Anterior open treatment of the inguinal hernia with a tension free mesh has reduced the incidence of recurrence and direct postoperative pain. The Lichtenstein procedure rules nowadays as reference technique for hernia treatment. Not recurrences but chronic pain is the main postoperative complication in inguinal hernia repair after Lichtenstein's technique. Preliminary experiences with a soft mesh placed in the preperitoneal space showed good results and less chronic pain.The TULIP is a double-blind randomised controlled trial in which 300 patients will be randomly allocated to anterior inguinal hernia repair according to Lichtenstein or the transinguinal preperitoneal technique with soft mesh. All unilateral primary inguinal hernia patients eligible for operation who meet inclusion criteria will be invited to participate in this trial. The primary endpoint will be direct postoperative- and chronic pain. Secondary endpoints are operation time, postoperative complications, hospital stay, costs, return to daily activities (e.g. work) and recurrence. Both groups will be evaluated.Success rate of hernia repair and complications will be measured as safeguard for quality.To demonstrate that inguinal hernia repair according to the transinguinal preperitoneal (TIPP) technique reduces postoperative pain to <10%, with α = 0,05 and power 80%, a total sample size of 300 patients was calculated.The TULIP trial is aimed to show a reduction in postoperative chronic pain after anterior hernia repair according to the transinguinal preperitoneal (TIPP) technique, compared to Lichtenstein.In our hypothesis the TIPP technique reduces chronic pain compared to Lichtenstein.ISRCTN 93798494 Inguinal hernia is a common surgical problem. In the Netherlands more than 26.000 unilateral inguinal hernia repairs are performed each year . TensionThe exact incidence of chronic pain is unknown. Well conducted, large and unselected epidemiological studies suggest that about 20% of patients are affected with chronic pain -7. A ranTo assess the objectivity of pain the visual analogue scale (VAS score) is frequently used nowadays . VAS hasEndoscopic hernia repair has been postulated to result in less chronic pain due to the preperitoneal placed position of the mesh.Several studies have been performed to investigate if endoscopic repair resulted in less chronic pain. A large mesh is placed in preperitoneal position to cover the myopectineal orifice after reduction of the hernia sac. Liem et al. concluded a lower incidence of pain after endoscopic hernia repair compared to open non-mesh repair . Grant eThe drawback of endoscopic hernia repair over the open approach is the added costs, particularly when disposable instruments are used . The othOne study prospectively investigated the incidence of pain after inguinal hernia correction under local anaesthesia. Some form of pain was reported by 19% of patients and severe pain by 6% of patients after one year .Other meshes have been developed and tested to reduce the chronic pain after inguinal hernia repair. A randomised clinical trial comparing the Prolene Hernia System, mesh plug repair and Lichtenstein method for open inguinal hernia repair showed that 39,7% of patients had some form of pain after three months. No difference could be detected between type of mesh used .No recent systematic review or meta-analysis regarding postoperative pain after inguinal hernia repair has been performed.Endoscopic preperitoneal approach in order to reduce pain is expensive and has several other disadvantages, but a cost-effectiveness meta analysis has to be performed yet.Since pain is often related to neuralgia and recurrences occur at the myopectineal orifice an alternative mesh was developed to be placed in the preperitoneal space, but with anterior approach. Preliminary experience with a preperitoneal placed mesh of 8-10 cm long and 6-7 cm wide in 116 patients showed a recurrence rate of 0,7% with a median follow up of 63 months . After aThe transinguinal preperitoneal (TIPP) technique with soft mesh combines the anterior approach according to Lichtenstein with the preperitoneal position of the mesh as known from the endoscopic total extra peritoneal technique (TEP).This paper describes the rationale of this product and the design of the study.Two techniques, Lichtenstein and TIPP, for inguinal hernia patients will be compared in a prospective randomised double blind clinical trial. Patients will be included at the outpatient departments of both hospitals by surgeons and supervised residents. Dedicated hernia surgeons will always supervise and/or perform the operations.Objective success: the percentage of operations with successful inguinal hernia reduction and direct postoperative - and chronic pain incidence lower than 25%.The primary endpoint is the incidence of direct postoperative pain and chronic pain after inguinal hernia repair according to Lichtenstein or TIPP using the visual analogue scale (VAS).The secondary endpoints are operation time, hospital stay, complications (e.g. infection), cost-efficiency analyses, time to return to daily activities/work and recurrence after Lichtenstein or TIPP procedures.TULIP is a double-blind, randomised controlled trial. Randomisation will be performed by pulling a sealed double blind envelope in the trial centre after contact by telephone prior to incision. Obviously, the surgeons know which technique they are performing during operation. The investigator assessing the outcome on the outpatient department is not informed. Operation reports are blinded and no  access is permitted or possible for the person assessing outcomes. The patient does not know which procedure has been performed because it is written down on paper and not mentioned in theatre.A total of 300 patients, with a unilateral primary groin hernia, visiting the outpatient clinics at the St. Elisabeth Hospital or TweeSteden Hospital in Tilburg will be randomised figure .Analyses of inguinal hernia patients in the past showed a number of approximately 600-700 per year in both hospitals, equally divided. This number is the sum of both hospitals and includes recurrences, children/elderly, incarcerated and bilateral inguinal hernia's. Apart from a positive informed consent, a lower amount can/will be included. Data will be collected by VAS-diary and SF36-list . Forms will be filled in by the patients at 14 days, 3 months and one year after surgery during follow up (figure 1).• Primary unilateral groin hernia• Age > 18, < 80 years• ASA classification 1-3• Signed informed consent letter• Recurrent hernia• Age <18 or >80 years• Scrotal hernia(s)• ASA classification >4• Acute incarcerated inguinal hernia(s)• Psychiatric disease or other reason making follow up or questionnaires unreliable• Previous preperitoneal surgery This study is conducted in accordance with the principles of the Declaration of Helsinki and "Good Clinical Practice Guidelines". The independent ethics committee of both participating hospitals approved the final protocol. Oral and written informed consent in form is obtained from the patient before inclusion in the trial..The TULIP Trial is registered at: All patients will be operated via anterior approach with a skin incision two centimetres above the Poupart ligament. In half of the study population the groin hernia will be corrected according to Lichtenstein, as described by Amid et al. . This is® mesh as described by Pélissier et al. [® mesh into the preperitoneal space adapts anatomically to the type of hernia. Type of hernia will be assessed using the European Hernia Society groin hernia classification [The other 150 inguinal hernia patients will be operated by the transinguinal preperitoneal (TIPP) technique with Polysoftr et al. . In thisfication . This clIn indirect hernias high dissection of the sac is performed and the sac is thus reduced in the pre peritoneal space (PPS) through the internal ring. Blunt dissection is carried out in the PPS, through the internal orifice and is then extended deep to epigastric vessels and transverse fascia, in the direction of the pubic spine, beyond its level. The patch is introduced in the PPS via the internal orifice. In regional or local anaesthesia asking the patient to strain allows correct anatomical spreading of the mesh, which is applied to the deep aspect of the fascia. The assessment is done by asking the patient to strain and to cough. External oblique aponeurosis was repaired superficial to the cord to restore the normal anatomy.In direct hernias, after division of the cremaster so as to check the internal orifice for an indirect sac, the transverse fascia is divided circularly around the hernia bulge and the sac is reduced. Blunt dissection is carried out in the PPS, medially in the direction of the pubic spine and laterally behind the epigastric vessels in direction of the iliac spine. The patch is introduced through the transverse fascia opening and spread in the PPS so as to cover all the weak inguinal area. When an indirect sac, even if it is small, is associated to the direct one, both sacs are dissected and reduced.A standardized general anesthesia/spinal anesthesia protocol will be used in both groups in combination with a standardized post operation regimen, based on VAS scores for pain and nausea. These regimes are based on current and acceptable practice and the standardization serves to avoid unnecessary bias.The choice of anesthesia technique will be left, in principle, to the preference of the patient. All patients will be seen, pre-operatively at the pre-operative screening outpatient clinic at one of the two locations. Standardized pre- and postoperative medication will be handed out to the patients to be used each day, during the first 5 days postoperatively, including any part of this period that the patient may already have been discharged. This includes, but is not limited to, paracetamol 1 gram four times daily and diclofenac 50 mg 3 times daily and as rescue medication zaldiar 50 mg 3 times daily when regular painkillers are not satisfying.The analysis will be performed on the basis of intention-to-treat principles.It is anticipated that the use of TIPP technique with soft mesh at least will lead to a reduction in postoperative chronic pain from 25% to 10%. The sample size calculation is based on α = 0,05 and a power of 80%. This leads to a required sample size of 300 patients. Taking into account a 5% loss-to-follow up, a total of 2 × 158 patients will be randomized. There are three postoperative follow up visits at the outpatient department at two weeks, three months and one year for both groups (Lichtenstein and TIPP). The expected study end is December of 2010 .. According to this list a random allocation of Lichtenstein and TIPP method was performed. Randomisation will take place by pulling a sealed envelope after phone call to the trial centre prior to incision at the theatre.The randomisation list was generated by using the website randomisation.com Operation forms are blinded in the electronic patients files and not available for the independent outpatient clinic researcher. The incision of the skin and anterior approach will be the same for both techniques.The TULIP is a double blind randomised controlled trial that aims to show a reduction in direct postoperative- and chronic pain after anterior inguinal hernia repair with placement of a soft mesh either in the inguinal canal (Lichtenstein) or in the preperitoneal space (TIPP).Hypothetically the TIPP technique reduces chronic pain drastically compared to Lichtenstein because of the placement of the soft mesh in the preperitoneal space.The authors declare that they have no competing interests. Objective analyses will be performed on the TULIP data. There will be no violating of this study protocol.GGK and PWHEV were involved in trial coordination, design protocol, writing manuscript.HJPS and PWHEV co-write manuscript "surgical technique" and reference manager. HJMO and PGG made comments on rough version manuscript. HJMO, KCJHML and PWHEV made comments on protocol and manuscript. KCJHML co-supervised protocol, conceiving study design, methods. PWHEV was the supervisor of protocol, manuscript and outpatient department. All authors approved the study and this manuscript.


The aim of this study was to investigate the analgesic effects of intravenous flurbiprofen axetil for the refractory pain in cancer patients.2109 patients were screened from the department of medical oncology, the first affiliated hospital of Anhui medical university in China between October of 2007 and October of 2008. Thirty-seven cases of cancer patients who had bad effect from anaesthetic drugs were received administration of intravenous flurbiprofen axetil with dose of 50 mg/5 ml/day. The pain score was evaluated for pre- and post- treatment by Pain Faces Scale criteria, and the side effects were also observed.Intravenous flurbiprofen axetil increased the analgesic effects. The total effective rate was 92%. The side effects, such as abdominal pain, alimentary tract bleeding which were found in using NSAIDs or constipation, nausea, vomit, sleepiness which were found in using opioid drugs did not be found.Intravenous flurbiprofen axetil could provide better analgesia effects and few side effects to patients with refractory cancer pain. It could also increase analgesia effects when combining with anesthetic drugs in treatment of moderate or severe pain, especially breakthrough pain, and suit to patients who can not take oral drugs for the reason of constipation and psychosomatic symptoms. Pain is a common problem in cancer patient. About one-third of patients being treated for cancer have pain. More than two-thirds of patients with advanced cancer have pain . ControlFlurbiprofen is a non-selective cyclooxygenase inhibitor used in clinic as nonsteroidal anti-inflammatory drug . FlurbipCancer pain cases whose pain had not been treated satisfactorily with routine narcotics were selected from the department of medical oncology, the first affiliated hospital of Anhui medical university in China between October of 2007 and October of 2008. Each cancer case was diagnosed and confirmed by histopathology or cytopathology. Clinical data and follow-up information were obtained from the hospital records. The study protocol was approved by the local institutional ethics committee, and verbal informed consent was obtained from each patient. Patients with difficulty communicating, a history of adverse response to flubiprofen axetil, or who felt no pain after received other analgesic drugs within 24 hours were excluded.All selected patients were received 50 mg/5 ml/day of intravenous flurbiprofen axetil injection , as flurbiprofen axetil 50 mg added in 100 ml of 0.9% isotonic saline every time through vein within 30 minutes. Dosage and usage of the anaesthetic drugs such as Oxycodone, Tramadol, Duragesic and adjuvant drugs such as diazepam, carbamazepine which being used initially were not changed, or be reduced and ceased after the pain was relieved completely. Other accompanying adjuvant treatments also had been included chemotherapy, radiotherapy, best sustain therapy, bisphosphonate therapy, and etc.We evaluated cancer pain intensity by Pain Faces Scale criteria , and thePain relief was recorded based on four-scale criteria : CompletCR and PR were regarded as effective response to cancer pain treatment.Side effects were observed and classified according to the WHO acute and sub-acute toxicity classifying criteria of anticancer drugs . Some syA total of 2109 patients were screened. 37 patients were enrolled based on the criteria . Other clinic characteristics of those patients were showed in Table Thirty-three cases of refractory cancer pain were received 50 mg of intravenous flurbiprofen axetil injection every day. Other four cases had to increase the dosage of flurbiprofen axetil to 100 mg a day for the reason of insufficient effect by 50 mg a day. Thirty-four patients were regarded as partial relief or complete relief. The total effective rate was 92%. The results of usage and analgesic effect were showed in Table The side effect, gastrointestinal toxicity such as abdominal pain, alimentary tract ulcers and bleeding which were found in NSAIDs or constipation, nausea, vomit, sleepiness and delirium which were found in opioid drugs did not be found in all of the 37 cancer pain cases.In this study, we testified that intravenous flurbiprofen axetil injection could increase the analgesic effects in refractory cancer pain. Lipid microspheres (LM) were target-drug delivery carriers which could congregate selectively in the site such as inflammation or injuring blood vessel and change the distribution of drugs in vivo ,14. FlurAnaesthetic anodynes were always used in moderate and severe pain patients. It acted in central nerve system, and the analgesic effects was not relative with the site or kind of pain. But, side effects always happened, such as constipation, breath inhibition, drug dependence, even exciting central nerve system when it was used for long time . FlurbipThe half-life time of flurbiprofen axetil was 5.8 hours. Its onset of action was about 15 minutes after being used, and continued about 3 hours in post-operation. When it was used in cancer patients, it began to work quickly about in 30 minutes, and the duration of action was about 9 hours . So it wSometimes oral NSAIDs drugs are restrictedly applied mainly for the reason to stimulate patient's gastric mucosa. Intravenous flurbiprofen axetil injection could avoid this side effect. In all of 1089 cases, the side effect incidence rate was very low about 2.9% . Most siIn general, cancer pain is considered as chronic. The pain intensity ranges from mild to severe and present for a long time. Harmless approach to therapy such as by oral or by cutaneous are suggested by WHO. But, for some reasons as constipation and psychosomatic symptoms, there has many patients whose can not take drugs by oral, or can not be used cutaneous anaesthetic drugs, intravenous flurbiprofen axetil could exactly remedy the anaesthetic drug's shortcoming, and let itself to be an important switch drug.The authors declare that they have no competing interests.HW collected the data and drafted the manuscript, ZC designed this study and modified the manuscript, GS, KG, YP, JH, YD, JN participated in its design and coordination. All authors read and approved the final manuscript.


Until now only limited research has been done on the prevalence of chronic pain in primary care. The aim of this investigation was to study the health care utilisation of patients suffering from pain. How many patients visit an outpatient clinic because of the symptom of pain? These data were compared with data from a similar study in 1991, to investigate whether improvements had been achieved.A total of 1201 consecutive patients visiting outpatient clinics were surveyed in six practices in the western part of Germany on randomly selected days by means of questionnaires. Topics were the point prevalence of pain and the period prevalence of chronic pain, its characteristics and its impact on daily life, as well as data on previous therapies for pain. A retrospective comparison was made with the data from a similar study with same design surveying 900 patients that took place in five practices during 1991.In 2006, pain was the main reason for consulting a doctor in 42.5% of all patients (1991: 50.3%). Of all respondents, 62% suffered from pain on the particular day of the consultation, and 40% reported that they had been suffering from pain for more than six months (1991: 36.4%). As many as 88.3% of patients with chronic pain reported a negative impact on their daily life due to this pain (1991: 68%), and 88.1% reported impairment of their working life because of chronic pain (1991: 59.1%).Pain, and chronic pain in particular, is a central problem in primary care. Over the last 15 years, the number of patients suffering from chronic pain has not decreased. In nearly half of all cases, pain is still the reason for health care utilisation in outpatient clinics. Pain represents a major primary health care problem with enormous impact on public health. Improvements can only be achieved by improving the quality of health care at the primary care level. It is estimated that at least 8 to 10 million patients in Germany (around 10% of the population) suffer from chronic pain. Approximately 500 000 to 800 000 patients have difficult and complex pain problems demanding specialist treatment [In the last few years, several epidemiological studies have been carried out. It is difficult to draw any reliable conclusions on the course and development of chronic pain in the outpatient care system. The direct comparison of study results over the years is hampered by heterogeneous populations, and by differences in sample sizes, randomisation techniques, methods, definitions of chronic pain and different estimates for prevalence levels. Consequently, data have revealed significant method-specific differences in the prevalence of chronic pain.Epidemiological population-based studies report a pain prevalence of between 2% and 46.5% depending on the investigation and definition ,7-9. PaiFifteen years after the first investigation , a similAt the beginning of 2006, six different practices in Bochum were selected as representative of the different disciplines for the diagnosis and treatment of pain . Upon approval of the ethics committee of the Medical Faculty of the Ruhr University Bochum, on randomly selected days all consecutive patients of all age groups entering these practices were asked to participate. Exclusion criteria were poor health, concerns about privacy and inability to understand the German questionnaire. It was planned to include up to 200 patients from each practice.General information about the survey was provided by a flyer distributed at the reception desk. In the waiting room, all patients were informed about the aim and purpose of the survey and how to fill in the questionnaire. Once they had given their consent, patients were asked to complete the self-administered questionnaire. In cases of difficulty in understanding a question, assistance was provided by the same person, who had a medical background. All questionnaires were anonymous.An investigation featuring the same study design had already been carried out in 1991 , and theThe questionnaire consisted of two different parts. [Additional file The denominators of the data collected in Part B included only patients who reported chronic pain. This part of the questionnaire contained the characteristics, duration and localisation of the pain. The intensity of pain was reported by means of an eleven-point numerical rating scale (NRS) ranging from 0 to 10 . Using multiple-choice questions, patients were asked about the impact of pain on their daily activities, sleep and respective employment status. Other questions dealt with previous therapies and their subjective effects. The questionnaire included two open questions about profession and diagnosis as well as multiple-choice questions. Multiple answers were allowed for certain questions .Statistical differences between the results of 1991 and 2006 were calculated by means of the chi-square cross tabulation test, using the statistical software StatView Version 5.0 for Macintosh and Windows. Statistical significance was considered at p < 0.05.In this section all results from 2006 are presented. For clear discrimination the figures from 1991 together with the significances are given in brackets following.In total 1201 questionnaires were completed (N = 1201) except for a limited number of questions (1991: n = 900). The refusal rate was 4.61%. The reason for exclusion was not always given. Only two patients were excluded because of poor health conditions. Both were not suffering from acute or chronic pain. Most of the excluded cases were related to the Turkish societies having difficulties with the German questionnaire. Women answered 61.7% of the questionnaires (1991: 60%). The mean age of all respondents was 53.4 years (1991: 48.6 years). The mean age of patients suffering from pain was 58.4 years. [Table More than half of the patients (55.6%) suffering from chronic pain were married (1991: 57%) and 9.4% of respondents with chronic pain were divorced (1991: 6.7%). Of the chronic pain sufferers, 43.6% had a general certificate of secondary education  while 23.5% of them had Abitur . The open question about profession could not be analysed because of missing answers. It was excluded to guarantee full comparability between the two questionnaires.2006 = 480) suffered from chronic pain . The greatest numbers of patients with chronic pain were seen in the general practice, with 50% , and the fewest were seen in the surgical practice, with 32% . In the oncology practice, 38.3% of all patients had chronic pain. Of all patients, 22.1% suffered from acute pain (1991: 25.3%). In both survey years, women suffered from chronic pain twice as often as men. [Table Pain was the main reason for the visit to the outpatient clinic in 42.5% of all participating patients in 2006 . A total of 62% of respondents suffered from acute or chronic pain on the day of the survey 2006 (1991: 61.7%). 40%  and joints in 33.1% (1991: 28.0%). Only 14.9% complained of headache . [Fig. The number of patients suffering pain for more than five years was as high as 67.5% , while 26% of patients recorded pain lasting longer than 20 years .A total of 73.2% of chronic pain sufferers estimated the intensity of their chronic pain to be between 6 and 10 on the numeric rating scale .In both time periods, the factors most frequently activating chronic pain were physical strain in 72.6% , weather conditions in 41%  and psychological strain in 34.5% (1991: 36.9%).The open question about the pain-causing diagnosis could not be analyzed due to missing answers.Among own efforts at relieving pain, analgesic medication was considered the best method by 65% of the respondents . [Fig. Impairment in everyday life caused by chronic pain was felt significantly more strongly than 15 years earlier. This became especially apparent during leisure in 63.1% , housekeeping in 54%  and personal hygiene activities in 19% . In 14.3% of the patients, workdays were lost because of their chronic pain (1991: 19.2%). Only 11.7% did not feel any impairment from their chronic pain . [Fig. Chronic pain had negative effects on the sleep of 66.3% of the patients (1991: 70.1%), and 24.8% were on sleeping pills because pain affected their sleep so much (1991: 34.8%).Only 6.3% of respondents with chronic pain had not yet had any specific pain treatment. The frequency of consulting a pain specialist had increased to 11.3% in 2006 .The methods used for pain therapy had increased: medication in 69.8% , injections in 51.2% , acupuncture in 49.7%  and operations in 21.2%  were used against pain.Medication was considered to be the most effective method in 34.4% , while 18.8% considered physiotherapy an efficient treatment , 17.7% obtained pain relief from acupuncture , and 24.7% of the patients did not consider any of these methods an efficient way of relieving pain (1991: 29.3%).This study is the first to directly compare data on the changes in pain prevalence on randomly selected days in a comparable population in primary care, focussing on pain as the reason for outpatient health care visits. The investigation was designed as an independent, unselected random sample of outpatient health care users following the same model as in the first survey carried out in 1991 .The point prevalence was unchanged from 15 years ago. Nearly every second patient consulted a primary care physician because of pain, and every fourth patient visited a doctor because of long-lasting pain. These figures illustrate the pain sufferer's high need for proper diagnosis and treatment.In the last 15 years, the possibilities for pain treatment have definitely improved in Germany, both with regard to therapy options and the number of pain specialists. The period prevalence of chronic pain lasting longer than six months, however, has not decreased accordingly. Within these 15 years a significant improvement – a decrease in chronic pain – was expected. In these years the number of pain specialists and interdisciplinary pain clinics in Germany increased considerably ,19. The The city of Bochum, with 380 000 inhabitants is an urban area in western Germany. All patients in Germany are primarily diagnosed and treated by their home physicians. It is up to the patient to decide which physician to use as a home physician. Patients can select any outpatient clinic for their home physician , but the primary care consultation always takes place with one of these home physicians. Different practices were chosen during the investigations to include a wide spectrum of possible consultations for pain. Therefore our figures give a fairly exact picture of pain in primary care.Our results are supported by previous and current studies. In collected data from Finland, the point prevalence of patients consulting a general practitioner due to pain was 40% . Also a There are no studies investigating trends of point prevalence of pain among health care users. The period prevalence of pain complaints was found to be stable in the adult Danish population over a five-year period . HoweverAmong other possible reasons, this could be explained by an increase in the reporting or awareness of pain as the leading symptom. The number of pain patients is expected to rise. The demographic changes in industrial countries alone account for the increased average age of all patients in the study. Patients suffering from long-lasting pain are ten years older than those suffering from acute pain or those without pain. Age is one predisposing factor for chronic pain. Increasingly, "pain in the elderly" plays an important role in public discussions ,25.LimitationsTo simplify the realisation of this survey, a one-dimensional definition of chronic pain by duration has been chosen. Certainly a multidimensional definition of pain would cover the pain problem better . HoweverData from open questions were excluded to guarantee comparability. Lack of answers led to insufficient data. It is assumed that the missing replies about profession were an issue of privacy and those about pain diagnosis were due to nescience.We did not study the doctors' records. Medical consultation records instead of our surveys would give a false negative picture of the pain problem, because pain diagnoses very seldom occur. The International Classification of Diseases (ICD) still has no specific diagnosis for chronic pain. Pain occurs as angina pectoris, persistent somatoform disorder or trigeminal neuralgia . RelatedThe inclusion of an oncology practice did not change the balance by increasing the pain prevalence. We have included these patients, because a criticism of our initial paper was the fact that cancer patients were omitted. It was suspected that this absence of cancer patients would have decreased the total prevalence. Surprisingly, fewer patients in oncology consulted the doctor due to pain. In the actual data from 2006 this assumption is not justified, as our figures demonstrate. We believe that comparability between the two studies was also provided by the inclusion of cancer patients.The most prominent pain problem remains back pain, where simple diagnostic and therapeutic tools are neglected ,29-31. POur random sample has revealed that, in particular, patients who are unemployed, divorced or who left school after grade 9 have a greater tendency to suffer from chronic pain. Similar results have been published ,34. SuchPain had a considerable impact on the daily life of the patients concerned. The fact that 90% see themselves as impaired in their daily activities illustrates the extent of the restrictions due to pain. Emotional changes due to pain lead to high psychological strain and loss of quality of life . In addiThese days pain causes more severe complaints and interferences. This assumption is supported by the fact that patients frequently complained of the psychosocial impacts of their chronic pain. Many patients with chronic pain continue working due to the increased pressure of the actual job market. The German health report presents fewer sickness leaves in the last decade . InteresThe average duration of pain in chronic pain sufferers was 10.7 years . PatientHowever, only a few patients have received pain treatment properly adjusted to their needs. Less than 24.7% of patients consider any of their therapies satisfactory in reducing their chronic pain . SurprisIn our study, only a few patients who visited the practices were unwilling to take part and were excluded. The personal contact in the practice waiting rooms may have been of help, as the rate of refusal was far lower than in other pain prevalence investigations using telephone interviews or postal questionnaires, where the rates of refusal were 29.2% and 64.1%, respectively ,50.Pain plays a central role in the health care system, and is one of the most frequent reasons for consulting a doctor. There is a strong association between pain and the greater use of health care services ,52. Primthe major health problem – is still not obligatory in undergraduate training in Germany.A solution to the continuing problem of chronic pain is only a careful undergraduate and postgraduate training in pain diagnosis and treatment ,55. PainPain is the reason for primary health care utilisation in nearly half of all cases. The family doctor plays a key role, being the first contact person for the patient , and theThe authors declare that they have no competing interests.CHF was the principal investigator, attended the questionnaire survey, did the statistical analyses, and drafted the manuscript. AWS contributed to the statistical analyses and participated in the drafting of the manuscript. MWZ was responsible for the concept, made a critical revision of the manuscript. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/9/299/prepubGerman Questionnaire. The file provides the German questionnaire used in this study.Click here for file


The use of opioid analgesics for patients with chronic nonmalignant pain is becoming more widely accepted, and long-acting formulations are an important treatment option.To assess conversion to extended-release OROS® hydromorphone from previous stable opioid agonist therapy in patients with chronic nonmalignant pain of moderate-to-severe intensity.In this open-label multicentre trial, patients were stabilised on their previous opioid therapy before being switched to OROS® hydromorphone at a ratio of 5 : 1 . The OROS® hydromorphone dose was titrated over 3–16 days to achieve effective analgesia, and maintenance treatment continued for 14 days.Study medication was received by 336 patients; 66% completed all study phases. Stabilisation of OROS® hydromorphone was achieved by 94.6% of patients, the majority in two or fewer titration steps . Mean pain intensity scores, as determined by the Brief Pain Inventory, decreased during OROS® hydromorphone treatment (p ≤ 0.001). The percentage of patients rating their pain relief as ‘good’ or ‘complete’ increased, and the use of rescue analgesics for breakthrough pain decreased. The interference of pain with everyday activities , and the effects on mood and enjoyment of life, also improved during the study . OROS® hydromorphone was well tolerated, and adverse events were those expected for opioid agonist therapy.Patients with chronic nonmalignant pain who had been receiving opioid therapy easily underwent conversion to OROS® hydromorphone, with no loss of efficacy or increase in adverse events. In contrast to immediate-release hydromorphone, OROS® hydromorphone produces relatively constant steady-state concentrations for 24 h. Conversion from previous opioid therapy can be easily achieved without loss of pain control or increase in adverse events using a morphine equivalents : OROS® hydromorphone conversion ratio of 5 : 1 .The current report presents final results of the individual study conducted in patients with nonmalignant pain. It demonstrates that conversion can be achieved without loss of pain control or increase in adverse events, and provides additional evidence of the safety and efficacy for the proposed 5 : 1 morphine equivalents : OROS® hydromorphone conversion ratio.Although the treatment of chronic pain with opioid agonists in cancer patients is widely accepted, the use of opioid analgesics for patients with nonmalignant pain has become widespread only in recent years, and remains controversial ,2. HowevHydromorphone is a hydrogenated semi-synthetic ketone of morphine that has been used for many years to treat moderate-to-severe cancer pain, for which it is regarded as an effective alternative to morphine ,4. HydroAn OROS® formulation of hydromorphone was developed recently. It utilises OROS® Push-Pull™ osmotic pump technology  to release hydromorphone at a controlled rate for up to 24 h. Clinical pharmacokinetic analysis has shown that, in contrast to IR hydromorphone, OROS® hydromorphone produces relatively constant steady-state concentrations for 24 h with much less peak-to-trough variation .The conversion of patients to OROS® hydromorphone from previous opioid agonist treatment was evaluated in an open-label, repeated-dose study. Preliminary results were presented as part of a pooled analysis, with a second study of identical design performed in patients with chronic cancer pain . The curThe study was an open-label, repeated-dose, single-treatment, multicentre trial conducted at 35 sites throughout the USA and Canada. Its protocol was approved by an Institutional Review Board at each site, and all patients provided written informed consent.Before the administration of study medication, patients were stabilised on their previous opioid therapy for at least 3 days. Stabilisation was defined as ≥ 3 consecutive days when the total daily baseline opioid dose remained unchanged, with ≤ 3 doses of rescue medication required for breakthrough pain. Patients were permitted to receive combinations of opioid drugs during this phase, and nonopioid and adjuvant analgesics also were allowed.When stabilised, patients were switched to OROS® hydromorphone hydrochloride using a 5 : 1 conversion ratio of morphine sulphate equivalent to hydromorphone hydrochloride ,10,11,12After the switch, OROS® hydromorphone was titrated over a period of 3–16 days. Each dose of OROS® hydromorphone was given for at least 2 days to ensure that steady-state blood levels of hydromorphone were achieved . If morePatients were treated on an outpatient basis, with five study visits over the treatment period. Stabilisation of prior opioid therapy began at visit 1 . OROS® hydromorphone titration started at visit 2, and OROS® hydromorphone maintenance therapy began at visit 3. Visits 4 and 5 occurred at the midpoint and end of the maintenance phase, respectively.During the study, IR hydromorphone could be prescribed as rescue medication for breakthrough pain, with the recommended dose generally ranging from 10% to 15% of the basic daily OROS® hydromorphone dose. No other opioid medication was permitted after conversion; however, patients were allowed to use nonopioid and adjuvant analgesics.Study patients were adults (≥ 18 years of age) with chronic nonmalignant pain and stable analgesic requirements . Exclusion criteria included hypersensitivity to hydromorphone or other opioid agonists; gastrointestinal disorders that could affect the intake, absorption or transit of study medication; significant disorders of the central nervous system; respiratory compromise; risk of serious decrease in blood pressure with an opioid analgesic; significant organ or metabolic dysfunction; a history of drug or alcohol abuse; requirement for radiation treatment; pregnancy or lactation; and use of any investigational drug within 30 days of study initiation.The efficacy of OROS® hydromorphone was assessed using the Short Form of the Brief Pain Inventory (BPI) . Pain inα) error of 0.05 was assumed. Statistical significance was set at p ≤ 0.05. No adjustment for multiple testing was applied.Changes in mean BPI pain intensity, pain relief and pain interference ratings from visit 2 to end-point (or the last observation carried forward from visit 3 or 4 for patients who withdrew) were assessed using the Wilcoxon signed rank test. To detect the smallest differences in BPI ratings, a type I . The study was completed by 222 patients (66%); 94 (28%) discontinued during the titration phase and 20 (8%) during the maintenance phase. Patient disposition is illustrated in The overall mean ± SD duration of OROS® hydromorphone treatment was 24.2 ± 12.2 days, with 306 patients (91%) receiving study medication for more than 7 days and 143 patients (43%) receiving it for more than 25 days.n = 209 (66%); one or two titration steps, n = 82 (26%); Three hundred and eighteen of the 336 treated patients (94.6%) achieved a stable dose of OROS® hydromorphone during the titration phase. Overall, the mean time to dose stabilisation was 4.2 ± 2.12 days. Stabilisation was achieved in two or fewer titration steps by 87% of patients [no titration, At the start of the OROS® hydromorphone titration period, mean rescue medication requirements were 4.8 ± 4.4 doses per day and 15.7 ± 20.5 mg per day. The frequency of rescue medication use, but not mean dose, declined during OROS® hydromorphone therapy .Mean BPI pain intensity ratings for pain at its worst, pain at its least, average pain and pain right now all decreased with OROS® hydromorphone treatment  . PatientIn addition to the improvement in pain intensity, patients reported a decrease in the degree to which pain interfered with their lives, as assessed by BPI pain interference scores  . InvestiDuring the study, adverse events were experienced by 79% of patients. The most common events were gastrointestinal symptoms  as well as headache, dizziness and somnolence . The majResults of the previous interim pooled analysis showed that patients with chronic malignant or nonmalignant pain could be switched easily from previous opioid therapy to OROS® hydromorphone . This fiThe efficacy results of the present study indicate that conversion from previous opioid therapy to OROS® hydromorphone can be achieved with no loss of pain control. Over the course of OROS® hydromorphone treatment, patients’ BPI pain intensity ratings  improved significantly (p ≤ 0.001) in comparison to the ratings recorded for their previous opioid therapy. The improvement in pain interference was similar. At the end of the maintenance period, there were statistically significant (p < 0.001) decreases in the degree to which patients’ pain interfered with general activity, mood, ability to walk, normal work, relationships with other people, sleep and general enjoyment of life. Such improvement can be expected to positively impact quality of life, as has been demonstrated for extended-release formulations of opioid agonists . A GermaAs has been demonstrated previously with extended-release morphine and oxycodone ,18, convOROS® hydromorphone was well tolerated throughout the study. The most common adverse events affected the gastrointestinal and central nervous systems, and were consistent with those expected to occur with opioid agonist therapy for chronic pain.Limitations of the present study include the open-label design and the lack of a control group. However, this study does show that patients can be switched easily from stable opioid agonist therapy to OROS® hydromorphone, and that titration of OROS® hydromorphone will enable achievement of a stable dose that maintains effective pain control. The 5 : 1 conversion ratio  also was well tolerated, with adverse events typical of those expected for OROS® opioid agonist therapy. Based on these promising results, the role of OROS® hydromorphone in the treatment of chronic nonmalignant pain should be further assessed by prospective, randomised and controlled trials.


In spite of recent advances in post-operative pain relief, pain following orthopedic surgery remains an ongoing challenge for clinicians. We examined whether a well known and frequently prescribed homeopathic preparation could mitigate post-operative pain.® in minimizing post-operative pain and analgesic consumption following surgical correction of hallux valgus. Eighty consecutive patients were randomized to receive either Traumeel tablets or an indistinguishable placebo, and took primary and rescue oral analgesics as needed. Maximum numerical pain scores at rest and consumption of oral analgesics were recorded on day of surgery and for 13 days following surgery.We performed a randomized, double blind, placebo-controlled trial to evaluate the efficacy of the homeopathic preparation Traumeel STraumeel was not found superior to placebo in minimizing pain or analgesic consumption over the 14 days of the trial, however a transient reduction in the daily maximum post-operative pain score favoring the Traumeel arm was observed on the day of surgery, a finding supported by a treatment-time interaction test (p = 0.04).Traumeel was not superior to placebo in minimizing pain or analgesic consumption over the 14 days of the trial. A transient reduction in the daily maximum post-operative pain score on the day of surgery is of questionable clinical importance.This study was registered at ClinicalTrials.gov. # NCT00279513 The management of postoperative pain following ambulatory orthopedic surgery is an issue of ongoing concern for patients and for physicians performing these procedures. Numerous studies have found pain control to be inadequate -6. Pain ® is an over-the-counter homeopathic preparation composed of extracts from a combination of plants and minerals that have been highly-diluted, though not beyond Avogadro's number  guidelines , and appStudy design was randomized and double-blind. Randomization blocks of four subjects were created, and then selected using random number sequence. The HEEL Company  prepared and supplied the study medication or an indistinguishable placebo in 100 consecutively numbered, sealed boxes, according to the randomization list. Sealed copies of the randomization list were held by the manufacturer and a hospital physician not otherwise involved in the trial. These were to be opened only in the event of a medical emergency necessitating knowledge of the treatment allocation of a given patient. Otherwise, patient and all study personnel remained unaware of treatment allocation until the trail was completed and the database sealed, at which point the allocation envelopes were to be opened and the randomization code unveiled. Each eligible patient was assigned the lowest numbered box available. Surgery was performed as orthopedically indicated, with all patients anesthetized using an ankle block of 20 cc Lidocaine 1% and Marcaine 0.5%. Upon completion of surgery, patients were instructed to take two tablets of the study medication five times daily for the first three days, and three times daily afterwards. The composition of Traumeel tablets is displayed in Table Patients were contacted by telephone every evening by a study nurse, who recorded the reported NSR and analgesic consumption values in the case report form. The nurse also encouraged study compliance. Patients were instructed to withhold study medication if the NRS score was three or less and no other analgesics had been consumed for two consecutive days. Patients were examined by a surgeon on days 6 and 13 days after surgery, and any adverse events, related or unrelated to treatment, were registered. On post-operative day 13, all study materials were collected from the patient.The primary outcome measure was maximum daily pain at rest, as measured by a horizontal, 11-point numerical rating scale (NRS-11) filled out on the day of surgery (day 0) and for 13 post-operative days. Secondary outcomes were total consumption of primary analgesics and number of days requiring rescue analgesics. Adverse events were monitored throughout the study.Statistical analysis was performed following the intention-to-treat principle. To compare the post-operative pain between the study groups, the area-under-the-curve (AUC) of the NRS pain scores recorded daily over the 2 weeks post-operative was used. We chose the AUC for both clinical and statistical reasons. Clinically, it summarizes the strength of pain and the number of days the patient experienced pain. Statistically, it is a summary measure which allows one to deal with repeated measurements with no need to adjust for the type 1 error rate. For each patient, an AUC was obtained by graphing the NRS pain scores recorded every day during follow-up, linking time-adjacent points by a straight line and calculating the area under the resulting polygon. When all 14 pain scores are available, this is equivalent to the sum of the 14 scores. Linear interpolation was performed to estimate the NRS score on those days that were missing. The mean AUCs were compared between study groups using the Mann-Whitney test. The repeated measures mixed model was used to test for an interaction between time and treatment allocation. Mann-Whitney tests were used to compare the total amount of primary analgesics consumed and the total number of days taking rescue analgesics. Post-hoc subgroup analysis was performed to assess the influence of type of surgery on post-operative pain scores. Surgical procedures were characterized as 'Chevron only', 'Additional osteotomy', or 'Triple or proximal osteotomy', and Mann-Whitney tests were performed in each subgroup to compare the area-under-the-curve of the NRS pain scores between treatment arms. Frequency of the main adverse events was compared using Fisher's exact test. Sample size was calculated using a conservative interpretation of the data obtained in our previous pilot study , a type Patient flow throughout the study is presented in Figure Overall, the mean area-under-the-curve pain scores during the 14 days of the trial were not significantly different between the groups . However, the mean pain score on the day of surgery appeared lower in the Traumeel group than placebo . In the 'Additional osteotomy' and ' Triple or proximal osteotomy' groups, differences in mean pain between the verum and placebo groups were negligible  and in the number of days on which rescue analgesics were required .Four patients in the placebo group (10%) and two in the Traumeel group (5.1%) developed wound infection. Six patients in the Traumeel group (15%) and four patients in the placebo group (10%) developed nausea and/or vomiting, though these differences were not statistically significant (p = 0.51 and p = 0.68 respectively). In the Traumeel group, one 82-year-old patient with type II diabetes developed cellulitis following wound infection. He was hospitalized for intravenous antibiotic treatment, but did not require further surgery. This was deemed a serious adverse event unrelated to the study medication.Traumeel was not superior to placebo in minimizing pain or analgesic consumption over the 14 days of the trial, however a transient reduction in the daily maximum post-operative pain score was observed on the day of surgery. Our statistical design did not allow for a significance test specific to that day, however a test for interaction was significant. Stratification by type of surgery did not alter these results. Because post-operative pain is maximal in the period immediately following surgery, this finding may be of clinical importance. Wound infection was more prevalent in the placebo group, but the difference was not statistically significant. Other adverse effects were too rare to analyze statistically.Our findings do not support those of a pilot study published in 2007 that suggested a 30% improvement in pain over 14 post-operative days, and a non-significant trend towards lower analgesic consumption. In that non-blinded study, 30 subjects were allocated by week of surgery to intraoperative injection of Traumeel, injection plus oral Traumeel, or no treatment. Both treatment arms were found superior to no treatment [Homeopathy is frequently attacked for its use of solutions diluted beyond Avogadro's number, and hence physical-chemical implausibility. That criticism was circumvented in this trial by employing a preparation of solutions that were dilute, but well within the material range.Relief of post-operative pain remains an ongoing challenge. While other treatment modalities have been examined, each has its own limitations. Valdecoxib and rofecoxib have both been found effective for relief of pain following hallux valgus surgery ,23 but wThis trial has several limitations. By choosing a cumulative 14-day measure for our primary outcome, we may have inadvertently diluted any effect that may have been present in the first days after surgery - those with the greatest pain. Homeopathic purists may find fault in the administration of a standardized combination homeopathic formula to all patients, based upon clinical diagnosis - as opposed to the individualized manner dictated by standard homeopathic practice. We were aware of this limitation at the outset; however, performing an individualized RCT would be far more complex, time-consuming, and fraught with methodological pitfalls. The mode of administration of the remedy may have played a role as well. In contrast to our pilot study, in the current study, for the sake of simplicity we chose to use only oral administration of the study medication, under the assumption that its effect would be similar to that of injection followed by oral therapy. In retrospect, that assumption may have been mistaken.® was not found superior to placebo in mitigating post-operative pain or analgesic consumption over the 14 days of the trial. A transient reduction in the daily maximum post-operative pain score, observed on the day of surgery, is of questionable importance. We recommend repetition of this trial, but using injected Traumeel and focusing on the early post-operative period.The homeopathic complex Traumeel SCONSORT: Consolidated Standards of Reporting Trials; MMC: Meir Medical Center, Kefar Saba, Israel; NRS: Numerical Rating Scale; SZMC: Shaare Zedek Medical Center, Jerusalem, Israel.The HEEL Company  has funded previous research at the Shaare Zedek Center for Integrative Complementary Medicine, and provided funding for the performance and monitoring of this project, supplied the study medication and placebo, and prepared the randomization list. However, it had by contractual agreement no control over the flow of the study, the data analysis, or the decision when and where to publish the study findings. The authors have full control over the primary data, and agree to allow the journal to review the data if requested.MO conceived the trial, and was central to its design, performance, and reporting.SRS was PI, participated in drafting the protocol, oversaw performance of the trial and participated in drafting the manuscript. NS and OP participated in study design and drafting of protocol and manuscript. MAK, SW, JR, GM, MI and MN screened patients and performed surgery and follow-ups. EL and LF participated in design of the trial, data management and analysis. All authors have read and approved the final manuscript.SRS and MAK are joint first authors.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6904/10/9/prepub


The epidemiology of chest pain differs strongly between outpatient and emergency settings. In general practice, the most frequent cause is the chest wall pain. However, there is a lack of information about the characteristics of this syndrome. The aims of the study are to describe the clinical aspects of chest wall syndrome (CWS).Prospective, observational, cohort study of patients attending 58 private practices over a five-week period from March to May 2001 with undifferentiated chest pain. During a one-year follow-up, questionnaires including detailed history and physical exam, were filled out at initial consultation, 3 and 12 months. The outcomes were: clinical characteristics associated with the CWS diagnosis and clinical evolution of the syndrome.Among 24 620 consultations, we observed 672 cases of chest pain and 300 (44.6%) patients had a diagnosis of chest wall syndrome. It affected all ages with a sex ratio of 1:1. History and sensibility to palpation were the keys for diagnosis. Pain was generally moderate, well localised, continuous or intermittent over a number of hours to days or weeks, and amplified by position or movement. The pain however, may be acute. Eighty-eight patients were affected at several painful sites, and 210 patients at a single site, most frequently in the midline or a left-sided site. Pain was a cause of anxiety and cardiac concern, especially when acute. CWS coexisted with coronary disease in 19 and neoplasm in 6. Outcome at one year was favourable even though CWS recurred in half of patients.CWS is common and benign, but leads to anxiety and recurred frequently. Because the majority of chest wall pain is left-sided, the possibility of coexistence with coronary disease needs careful consideration. Chest pain is a frequent complaint in ambulatory care, and while well described in emergency settings, it is less well studied in general practice. The causes are diverse, including a broad spectrum from life threatening diseases to benign causes such as chest wall syndrome (CWS) ,2. This 58 GP's in private practices included all consecutive patients presenting with thoracic pain (as they main or ancillary symptom) over a 3 to 9 (median 5)-week period from March to May 2001.Physicians recorded their observation and their diagnostic hypotheses on questionnaires developed for the study by the research group which include GPs and specialists in clinical epidemiology. The questionnaires were validated in a pilot study but were not used elsewhere. All questionnaires were filled out immediately after identifying a complaint of chest pain and after each step of consultation: the initial appraisal, completed history, physical exanimation, emergency examinations and at the end of the index encounter. The suspected diagnosis was noted after each step, as were detailed history and physical examination, level of anxiety expressed by patients and physicians, cardiovascular and thrombo-embolic risk factors, laboratory results in emergency, comorbitidies, medication and treatment decision at the end of the consultation. The questionnaire included 58 items for history including precise description of pain, provoking factors, duration, evolution, intensity, quality, modification with position, ancillary symptoms and open text to describe the chest pain as well as precise localisation on an anatomical map. Physical signs included 22 items in 5 anatomical systems: general signs, cardiovascular, respiratory, parietal, neurological, and psychiatric signs.Questionnaires at 3 months and 12 months evaluated new complaints, investigations, new treatments, hospitalisations, and deaths. For the follow-up, we performed ambulatory check-up examinations or a telephone interview when necessary (5% patients).The specific diagnosis retained by GPs at the end of the initial encounter was compared with the 3 and 12-month diagnosis. The final diagnoses were reviewed independently by a group of clinicians and discussed in the case of inconsistency. In the case of a new diagnosis, the GPs were contacted to confirm or reject the alternative diagnosis. The GPs sent all filled out questionnaires to the study coordination centre. All questionnaires were doubled entered by an independent company to ensure accuracy. For analysis, we presented the 300 cases with chest wall syndrome. We preferred to retain the 3-month diagnosis as the follow-up was perfect (100%).t test was used for continuous variables, while the chi-square test was employed for data expressed as proportions. All statistical analyses were performed with Statview 5.0 or Stata 7.0. Clinical factors significantly associated with having a CWS were identified in an univariate analysis. To precisely determine independent indicators of a CWS, factors identified in univariate analysis were introduced in a multivariate logistic regression.In the data analysis, the This study was approved by the local ethics committee of the Medical Faculty (University of Lausanne) and each patient gave consent to study participation.Among 24 620 primary care encounters, 672 consecutive patients presenting with thoracic pain (2.7%) were included. At 3-month follow-up, the main diagnostic groups were: thoracic wall pain 51% , cardiovascular diseases 16% , psychogenic pain 11%, respiratory diseases 10%, gastrointestinal disorders 8%, and no diagnosis 4%. CWS (300 cases), represented 1.2% of all consultations, and was thus more common than coronary artery diseases (CAD) (84 cases or 0.34%). Follow-up amounted to 100% and 97% at 3 and 12 months, respectively.For the CWS, we found 155 women and 145 men. The overall mean age was 50.3 ± 18.2. The CWS was found for all range of ages including teenagers and patients more than 75. CWS was new in 62% of cases, old or recurrent in 35% and indeterminate in 3%. In half of the patients, the complaint was the principal one. 90% of the patients were already known by the GPs meaning the patient was occasionally or regularly under the care of the GPs. Comorbidity was noted for 250 patients (83%) with most notably for psychiatry comorbidity , cardiovascular diseases  or rheumatologic disease . Six patients had neoplasic diseases, including two lung cancers.The pain intensity was described as moderate by 75% of patients, and severe by 23%, and lasts hours, days or weeks. In a majority of patients (71%), it is amplified by factors such as a specific position or motion, by lying position, and breathing. The patients often reports bouts of pain lasting from a few seconds to days (50%) or continuous pain for hours to weeks (35%). However, acute and intense pain can happen (9%). The reported pain is mostly well-localized. The left side is predominantly affected compared to the right side. Pain can radiate to the left arm (18 patients) or the right arm (4), the back (5), the neck or the abdomen (3 patients respectively). Palpation of the thorax often reveals a tender point within the reported painful area. This is present in 214 of the 300 patients. The GPs reported a positive response to provocative manoeuvres in some patients but these haven't been systematically identified.CWS can be associated with original characteristics such as coughing or long lasting dyspnoea, pre-existing anxious state, thoracotomy, or various rheumatologic conditions table . In 8 paThe CWS frequently causes anxiety for patients and for doctors. 54% of patients experiencing moderate intensity pain expressed anxiety compared with 93% of the patients experiencing acute and intense pain. In the first case, 10% of the doctors expressed concern or think of serious trouble, and 26% in the second case.Compared to other non-rheumatic thoracic pain, CWS has few distinctive characteristics but the clustering of predictors led to a more precise picture. The pattern of the six most determinants predictors allowed the attribution of a clinical score to the patient (one point for each one of the six factors present) table . The preFrancophone patients familiarly speak of"intercostal rheumatism". GPs differ in their use of vocabulary such as "musculoskeletal pain, parietal or intercostal pain, Tietze's syndrome, chondrocostal pain, slipping rib syndrome, etc". CWS could be considered as an entity but may often be characterised as individual syndromes defined by different points of maximum tenderness on the chest wall. These different syndromes are described individually in studies and more systematically in some textbooks -21. In tDuring the year of follow-up, 171 patients (57%) were found to have suffered CWS more than once. Four patients died and 6 were hospitalised for causes independent of CWS. One patient was hospitalised and diagnosed with CWS. One patient was newly diagnosed with myocardial infarction and 3 with coronary heart disease; the initial diagnosis of CWS was not questioned in any of these cases. On the other hand, the initial diagnosis of CWS was abandoned in 16 patients for whom oesophagitis (7), anxiety or somatizing (4), coronary heart disease (3), lung cancer (1) and parietal metastases (1) were diagnosed. This illustrates the variety of conditions with which CWS can be confused.In this prospective study, CWS was present in 1.2% of the consultations. Thus, CWS was responsible for 44.6% of chest pain cases, for which it was by far the most frequent cause. Indeed, it was three times more frequent than pains of cardiac origin. On average, GPs encountered one to two cases a week. This prevalence agrees with other studies in ambulatory settings ,22,23. BThe strong prevalence of pain on the left side of the chest is intriguing. It is mentioned only by Lipkin et al to our knowledge  but is aThe aetiology of CWS is usually ill-defined. However, the painful areas are found in zones of muscular or tendinous insertions on the bones, or on cartilage or mobile zones of bone-cartilage transitions, such as the costochondral junctions. Actual inflammatory lesions are probably an exception as suggested by the absence in our study of cases of real Tietze' syndrome and of rheumatoid arthritis, a well-known inflammatory soft tissue disorder. Factors favouring pain may not be the same in all patients as disorders such as traumatic origins following a long lasting cough, thoracotomy, or an overuse of respiratory muscles in the case of asthma can all give rise to CWS. In situations of anxiety and tension, Bass et al suggest a mechanism of amplification of the pain in which anxiety increases the common sensibility of a specific point that the patient believes is a threatening somatic condition, thus increasing anxiety ,31.To give a precise diagnosis of CWS is important for the patients suffering from chest pain and fearing a life threatening disease. A clear diagnosis of CWS is reassuring in comparison of just ruling out a serious disease without a precise diagnosis. Furthermore, the definition of a precise syndrome is more than a mere academic interest. This makes understandable the particularities attached to certain chest wall syndromes. For instance, the pectoral syndrome (and even the axillary syndromes) is the cause of practically all acute presentations of CWS, and patients commonly suspect these syndromes to be coronary disease or, in the case of women, to be breast cancer. The muscular origin can explain the frequent radiation of pain to the left arm . The uppThere are caveat to our data. It is possible that a benign affection such as CWS has been underreported by GPs. It is not clear that all the CWS characteristics were systematically reported in all the patients, and that even all important questions were asked in the questionnaire. Moreover, standard criteria for the diagnosis were lacking and the diagnosis was generally made without outside supervision. In this survey, some diagnostic errors are inevitable. However, the follow-up after one year may clarify cases in which severe conditions were mistaken for CWS. On the other hand, it is also possible that the year of follow-up, together with the CWS-motivated investigation, allowed accompanying conditions to be identified. These may include cases of coronary heart disease that GPs misdiagnosed as simple CWS. Another confusing factor lies in the fact that some chest wall pain could have its origin outside the anterior chest wall if the precordial catches and "vertebrothoracic" disorders are taken into consideration ,38. NeveCWS is a frequent condition with good prognosis, low morbidity and no mortality. Evolution has only been negative in cases of misdiagnosis, mainly in the presence of malignant conditions or in cases of coincidental diseases such as heart or neoplasic disease or pneumonitis. Nevertheless, this condition tends to recur. It also causes real anxiety and frequently suggests to the patient the possibility of heart disease. Moreover, in a few cases, it is difficult to distinguish between coronary heart disease and CWS on a clinical basis partly because the majority of chest wall pain is left-sided.The authors declare that they have no competing interests.FV, BB, LH, and BF participated in the conception and design of the study, analysis and interpretation of data, drafting and revising the manuscript, and inclusion of patients for BF, FV and LH. AP participated in the conception and design of the study, drafting and revising the manuscript. BF will act as guarantor for the paper.The pre-publication history for this paper can be accessed here:


We wished to determine if there were differences in pelvic and non-pelvic tenderness between men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) Type III and men without pelvic pain.Manual Tender Point Survey (MTPS) as described by the American College of Rheumatology on 62 men with CP/CPPS Type IIIA and IIIB and 98 men without pelvic pain. We also assessed tenderness of 10 external pelvic tender points (EPTP) and of 7 internal pelvic tender points (IPTP). All study participants completed the National Institutes of Health Chronic Prostatitis Symptom Inventory (NIH CPSI).We performed the We found that men with CPPS were significantly more tender in the MTPS, the EPTPS and the IPTPS. CPSI scores correlated with EPTP scale but not with IPTP scale or prostate tenderness. Prostatic tenderness was present in 75% of men with CPPS and in 50% of men without CPPS. Expressed prostatic fluid leukocytosis was not associated with prostatic tenderness.Men with CP/CPPS have more tenderness compared to men without CPPS. Tenderness in men with CPPS is distributed throughout the pelvis and not specific to the prostate. Idiopathic prostatitis  and prostatodynia have been renamed by a National Institutes of Health (NIH) consensus panel to Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) Types IIIA and IIIB, respectively. These syndromes are characterized by pelvic pain, a negative prostatic localization culture, and no specific diagnosis accounting for the pain. Voiding symptoms may or may not be present. Type IIIA is differentiated by leukocytes in the expressed prostatic secretions (EPS) and Type IIIB is characterized by a lack of inflammation in the EPS . RecentlPelvic tenderness has not been investigated in normal men. In CP/CPPS, tenderness of the prostate is often present ,4, howevThe Manual Tender Point Survey (MTPS) as a standardized method to evaluate fibromyalgia (FM)[The quantification of tenderness is difficult and subject to considerable inter-rater variability,6. Howevlgia (FM). This inlgia (FM). Patientlgia (FM). The purlgia (FM), would sThe University of Washington's institutional review board approved the study reported here as part of a more comprehensive study of men with pelvic pain. All subjects signed written consents explaining study procedures. Other findings from the larger study have been reported previously-16. PatiC. trachomatis, U. urealyticum, M. hominis, and T. vaginalis. Expressed prostatic secretions (EPS) were assessed for leukocyte concentration by hemocytometer counts using a phase contrast microscope[C. trachomatis or N. gonorrhoeae, genitourinary malignancy, evidence of suicidal ideation or psychosis, post-surgical pain, pain from another source in the genitourinary tract , history of radiation therapy, or history of genitourinary tuberculosis.Patients and controls were evaluated during a screening visit to the clinic. Study participants were requested not to take anti-microbial agents within six weeks of examination and were instructed to abstain from ejaculation for 48 hours prior to their appointment. All subjects provided demographic information on questionnaires and the NIH Chronic Prostatitis Symptom Index (CPSI), a measure of pain severity, urinary symptoms and quality of life,18. Follicroscope. We defiicroscope. PatientThe MTPS was performed by applying with a thumb 4 kg of pressure to each of the 18 tender and 3 control points Fig . The subEach of the three examiners  practiced until he could apply 4 ± .25 kg ten times in a row on a "Chatillon" dolorimeter. Study participants were examined with the MTPS, then thA few pain patients and controls had missing tenderness measure values for some points  because of omissions in record keeping. The three examiners examined patients comparable in symptom severity according to the NIH CPSI scores .19Second, we analyzed the original scale of severity scores separately for each examiner using the Mann-Whitney test to compare controls to pain patients. This analysis was based on the premise that if there were differences between controls and pain patients, the difference would be seen within the group of subjects examined by each examiner. Consistency in significant differences would lead to the conclusion that the two groups of subjects are different regarding the tenderness scales, although we cannot specifically state the magnitude of that difference across clinicians.Descriptive analysis was performed for all variables in the study. Differences between pain patients and controls in demographic characteristics were assessed by t-tests for age and Chi-square tests for all other variables. Despite the training protocol, there were some systematic differences between examiners in tender point examination scores. Given that the distributions of the tender point measures were not normal, we used two complementary approaches to examine differences between groups while accounting for examiners. First, we dichotomized each tenderness scale severity score  was compared to tenderness  were analyzed using the Mantel-Haenzel method Table . Pain paThe second approach used the originally observed scores without dichotomization. In comparisons of the median scale scores of the patient and control groups for each examiner, there were statistically significant differences for all scales except the control sites Table . For exaAdditionally, Spearman correlation was calculated for the tenderness points scores and the NIH CPSI for the pain patients. All tender point scales were statistically significant at 0.001 level, varying from estimated correlations of r = 0.29 (IPTPS and Control) to 0.73 (IPTPS with prostate score). The NIH CPSI Pain scale was correlated significantly with the FM and EPTPS, but not the IPTPS or prostate score suggesting that the CPSI pain score is more related to external than internal tenderness. However, plots of NIH CPSI versus each scale (graphs not shown here), showed that the associations are not necessarily linear, and therefore, they have limited value in describing the association between the variables.3 in the EPS sample. There was no association between inflammation in EPS and the dichotomous prostatic tenderness (p = 0.42) or FM, IPTPS, and EPTPS dichotomous variables .EPS was obtained for 64 controls and 40 patients. Inflammation was defined as having leukocyte counts > 500/mmProstatic tenderness has been described in men with prostatitis and CP/CPPS and is considered to be a characteristic of both CP/CPPS Type IIIA and IIIB. HoweverThe finding of increased tenderness in MTPS tender points in men with CP/CPPS is in accord with findings of diffusely increased tenderness in women with interstitial cystitis, a syndrome possibly related to CP/CPPS. We hypoLimitations of this study should be acknowledged. The sample came from a university tertiary care population and the study findings may not generalize to other populations. The control group was a convenience sample of volunteers and could have selection bias. Controls were younger, and although we found no relationship of tenderness scores to age, other unknown differences may have contributed to the differences found between patients and controls in examination findings. Furthermore, we did not assess test-retest stability of the tender point examination scores, and there were interrater differences. The determination of tenderness is a standard part of clinical examination, although variation from examiner to examiner is well known clinically and experimentally,6. AlthoWe found that men with CP/CPPS have generalized internal and external pelvic tenderness. The pathophysiology of CP/CPPS involves the entire pelvis and not only the prostate. Our findings suggest that further research involving the assessment of intra-and extra-pelvic tender points may prove fruitful in increasing scientific understanding of, and developing more effective treatments for, male chronic pelvic pain syndromes.MTPS-Manual tender point scaleIPTPS-Internal pelvic tender point scaleEPTPS-External pelvic tender point scaleCP/CPPS-Chronic prostatitis/chronic pelvic pain syndromeNIH CPSI-National Institutes of Health Chronic Prostatitis Symptom IndexThe author(s) declare that they have no competing interests.REB: Principal investigator for study. Designed and carried out study.MEC: Assisted with design, performed statistical analysis, reviewed manuscript.IR: Performed study procedures and reviewed manuscript.JAT: Assisted with design, analysis and manuscript review.All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Unstable spinal lesions in patients with ankylosing spondylitis are common and have a high incidence of associated neurological deficit. The evolution and presentation of these lesions is unclear and the management strategies can be confusing. We present retrospective analysis of the cases of ankylosing spondylitis developing spinal instability either due to spondylodiscitis or fractures for mechanisms of injury, presentations, management strategies and outcome.In a retrospective analysis of 16 cases of ankylosing spondylitis, treated surgically for unstable spinal lesions over a period of 12 years (1995-2007); 87.5% (n=14) patients had low energy  trauma while 12.5% (n=2) patients sustained high energy trauma. The most common presentation was pain associated with neurological deficit. The surgical indications included neurological deficit, chronic pain due to instability and progressive deformity. All patients were treated surgically with anterior surgery in 18.8% (n=3) patients, posterior in 56.2% (n=9) patients and combined approach in 25% (n=4) patients. Instrumented fusion was carried out in 87.5% (n=14) patients. Average surgical duration was 3.84 (Range 2-7.5) hours, blood loss 765.6 (± 472.5) ml and follow-up 54.5 (Range 18-54) months. The patients were evaluated for pain score, Frankel neurological grading, deformity progression and radiological fusion. One patient died of medical complications a week following surgery.P=0.001), while the neurological status improved in 90% (n=9) patients among those with preoperative neurological deficit who could be followed-up (n =10). Frankel grading improved from C to E in 31.25% (n=5) patients, D to E in 12.5% (n=2) and B to D in 12.5% (n=2), while it remained unchanged in the remaining - E in 31.25% (n=5), B in 6.25% (n=1) and D in 6.25% (n=1). Fusion occurred in 11 (68.7%) patients, while 12.5% (n=2) had pseudoarthrosis and 12.5% (n=2) patients had evidence of inadequate fusion. 68.7% (n=11) patients regained their pre-injury functional status, with no spine related complaints and 25% (n=4) patients had complaints like chronic back pain and deformity progression. In one patient (6.2%) who died of medical complications a week following surgery, the neurological function remained unchanged (Frankel grade D). Persistent back pain attributed to inadequate fusion/ pseudoarthrosis could be managed conservatively in 12.5% (n=2) patients. Progression of deformity and pain secondary to pseudoarthrosis, requiring revision surgery was noted in one patient (6.2%). One patient (6.2%) had no neurological recovery following the surgery and continued to have nonfunctional neurological status.Intra-operative adverse events like dural tears and inadequate deformity correction occurred in 18.7% (n=3) patients  which could be managed conservatively. There was a significant improvement in the Visual analogue score for pain from a pre-surgical median of 8 to post-surgical median of 2 (In ankylosing spondylitis, the diagnosis of unstable spinal lesions needs high index of suspicion and extensive radiological evaluation Surgery is indicated if neurological deficit, two/three column injury, significant pain and progressive deformity are present. Long segment instrumentation and fusion is ideal. Ankylosing spondylitis is a chronic inflammatory disorder belonging to the family of seronegative spondyloarthropathies. Ankylosing spondylitis has a prevalence of 0.1 to 1.4% correlating with the frequency of HLA B 27.1The initial presentation is with a low backache, due to early involvement of the sacroiliac joints and the lumbar spine, which eventually progresses to the cervical region.6718The history of significant traumatic event is not elicited in most of these patients.678In this retrospective analysis, we report the mechanics of these unstable spinal lesions, their presentation, diagnostic difficulties, strategies in the surgical management and the outcome in patients with ankylosing spondylitis.We retrospectively analyzed 16 cases of ankylosing spondylitis, over a period of 12 years (1995-2007), presenting with spinal instability that was managed and followed up for mean 54.5 months (Range 18-154 months) . The stuThe presentation included persistent back pain, neurological deficit and progressive deformity either in isolation or combination. The pain was characterized by worsening of an already existing back pain. The duration of complaints before the presentation was variable. Spinal instability was defined on the basis of clinical and radiological features. The clinical features included a sustained elevation in the severity of chronic back pain that was further accentuated by loading the spine, in association with or without neurological deficit, leading to restriction of the activities of daily living and an increase in the requirement of analgesic dosage with localized spinal tenderness on examination. On the other hand, the radiological feature included a breach in the integrity of the spinal columns (two of three). Flexion and extension views were not attempted due to the apprehension of inducing or worsening of neurological deficit.At the time of admission and follow-up, patients were assessed clinically and radiologically. In addition to noting the pain scores, a detailed clinical examination and neurological evaluation by using Frankel score was performed.1921The surgical indications included neurological deficit, evidence of spinal instability with progressive pain and deformity. The selection of the approach and the surgical procedure was based on the presentation of patient, neurological evaluation, the nature and location of the lesion, spinal alignment noted on clinical and radiological evaluation, intra-operative findings and the presence of co-morbid conditions. The surgical procedure in majority of the cases included decompression, stabilization and fusion with bone grafting. Deformity correction was attempted in a few selected cases with a severe progressive deformity. A combination of posterior and anterior approach was used in the presence of three-column instability with significant anterior/middle column defect and a kyphotic spine requiring posterior stabilization and anterior reconstruction. An exclusive posterior approach was used in patients with minimal kyphosis and no significant anterior/middle column defect, even after posterior stabilization. An exclusive anterior approach could be used in a few patients with significant anterior/middle column defect with minimal kyphosis and a relatively intact posterior column. A consideration to the regional distribution of the lesion was also given while deciding the approach. Anterior approach to dorsal and dorsolumbar regions could result in significant morbidity especially in patients with poor pulmonary function and this risk was given due consideration.Majority  of the patients were instrumented to augment the unstable spine, posterior stabilization being most common. A combined posterior and anterior instrumentation was used in highly unstable spinal lesions requiring additional stabilization. A pure anterior instrumentation was carried out either in the cervical region, where plating was convenient or in a lesion with predominant anterior defect with minimal kyphosis with an intact posterior column, in which case only an anterior surgery was considered sufficient. Instrumentation was avoided when the spinal stability was adequate or when instrumentation was not possible due to poor soft tissue cover. The surgical duration and the intra-operative blood loss were also noted.The follow-up duration was calculated from the date of admission. The patients were evaluated clinically and radiologically every three months. The following criteria were used to assess the operative results. The severity of pain evaluation was based on Visual analogue scale while the neurological assessment was based on Frankel grading.The deformity was assessed clinically and radiologically based on chin brow angle, wall occiput distance, finger floor distance and the angle of kyphotic deformity. The evaluation of radiological fusion was based on consolidation of the graft, healing at the interface with appearance of trabecular pattern across the fracture site, along with absence of implant failure/back out. A return to pre-injury functional status was also noted. Results were graded on the basis of improvement or maintenance of the above mentioned criteria at the time of follow-up in comparison to the pre-injury and early postoperative status.The mean age of patients was 46.1 (range 30-75 years). There were 25% (n=4) cervical, 43.8% (n=7) dorsal, 6.2% (n=1) lumbar, 6.2% (n=1) cevicodorsal, 12.5% (n=2) dorsolumbar along with 6.2% (n=1) combined cervical and lumbar lesions. The mechanism of injury was identified as low energy in 87.5%. (n=14) A high energy injury was noted in 12.5% (n = 2). The mean age of patients suffering from low energy injuries was 46.7 (± 12.6) years and that for patients with high energy injury was 42 (± 14.1) years. 68.7% (n=11) patients had neurological deficit with pain probably due to spinal instability at the time of presentation, while 32.2% (n=5) patients presented predominantly with pain due to spinal instability. Thus the incidence of neurological deficit in this series was 68.7% (n=11). The severity of deficit as assessed by Frankel grading was Grade B in 18.75% (three) patients, Grade C in 31.25% (five) and Grade D in 18.75% (three).75% (n=12) patients had co-morbid medical conditions like hypertension, diabetes mellitus, poor pulmonary function, alcoholic liver disease and thyroid dysfunction. One patient (case no. 13) had to undergo a preoperative tracheostomy in view of anticipated difficult intubation due to poor visualization of the glottis during airway assessment. In the remaining patients, equipment to deal with difficult airway was kept standby during anesthesia.All the patients were treated surgically. 87.5% (n=14) patients underwent decompression with instrumented fusion, while 12.5% (n=2) had decompression with uninstrumented fusion ; 18.8% (n=3) cases were treated by anterior surgery, 56.2% (n=9) by posterior surgery and 25% (n=4) by a combined approach; out of the two uninstrumented fusion, case no. 2 (D10-11 Andersson’s lesion) the spinal stability was considered adequate, while for case no. 4, (D11-12 Andersson’s lesion) the surgery for posterior instrumentation had to be avoided in view of poor skin condition, inadequate muscle cover and anticipated difficulty in achieving appropriate closure over the implant. 64.2% patients (Nine) were instrumented posteriorly  Figures ‐c, 2a‐b;The mean patient follow-up was 54.5 (Range 18-154) months excluding a single mortality (case no. 16) in the post-surgical period due to medical complications. Of the 10 patients with neurological deficit who could be followed up, post surgical improvement in neurological status was observed in 90% (nine), while no significant recovery could be documented in one patient (case no. 3). Frankel grading improved from C to E in 31.25% (five) patients, D to E in 12.5% (two) and B to D in 12.5% (two).P=0.001). A suboptimal relief in the intensity of pain was observed in 18.7% (three) patients . Deformity correction could be attempted in 31.25% patients (five). These patients had presented with progressive worsening of the deformity following the onset of pain due to instability, and hence spinal deformity was an important component of their complaints. Three patients  had complete correction (about 20-40 degrees) to their pre fracture sagittal alignment, while another (case no. 6) had partial correction (about 20 degrees). In one of the patients (case no. 8), only about 10 degrees of deformity correction could be achieved, resulting in major residual kyphotic deformity. Although the improvement in severity of the deformity was noted on the basis of clinical and radiological features, a detailed quantitative analysis of the deformity correction was not a part of this study.There was significant improvement in the Visual analogue score for pain from a pre-surgical median of 8 to post-surgical median of 2  patients had returned to pre-injury functional status, with no major spine related complaints or evidence of clinical or radiological deterioration, while 25% (four) patients had mild to severe symptoms. Clinical and radiological evidence of fusion was present in 68.7% (n=11) patients. Features of pseudoarthrosis were noted in 12.5% (n=2) patients  at the final follow-up. Of these, case 4 had moderate pain with no progression of the deformity, which could be managed conservatively; while case 8 experienced worsening in the intensity of pain and deformity and was offered revision surgery. On the other hand, 12.5% (two) patients  had radiological evidence of inadequate fusion of which case 13 had minimal complaints while case 14 had moderate pain. Both the cases had no evidence of deformity progression and could be managed conservatively.The early complications included intraoperative dural tears in two patients  and a sub optimal correction of a C1C2 rotatory subluxation in one patient (case no. 6). Both the patients with dural tears had a posterior approach taken for the surgery, with significant dural adhesions to the calcified ligamentum flavum, and could be managed by primary repair of the tear and appropriate postoperative measures. Appearance of significant anterior column defect following reduction by a posterior approach was observed in 18.8% (three) patients . These patients were offered an anterior surgery to tackle the void, of which one (case no. 11) underwent the procedure at the same stage, since the problem was anticipated pre-operatively. There was one case of mortality (case no. 15) due to medical complications a week following surgery.The late complications were observed in 25% (n=4) patients; case 13 with inadequate radiological fusion but minimal complaints requiring no additional measures, case 14 had inadequate fusion with moderate pain which could be managed conservatively. Case 4 had pseudoarthrosis with moderate pain requiring only conservative measures and case 8 had major problems, in the form of increased back pain and progressive deformity. This patient had a lower dorsal fracture, which was managed with a posterior instrumented fusion, but finally developed a pseudoarthrosis. This could be attributed to the lack of anterior surgery to augment the posterior surgery, which was necessary to achieve a three-column fusion.The ankylosed spine is susceptible to develop unstable lesions either due to vertebral fractures or an Andersson’s lesion (spondylodiscitis).85691013144An uncommon mode of presentation, in the form of acute spinal instability with neurological deficit, was seen in only 12.5% (two) patients with high energy trauma.467615A very high index of suspicion is necessary to arrive at this diagnosis in view of the occult nature of these lesions, pre-existing pain, deformity and few features suggesting the presence of a spinal fracture or spondylodiscitis in majority of the cases. In addition to plain radiography, the patients should be screened by magnetic resonance imaging and computed tomography.Surgical intervention is indicated in presence of a two/ three-column injury, neurological deficit, a progressive deformity and significant pain due to instability.244The principles of surgical management include neural decompression and an attempt to achieve global fusion with bone grafting and instrumentation whenever necessary. Indications for a combined anterior-posterior approach in a three-column injury areIndications for only posterior approach in a three-column injury areInstrumentation was necessary to augment the fusion as was evident in 87.5% of our cases. In an ankylosed spine, long segment instrumentation is necessary to counteract the strong deforming cantilever forces and prevent an implant failure.The possibility of spinal instability, either due to a fracture or spondylodiscitis, should be extensively explored in patients with an ankylosed spine, who present with symptoms compatible with spinal injury, even without a history of trauma. The incidence of neurological deficit in these patients is significant. Management is challenging in view of the tendency of these lesions to develop a pseudoarthrosis, existing co-morbidities, complex surgical and anesthetic problems and high functional demands due to young age of these patients. The selection of the surgical approach is based on nature of the lesion, its location, the spinal curvature and the presence of neurological deficit.The surgical procedure includes decompression, stabilization and fusion of the spine in appropriate alignment. Optimum surgical treatment can rehabilitate these patients to lead a productive and a near normal life.