Medial tibial stress syndrome (MTSS) is one of the most common lower leg injuries in sporting populations. It accounts for between 6 and 16% of all running injuries, and up to 53% of lower leg injuries in military recruits. Various treatment modalities are available with varying degrees of success. In recalcitrant cases, surgery is often the only option.To evaluate whether ultrasound-guided injection of 15% dextrose for treatment of recalcitrant MTSS decreases pain and facilitates a return to desired activity levels for those who may otherwise be considering surgery or giving up the sport.The study design was a prospective consecutive case series involving eighteen patients: fifteen male and three female; (mean age = 31.2 years) with recalcitrant MTSS. They were referred from sports injury clinics across the UK, having failed all available conservative treatment.An ultrasound-guided sub-periosteal injection of 15% dextrose was administered by the same clinician (NP) along the length of the symptomatic area. Typically, 1 mL of solution was injected per cm of the symptomatic area.Post-hoc Wilcoxon signed-rank tests with Bonferroni corrections were performed to determine VAS average pain response to treatment over five paired periods.Pain was assessed using a 10-cm visual analog scale (VAS) at baseline, short-term, medium-term (mean 18 weeks), and long-term (mean 52 weeks) follow-up. Symptom resolution and return to activity were measured using a Likert scale at medium and long-term follow-up. Statistical analyses were performed using SPSS for Mac version 19.0.0 . The Shapiro-Wilk test was used to evaluate the normality of the distribution of data. Friedman’s non-parametric test was used to compare the within-patient treatment response over time. p < 0.01) reduction in median VAS pain score at medium and long-term follow-up compared to baseline. Median improvement per patient was 4.5/10. Patients rated their condition as ‘much improved’ at medium-term follow-up and the median return to sports score was ‘returned to desired but not pre-injury level’ at medium-term and long-term follow-up. No adverse events were reported.Patients reported a significant (Ultrasound-guided 15% dextrose prolotherapy injection has a significant medium-term effect on pain in MTSS. This benefit may be maintained long-term; however, more robust trials are required to validate these findings in the absence of controls.Clinicians should consider the use of ultrasound-guided injection of 15% dextrose as a viable treatment option to reduce pain and aid return to activity for patients with recalcitrant MTSS. MTSS is one of the most common lower leg injuries in sporting populations . It accoThe diagnosis is reliably based on a detailed history and physical examination with pain provoked on palpation of the lower one-third of medial tibial .In the early stages of the condition, pain tends to occur at the beginning of exercise, may diminish as activity proceeds, and recurs at the end , 5, 6. UMTSS is predominantly managed conservatively. Treatment modalities that have shown potential benefit include extracorporeal shockwave therapy (ESWT), ultrasound therapy, iontophoresis, ice massage, periosteal pecking –13, non-Winters et al. (2019) found linear microcracks in the biopsies of athletes with MTSS with no repair reaction, suggesting unrepaired microdamage as underlying pathophysiology .Proliferative injection therapy (prolotherapy) has been used clinically since the late nineteenth century and has been mentioned in medical journals since at least 1937 . The ratTrials of prolotherapy have found it to be beneficial in the treatment of lateral epicondylopathy , osteitiThis prospective case series study sought to evaluate whether ultrasound-guided injection of hypertonic dextrose decreases pain and facilitates a return to desired activity levels for those who may otherwise be considering surgery or giving up the sport. We hypothesise that prolotherapy improves pain and facilitates a return to sport at the desired level.Sports physicians, orthopaedic surgeons, podiatrists, podiatric surgeons, and physiotherapists working in sports injury clinics who were known to the main 2 authors  across the UK were contacted via email and invited to refer patients with painful, recalcitrant MTSS that had not responded to other conservative treatment modalities, whom they felt might benefit from the trial intervention Fig. .. The faInclusion criteria were patients with persistent, painful MTSS assessed and confirmed by the lead clinician (NP). Exclusion criteria were previous periosteal surgery for MTSS, previous or current tibial stress fracture, or contraindications to the intervention such as pregnancy or anticoagulant therapy.Patients were assessed by the lead clinician and the diagnosis of MTSS was confirmed by a history of exercise-induced pain over the posteromedial border of the middle to the distal third of the tibia, a positive Shin Palpation Test  both at rest and following exercise, and MRI changes showing periosteal or bone marrow oedema.Ethical approval was granted by the Queen Mary University of London Ethics Review Board (QMREC2009/22). Participants provided signed written informed consent. Subsequently, a detailed medical history and biographical data were taken and an examination was performed.The injection procedure is very simple and within the expertise of all clinicians who are used to injection techniques for musculoskeletal pathology. It is primarily performed in the out-patient department (OPD) and does not require a local anaesthetic even though local anaesthetic is used to dilute 50% glucose down to 15%. In some cases where pain tolerance is poor, it can be performed under a general anaesthetic. In this study, all subjects were treated in OPD. The target area for needle placement in the area anterior to the deep crural fascia Figs.  and 3. aThe patients’ ‘average pain’, defined as the most pervasive severity of pain throughout 24 h, was measured using a 10-cm visual analog scale (VAS). The VAS is sensitive , reliablA Likert  symptom Return to the sport was assessed with a five-point activity scale at medium-term and long-term follow-up: 1– not active at all, 2– no return to sport, 3– returned to the sport at an unsatisfactory lower level, 4– returned at desired but not pre-injury level, 5– returned at the pre-injury level. Although not reported in other literature, treatment aimed to enable patients to return to their desired sports at pre-injury levels. All other activity scores were considered a treatment failure.p-value less than 0.05. The Shapiro-Wilk test was used to evaluate the normality of the distribution of data. The distribution of data were negatively skewed and not normally distributed (Shapiro-Wilk = 0.009) therefore appropriate non-parametric tests were performed to evaluate the changes in pain levels.Statistical analyses were performed using SPSS for Mac version 19.0.0 . Statistical significance was set at a Median values and interquartile ranges were calculated to compare baseline and follow-up data for VAS average pain scores, Likert symptom resolution, and return to sports scores.Post-hoc Wilcoxon signed-rank tests with Bonferroni corrections were performed to determine VAS average pain response to treatment over five paired periods . The Bonferroni corrected alpha value was (p < 0.01).Friedman’s non-parametric test was used to compare the within-patient treatment response over time. Twenty-five legs of eighteen patients were injected, of that twenty-five, seven legs were injected a second time. For data collection, each patient was treated as a whole case rather than individual legs.On average, patients reported that post-injection pain took three days to settle. Side effects were not asked for specifically, but there were no self-reported adverse events following injection.The mean age and duration of symptoms for the patients are summarised in Table Data for eighteen patients were available for analysis of treatment effect to medium-term and fifteen patients to long-term follow-up. Three patients were lost to follow-up and these data points were not imputed but omitted from the long-term analysis.Medians and interquartile ranges for the three outcome measures are displayed in Table.There was complete resolution of symptoms at 18 weeks and 52 weeks in two patients (11%). There were much improved symptoms at 18 weeks in eight patients 33%) and 52 weeks in three patients (20%). At 18 weeks, six patients (33%) were somewhat improved and at 52 weeks the same improvement was observed in three patients (20%). There was no change in symptom resolution at 18 weeks in two patients (11%) and 52 weeks in seven patients (47%). There were no patients who were worse or made worse following prolotherapy  returned to pre-injury level return to sport, and at 52 weeks four patients (27%). At 18 weeks, five patients (28%) returned to the desired but not pre-injury level return to sport, and at 52 weeks, four patients (27%). At 18 weeks, eight patients (44%) returned to the sport at an unsatisfactory level, and at 52 weeks, six patients (40%). One patient failed to return to any level of sport or activity and elected to undergo surgery Table...p < 0.001. There was a statistically significant difference between the mean pain ranks over time. Therefore, a post-hoc analysis was warranted. Friedman’s test was also significant to long-term follow-up, reporting a Chi-squared value of 27.5, p = < 0.001.Friedman’s test of the VAS average pain scores to medium-term (mean 18 weeks) reported a Chi-squared value of 30.3, p-values for the five paired periods are reported in Table p < 0.001) and 18 weeks follow-up (p < 0.001). One patient had an increase in pain at 4 weeks which subsequently decreased at 18 weeks follow-up and another patient reported no change at 4 weeks and 18 weeks. Between 4 weeks and 18 weeks after the injection, the pain increased in seven patients (38.8%), decreased in five (27.7%), and remained the same in six patients (33.3%) (p = 0.405). Between baseline and 52 weeks, pain decreased in 13 patients (86.7%), remained the same in one patient (6.7%), and increased in one patient (6.7%) (p = 0.001). Between 4 weeks and 52 weeks, pain decreased in five patients (33.3%), remained the same in four patients (26.7%), and increased in six patients (40%) (p = 0.322).Changes in VAS average pain score rank and p < 0.01). The changes in VAS average pain from 4 to 18 weeks and 4 to 52 weeks were not significant (p > 0.01).After Bonferroni corrections were applied, the change in VAS average pain from baseline to 4, 18, and 52 weeks follow-up were statistically significant (The pain was significantly reduced (p < 0.01) over short, medium, and long-term compared to baseline, with only two patients not reporting a reduction in VAS average pain over these periods Table . The medp-value for average pain reduction, possibly due to the lower statistical power at this stage of follow-up. There was also a trend for improvement in pain to recede from 4 weeks post-injection, suggesting that pain control is most effective within the first month after administration. This is a potential window of opportunity to implement other conservative management options that could facilitate long-term pain control.However, a wider range of pain scores was seen in the long-term Fig. ., in addAt 18 weeks (medium-term) follow-up, ten patients (55.5%) reported their MTSS as ‘completely recovered’ or ‘much improved’, indicating treatment success at this stage. Six patients 40%) fulfilled these criteria at 52 weeks follow-up, which signifies a potential longer-term decline in treatment effect (Table 0% fulfilFive patients (27.7%) reported a return to sport at pre-injury levels at medium-term follow-up and four patients (26.7%) at long-term follow-up. Treatment seems to have a limited effect on this outcome measure. However, ten patients (55.5%) were active at the desired level or more at medium-term follow-up and eight (53.3%) at long-term follow-up, which suggests we may have been too stringent in selecting the treatment success criteria for this outcome measure. One patient elected to undergo surgery, as at 52 weeks there was no improvement and failed to return to sport.Dextrose prolotherapy injection was well tolerated and significantly improved pain in the short term and, its effect was retained in the long term. Adequate symptom resolution and return to sport were achieved at medium-term follow-up and return to sport were maintained long-term. This prospective consecutive case study consisting of selective recalcitrant cases, therefore, suggests that prolotherapy has a significant effect on short, medium, and long-term pain reduction but in the absence of controls, a more robust study is required to show this benefit.Prolotherapy is an effective treatment modality in the management of recalcitrant MTSS and even though one patient elected to undergo surgery, this study was not designed to assess whether there will be a reduction in the number of patients that may require surgery. This study did not involve any histological sampling to explain the effect on the tissue. We postulate that 15% glucose acts as an osmotic and chemical irritant (dehydrating cells) along with damage to tissue through needling causing local trauma and bleeding. This provokes a cascade of inflammation, proliferation, and re-modeling. The rationale behind prolotherapy is that injecting proliferants, such as hypertonic glucose solution, into damaged connective tissue, initiates inflammation, which leads to a healing cascade resulting in fibroplasia, deposition of new collagen, and tissue hypertrophy . It is aHowever, in sport, the benefit of a pain-free phase can be effectively used to provide a platform for early rehabilitation and a window of opportunity to plan a return to sport or physical activity-specific rehabilitation.As the first study investigating this novel injection technique, the use of a non-blinded, consecutive case series design without randomisation or a control group was a pragmatic choice given the difficulties of recruiting participants. Evidence of treatment effect is therefore limited. Despite results showing a significant treatment effect on pain, the mechanism by which it exerts this effect cannot be determined, and therefore the possibility of a placebo effect cannot be excluded in addition to the possibility these patients may have improved with time without treatment.Patients were only included in the study if they had MRI evidence of periosteal changes or bone marrow oedema. MTSS is a clinical pain syndrome with unknown aetiology. The evidence suggests that periosteal and bone marrow oedema are absent in the majority  of clinically diagnosed cases with MTSS . FurtherThree patients were also lost to long term follow up, despite every effort to contact them to complete the study. In a consecutive case series of 18 subjects, this was a great loss.Given that there were no validated scales to specifically assess treatment outcomes in EILP patients at the time of this study, we adapted Likert scales to measure symptom resolution and return to sport. Although Likert scales are sensitive indicators of clinical trial endpoints , the lac’s study [The current literature on the effects of prolotherapy on chronic musculoskeletal conditions  is limited. Two case-series investigating the efficacy of dextrose prolotherapy injections at reducing pain in lateral epicondylitis  and chro’s study , which iFuture studies require more robust methodologies including larger participant numbers, a control group or crossover design, randomisation, and, if possible, blinding to improve the validity of the results. Adverse effects should be explicitly sought to permit a more thorough treatment profile to be compiled.VAS average pain data from follow-up and one and two weeks post-injection appear of limited application regarding treatment direction, with the decision to re-inject patients with the suboptimal symptomatic response coming at four weeks or later. Follow-up at four weeks then monthly may allow better monitoring of the treatment response over the medium- to long-term and facilitate the decision to re-inject for those patients whose symptoms have not responded as well as predicted.With some patients requesting a second injection, it may be prudent to administer more than one prolotherapy injection per symptomatic leg, reflecting the protocols of other studies where injections were administered weekly or monthly, ranging from 2 to 12 injections over the study period , 32, 33,


Current findings suggest that percutaneous vertebroplasty (PVP) is a suitable therapeutic approach for osteoporotic vertebral compression fractures (OVCFs). However, a significant minority of patients still experience residual back pain after PVP. The present retrospective study was designed to determine the risk factors for residual back pain after PVP and provides a nomogram for predicting the residual back pain after PVP.  We retrospectively reviewed the medical records of patients with single-segment OVCFs who underwent bilateral percutaneous vertebroplasty. Patients were divided into group N and group R according to the postoperative VAS score. Group R is described as the VAS score of residual back pain ≥ 4. Pre- and postoperative factors that may affect back pain relief were evaluated between two groups. Univariate and multivariate logistic regression analysis were performed to identify risk factors affecting residual back pain after PVP. We provided a nomogram for predicting the residual back pain and used the receiver operating characteristic curve (ROC), concordance index (C-index), calibration curve, and decision curve analyses (DCA) to evaluate the prognostic performance. P=0.026), posterior fascia oedema , severe paraspinal muscle degeneration , and blocky cement distribution  were independent risk factors for residual back pain after PVP. The AUC value was 0.780, suggesting that the predictive ability was excellent. The prediction nomogram presented good discrimination, with a C-index of 0.774 (0.696∼0.852) and was validated to be 0.752 through bootstrapping validation. The calibration curve of the nomogram demonstrated a good consistency between the probabilities predicted by the nomogram and the actual probabilities. The nomogram showed net benefits in the range from 0.06 to 0.66 in DCA.  Among 268 patients treated with PVP, 37 (13.81%) patients were classified postoperative residual back pain. The results of the multivariate logistical regression analysis showed that the presence of an intravertebral vacuum cleft (IVC) (OR 3.790,  The presence of IVC, posterior fascia oedema, blocky cement distribution, and severe paraspinal muscle degeneration were significant risk factors for residual back pain after PVP for OVCFs. Patients with OVCFs after PVP who have these risk factors should be carefully monitored for the possible development of residual back pain. We provide a nomogram for predicting the residual back pain after PVP. With the aging of the social population, incidence of osteoporosis is constantly increasing, seriously affecting life quality of elderly patients . OsteopoHowever, residual back pain still exists in a proportion of patients after percutaneous vertebroplasty (PVP), and it even affects daily life due to moderate or severe back pain, which is of great concern . It has The clinical data of patients with single-segment OVCFs who underwent bilateral percutaneous vertebroplasty from January 2017 to April 2019 were retrospectively reviewed. The inclusion criteria are as follows: (1) patients having obvious thoracolumbar and back pain and limited physical activity, especially in cases of turning over or getting up. (2) T score ≤ −2.5 at spine/hip with dual energy X-ray absorptiometry (DXA). (3) The signal change of the lumbar fracture of lumbar magnetic resonance imaging (MRI) suggesting a hyperintense T2 signal and a hypointense T1 signal or a whole-body bone scan performed an active bone metabolism. Exclusion criteria are as follows: (1) patients with OVCFs caused by tumor, infection, or tuberculosis. (2) Patients having coagulation dysfunction, combined systemic disease, and inability to tolerate the procedure. (3) Systemic or local infection. (4) Spinal cord compression and obvious neural symptoms such as numbness and/or muscle weakness. (5) Incomplete follow-up data. From January 2017 to April 2019, a total of 357 patients in our institution were diagnosed with OVCFs and underwent bilateral PVP/PKP. Of these 357 patients, 89 who did not meet the inclusion criteria or meet any of the exclusion criteria were excluded. Finally, our study screened a total of 268 patients who met the criteria, including 53 males and 215 females. The patient was placed in the prone position, the abdomen was vacated, and the fractured vertebrae were located under C-arm fluoroscopic guidance. The puncture needle was inserted into the vertebral body via bilateral arch pathways. The tip of the puncture needle was located in the anterior middle third of the vertebral body on the lateral view, and the anterior-posterior view was located between the inner edge of the ipsilateral pedicle and the vertebral body midline. The working channel is established and the high-viscosity cement is slowly injected under C-arm fluoroscopy until the bone cement approaches the posterior wall of the vertebral body where leakage may occur, and the working channel is slowly withdrawn after the cement has hardened. The whole procedure was done with the assistance of C-arm fluoroscopy.All patients were given oral calcium and vitamin D postoperatively and an intravenous infusion of zoledronic acid  once a year thereafter for 3 years. Patients were reviewed on the postoperative 24 h for anteroposterior and lateral radiographs and discharged 2 to 3 days after surgery. X-Ray film of the injured vertebra was reviewed periodically after surgery. Nonsteroidal anti-inflammatory drugs (NSAIDs) or opiate analgesics cannot be given to patients after the vertebroplasty procedure, unless patients did not experience adequate pain relief.In this study, the VAS score was used to assess the mean severity of back pain in patients with OVCFs at 24 h, 3 d, and one month after PVP. Residual back pain was defined as the VAS score ≥ 4 both 3 d postoperatively and one month postoperatively. Finally, the patients were divided into group N and group R, based on the VSA score.Pre- and postoperative factors that may affect back pain relief were evaluated, including the (1) demographic characteristics , augmentation position, and BMI) and BMD; (2) VAS, ODI, and preoperative radiological parameters  , posteriThe anterior vertebral height (AVH) and Cobb angle (LKA and Cobb's method) of the fractured vertebral body were measured before surgery and 24 h after surgery. AVH change was defined as postoperative AVH-preoperative AVH. The anterior vertebral height ratio (AVHR) was defined as the height of the anterior wall of the compressed vertebral body/ × 2 . The antt-test or analysis of variance (ANOVA) was used for comparison between groups. Independent risk factors associated with residual back pain were assessed using multivariate logistic regression analysis.Categorical variables were expressed as rates, and the chi-square test was used for comparison between groups. Continuous variables were expressed as mean ± standard deviation, and independent samples P < 0.05.A receiver operating characteristic (ROC) curve was drawn. The area under the curve (AUC) value was calculated to evaluate the sensitivity and the specificity. Nomogram was created by R software. Finally, we evaluated the stability of the prognostic nomogram by internal validation with 1000 bootstrap samples. Calibration plots were generated to examine the performance characteristics of the predictive nomogram. The Harrell's concordance index (C-index) was used to assess the prognostic accuracy. Decision curve analysis (DCA) was assessed whether the model improves forecasted net income. The data were statistically analyzed using SPSS version 24  and R version 3.6.1 . Differences were defined as statistically significant at Among 268 patients treated with PVP, 37 (13.81%) patients were classified postoperative residual back pain. Another 231 patients who were identified as having no residual back pain during the same period were included as group N. As shown in The differences in VAS, ODI, AVH, AVHR, and Cobb angle between the two groups were not statistically significant . There wThe volume of bone cement, AVHRR, and Cobb angle change were higher in group N than in group R, and the incidence of bone cement leakage was higher in group R than in group N, but none of the differences were statistically significant . The incP=0.026), posterior fascia oedema , server paraspinal muscle degeneration , and blocky cement distribution  were independent risk factors for residual back pain after PVP, as shown in The results of the multivariate logistical regression analysis showed that the presence of an IVC , moderate pain relief in 12 patients (32%), and inadequate pain relief in 2 patients (5%). Dohm et al.  compared3%, moderIn our study, we found that bone mineral density and bone cement volume were not risk factors for residual back pain after PVP. Osteoporosis is an important factor in the occurrence of vertebral fractures, as well as a risk factor for the collapse of fractured vertebral bodies after PVP and even secondary fractures of adjacent vertebral bodies. When multiple vertebral bodies collapse after surgery, the sagittal balance of the patient changes and the body compensates for the increased damage to the low back muscles in order to regulate the balance, leading to chronic low back pain, and the same is true for adjacent vertebral body fractures secondary to PVP ,20. TherThe injection of bone cement can enhance the vertebral strength and stiffness and effectively prevent the progressive vertebral collapse, thus relieving the back pain to some extent ,23. HoweAlthough the majority of patients with OVCFs are due to low-energy injury, there are still 18 patients with posterior fascia oedema. A prospective observational study by Yan et al.  found thPVP and PKP are considered the ideal methods to treat OVCFs with IVC . HoweverParaspinal muscle degeneration was not mentioned in previous studies as a risk factor for residual pain after PVP. However, the relationship between the paraspinal muscles and degenerative disc disease has become of great interest in recent years ,35. SeveThis study currently has some limitations. First, our study is a retrospective study with a relatively small sample size, which may result in some bias. Second, only PVP performed by bilateral approach has been taken into consideration, which may have introduced selection bias. However, previous studies demonstrated the PVP surgery approach  was not a significant influence factor for residual back pain . TherefoOur findings suggest that the IVC sign, posterior fascia oedema, blocky cement distribution, and severe paraspinal muscle degeneration are important risk factors for residual back pain after PVP in patients with OVCFs. We provide a nomogram that accurately predicts the risk of residual back pain after PVP.


Chronic non-specific low back pain syndrome (cnsLBP) is a severe health problem in developed countries, which has an important effect on patients’ quality of life and is highly determined by socio-demographic factors and low back pain specific knowledge. We examined patients’ health-related quality of life according to the results of the Short Form Health Survey (SF-36), low back pain knowledge (LBPKQ) and the social determinants of the participants.We carried out our research in the first half of 2015 in Southern Transdanubia, Hungary. The examination included 1155 respondents living with chronic non-specific low back pain. The confidence interval of 95% was used, and the level of.p < 0.05 using SPSS 22.0 software.significance was p < 0.05). A greater decrease of function (Roland Morris scores (RM)) accounts for a lower HRQoL and higher knowledge level. We found significant differences in LBPKQ scores according to sociodemographic parameters. The general health status was positively correlated with LBPKQ (p = 0.024) adjusted for demographic and pain and functional status.The SF-36 questionnaire is suitable for the examination of patients’ health-related quality of life (Cronbach’s Alpha> 0.76), as the LBPKQ’s Cronbach’s Alpha was 0.726 also, which showed good validity. Longer-term disease meant a lower health-related quality of life (The negative effect of the symptoms on patients’ quality of life is proved, which is determined by different socio-demographic parameters furthermore by knowledge. Above all could be useful information for professionals to adopt the right interventions. Chronic non-specific low back pain syndrome (cnsLBP) is a severe health problem in developed countries. Low back pain (LBP) syndrome can be classified according to the duration of the pain as well as the causes triggering the pain. Based on the duration of the pain it can be acute, subacute or chronic. In the case of acute LBP pain lasts for up to 6 weeks, in case of subacute LBP lumbosacral pain lasts from 6 to 12 weeks. Having chronic LBP pain stays for more than 12 weeks. In the case of non-specific LBP diagnosis, a clarified cause can be defined only in 15% of the cases .Prevalence of chronic LBP (cnsLBP) among adults is 60% , 5. PrevFurthermore, the effect of the disease is notable for social and economic subsystems also because in developed societies cnsLBP is the most common reason for a leave of absence from work . The finWaxman et al. examined the correlation between cnsLBP and symptoms of depression. Pain encourages the patient to tackle the disease, influences the quality of life, and decreases life satisfaction , 10.Nevertheless, studies on quality of life examine the indirect expenses of cnsLBP from the point of view of the individual and also their impact on subjective quality of life, in terms of how much the average of the patients’ HRQoL dimensions differs from the one of healthy population or how much it changes after certain treatments had been applied –19.From the 1990s on the number of studies about quality of life has multiplied in the field of medical-sanitary research; Veresciagina et al. as well as studies of Dahl et al. proved that 36-Item Short Form Health Survey (SF-36) questionnaire is suitable to measure cnsLBP patients’ quality of life , 19.Patients do not have adequate knowledge on the quantity of physical activity and the type of physical activity that can be performed in cnsLBP , 21. AlsIn many diseases, prevention and rehabilitation programs supplemented with patient education are more effective. A patient with a better disease specific knowledge, who understands the cause, pathomechanism of the disease, has the right knowledge of prevention and treatment options, can participate more effectively and actively in prevention or rehabilitation. Thus, patient education is an essential part of primary prevention, to prevent the disease, secondary prevention to reduce the impact of the disease, and tertiary prevention to soften the impact of the illness –26.Weckbach et al. examined 248 patients low back pain knowledge, where they found that only 32.6% of them could respond correctly to the knowledge scale questions . PatientOne of the objectives of our research is to assess the quality of life (HRQoL) of nscLBP syndrome patients and the functional status of the spine, testing the validity of the HRQoL scale and comparing the scales with healthy adults’s mean values. We hypothesized that the socio-demographic parameters, self-rated physical disability (RMDQ - Roland Morris Disability Questionnaire) and low back pain specific knowledge (LBPKQ) would determine significantly the HRQoL measures by SF-36of nscLBP patients. This study aims help the better understanding of the disease and encourage health care workers to considering socio-demographic and knowledge factors also in planning interventions.Patients with cnsLBP (participating in physiotherapy treatment) were recruited into a cross-sectional, observational study between 1 January – 15 July 2015 in Southern Transdanubia, Hungary.The study based on a convenience sample. Inclusion criteria: patient treated in the Southern Transdanubian region, of age over 18, with chronic ongoing for at least 12 weeks) non-specific low back pain. Exclusion criteria: acute and subacute low back pain syndrome, low back pain with non-musculoskeletal origins , spine surgery in the preceding 6 months, chronic pain syndrome, depression.The method of our research was a paper and pencil questionnaire that furthermore contained an information sheet about the details of the research and ethical information stating that by filling in the questionnaire the respondent agrees to take part in the study.This study followed the principles of the Declaration of Helsinki, ethics approval number: ETT TUKEB 5739/2015).The present research consisted of three validated standard questionnaires and a demographic questionnaire designed by our team.The 36-Item Short Form Health Survey (SF-36)  was usedThe assessment of spine prevention and low back pain disease-specific knowledge was performed with validated Low back pain knowledge questionnaire . The queRoland Morris Disability Questionnaire (RMDQ) was used to measure the functional status of the spine. The 24-item RMDQ can be applied in the cases of acute, subacute and chronic low back pain patients to measure the functional status and the decreased function of the lumbar spine during daily physical activity. The questionnaire has been validated in Hungary, its maximum score being 24 that indicates decreased function/restraint, value 0 implies the maximum , 30.p-values < 0.05 were indicated as being of a statistical significance adjusting also for multiple comparisons.Descriptive statistics were used to summarize demographic parameters. The continuous variables were analysed by using non-parametric statistical tests . Multiple regression analysis was performed using a linear regression model to identify the determinants of HRQoL for the SF-36. Cronbach’s alpha was used to measure the instruments’ internal consistency. SPSS 24.0 was used for all data analyses and all Patients with cnsLBP were recruited into our cross-sectional study, through selection 1500 forms were planned to be included in our research; after falling-off (due to rejection or exclusion because of inadequate filling in) 1155 participants  were included. Their mean age was 45.25 ± 16.90.p = 0.17) and place of residence (p = 0.35) no significant difference was found between genders. According to their marital status, the ratio of the married was significantly higher among men (50.93%), the ratio of the widow was higher among women (9.99%). 65.89% possessed secondary level qualification, among men the ratio of those having a lower qualification is significantly lower (p < 0.01). 67.53% are active employees (among women the ratio of the inactive is significantly higher: 35.99% (p < 0.01), 56.45% of respondents do sedentary work.Among 1155 participating cnsLBP patients the ratio of women was 61.99%, two-thirds of the respondents were town residents, 46.03% of them were married. Based on their age  [Respondents evaluated all HRQoL dimensions with significantly lower scores compared to the healthy population  dimension that resulted in lower value but showing no significant difference  = 0.24) . Accordi4 . AccorThe validity of the LBPKQ was examined, the Cronbach’s Alpha = 0.72. The mean LBPKQ score was 7.81 ± 2.68. We tested the LBPKQ score differences according to different socio-demographic parameters and we found significant differences in scores by age, education, place of living, work type and marital status also Table .Table 3In the course of our examination we assumed that the increase of the years spent since the first episode of low-back pain implies a further decrease in the quality of life of cnsLBP patients. Regarding all 8 dimensions of the questionnaire significant correlation was found between the number of years spent in pain and the mean value of the certain HRQoL dimension (p < 0.05).p < 0.01) (Table Among the examined scores weak correlation was found (R < 0.30), except for PF that showed medium strength correlation with the number of years, indicating significantly decreased function by the ongoing of years  (showing negative weak or medium strength correlation) Table .LBPKQ was showed a significant positive correlation with general health, pain, social function and role of physical health Table ..p < 0.01), Beta constant: 56.95, Beta LBPKQ: 0.58 p = 0.02) adjusting for functional status and socio-demographic parameters .We examined the relationship between SF-36 HRQoL dimensions and LBPKQ scores and the found positive significant correlation only in general health status  dimension that although fell behind the mean value of the healthy population by a few score points, it did not differ significantly among nscLBP patients. Therefore, on the whole it can be stated that regarding social function the examined patients’ judgement on social function does not differ from the one of healthy population .In our survey, the participants’ low back pain prevention knowledge was between 6.20–8.39 points. We also found similar results in international literature Maciel et al.  measuredPatients who participated in education and back school programs reached 16–22.2 points , 26. TheIn our research the LBPKQ was showed a significant positive correlation with general health, pain, social function and role of physical health, which fact has important role in planning the future interventions for cnsLBP patients.While examining the quality of life of patients bearing nscLBP syndrome our research has proven that chronic pain has a notable effect on patients’ quality of life. The longer nscLBP syndrome has been present in patients’ lives, the less favourable their quality of life is. The disease accounts for greater and greater measures of restraint regarding functional, bodily and mental health. Similar results were found when comparing RMDQ and SF-36 results: the greater the level of pain and restraint is, the more unfavourable the patients’ bodily and mental health is, furthermore the more unfavourable social function turns into. In our research patients evaluated the functional status of their spine 4.81 ± 4.59 through RMDQ. The functional status of the spine of nscLBP patients participating in international studies resulted diverse. On the whole it can be stated that studies specifying interventions are characterized by higher RMDQ values while quantitative research as the present one found lower values . The rise of age results in the decrease of HRQoL considering GH, BP, RP, PF dimensions. In the sample of the present research the elderly age-group is not represented, only the middle-aged and the aging along with the young, which fact must be taken into consideration when examining and evaluating age.According to further findings among nscLBP patients possessing qualifications in higher education general health and physical functioning are more favourable in comparison with patients with lower education that may be explained by the assumption that people with higher education devote more attention and apply a wider range of treatment options, resulting in a higher quality of life. Moreover, low education has a significantly negative effect on social and mental health as well that reinforces nscLBP patients’ exclusion and the accumulation of further negative effects –7.Regarding marital status, confirming data coming from literature, divorced and single respondents replied with less favourable values in case of dimensions concerning mental health, that proves the health preserving and improving effect, also in the case of chronic diseases, of cohabitation and marriage  Table 44.However, there are some important limitations of our research that should be mentioned in the present study. Firstly, our sample is not representative, the ratio of city residents is high while one of people with low education is low. Also, the sample was recruited exclusively from people coming from the Southern Transdanubia, therefore it cannot be generalized to the whole Hungarian population – conclusions in that concern can be drawn only when considering the mentioned limitation. Secondly, the HRQoL and RMDQ were measured using self-administered questionnaires, which could give bias.The present study confirmed that SF-36 is reliable to measure the HRQoL of nscLBP patients, furthermore, the patients’ HRQoL was significantly lower than the healthy populations. The LBP specific knowledge was significantly correlated with HRQoL. The age, gender – women, sitting (job) was negatively associated with most of the physical and mental HRQOL, and higher education or paid job were positively associated with physical or social HRQOL. Finally, if the marital status is divorced or single, it was negatively associated with mental HRQoL. According to these significant socio-demographic determinants an even more specific and well-aimed intervention can be framed in order to improve the HRQOL of this population.


Abdominal pain is a debilitating symptom affecting ∼80% of pancreatic cancer (PC) patients. Pancreatic duct (PD) decompression has been reported to alleviate this pain, although this practice has not been widely adopted. We aimed to evaluate the role, efficacy, and safety of endoscopic PD decompression for palliation of PC post-prandial obstructive-type pain.A systematic review until 7 October 2020 was performed. Two independent reviewers selected studies, extracted data, and assessed the methodological quality.We identified 12 publications with a total of 192 patients with PC presenting with abdominal pain, in whom PD decompression was attempted, and was successful in 167 patients . The use of plastic stents was reported in 159 patients (95.2%). All included studies reported partial or complete improvement in pain levels after PD stenting, with an improvement rate of 93% . The mean duration of pain improvement was 94 ± 16 days. Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events (AEs) were post-sphincterotomy bleeding (1.8%), post-ERCP pancreatitis (0.6%), and hemosuccus pancreaticus (0.6%). AEs were not reported in two patients who underwent endoscopic ultrasound-guided PD decompression. In the 167 patients with technical success, the stent-migration and stent-occlusion rates were 3.6% and 3.0%, respectively. No AE-related mortality was reported. The methodological quality assessment showed the majority of the studies having low or unclear quality.In this exploratory analysis, endoscopic PD drainage may be an effective and safe option in selected patients for the management of obstructive-type PC pain. However, a randomized–controlled trial is needed to delineate the role of this invasive practice. Pancreatic cancer (PC) is the fourth leading cause of cancer-related death in the USA . Fewer tAlthough PC is commonly asymptomatic in the early stages despite upstream biliary and/or pancreatic ductal dilatation , abdominThe two principal mechanisms of PC abdominal pain are ductal hypertension secondary to obstruction and neuropathy secondary to neoplastic infiltration of regional nerves . These mGiven the importance of palliation in PC patients and safety concerns for traditional pain control techniques, endoscopic pancreatic duct (PD) hypertension alleviation, via stenting, was hypothesized to benefit a subgroup of patients with obstructive-type post-prandial pain , 13. Alta priori protocol [This systematic review was reported following the ‘preferred reporting items for systematic reviews and meta-analyses’ (PRISMA) with an protocol . Supplementary File 1. A medical reference librarian conducted an extensive search of multiple databases without any language restriction from the inception of the database to 7 October 2020. The data sources and search strategies are provided in The inclusion criteria consisted of randomized–controlled trials (RCTs), experimental studies, and non-randomized observational clinical studies, including case reports and case series that reported the use of endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS) in PD decompression to alleviate PC-associated abdominal pain. This type of pain is defined as upper abdominal pain in the setting of main PD obstruction with or without documentation of post-prandial exacerbation of pain. In the case of multiple publications emanating from the same center at different periods, we elected to include the most recent report to avoid duplication of patients.While obstructive-type abdominal pain is mainly post-prandial in nature, this characteristic was rarely specified. Accordingly, a general definition of PC-associated pain was adopted to capture all relevant studies, which underwent a rigorous appraisal and methodological quality assessment.in vitro studies, non-endoscopic PD decompression, and those with insufficient clinical data. Patients who met the American College of Gastroenterology criteria for acute pancreatitis were excluded [We excluded duplicated studies, reviews, animal/excluded .Two independent reviewers (P.S. and F.H.) selected the studies and extracted the relevant data onto a standardized form. Data included the year of publication, country of origin, publication language, publication format , type of study , number of patients, mean age, sex, tumor location, baseline symptoms, radiological findings before the intervention , pain characteristics, clinical reasoning  to patient selection, type of intervention (ERCP or EUS-based), technical success, type of stent if placed , length of the stent, adverse events (AEs), symptom improvement , mean rate and duration of pain improvement post intervention, and follow-up period.Given that pain is always a subjective phenomenon , regardlThe same two reviewers assessed the methodological quality of included studies with discussion and adjudication by the corresponding author in case of disagreement. We used the methodological quality and synthesis of case series and case reports tool reported previously . AccordiI-squared statistic and Cochrane Q test. Given the non-comparative design of the majority of the included studies and the heterogeneity between studies, publication bias was not evaluated using funnel-plot-based statistical tests [P < 0.05 was considered significant. Statistical analysis was done using Stata 16 software . The remaining outcomes were reported narratively.When the included series provided information sufficient to produce a rate of pain improvement (i.e. a numerator of patients with improved pain and an explicit denominator), we estimated an event rate from each study. Studies contributing fewer than four patients were not included in the meta-analysis because an event rate cannot be calculated. The Freeman–Tukey double arcsine transformation was used to stabilize the variance and produce 95% confidence intervals (CIs) with sensitivity analyses using the logit transformation . We poolal tests . P < 0.0We identified a total of 192 eligible patients (190 underwent ERCP and 2 underwent EUS), in whom PD stenting was successful in 167 (87.0%). Patients with PD stenting had a mean age of 62.5 years and 98 patients were males (58.7%) .et al. [Clinical decision-making in patient selection for PD drainage is relayed in et al.  did not et al. , 38, 39,et al. , 35 and et al. . Tumor let al. , 38, 39.Among 192 patients, 190 underwent an ERCP-guided PD stent placement attempt and 2 underwent EUS-guided decompression with PD stent placement . Technicet al. [et al. [Repeat endoscopic intervention was explicitly reported in 16/167 patients due to stent occlusion (5 patients), migration (5 patients), and concurrent biliary-stent obstruction with cholangitis in the remaining 6 patients , 33, 39. [et al. , post-sp [et al. , 39 and  [et al. , 33. TheP < 0.05)   [29, 37, < 0.05)  [3, 29, ) + 7 h , 34, 36.)  (+ 7 h . Patient) + 7 h , 33–39..P < 0.05Two studies reported a need for further interventions after PD stenting in some patients, for either symptom recurrence or cancer resection. These interventions included palliative double-bypass surgery (three patients) and classical Whipple procedure (one patient) , in addiThe assessment of the studies’ methodological quality is shown in Pain is a common symptom of PC, and the frequency and severity of pain are associated with worse survival . AlthougCurrent paradigms in cancer pain management follow the four-step ‘analgesic ladder’ . This apWhile PD stenting is a widely accepted practice for chronic-pancreatitis obstructive-type pain, it is often not considered for malignant strictures, although it has been suggested by the British Society of Gastroenterology guidelines for PC pain management . In thiset al. [In PC, abdominal pain may be broadly divided into neuropathic pain and obstructive pain. The former has been described as a continuous, dull aching pain in the epigastrium or upper back, which is unrelated to meals. A similar neuropathic character of pain has been described in patients with chronic pancreatitis . Obstrucet al. , whereinet al. [The increased ductal pressure may lead to ductal leakage and parenchymal infiltration by pancreatic juice , resultiet al. , PD stenet al. . Howeveret al. .It should also be noted that acute pancreatitis can be a complication of PC, which can lead to severe acute pain, and may occur in 6%–14% of patients . HoweverAlthough our study suggests that PD stenting in selected patients with PC may be effective, this intervention is challenging and should only be pursued by an experienced endoscopist at a high-volume center, similar to what is required for pancreatic interventions in general. Before the procedure, the ductal anatomy needs to be delineated by cross-sectional imaging, or EUS, to localize the stricture accurately and to rule out ductal anomalies, such as pancreas divisum, seen in 7% of patients and which would warrant ductal access via the minor papilla . PD-striPD stenting is associated with unique complications, such as acute pancreatitis, bleeding, ductal rupture, and cholangitis , 58–61. a priori protocol and rigorous methodological quality appraisal.Our study has several shortcomings, which limits the quality of this review and may lead to uncertainty of the conclusion. First, no RCTs were identified in the systematic review and the meta-analysis is unable to quantify the degree of pain improvement mainly due to the low utility of validated pain score assessments in the included studies, which are mostly case series and case reports with a small number of patients. Furthermore, the placebo effect may also be a possibility given the non-comparative nature of the majority of the included studies. Second, missing data precluded gathering complete information and not all patients were followed until their demise to establish the durability of the therapy. Third, substantial selection bias exists, although this should be viewed critically, and perhaps favorably, since such invasive therapy should only be offered to PC patients with PD obstruction who are not considered surgical candidates. However, there were no systematic or precise inclusion criteria explicitly stated in most of the studies. Fourth, other confounding factors such as the use of concomitant chemotherapy, which has been shown to improve pain relief and the quality of life in PC patients , were noAnother main limitation is the inability of our meta-narrative evaluation to precisely estimate the AEs rate when the technique is applied. Although we reported all purported events as relayed in the original publications, uncertainty remains regarding the denominator used in three of the original reports , 37, 39.Although this is the first systematic study that synthesizes all available evidence on the role of PD stenting in PC abdominal pain palliation, our results are inconclusive and instead suggest that a well-designed RCT is warranted, with numerous other questions remaining. This includes the most appropriate type and size of stents, the route of stent insertion , response according to tumor location, the appropriate interval of stent exchange, and the role of multiple stents. Patients with a PD stricture might also have underlying neuropathic pain, which will need to be addressed by other interventions.In conclusion, for selected PC patients with obstructive-type pain symptoms and PD obstruction, PD stent placement may be an effective palliative approach, with an acceptable AEs profile. However, this systematic review and meta-analysis were based on the limited available literature of nonrandomized and retrospective data, with very low certainty in the evidence. While the analysis is exploratory, conclusive evidence should be derived from a larger-scale, well-executed, and adequately powered prospective randomized–controlled trial to corroborate these findings and help a subset of patients suffering from a highly morbid sequela of PC.Gastroenterology Report online. P.S., F.H., and L.J.P. collected the data. S.P., F.H., F.B., and M.H.M. analysed and interpreted the data. F.B. conceptualized and designed the study. S.P. and F.H. drafted the manuscript. L.J.P., M.H.M., B.K.A.D., V.C., M.D.T., and F.B. interpreted the data and critically revised the manuscript. All authors read and approved the final manuscript.No specific grant was received from any public, commercial, or not-for-profit sectors for this research activity. V.C.: Shareholder: Nevakar corporation, Consultant: Interpace Diagnostics. B.K.A.D.: Consultant: Metamodix, BFKW, DyaMx, Boston Scientific, USGI Medical, Hemostasis. Research support: Apollo Endosurgery, USGI, Spatz Medical, Boston Scientific, GI Dynamics, Cairn Diagnostics, Aspire Bariatrics, Medtronic. Speaker: Johnson and Johnson, Endogastric solutions, Olympus. The remaining authors declare that there is no conflict of interest in this study.goab001_Supplementary_DataClick here for additional data file.


Introduction: Surgery for chronic anal fissure is challenging for every proctologist. Solving the pain by guaranteeing rapid and effective healing is the objective, but what is the price to pay today in functional terms? Though this result is nowadays partially achievable through interventions that include the execution of an internal sphincterotomy among the procedures, it is necessary to underline the high rate of patients who can present faecal incontinence. The aim of this study is to explore the effectiveness of scanner-assisted CO2 laser fissurectomy.Methods: From April 2021 to September 2021, all consecutive patients who affected by chronic anal fissure suitable for surgery, meeting the inclusion and exclusion criteria, were evaluated. All planned data were recorded before surgery, then at 24 h, 1 week, and 1 month follow-up. A scanner-assisted CO2 laser was used in this study to achieve a smooth and dried wound with a minimal tissue thermal damage, to ensure good postsurgical pain control, rapid and functional, elastic and stable healing, and to prevent potential relapses. Paracetamol 1 g every 8 h was prescribed for the first 24 h and then continued according to each patient's need. Ketorolac 15 mg was prescribed as rescue.Results: Mean pain intensity ≤3, considered as the principal endpoint, was recorded in 26 out of the 29 patients who enrolled in the study with a final success rate of 89.7% at 1-month follow-up. Pain and anal itching showed a statistically significant reduction while bleeding, burning, and maximum pain, and REALIS score showed a reduction too at the end of the follow-up period. Reepithelisation proved to be extremely fast and effective: 22 of 29 (75.9%) showed a complete healing and 5 showed a partial reepithelisation at 1-month follow-up.Discussion: Outcomes of this study showed that it is undoubtedly necessary to change the surgical approach in case of anal fissure. The internal sphincterotomy procedure must be most of all questioned, where the availability of cutting-edge technological tools must be avoided and offered only in selected cases. Scanner-assisted CO2 laser showed great results in terms of pain control and wound healing, secondary to an extremely precise ablation, vaporisation, and debridement procedures with minimal lateral thermal damage. Chronic anal fissure usually causes recurrent pain mostly at defecation and bleeding per annum which negatively affect patients' life quality .Sometimes, it can worsen and evolve into a perianal abscess or fistula in anus and this helps to reinforce the indication to a surgical resolution.Anal fissure has a widespread diffusion and its incidence is 10–15% among all proctologic consultations .An epidemiologic study underlined that United States count approximately 3,42,000 new anal fissure cases per year where the main affected are middle-aged and younger people with an equal male to female ratio  after internal sphincterotomy –11, it s2 laser technology, already widely used in speciality such as colposcopy, with a similar approach.To avoid the high rate of incontinence secondary to internal sphincterotomy and at the same time ensure good postsurgical pain control and a rapid surgical wound healing too, we explored the effectiveness of scanner-assisted CO2 laser technology is well known in various surgery fields, from the late 70s. Its wavelength of 10.600 nm is entirely absorbed by water, thus making this laser undoubtedly the best surgical one, due to its excellent characteristics of tissue interaction.CO2 laser technology have brought to sources excited with radiofrequency  and the introduction of tools such as surgical scanners, in association with focusing handpieces and high precision microspot micromanipulators coupled to surgical colposcopes or high-definition cameras, which allow to overcome the results of first CO2 laser generation. Scanners allow to move a micrometric focused spot on the tissue in an extremely fast  and precise manner, reproducing predefined shapes of cutting and plane ablation. By this way, surgical procedures are extremely selective, and the surrounding healthy tissues are not thermally damaged. Furthermore, coagulation feature of the laser can be improved when needed by simply adapting scanning and emission mode settings.Nevertheless, improvements in COIn general, laser surgery is a minimally invasive procedure that reduces hospitalisation time, decreases the postoperative pain, oedema, and discomfort, and results in fewer complications, faster and more functional wound healing , 13.The aim of this study is to overcome the limits of the current surgery for chronic anal fissure in terms of postoperative pain, pain and other symptom resolutions, healing time, incontinence rate, and patient's satisfaction with respect to safety and reproducibility.From April 2021 to September 2021, all consecutive patients who arrived at the clinics of SOSD Proctologia (USL Toscana Centro-Firenze) and affected by chronic anal fissure , 8 suitaWe planned a strict selection to obtain homogeneous group of patients: we considered only patients complaining anal pain secondary to a single chronic anal fissure unresponsive to medical therapies, ASA 1 and 2 only and Lee index <1 , who areWe excluded those patients with concomitant perianal abscess or fistula in anus or any anal disease or previous proctologic surgeries, with history of radiotherapy, pregnancy, age below 18 years, Crohn's disease, constipation requiring manual manoeuvres during evacuation, anal neoplasms, human immunodeficiency virus infection, faecal incontinence, proctitis, severe systemic diseases, uncontrolled comorbidities as diabetes, kidney failure, and anticoagulant therapy.All participants provided with verbal and written informed consent either to surgery or to participation in the study.All patients underwent a complete medical history, clinical evaluation, proctologic physical examination, anoscopy and endoanal ultrasound. All data were collected at different time, preoperative (T0), at 24 h (T1), then at 1 week (T2), and finally at 1-month follow-up (T3), and recorded in a prospective maintained database.All data collected are reported in The principal endpoint was mean anal pain intensity ≤3 (VAS 0–10).Anal pain intensity and symptom intensity were measured by means of a 10-point visual analogue scale (VAS) .The following secondary endpoints considered were as follows: maximum pain intensity (VAS 0–10), maximum pain duration , days of painkiller intake, specific symptoms, and REALISE score .Then, we focused on other secondary endpoints: the proportion of patients healed at 1 week and then at 1-month follow-up and graded according to a previous published degree of reepithelisation scale ; by the end of fissurectomy, all patients were found to be at the lowest grade .Finally, we also considered patient's satisfaction at 1 month and surgeons' satisfaction (about surgery), and these were recorded through a VAS 0–10 scale.Short-term complications were recorded; reoperation and discharge within 2 h were evaluated too.Failure to follow the protocol, further surgery during the follow-up, patient request.Patients were instructed to correct constipation already before surgery by taking stool softeners and sticking to a diet rich in fibres and fluids.After surgery, all patients received written instruction thoroughly explained before discharge.Surgical wound protection protocol required patients to apply a 3% sucralfate cream –20 Emof, 22.Paracetamol 1 g every 8 h was prescribed for the first 24 h and then continued according to each patient's need. Ketorolac 15 mg was prescribed as rescue.All patients were treated under local anaesthesia  performed directly on anal fissure with a 25-G needle, in an ambulatory setting with a planned discharge time of 2 h.2 laser, with 80 W of max power; this system is also equipped with a second 50 W 980 nm diode laser source fibre delivery, which results very useful in those procedures where higher coagulative power is necessary , EndoScan and microscan scanners connected to long focal 5” handpieces.2 laser provided with the appropriate accessories was used to treat various proctologic pathologies, such as abscesses, fistulas, condylomas, AIN, as the CO2 laser scanning fast vaporisation and excision are extremely effective on soft tissue surgery. The article's aim is nevertheless to focus on the fissurectomy procedure.The scanner-assisted COThe procedure involves two surgical stages: vaporisation and superficial vaporisation and debridement.2 laser was used in fissurectomy to vaporise sentinel skin tag, sentinel polyp, and fissure margins.The COHere, the parameters for vaporisation used according to the scanning shape and depending to the area to treat: Clover (interpolated double ellipsoid): UP Mode, 15–20 W, dwell time 0.2 ms, continuous or repeated scanning (T-Off 0.1 s); hexagon: CW Mode, 18–25 W, dwell time 0.1 msec, repeated scanning (T-Off 0.1 s).Then, fissure superficial vaporisation and debridement, to obtain a more uniform plane eventually removing biofilm and stimulate the tissue to regenerate, was performed using these parameters: Clover (interpolated double ellipsoid): UP Mode, 4–8 W, dwell time 0.2 ms, continuous or repeated scanning (T-Off 0.1 sec); hexagon: CW Mode, 12–18 W, dwell time 0.1 ms, repeated scanning (T-Off 0.1 s).In case coagulation was needed, the laser emission mode was switched to CW and the power reduced.2 laser , or using a monopolar electrosurgical energy or by suture.Haemostasis, when needed, was achieved by defocusing the COThe surgical goal is to achieve a smooth and dried wound with a minimal tissue thermal damage, to ensure good postsurgical pain control, rapid and functional, elastic and stable healing, and to prevent potential relapses –5.All surgical data were recorded: from the number of vaporised sentinel polyp to the number of skin tag treated. Surgical time, intraoperative, 24 h, 1 week, and 1-month complications and surgeon's satisfaction (VAS 0–10) were recorded too.2 laser treatment in a selected patient group: the clinical and follow-up data were stored in a prospective maintained database.In this study, the statistical analyses focused on postoperative results related to specific scanner-assisted COp-value < 0.05 was considered significant.Association between median VAS after surgery, time of treatment after diagnosis and grade of reepithelialisation variables, patients' characteristics, and surgical procedure were examined by chi-square and Fisher's exact tests. p < 0.05 was considered significant.XLSTAT software (version 2021.3.1)  was used for statistical analysis: This was a retrospective single centre study and is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement for cohort studies .2 laser, as reported in During the study conduct period, we subjected 105 patients to proctology surgery using a scanner-assisted COIn total, 29 out of the 105 patients were those who met the inclusion and exclusion criteria of the study. The mean age of these patients was 49.7 years old (range 19–84). Totally, 6 of them were women, and 3 patients out of 29 was suffering from an anterior fissure whereas 26 out of 29 from a posterior fissure. The number of sentinel skin tag was 23 whereas the number of sentinel anal polyp was 9.In summary, the number of fissurectomy procedures alone was found to be 5 whereas the number of associate surgical procedure, for example, fissurectomy with simultaneous polyp vaporisation and/or sentinel skin tag vaporisation, was 24.Recorded fissure and fissurectomy-related symptoms are reported in Overall, 17 patients reported a preoperative history of constipation in particular with episodes of hard stool and 2 of diarrhoea. Only one patient reported anal sex.During the period of examination, 1 month after surgery, 3 patients experienced episodes of constipation, none of diarrhoea, and 1 felt confident to restart anal intercourse.The duration of symptoms mean time was 10.6 months (range 3–36).REALISE score was employed to evaluate and asses the severity on anal fissures. Data are reported in Pain severity was carefully evaluated and recorded .Mean pain intensity ≤3, considered as the principal endpoint, was recorded in 26 out of the 29 patients who enrolled in the study with a final success rate of 89.7% at 1-month follow-up. This percentage reached 85.7% in our cases only 1 week after procedure.Compliance with anal cream application was evaluated questioning each individual patient on the correct and daily application: at 1 week, 22 out of 29 responded positively whereas only 20 out of 29 at 1-month follow-up.Degree of reepithelisation of the postsurgical fissure was measured .p < 0.855), gender (p < 0.568), operative time (p < 0.506), and associate surgical procedure group (p < 0.258).No statistical correlations were found between grade of reepithelialisation after 1 month and age (p < 0.017).A most important relief, in our data, was the excellent clinical result in term of reepithelisation grade 3 in the subgroup of patient's compliant with the application of anal cream (p < 0.258), was found in our data between the precocity of treatment, related to pain symptom duration before laser treatment, and reepithelisation grade. The mean duration of pain before treatment in our data was 10.6 months.An interesting correlation, even without statistical value (Those treated before the mean time of 10.6 months showed a very good result in term of success (grade 3 reepithelisation) (86.7%) vs. patients treated after 10.6 month (64.2%).A correlation was also sought between the trend of mean pain intensity and reepithelisation but it was not found.On average, the surgical procedure lasted 19.3 min (range 10–40).2 laser surgery.We must also report that no changes in surgical strategy have been recorded, confirming the efficacy of the anaesthetic technique, selection of patients, accuracy of the care pathway and, last but not least, the safety and reproducibility of the scanner-assisted COThe recorded complications were 3 at 1 week of follow-up, all related to the painful oedema of the surgical wound margins, whereas only 1 case continued to have oedema 1 month after surgery.No reoperation during the follow-up period was performed. Any patients complained about of faecal incontinence of all grades.The satisfaction of the treated patients was 8.83 (VAS 0–10) at 1 week and 9.17 at 1 month. The 3 cases of failure, according to our protocol (mean pain severity scored ≤3), recorded scores 5, 7, and 7 again, respectively. Surgeons' satisfaction that was measured at the end of the surgical procedure was 9.07 (range 7–10).Anal surgery is taxed by a high rate of postoperative pain. Anal fissure stigmata symptom is high intensity and long duration pain, so long that it is disabling for patients.Most patients with anal fissure report a good response to medical therapy in terms of both pain control and healing (87%) ; howeverWhen none of the medical therapies adopted are effective, excluding the possible presence of a neoplasm through the execution of a biopsy, mandatory in doubtful cases, it is necessary to proceed with surgery. Among the numerous surgical operations proposed, from anal stretch to standardise anal dilatation with pressurised balloons to anoplasty, internal sphincterotomy has been found to be the “gold standard”.In a Cochrane review by Nelson et al. , a prospThough its extreme efficacy in controlling anal pain derived from the spasm of the internal anal sphincter and its capability to heal the fissure have widely been proved, it is necessary to critically analyse the result of the internal sphincterotomy which has a high rate in various degrees incontinence.Therefore, the problem we had to face was to find a surgical solution for those patients who failed in medical therapies, a surgical solution that had to be able to heal the fissure without postoperative burden and faecal incontinence.According to experience, the majority of patients (89.7%) reached the main goal of mean intensity pain ≤3 (VAS 0–10) 1 month after the operation. Moreover, this percentage had already reached optimal outcomes (85.7%) 1 week after procedure: clear evidence of high value in terms of both absolute effectiveness and speed. The maximum pain intensity disappeared in 68% of our cases after 1 month although 5 patients started from a value of VAS ≥ 7. The initial mean value was equal to 9.03 whereas it was equal to 1.59 after 1 month.This result is comparable with reports in the literature of internal sphincterotomy surgery .Moreover, it is interesting to notice the healing rate speed of this approach compared with traditional fissurectomy .However, our aim was to analyse the symptom pain from different points of view, as suggested by other authors .Maximum pain intensity at 1 month disappeared in 20 out of 29 patients, 5 of them had a VAS ≥7. The initial mean value was equal to 9.03 whereas it was equal to 1.59 after 1 month.In particular, we measured the duration of the maximum perceived pain, an important consequent element of disability but often little considered in the literature: 1 month after treatment, 1 patient reported a duration of pain between 30 and 60 min, 1 patient a duration between 10 and 30 min whereas 5 patients <10 min.Anal digital exploration by the surgeon was evaluated and was measured at both 1-week and 1-month follow-up, resulting in zero-not painful, respectively, in 17 and 21 out of the 29 patients who were examined. This report has the function of objectifying the patient's pain during the visit and associating it with what was reported during the collection of the medical history.Digital exploration also has the function of monitoring the healing process and adopting any changes in the postsurgical medical strategy, from the indication to the use of other creams , 31, 32 Stepping back to the symptom pain, we have also investigated the pain impact on the daily patients' life by measuring how long was the painkiller self-intake period: at 1 week, the average number of days reached a value of 4.48 and 11 out of 29 patients reported that they continue to intake painkillers because of the need; at 1 month, the mean reached a value of 8.7 days with only 5 patients continuing to take painkillers.This result indirectly indicates how much the pain weakens each patient and represents an objective element of analysis that allows to homogenise the subjective variables of each treated case.Since the painkiller days was taken, value of 8.7 shows that particular attention has to be paid to the first week; moreover, any strategies to be adopted in addition to those explored, which may allow a reduction in this value, should be evaluated.Anyway, we never forget that the anal fissure can be characterised not only by the pain symptom but also by other symptoms that can be equally weakening and that we therefore wanted to analyse bleeding, anal itching, and burning .Our experience demonstrates that the strategy adopted is able to determine a significant reduction primarily not only in pain but also in the other 3 symptoms too. In particular, the result on burning, however, deserves to be analysed: though surgery halves the symptoms, 7 patients still continue to suffer from it 1 month after and in any case present together with pain in the 3 patients with mean VAS ≥ 3.The recent introduction in the literature of a score dedicated to the clinical evaluation of the anal fissure, or the REALISE score  allowed Despite the low number of failure cases, we still wanted to evaluate what the variables affecting the outcome might be.The statistically significant correlation between adherence to the anal cream application and healing demonstrated, in our experience, the importance of this local postoperative procedure: clearly emerged from the literature and also the need to continue with the suggested treatment for at least 6 weeks .These data are essential to better educate patients in postsurgical wound care. Our mind to allow functional healing is to daily treat these wounds by applying a cream with a finger, as claimed by other authors .About reepithelisation our experience shows an important correlation with adherence to the anal cream application and no correlation with other variables.An important relief was the relationship with symptoms' duration: those patients with a shorter symptom duration actually demonstrated a better healing tendency than the others, suggesting the early use of fissurectomy.In addition, the lack of correlation between pain resolution and level of healing opens up an interesting discussion and also confirming what the literature has already demonstrated. In fact, it had already emerged that the pain had a faster resolution than reepithelialisation, a dynamic that must be known by an expert and essential to proctologist to better follow the healing process .Looking at the pure numbers, we would like to underline that 27 out of 29 patients demonstrated complete (22) or partial (5) reepithelisation.This result is extremely superior to the reports in the literature regarding traditional diathermy fissurectomy, which averages a mean healing time of 10.3 weeks . Althoug2 laser technology, widely used in several surgical fields  for many years, has enjoyed a technological upgrade thanks to the introduction of scanning units that have allowed the execution of extremely delicate, precise, and effective procedures.CO2 laser for a multipoints myotomy of the internal anal sphincter , demonstrating an extremely rapid healing with no relapses at 1 year of follow-up .2 laser technology in proctologic surgery and, more specifically, in the treatment of chronic anal fissure through a fissurectomy procedure.This study reports the very first application of a scanner-assisted COThe limits this procedure presents are related to the small number of patients treated in addition to the fact that it was conducted in a single centre, without randomisation too.The excellent outcomes obtained are however an excellent basis to develop future experiences.It will also be essential to explore the possibility of carrying out this procedure in the context of enhanced recovery after surgery programmes and possibly in association with different anaesthetics or analgesics.In future, it will be necessary to design multicentre randomised trials that can confirm the results obtained either in terms of fissure healing, low complications , and postoperative pain, studies that can make use of new digital technologies such as telemedicine  or the u2 laser turned out to be a useful aid in proctology surgery and in particular during fissurectomy, as it allows extremely precise ablation, vaporisation, and debridement procedures with minimal lateral thermal spread.Scanner-assisted COThe wide versatility of pulse shape and energy delivery has proved to be both an added value by allowing an extreme modulation of the energy delivered but also a limitation due to the lack of consolidated experience with the use of this technology in this surgical field.Randomized multicentre studies based on comparison with traditional techniques are the next step necessary to ensure the good results obtained with this experience.The original contributions presented in the study are included in the article/IG: surgical procedures, data collection, and paper writer. TC: surgical procedures, data collection, and statistics. CL, FC, PD, GR, and CT: surgical procedures and data collection. GT: paper writer. FB, AA, SG, and AP: data collection. LG: laser supervisor and paper revisor. CE: study organizer, surgical procedure, and data collection. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.