accepted treatment options that show variable results include tricyclic anti-depressants, benzodiazepines, antipsychotic drugs , and SSRIn this study we aimed to observe the long-term efficacy of high velanfaxine doses combined with clonazepam in a particular subgroup of BMS patients who do not respond to current clinical management.Patients with burning mouth symptoms that were resistant to current available treatments were selected at presentations for long follow-up, since the beginning of 2010. After the publication of ICHD-III beta all patients fulfilled the BMS criteria were identified and among them those they had no improvement after at least three consecutive drug treatments were followed. Pharmacotherapy might include any agent for chronic pain alone, or in combination with psychotherapy, counting anti-depressants and anti-epileptics in various doses and treatment durations, without any specific pattern. After three consecutive treatment attempts without a 50% reduction in daily pain, as defined by patients them selves, the selection criterion was fulfilled. No exclusion criteria were applied. Once a patient had recruited, a daily pain diary was delivered to follow pain duration and severity during follow-up period. A relevant physician treated any concomitant non-neurological condition according to current clinical practice but treatments with local anesthetics, anti-epileptics and anti-depressants were not allowed. Antiarrhythmic agents that may have analgesic effects could be used only after approval by the research team. All participants were told that they will get two treatments simultaneously that have been trialed alone, but not in combination before. The potential treatment adverse effects were announced as well. A specific investigation protocol was designed for diagnostic reasons including brain and facial MRI, trigeminal blink reflex and peripheral nerve conduction studies apart from other tests necessary because of patients’ particular comorbidity and medical history. Participants allowed to performed neurophysiological studies of facial nerve in private laboratories, thus no common methodology used. All patients had a specific oral and orofacial clinical examination to exclude any oral condition or temporomandibular joint and occlusion dysfunction from an expert. In addition all patients had a neuropsychological evaluation with a battery of tests including the Hamilton Rating Scales for Anxiety and Depression, as well as clinical psychiatric consultation. In all participants cognitive psychotherapy treatment was suggested, in addition to pharmacotherapy. Participants used the analogue visual scale (VAS) to assess mean daily pain.® oral solution 2.5 mg/ml). Patients were asked to keep the solution in their mouth for 5 min before swallowing, in one evening dose of 2.5 mg. After 5 days the dose increased up to 5 mg daily, divided into three doses . Always the solution should be kept in the mouth for at least five minutes before ingestion. Previous treatments were removed gradually within 6 months in six cases.In all patients venlafaxine was added at high doses (300 mg daily), together with clonazepam. Oral solution of clonazepam was used  with the mean duration of the condition lasting 4.3 ± 1.4 years. All were followed-up in our department for more than 2 years (mean follow-up duration 35.4 ± 12.1 months).The clinical characteristics of patients are presented in Table Neurological and physical examination were normal in all cases apart from those they co-suffered from PD . Sensory tests in face for small and large fibers were within normal limits in all patients . Bilateral tongue taste tests  were abnormal however in five cases . Testing was unpleasant in all cases because it triggered pain.Brain and facial MRI was performed in all cases. In five patients medium small vessel disease was found in brain with periventricular location. In one patient lacunes with midbrain were seen in addition. Facial MRIs showed no abnormalities related to BMS clinical picture. Facial nerve conduction studies were normal in all cases . In three cases ipsilateral to pain a slight decrease in facial nerve conduction was observed  and blink reflexes were performed that were normal (R1 and R2 responses) without significant differences between two sites (patient with midbrain lacunas included). Thus, in all cases paraclinical investigation, including routine blood tests  did not reveal any significant abnormality, related to patients’ symptoms.Previous treatments included anticonvulsants  and anti-depressants  in various doses Table . No patiIn cases 3 and 8 Table  gabapentA receptors that have been identified within the tongue nerve fibers of rats [A receptors located within the brainstem [BMS is rather a rare chronic idiopathic pain condition affecting 1‰ of people, predominantly elderly women that often resist to common treatment with anti-epileptics and anti-depressants. We describe here eight cases of female patients with refractory BMS and depression who followed for more than two years. Pain was severe, daily and exaggerated during the night in all cases. Repetitive trials with anti-depressants and anti-epileptics agents commonly used in chronic pain syndromes had failed, but all responded to a combination of high dose venlafaxine and oral solution of clonazepam. Participants experienced several adverse events in the treatment initiation but after a while they tolerated it. BMS treatment remains controversial  yet ther of rats  and enharainstem . Becauserainstem . No caseVenlafaxine, a serotonin-norepinephrine reuptake inhibitor (NSRI) that controls equally depression and chronic pain , 32 was Other studies showed that the majority of BMS patients present with several additional unexplained extra-oral comorbidities, indicating that various medical disciplines should be involved in the BMS diagnostic process and that BMS may be classified as a complex somatoform disorder rather than a neuropathic pain entity .This study carries several limitations. It is an uncontrolled observational study with a small number of patients, thus placebo biases cannot be excluded. In a meta-analysis of placebo-controlled trials for BMS, treatment with placebos produced a response that was 72% as large as the response to active drugs . These hBMS is often misdiagnosed and pain physicians or headache specialists should be aware of the condition. Notably, brain and facial MRI and facial nerve conduction studies showed no significant findings. Secondary burning sensation due to drugs  or thyroid hormone dysregulation should be ruled. BMS has high psychiatric comorbidity but can occur in the absence of psychiatric diagnosis. Patients with atypical chronic pain syndromes must be considered as potential candidates for under-diagnosed depression (major) and suicidal thoughts. Other common BMS comorbidities include PD that should be treated accordantly. Thus, BMS management requires multidisciplinary management.Refractory BMS deserves bottomless psychiatric evaluation and management when current available treatments fail. Paraclinical investigation including brain imaging and peripheral facial nerve conduction evaluation may be needed. Controlled, large-scale trials with high dose NSRIs in combination with mouthwash and systemic clonazepam are required to establish this treatment that might help to improve pain control in this rare and severely disable pain condition.


Interventional Pain Management (IPM) is performed in multidisciplinary chronic pain clinics (MCPC), including a range of invasive techniques to diagnose and treat chronic pain (CP) conditions. Current patterns of use of those techniques in MCPC have not yet been reported. We aimed to describe quantitatively and qualitatively the use of IPM and other therapeutic procedures performed on-site at four Portuguese MCPC. A prospective cohort study with one-year follow-up was performed in adult patients. A structured case report form was systematically completed at baseline and six and 12 months.n = 28), postoperative CP, and knee pain (n = 16 each). From 195 IPM prescribed, nerve blocks (n = 108), radiofrequency (n = 31), and viscosupplementation (n = 22) were the most prevalent. Some IPM techniques were only available in few MCPC. One MCPC did not provide IPM. Among 808 patients referred to the MCPC, 17.2% had been prescribed IPM. Patients with IPM were on average younger and had longer CP duration and lower levels of maximum pain and pain interference/disability. The three main diagnoses were low back pain ( IPM are seldom prescribed in Portuguese MCPC. Further studies on IPM safety and effectiveness are necessary for clear understanding the role of these techniques in CP management. Chronic pain (CP) is a worldwide public health problem that causes a substantial burden on healthcare systems and society, taking into account its high prevalence, economic costs, and the quality of life impairment of the patients and their families. CP requires a multidisciplinary approach for its adequate assessment and management –5. For mCP is one of the most common reasons why people seek medical care . The ecoIdeally, supported by the most recent guidelines for the CP management, these patients should have access to a multidisciplinary range of diagnostic and therapeutic modalities appropriate to their clinical condition –17. The In Portugal, there is no available information regarding patterns of prescription of IPM or OTP performed on-site at MCPC. Therefore, as a part of a larger real-world outcomes research prospective cohort study on CP patients followed at MCPC, this study inquired about the utilization of those techniques and procedures. We aimed at describing quantitatively and qualitatively the patterns of prescription of IPM and OTP performed on-site at MCPC in Portugal.https://doi.org/10.1155/2017/8402413).Participants were recruited at their first consultation in four MCPC from the North of Portugal, in the context of a large real-world outcomes research project. The eligible population included adult patients (≥18 years old) with chronic noncancer pain lasting more than 3 months (the standard IASP criteria for CP ) or withAll participating patients were previously informed of the study objectives and about the data selection and collection procedures, and questions regarding the study, posed by the patients, were properly answered by the research team. All participating patients signed an informed consent form. The study protocol was approved by institutional review boards, ethics committees of the participating hospitals, and CNPD, the Portuguese Data Protection Authority.A structured questionnaire was used in baseline interviews. For the purpose of the present study the following data were systematically collected: demographic characteristics, clinical and pain characteristics, and IPM and OTP performed on-site at MCPC prescribed. The Brief Pain Inventory (BPI)  which isIn the descriptive analysis of the sample  and subsamples (patients with and without IPM), we defined the general characteristics, including sociodemographic , professional/occupational status, pain characteristics , general health, and clinical variables  10 diagnostic classification). The persistence pattern of pain was classified as continuous, pain present every day/always, or discontinuous .n) and relative (%) frequencies; continuous variables were described using the median and interquartile ranges considering the tested asymmetric  distribution or mean and standard deviation otherwise. We used the Chi-square test, or the Fisher's exact test, to test hypotheses for categorical variables. In the case of continuous variables  the Mann–Whitney test was used. For all hypothesis tests a significance level of α = 0.05 was considered. The statistical analysis was performed using the software SPSS v21.0®.Categorical variables were described as absolute (p < 0.001). Elderly patients (over 75 years) were less frequently prescribed IPM. Patients with IPM were mainly full- or part-time workers while those without IPM were mostly retirees (p < 0.001).Sociodemographic characteristics of all patients, patients with IPM, and patients without IPM are described in p = 0.006). Patients in both groups referred to almost exclusively continuous pain. Significant differences in pain intensity could only be seen for pain at its worst . The location of the pain was heterogeneous and statistically significant differences were found; in all patients that indicated pain in unspecified bones, joints, and muscles 92.1% were patients without IPM, whereas among all cases of pain in inguinal and pelvic region 31.2% are reported by patients with IPM (p = 0.047). Patients with IPM had significantly lower pain interference score (p < 0001). Specifically, pain-related interference was inferior in general ability , walking ability , normal work , relations with other people , and enjoyment of life . More than 57% of patients who had no pain interference had invasive techniques for pain management, while 88.1% of patients with severe interference did not had IPM prescribed. In general health no differences were found.p = 0.013) and 4.2% of patients with cancer pain (p < 0.001), while it was used in 36.7% of patients with low back pain with sciatica (p = 0.011), 41% of patients with knee (p < 0.001) pain, and 46.4% of patients with pelvic or perineal pain (p < 0.001) (Supplement 2).Using the ICD 10 to classify patient's pathologies, 34 diagnoses were obtained from all patients. The five most prevalent diagnoses in patients with IPM were low back pain (28 patients), chronic postoperative pain (16 patients), knee pain (16 patients), pelvic and perineal pain (13 patients), and low back with sciatica (11 patients). We only found five significant differences between patients with and without IPM in what concerns the diagnosis. IPM was only used in 2.8% of patients with fibromyalgia .There are very few studies focused on IPM utilization patterns in multidisciplinary CP clinics , 24. To We found that nerve blocks were the most frequent IPM prescribed in MCPC; with a total of 420 IPM or OTP prescribed during the one-year follow-up. A total of 139 patients (17.2%) in our cohort received IPM for their CP management. Of those, almost 32.4% had pain for over 10 years and 92.1% of these reported a continuous pain pattern. There was a diversity of IPM prescribed in the participating MCPC, and botulinum toxin, viscosupplementation, neurostimulation, and radiofrequency were only available in very few centers. In our cohort there is a higher prevalence of women with CP which is in accordance with the available literature , and aveIn general, the success of these techniques is partly dependent on the experience and skill of the provider. There is controversy over the evidence that supports these techniques , as therIn the present study, IPM were prescribed mainly to patients that did not report significant interference of pain, as measured by the functional interference scale of the Brief Pain Inventory, while the vast majority of patients that reported severe interference were not prescribed IPM. The reasons for these unexpected results are not clear at present, and one can only speculate that patients with severe interference suffered from conditions and/or had a health status  less likely to be treated by IPM, but additional data is required to investigate this issue.Among the great variety of IPM used in multidisciplinary pain management , 25, sixNerve blocks, the most frequently prescribed technique in the present study (88 patients), consist in anesthetics delivered to visceral and peripheral nerves in order to interrupt nociceptive input at the source of pain , 28. ThiViscosupplementation consists of intra-articular injection of hyaluronic acid derivatives. It is one of the more used local treatments for osteoarthritis along with corticosteroid injection. It has been used mainly in knee joint, where it shows moderate and significant pain reduction and increased function , but a rRadiofrequency denervation consists in nerve ablation using heat generated by a radiofrequency current . Facet jBotulinum toxin injections as well as acupuncture and dry needling techniques are effective options for myofascial pain, namely, trigger point's deactivation , 38. HowEpidural injection was primarily recommended for radicular pain from a herniated disc but could also be performed in patients with spinal stenosis and other low back pain conditions , 26. Fai angina pectoris [Neuromodulation is used in some Portuguese MCPC. However, during the recruitment period of our study there was only one patient who was referred to this treatment . Spinal pectoris .Taking into consideration OTP performed on-site, prescribed in the MCPC, acupuncture was the most frequently prescribed. Some evidence supports acupuncture effectiveness for chronic low back pain treatment , fibromyPain is a common symptom in cancer patients. In spite of advances in pain management, effective pain control remains an ongoing challenge, despite high doses of opioids . Drugs iThe present findings clarify which and in what extent IPM and OTP performed on-site at MCPC are being prescribed. This study has several strengths, namely, inclusion of several MCPC, a well-structured and detailed questionnaire, telephonic interviews performed systematically, a restricted and trained team, a large sample, and a 12-month follow-up period. The data presented are unique and to the best of our knowledge there are no similar data in other MCPC that describe their current clinical practice and are useful for comparison and benchmarking.We have a comprehensive and systematic description of IPM and OTP performed on-site, prescribed, and actually used in MCPC, constituting the clear added value of our study. However, some IPM can be performed for therapeutic or diagnostic purposes and this has not been differentiated in the present study. Further ongoing research will provide data on the evaluation of real-world effectiveness and patient's reported satisfaction by type and timing of techniques performed.In Portugal IPM is available in most MCPC, but with marked diversity in the types of techniques and clinical indications. IPM is still seldom prescribed, with only 17.2% of patients having IPM as part of their management. Future studies focused on patient's reported effectiveness and satisfaction are needed.Supplement 1: Methodological flowchart of patients' selection. Supplement 2: Diagnostic classification of all patients, CP patients with IPM and CP patients without IPM. Supplement 3: Prescribed IPM and OTC performed on-site at multidisciplinary chronic pain clinics by multidisciplinary chronic pain clinics, at baseline, six months and twelve months.


Background. Lower back pain is a common reason for disability and the most common cause is lumbar disc herniation. Percutaneous epidural adhesiolysis has been applied to relieve pain and increase the functional capacity of patients who present this condition. Objectives. In this study, we retrospectively evaluated the factors which predict the outcome of percutaneous epidural adhesiolysis in patients who were diagnosed with lumbar disc herniation. Methods. Electronic medical records of patients diagnosed with lumbar disc herniation who have received percutaneous epidural adhesiolysis treatment were reviewed. The primary outcome was the factors that were associated with substantial response of ≥4 points or ≥50% of pain relief in the numerical rating scale pain score 12 months after the treatment. Results. Multivariate logistic regression analysis demonstrated that the presence of high-intensity zone (HIZ) at magnetic resonance imaging was a predictor of substantial response to percutaneous epidural adhesiolysis for 12 months (P = 0.007). The presence of a condition involving the vertebral foramen was a predictor for unsuccessful response after 12 months (P = 0.02). Discussion and Conclusion. The presence of HIZ was a predictor of favorable long-term outcome after percutaneous epidural adhesiolysis for the treatment of lower back pain with radicular pain caused by lumbar disc herniation. Lower back pain is one of the most common causes of disability worldwide and is often accompanied by radicular pain , 2. The Although the natural course in more than 80% and 90% of patients is symptom improvement within the first 6 and 12 weeks, respectively, treatment for relief during the symptomatic period is essential, as significant disability during daily activities may occur . If the Since its introduction in the late 1990s, percutaneous epidural adhesiolysis has been applied to relieve pain and increase the functional capacity of patients who present chronic lower back pain with or without radiculopathy, which are refractory to conservative treatment , 15. ManIn this study, we retrospectively evaluated the factors predicting the outcome of percutaneous epidural adhesiolysis on patients diagnosed with lumbar disc herniation who present symptoms of lower back pain with radicular pain that were refractory to conservative treatments including epidural steroid injections.This study was approved by the local ethics committee (BD2015-60), and the necessity to obtain informed consent was waived because of the retrospective nature of the analysis that reviewed previously recorded patient data. The electronic medical records of patients who were diagnosed with lumbar disc herniation presenting symptoms of lower back pain with radicular pain that have received percutaneous epidural adhesiolysis treatment were reviewed. The data for every patient treated with percutaneous epidural adhesiolysis for this condition at Seoul Sacred Heart General Hospital between November 2011 and October 2013 were collected. Inclusion criteria for the patient data collection included the following: patient age > 20; symptoms of lower back pain with radiculopathy; subacute or chronic symptoms lasting more than 6 weeks; failure to respond to conservative treatment including medication and physical therapy; symptoms refractory to interlaminar or transforaminal epidural injections; definitive diagnosis of lumbar disc herniation which was confirmed by magnetic resonance imaging (MRI). The percutaneous epidural adhesiolysis technique was standardized to all patients receiving the procedure. Each patient received a transforaminal epidural injection twice in 2- or 3-week intervals, and if the symptoms persisted or the relief was insufficient, the patient received percutaneous epidural adhesiolysis after a >1-month interval between the last epidural block. The patient data including any one of the following exclusion criteria were removed from the analysis: inadequate data or loss to follow-up before the first year after percutaneous epidural adhesiolysis, diagnosis other than lumbar disc herniation, history of previous percutaneous epidural adhesiolysis, previous lower back or lower limb surgery, and percutaneous epidural adhesiolysis techniques other than the catheter-guided technique.All of the procedures were performed under fluoroscopic guidance on an outpatient basis. The patient was placed in a prone position with a pillow under the abdomen to secure the position and minimize lumbar lordosis. The administration of opioids or sedatives for mild sedation and analgesia during the procedure was decided at the discretion of the attending physician. The caudal approach was used under fluoroscopic guidance. The 16 G RK Tuohy introducer needle was inserted through the sacrococcygeal ligament and placed in the sacral canal. A radiopaque contrast dye  was injected via the introducer needle to confirm epidural placement of the needle, and epidural filling defects were identified by the epidurogram. The filling defects were further compared with the MRI findings and the dominant symptom of the patient. After appropriate confirmation of the pathology, a metal-reinforced Racz epidural catheter  was inserted through the epidural needle towards the target area, which was determined by imaging and patient symptoms. A radiopaque contrast dye was again injected to confirm the appropriate position of the catheter tip at the site of pathology and to further verify any intravascular, intrathecal, or other extraepidural filling . The catThe patient characteristics, outcome measures, and follow-up data were obtained and reviewed retrospectively from the computerized patient record system. Demographic data including age, gender, height, weight, and body mass index were collected. Past medical history including the presence of oral analgesic medication, history of physical therapies, history of blocks other than epidurals, and history of previous epidural injections were collected. Procedure-related clinical data and radiographic data included the type of herniated intervertebral disc , the presence of HIZ , and theThe primary outcome was the factors associated with patients who had a favorable outcome 12 months after percutaneous epidural adhesiolysis treatment. The favorable outcome was defined as patients presenting substantial responses in the NRS pain score. Secondary outcomes included mean NRS scores at each time point, the proportion of substantial responders at each time point, complications, and the proportion of patients who needed surgical treatment during the 12-month follow-up period.t-tests or the Mann-Whitney U test as appropriate, and categorical variables were tested using the chi-square test with Yate's correction or Fisher's exact test as appropriate. The odds ratio (OR) and 95% confidence interval (CI) were provided to show the reliability of the estimates. Multiple logistic regression analysis was used for the multivariate analysis to identify individual predictors of substantial response that were suggested by the univariate analysis. All P values < 0.05 by univariate analysis were included in the multivariate analysis. Continuous variables were first assessed for normality using the Shapiro–Wilk test. P values less than 0.05 were considered statistically significant, and two-tailed tests were used for all experimental outcomes. SAS version 9.3  was used for statistical analysis.Descriptive statistics were used to report the demographic and clinical characteristics. Continuous variables were presented as the mean with standard deviation (SD) or median with interquartile range (IQR). Categorical variables were expressed as absolute numbers with frequencies or percentages. For analysis of primary outcome, univariate analysis was first performed. The numerical variables were tested with Student's P = 0.005), initial NRS score at 1 month (P = 0.007), and the presence of HIZ (P = 0.002). The patients in the substantial responder group were more likely to have a lower proportion of disc herniation involving the vertebral foramen, have a HIZ on MRI, and have a lower pain score 1 month after percutaneous epidural adhesiolysis compared to the nonresponder group.A total of 875 lower back pain with radicular pain cases treated with percutaneous epidural adhesiolysis between November 2011 and October 2013 were collected and reviewed. Among these, 427 cases were diagnosed with lumbar disc herniation, of which 20 cases were removed from the analysis due to insufficient records. Thus, a total of 407 patients were analyzed. The demographic and clinical characteristics of the study patients are summarized in P = 0.141). Patient satisfaction with the treatment results was significantly different between the two groups. The substantial responder group had a mean GPES score of 5.69 (1.13), whereas the nonresponder group had a mean score of 2.19 (1.08) (P < 0.001). The total number of immediate complications was 26 (6.4%, The results of univariate and multivariate analyses are listed in 26 6.4%, , with noThe results of our present study demonstrate that the presence of HIZ on MRI is an independent predictor of favorable long-term outcome in patients who have received percutaneous epidural adhesiolysis for the treatment of lower back pain with radicular pain that is caused due to lumbar disc herniation. In contrast, vertebral foraminal involvement by the herniated lumbar disc was a predictor of unsuccessful outcome after percutaneous epidural adhesiolysis.Symptomatic lumbar disc herniation with radiculopathy accompanies lower back pain in approximately 10% of cases . The lifIn our present study, we further evaluated the prognostic factors for the successful treatment of percutaneous epidural adhesiolysis. The presence of HIZ and foraminal involvement of the lesion were the 2 important prognostic factors for successful treatment response. The HIZ on the T2-weighted MRI was first described by Aprill and Bogduk in 1992 . It is cPrevious studies that have evaluated the outcome of percutaneous epidural adhesiolysis reported foraminal stenosis as a predictor of unsuccessful treatment outcome , 17. ThiThere were several noteworthy limitations of our present study. First, only patients who had sufficient data and who were followed up for 12 months were included in our analysis, and those with inadequate data or who were lost to follow-up were excluded. Although the number of follow-up losses or inadequate records was relatively small, and did not exceed 5% of the total number of cases, there is a possibility that these losses may have been due to dissatisfaction with the treatment results. Indeed, in prospective studies with an intention-to-treat design, follow-up losses are occasionally considered to be treatment failures . Second,In conclusion, the presence of HIZ on MRI is likely to predict a favorable outcome after percutaneous epidural adhesiolysis treatment in patients diagnosed with lumbar disc herniation who present lower back pain with radicular pain. The presence of foraminal disease is a prognostic indicator of an unfavorable outcome. These results may expand the indications for percutaneous epidural adhesiolysis but should be validated by a future randomized prospective study.


Spinal brucellosis is a less commonly reported infectious spinal pathology. There are few reports regarding the surgical treatment of spinal brucellosis in existing literature. This retrospective study was conducted to determine the effectiveness of single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation for lumbosacral spinal brucellosis.From February 2012 to April 2015, 32 consecutive patients  with lumbosacral brucellosis treated by transforaminal decompression, debridement, interbody fusion, and posterior instrumentation were enrolled. Medical records, imaging studies, laboratory data were collected and summarized. Surgical outcomes were evaluated based on visual analogue scale (VAS), Oswestry Disability Index (ODI) and Japanese Orthopaedic Association (JOA) scale. The changes in C-reactive protein (CRP) levels, erythrocyte sedimentation rate (ESR), clinical symptoms and complications were investigated. Graft fusion was evaluated using Bridwell grading criteria.P < 0.05). According to JOA score, surgical improvement was excellent in 22 cases (68.8%), good in 9 cases (28.1%), moderate in 1 case (3.1%) at the last follow-up.The mean follow-up period was 24.9 ± 8.2 months. Back pain and radiating leg pain was relieved significantly in all patients after operation. No implant failures were observed in any patients. Wound infection was observed in two patients and sinus formation was observed in one patient. Solid bony fusion was achieved in 30 patients and the fusion rate was 93.8%. The levels of ESR and CRP were returned to normal by the end of three months’ follow-up. VAS and ODI scores were significantly improved (Single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation is an effective and safe approach for lumbosacral brucellosis. Human brucellosis remains the most common zoonotic disease worldwide, with more than half a million new cases annually . It is aThe clinical features of spinal brucellosis are non-specific and can overlap with a wide spectrum of other infectious and non-infectious diseases . DespiteAlthough spinal brucellosis is rarely fatal, it can be severely debilitating and disabling. The disease can result in disc destruction, sclerosis of the vertebral body, and abscess formation . If not A total number of 32 consecutive patients  with lumbosacral brucellosis treated by single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation from February 2012 to April 2015 in our institution were included in this study (Table Indications for surgery in our study include: (1) persisting pain due to spinal instability which is caused by severe disc or/and vertebral destruction; (2) severe or progressive neurologic dysfunction; attributed to the nerve root compression by inflammatory granuloma, epidural abscesses; (3) the extensive or obvious paravertebral abscess formation or sequestrum formation in the vertebral body, no response to the antibiotic treatment; all cases were operated by the same senior author. Various parameters including blood loss, surgical time and intraoperative complications were recorded.All the surgeries were carried out under general anesthesia with endotracheal intubation. Each patient was placed on a four-poster spinal frame in the prone position. A midline longitudinal incision was made over the spinous process of the infected vertebra. The posterior spinal construction including the spinous processes, lamina, and facet joints was exposed and the transverse processes were left intact. Pedicle screws were placed into both sides of the affected vertebra with the assistance of c-arm fluoroscopy. In order to achieve adequate debridement, the pedicle screws were placed as close to the superior or inferior end plate as possible to keep them away from the site of infection. The screws were fixed to a temporary rod on one side where neurologic and radiological manifestation was less severe. A facetectomy was then performed at the involved level on the other side where bony destruction, epidural abscess, and radiculopathy were severe Fig. . The epiIntravenous antibiotics were routinely administered for one to three days postoperatively. The drainage tube was usually removed when volume was less than 30 ml/ day. All patients received the WHO recommended oral regimen, consisting of 200 mg doxycycline plus 600-900 mg rifampicin, for a minimum 3 months after operation. All patients remained in bed for 3-5 days and then mobilized under the effective support of a lumbosacral brace. X-ray examination was performed in all patients before discharge to evaluate the location of the graft and instrumentation Fig. . Brace pPatients were followed-up at 1, 3, 6 months and then annually. Medical records, imaging studies, laboratory data, neurologic and functional data were recorded and analyzed. The activity of infection was monitored with erythrocyte sedimentation rates (ESRs), and C-reactive protein (CRP) .The interbody fusion was evaluated by radiographs at the last follow-up Fig. , Fig. 2it test was used to evaluate preoperative and final follow-up changes in laboratory  and quantitative scores . Any discrepancy in normal distribution was analyzed using the rank sum test. Statistical significance was set at P < 0.05.All statistical analyses were performed with SPSS 20.0 statistical software. The Student’s Brucella agglutination test was ≥1/160 in all cases and blood culture was positive in 8 cases (25%). The clinical symptoms are summarized in Table . SurgeryP < 0.05)  and posterior instrumentation for lumbar spine tuberculosis . TLIF haThe lesion of spinal brucellosis mainly located in the intervertebral space. Therefore, the operating space obtained by resection of both sides of the facet joint is sufficient for thorough removal of the pathology and complete decompression of bilateral nerve roots. Also, graft bone implantation can be easily accomplished via the path that runs through the far-lateral portion of the vertebral foramen. Moreover, in most cases of spinal brucellosis, destruction of vertebral body is not severe and often limited in the endplates of involved segments. Thus, transpedicular screws can be placed in the affected vertebra, which would allow minimal surgical exposure and short segmental fixation, and can save motion segments. As we know, interbody fusion and posterior instrumentation can provide reliable segmental stability and acceptable interbody fusion rates. In our study, the average time for bed rest was only 3.78 ± 1.68 days, and all patients were able to walk before discharge. At the last follow-up, 30 patients achieved solid fusion, and the total fusion rate was 93.8%. All patients returned to normal activities. According to JOA score, surgical improvement was excellent in 22 cases (68.8%), good in 9 cases (28.1%) and the improvement rate was 82.7%.For the patients with definitive surgical indications of lumbosacral brucellosis, single-stage transforaminal decompression, debridement, interbody fusion, and posterior instrumentation is an effective and safe surgical technique that should be considered as a choice for the treatment of lumbosacral brucellosis.


The most frequent patient nominated treatment goals related to physical activity (39%), followed by nutritional goals (23%). Traditionally, pain management programs have included physical, psychosocial, and medical, but not nutritional, interventions. By contrast, patients identified and reported important nutrition-related treatment goals. There is a need to test nutrition treatment pathways, including an evaluation of dietary intake and nutrition support. This will help to optimize dietary behaviors and establish nutrition as an important component of multidisciplinary chronic pain management.We describe the characteristics of patients attending an Australian tertiary multidisciplinary pain service and identify areas for nutrition interventions. This cross-sectional study targets patients experiencing chronic pain who attended the service between June–December 2014. Self-reported data was captured from: (1) an Electronic Persistent Pain Outcomes Collaboration (ePPOC) referral questionnaire, incorporating demographics, pain status, and mental health; (2) a Pain Assessment and Recovery Plan (PARP), which documents patients’ perceived problems associated with pain and personal treatment goals. The ePPOC referral questionnaire was completed by 166 patients and the PARP by 153. The mean (SD) patient age was 53 ± 13 years, with almost 60% experiencing pain for >5 years. Forty-five percent of patients were classified as obese (BMI ≥ 30 kg/m Chronic pain is defined as pain that persists beyond the usual time for tissue healing, or pain that continues beyond three to six months . MusculoApproximately 3.2 million Australians experience chronic pain and this is estimated to rise to 5 million by 2050 as the population ages . Treatmen > 1,000,000) and when controlling for age, gender, race, education, smoking, and the presence of health care coverage, the associated risk for experiencing pain was 3.5 times greater for those who were in the obese III (BMI ≥ 40 kg/m2) category compared to those in the normal BMI (18.5–24.99 kg/m2) category . In. In17]. Patients who attended HIPS between June–December 2014 were identified by searching the Electronic Persistent Pain Outcomes Collaboration (ePPOC) database . The Medn = 11) ranged from retired to full time work). In addition, n = 13) and the possible answers ranged from kidney disease to osteoarthritis). The ePPOC survey also included a question asking if patients required assistance filling out the form with the option of a yes/no answer. The ePPOC referral questionnaire consists of eight sections and was completed by patients before they entered the pain service. As a patient centered treatment plan that facilitates goal setting, the PARP questionnaire was developed by the HIPS team to encourage the use of active self-management skills to treat pain. This tool allows patients to select perceived problems associated with their pain experiences, set individualized goals, and nominate the solutions that they would like to pursue. Problems and solutions can be selected from five areas: biomedical, mindbody, connection, physical activity, and nutrition. The biomedical domain considers the balance of body structure and nervous system contributions to pain along with medication use, mindbody addresses thoughts and emotions related to pain, and connection explores the linkage with people, places, and purpose. The activity domain covers the patient’s ability to undertake physical activity and reduce sedentary behaviour. The nutrition section provides an opportunity for patients to self-report waist circumference and patients are provided with a tape measure and brief instructions on how to do this. Patients can also list any intention to focus on a balanced diet and/or other strategies  to improve diet quality.Ethics approval for the current study was obtained from Hunter New England Health (HNEH) (15/07/15/5.01) and the University of Newcastle (H-2015-0266).p < 0.05), post-hoc testing was carried out. All statistics were generated using Stata13 [p-values.Data were extracted from each survey and linked via patient MRNs. The date of birth was obtained to calculate the age of the participants and this was subsequently collapsed into 20 year age brackets. Height and weight were used to calculate BMI using standardized equations. Where patients were able to list “other” comorbidities, the answers were collated and those which fell under one of the pre-existing comorbidities were moved to that group. Patient goals were categorized and collated based on the five domains in the PARP. A patient’s BPI severity, BPI interference, PSEQ, PCS, and nutrition-related goals were collated for those patients with adequate data to allow a BMI calculation. This data was then compared based on the BMI category . Sample statistics were used to explore associations between these variables. BPI severity and PCS were analysed using ANOVA, while BPI interference and PSEQ were analysed using a non-parametric Kruskal Wallis test. A chi-squared test was used to compare BMI categories and the % patients who selected a nutrition-related goal. For those results which were statistically significant ( Stata13  and descn = 153) of patients also completed the appropriate PARP, which was analysed separately. Thirteen patients had insufficient data due to the completion of an earlier version of PARP that could not be merged.A total of 166 patients consented for their data to be used in research and had a complete ePPOC referral questionnaire at the time of entry to the service, which was subsequently included in the study. This is just over one third of the total patient cohort that HIPS would see, at any stage of treatment, in a six month period. Of these, 93% (n = 8) and 1% being of Maori descent (n = 1). Thirty seven percent described their work status as unemployed (due to pain) and listed osteoarthritis/degenerative arthritis (25%) and depression/anxiety (22%) as the top two most common comorbidities experienced in addition to pain. Twelve percent chose the comorbidity category “other, please specify”, with 40% specifying a pain-related condition, and of this, 28% listed fibromyalgia. Other comorbid conditions included asthma (8%) and sleeping difficulties (8%). Thirty six percent of patients reported having <2 comorbidities (from the 13 listed categories), and 64% of patients reported ≥2 comorbidities [Information provided via the ePPOC referral questionnaire identified that 57% of patients were female , with a bidities . On averBased on the data provided by the DASS-21 tool, 81% of patients had some degree of depression . The anxiety component of the DASS-21 showed that 57% of patients had some degree of anxiety . Similarly, the stress component showed that 76% of patients had some level of stress . The average (SD) score for each component was 21.75 ± 12.57, 14.62 ± 10.60, and 20.67 ± 11.44, respectively.what was the cause of your pain?” were selected by the 166 patients. The top answer for patient perceived causes of pain was injury at work/school (24%) and the main pain site selected by patients was the back (40%)  of patients stated that they had experienced pain for more than five years. The majority of patients (71%) reporting taking ≥1 opioid-based medication. Of the total medications listed by patients, 33% were related to pain relief: 16% were opioids, 6% paracetamol, 5% NSAIDS, and 5% combination analgesic (paracetamol/NSAID and codeine). The BPI was completed by 161 patients with the pain severity score: 21% mild, 42% moderate, and 35% severe. The mean BPI severity score was 6.32 ± 1.72 (range 1.3–10) and the BPI interference score was 7.32 ± 2 (range 0.3–10) out of a possible 10. The PSEQ categorizes pain self-efficacy and the average (SD) score was 19.59 ± 12.01, with 6% rated as having minimal impairment, 13% mild, 26% moderate, and 55% severe. The average PCS score was 30.07 ± 13.10, which just falls into the severe category. Just over half (51%) of patients fell into the severe category, with 25% falling into the high category and 24% into the mild category.A total of 185 answers to the question “ck (40%) . Just unWhat health professionals are you seeing?”. These professionals can be categorized into 43 professions. The top professionals (excluding “other”) that were listed included general practitioners, physiotherapists, psychologists, and surgeons . The least commonly reported was a dietitian, which was listed by one patient.In terms of health service use over the preceding three months, patients had visited their GP a mean of 4.5 times and saw a health professional (other than a doctor) three times due to pain. There were 280 professionals listed by 107 patients in response to the question “2 (range 18.52–54.46 kg/m2) (2), 33% were in the overweight category (25–29.99 kg/m2), and 45% were in the obese category (≥30 kg/m2). The average BMI of those taking opioids (30.96 kg/m2) and not taking opioids (29.71 kg/m2) was similar. The mean waist circumference (reported by n = 138) was 104 ± 19.40 cm (range 66–165 cm). Of these, 82 females reported a waist circumference with a mean of 101.21 ± 19.70 cm (range 66–150 cm) and males (n = 56) 108.61 ± 18.23 cm (range 82.5–165 cm). Eighty seven percent of females and 77% of males recorded waist circumferences that categorized them (≥80 cm and ≥94 cm respectively) as at risk of developing chronic disease [A total of 117 patients had anthropometric data recorded. The mean BMI was 31 ± 7 kg/m6 kg/m2) . AccordiMost patients reported that they drank alcohol less than one day per week (70%), with 3% stating that they drank every day of the week. Of those who did drink alcohol, 57% indicated that they consumed one to two drinks per day and 6% reported having eight to 15 drinks per day. Fourteen percent of patients reported that they used alcohol to relieve pain, 42% said that they did not, and 44% did not answer this question. The majority of patients (54%) reported that they consumed one to three caffeinated drinks  per day, with 2% stating that they had >8 per day.Based on the data provided from the PARP, 34–39% of patients chose to make a nutritional change. These changes included: reducing the sugar intake, and increasing the intake of water, fruit, and vegetables. In addition, 13% of patients selected “referral to a dietitian” as a service needed to assist them with changes to their nutrition-related health. Patients were able to list and prioritize a treatment goal which could be selected from the five PARP domains . Of the 153 patients who completed the PARP, 141 set one or more goal(s). In a descending order of frequency, patients chose the following: physical activity , nutrition , connection , mindbody , and biomedical  . Ten per2), overweight BMI (25–29.99 kg/m2), and obese (>30 kg/m2) were compared in terms of their pain-related scores  and nutrition-related goals (p = 0.79), PCS (p = 0.93), or number of nutrition-related goals (p = 0.84) selected by patients by weight category. Statistically significant differences were found for BPI interference (p = 0.02) and PSEQ (p = 0.04) by weight status group. However, a post-hoc analysis indicated that the only significant difference in BPI interference was between those in the overweight versus obese groups (p < 0.001).Patients who had a normal weight BMI  of patients in this study reported depression and anxiety as a comorbid condition. When compared to data provided by the DASS-21, there is a large difference, with 81% and 57% of patients experiencing a degree of depression and anxiety, respectively. The discrepancy between these two results may be explained by the way in which the data was collected. Patient comorbidity is a self-reported measure which relies on the patient’s awareness and honesty, whereas the DASS-21 is a validated objective tool which is more accurate in identifying levels of depression and anxiety. In addition, those who were categorized with depression or anxiety via the DASS-21 may not have been formally diagnosed and therefore did not list these conditions as a comorbidity. When compared to national data, a similar trend exists, where over one third (34%) reported depression and anxiety as a comorbid condition  while 76The most common pain site listed by patients attending HIPS reflects national data, with 43% in both populations selecting back pain . NationaA large percentage (71%) of patients at HIPS reported taking ≥1 opioid medication, compared to the national cohort in 2014, where 61% patients were taking opioids on ≥2 days/week. The frequency of opioid consumption in the HIPS population is unable to be determined in this study, which is a limitation. There was also no difference between the BMI in those taking opioids and those not taking opioids, which suggests that there is no linear relationship between weight status and opioid consumption. It also suggests that there may not be a difference in the dietary status based on opioid consumption. The results found in Meleger et al. may apply to patients who experience chronic pain and do not take opioids . Interes2 (obese category) compared to 28.9 ± 7.4 kg/m2 (overweight category) for the national pain services cohort in Australia. The study showed that 78% of the patients were overweight or obese, which is 115% higher than the national pain service data and 124% higher than HNELHD data. A wider gap exists between these populations when looking at obesity alone. Forty five percent of patients were obese, which is 122% higher than the national pain service data and 167% higher than HNELHD data. This study found that 21% of patients were in the normal (18.5–24.99 kg/m2), 33% in the overweight (25–29.99 kg/m2), and 45% in the obese (≥30 kg/m2) BMI category. In comparison, the national ePPOC report states that 3% patients fell into the underweight BMI category (<18.5 kg/m2), 29% in the normal, 31% in the overweight, and 37% in the obese category [p < 0.001). All other results were not significant, suggesting that in this cohort, body weight is not significantly associated with the severity of most pain-related outcomes. The results from the current audit of a clinical population are not consistent with the current literature, where studies have shown a direct relationship between an increasing weight status and poorer pain experience [The average BMI and percentage of patients who fell into the overweight or obese category was higher at HIPS compared to the national pain service data  and the category . In 2014e obese ≥ kg/m2 BMperience . A limitThere is a substantial difference in the waist circumference between patients at HIPS and the general population of HNELHD. The average waist circumference for females attending HIPS compared to HNELHD was 101.2 cm and 87.5 cm, respectively. For males, the mean waist circumference was 108.6 cm at HIPS and 97.5 cm at HNELHD. The percentage of females considered “at risk” of developing chronic disease based on their waist circumference from the HIPS cohort and the HNELHD is 87% and 65.4% respectively. For males, 77% of the HIPS cohort and 59% of the HNELHD cohort had a waist circumference over the guidelines. In both females and males, the HIPS cohort had a higher percentage “at risk”, compared to the HNELHD.The relationship between obesity and chronic pain is complex, with a higher weight status being a risk factor for developing chronic pain . ConversThe study results indicate that dietary strategies that address personal nutrition-related problems were commonly chosen by patients, along with other lifestyle-related goals. Lifestyle-related goals comprised 62% of the goals chosen by patients, with nutrition selected as a target for one quarter of these patients. In contrast, only one patient had ever been referred to a dietitian. This highlights that there is a major disparity between the expressed needs of the patients and resources currently available within the health system to support those needs. This could be due to lengthy waiting lists for public dietetic services, a lack of awareness of alternative dietetic services in the community, and/or perceived expense for private health services. This disparity is also present in current literature as there is limited, yet growing support to include nutrition in chronic pain management services, particularly to support and complement physical activity in weight management ,37. HoweThere are several limitations of the current study. Firstly, this was a one-off measure which limits the validity of drawing causal relationships. Secondly, the use of self-reported measures may be a source of bias. Height and weight data are self-reported by the patients as they fill in the questionnaire. However, self-report has been previously shown to be valid in other studies, including in a population of young adults . PatientBehaviour change can be challenging to achieve, especially in a population with chronic pain whom have complex health issues and diverse social backgrounds. In practice, multi-modal behavioral strategies  are used to maximize the likelihood of achieving treatment benefit. It is also important to consider that personalized interventions are important for populations such as those with chronic pain. The current study highlights the need for testing a comprehensive nutrition-based intervention as part of the overall treatment package for chronic pain and its comorbidities. Future research should evaluate the feasibility and effectiveness of such an approach.The current study has identified that patients attending a chronic pain management service report nutrition as an area of need that is currently not met within the treatment of chronic non-cancer pain. Patients referred to HIPS were more likely to be overweight or obese compared to community norms or patients referred to other pain services across Australia. In addition many patients expressed a desire to make nutrition-related lifestyle changes. Within a self-management approach, patients are able to initiate such changes themselves. However, the dietetic staff required to address this in a comprehensive way and support the nutritional change process are currently lacking. The addition of dietetic expertise to the routine workforce of a multidisciplinary pain team could support patient self-management in the area of nutrition and enable the development of pain specific, appropriate resources and outcome measures.