Introduction: The aim of this study is to clinically compare isolated calcaneal spur excision and plantar fascia release in addition to spur excision in patients with plantar heel pain accompanied by a calcaneal spur.Method: Patients who did not benefit from conservative treatment and underwent surgical excision of the calcaneal spur and/or plantar fasciotomy were retrospectively evaluated. The patients were divided into two groups according to the surgical procedure performed. The evaluation was done according to the pre- and postoperative foot function index (FFI) using pain and functional evaluation. Pain, disability, and activity restriction were evaluated with FFI. The radiological results and FFI scores of both groups were measured before and after surgery, and the difference between the groups was compared.Results: Of the 46 patients in our study group, 30 (65.2%) were female, and 16 (34.8%) were male. The average age was 41.2 years. There was a significant improvement in postoperative FFI scores in both groups. There was no significant difference in postoperative functional results when the groups were compared.Conclusion: In patients whose plantar heel pain associated with calcaneal spur does not improve despite conservative treatments, both isolated spur excision and plantar fascia release in addition to spur excision may be effective treatment modalities that improve foot functions. Plantar heel pain is a common clinical condition in orthopedic practice and is observed in about 10% of the population . AlthougPlantar calcaneal spur (PCS) is defined as the growth of calcaneus tuberosity and is observed in about 15% of the population. Although the relationship between PCS and plantar heel pain has been described before, it can also be asymptomatic . It has The first treatment options for plantar heel pain accompanied by PCS are always conservative treatments ,3,4. CalIn this study, we aimed to evaluate the clinical outcomes of patients who did or did not undergo plantar fasciotomy in addition to calcaneal spur excision in patients who did not respond to conservative treatment for symptomatic PCS.This article was previously posted to the Research Square preprint server on July 19, 2022.Patients who applied with the complaint of heel pain between 2015 and 2021, were diagnosed with calcaneal spur clinically and radiologically, did not benefit from nonsteroidal anti-inflammatory drug use and physical rehabilitation for 12 months, and underwent surgical calcaneal spur excision and/or plantar fasciotomy were evaluated in the study retrospectively. Patients whose calcaneal spur was less than 3 mm on lateral radiography, who had a follow-up of less than six months, and who had significant pes planus, pes cavus, or other plantar arch deformity were excluded from the study. The remaining 46 patients were included in the study. The patients were divided into two groups according to the surgical procedure performed. The first group was determined as those who had undergone isolated calcaneal spur excision, and the second group was determined as patients who had undergone plantar fasciotomy in addition to calcaneal spur excision.All patients had been treated by the same surgeon. A horizontal incision of 3-4 cm was made on the medial heel, centering the PCS through the baseline. In patients who underwent partial plantar fasciotomy (PPF), using dissection scissors not exceeding 1/2 thickness of the fascia, the proximal-central part of the fascia was loosened before PCS excision was performed, and the lateral and deep fascia parts were preserved. PCS was osteotomized under microscopic guidance. The PCS was held with forceps and peeled off from the surrounding soft tissue connections. The PCS residue was corrected with a rasp. In both groups, the length of the Achilles tendon was elongated and its tension was reduced by applying a splint that kept the ankle in 90 degrees dorsiflexion for two weeks postoperatively. After the 15th day, the splint was applied only at night and continued for a month. In both groups, the patients were mobilized without any weight-bearing for the first 15 days after the surgery, and with partial weight-bearing after the 15th day. In the first month, they were mobilized on foot, without support.Clinical evaluationThe evaluation was done according to the pre- and postoperative foot function index (FFI) using pain and functional evaluation. Pain, disability, and activity restriction were evaluated with FFI. With the nine-parameter pain scale, the level of foot pain in various situations in daily use is measured. With the nine-parameter disability scale, the difficulty level of functional activities related to foot problems is measured. With the five-parameter activity restriction scale, the degree of activity restriction due to foot problems is measured . High scThe radiological results and FFI scores of both groups were measured before and after surgery and the difference between the groups was compared Figures , 2. ThenStatistical analyses of the data were done using SPSS v. 18.0  in silico. Descriptive statistics were presented as minimum-maximum and mean ± standard deviation values. Preoperative and postoperative clinical scores were compared using the paired sample test. The independent sample t-test was used to compare the groups. P-value < 0.05 was considered significant.Of the 46 patients in our study group, 30 (65.2%) were female, and 16 (34.8%) were male. The mean age was 41.2 years (range: 23-62), the follow-up period was 36.17 months (range: 14-64), and the preoperative waiting time was 16.2 months (range: 12-24) (Table The mean preoperative FFI pain score was 58.96 (range: 48-68), the mean postoperative FFI pain score was 11.15 (range: 6-18), the mean preoperative FFI disability score was 53.02 (range: 44-64), the mean postoperative FFI disability score was 9.09 (range: 4-15), the mean preoperative FFI activity restriction score was 13.17 (range: 9-18), and the mean postoperative FFI activity restriction score was 4.11 (range: 2-10).The average PCS size was measured as 4.43 mm . A general evaluation table of the data was made Table .In the group where isolated PCS excision was performed, the mean preoperative FFI pain score was 58.69 (range: 54-64), and the mean postoperative FFI pain score was 12 (range: 7-18). The FFI pain score was significantly decreased (p < 0.001). The mean preoperative FFI disability score was 52.5 (range: 48-58), and the mean postoperative FFI disability score was 9.06 (range: 5-14). The FFI disability score was significantly decreased (p < 0.001). The mean preoperative FFI activity restriction score was 12.31 (range: 9-18), and the mean postoperative FFI activity restriction score was 3.88 (range: 2-9). The FFI restriction score was significantly decreased (p < 0.001).In the group where PCS excision and PPF are applied, the mean preoperative FFI pain score was 59.1 (range: 48-68), and the mean postoperative FFI pain score was 10.7 (range: 6-16). The FFI pain score was significantly decreased (p < 0.001). The mean preoperative FFI disability score was 53.3 (range: 44-64), and the mean postoperative FFI disability score was 9.1 (range: 4-15). The FFI disability score was significantly decreased (p < 0.001). The mean preoperative FFI activity restriction score was 13.63 (range: 10-18), and the mean postoperative FFI activity restriction score was 4.23 (range: 2-10). The FFI restriction score was significantly decreased (p < 0.001).There was no significant difference in postoperative functional results when the groups were compared Table .The first step in the treatment of plantar fasciitis is conservative treatment . ConservIn this study, surgical treatment was applied to patients who had plantar heel pain for 12 months, were diagnosed with plantar fasciitis, and did not respond to conservative treatments for at least 12 months. As measured by the FFI scores of patients who underwent isolated calcaneal spur excision and calcaneal spur excision combined with plantar fascia release, clinically significant improvement was observed in the foot and ankle.Surgical treatment options for plantar fasciitis include surgical methods such as conventional open fasciotomy, endoscopic fasciotomy, neurolysis or denervation, osteotomy of the calcaneus, spur excision, or drilling ,12-17. AThe etiology of plantar heel pain is complex and multifactorial ,4. The mThere are some limitations of this study. The first is the small number of patients. The fact that it is single-centered and affects the genetic and psychological characteristics of the patients creates a limitation. Limitations arising from the retrospective nature of the study are among others.In conclusion, in patients with plantar heel pain who do not benefit from conservative treatment, spur excision can be performed in isolation, or additional plantar fascia release can be applied. In both surgical procedures, functionally satisfactory results can be obtained with low complication rates.


Burning mouth syndrome (BMS) and pelvodynia are chronic pain still poorly understood and the links between them are all the more so. Health professionals therefore have few resources to understand, diagnose and treat these pains. They may consider and treat these ailments individually, which does not represent optimal care management for the patient and leads to overmedication. This article aims to highlight their contiguity from epidemiological, etiological, diagnostic, and therapeutic perspectives. This study was based on articles which were found using databases such as PubMed and Web of Science. No exclusion criteria were used. Fourteen studies were reviewed. This present work shows that the clinical presentations of these syndromes are similar, as exemplified by their strong association with anxiety and depression. The neurophysiological mechanisms involved in these conditions are similar to those in patients. The diagnosis is essentially based on visual examination and an elimination of all other possible causes. In addition, this work promotes the fact that a common therapy can be implemented when BMS and pelvodynia co-occur. However, the literature on the subject is still very limited. This can be deepened by exploring all the effective treatments in BMS and vulvodynia for penoscrotodynia. Finally, for all these pains, there is a therapeutic order to respect starting with a psychological approach, then topical treatments, systemic therapy and surgical. This therapeutic gradient assists practitioner in their patient’s pain management. This article also allows health care providers to quickly find an effective systemic treatment for a patient with both BMS and pelvodynia. Burning mouth syndrome (BMS), also referred to as stomatodynia or glossodynia, is defined by the occurrence of chronic and spontaneous pain, which is frequently perceived by patients as an oral burning sensation. Pain is most often localized on the lingual mucosa, but can equally affect other mucosa in the oral cavity. Primary BMS is associated with anxiety and depressive disorders in middle-aged women. The prevalence is estimated between 1.5% and 5.1% in the general population.,4 Burning sensation can be associated with oral dysesthesia, taste disorders, food hypersensitivity, and xerostomia.,6In 2003, Scala et al proposed a distinction between “primary BMS,” which is an essential or idiopathic form of BMS without any somatic cause and “secondary BMS,” which results from a local or systemic pathological condition.The International Headache Society categorizes BMS as neuropathic and facial pains in the first edition of the International Classification of Orofacial Pain (2020) and has described it as “An intraoral burning or dysaesthetic sensation, recurring daily for more than 2 hours per day for more than 3 months, without evident causative lesions on clinical examination and investigation.”The pathophysiology of primary BMS is extensively debated but remains poorly understood despite numerous hypotheses attempting to explain its etiopathogenic mechanisms. A recent systematic review demonstrated neuropathic involvement at various levels of neuraxis with the implication of psychological factors, as well as psychiatric disorders, such as anxiety or depression symptoms. Depending on the patient, neuropathic and psychogenic components may exist simultaneously, with a preponderance of one or the other, or may exist individually. These 2 components cannot be dissociated when defining a BMS.,6,9BMS is commonly associated with chronic pain outside of the orofacial sphere. Indeed, other “dynias,” which involve similar mechanisms and symptoms, can be found in patients with BMS, especially vulvodynia in women and penoscrotodynia in men as well as pudendal neuralgia, which are grouped together under the term “pelvodynia.” Several authors describe these associations in the literature, but they remain poorly documented.This study aimed to analyze the literature regarding the association between stomatodynia or BMS and pelvodynia.To inform this literature review, a comprehensive analysis was performed using PubMed and Web of Science databases. The medical subject headings keywords used were stomatodynia and vulvodynia, stomatodynia and penoscrotodynia, burning mouth syndrome and vulvodynia, burning mouth syndrome and penoscrotodynia, glossodynia and vulvodynia, and burning mouth syndrome and pudendal neuralgia.Duplicate and irrelevant articles were excluded from analysis. Studies were limited to those adhering to the inclusion criteria for studies suggesting BMS and vulvodynia or penoscrotodynia simultaneously. No exclusion criteria were used. The articles were from French and English languages.For each included study, the full text was reviewed to extract the epidemiological, etiological, diagnostic, and therapeutic data.,4,10–15 1 was a systematic review and 4 were case reports.,6,9,17After reading the titles and abstracts, all articles were included. In total, 34 articles were selected: 17 from PubMed and 17 from the Web of Science. After eliminating duplicate or unrelated articles, 14 were included in the data extraction process. The flow diagram in Figure ,10,14,17 and Western Europe .–13,15,16All the publications included in this review originated from 2 geographical areas: North America ,14 Notably, BMS and pelvodynia have only been studied in developed Western countries and appear to primarily affect Caucasian populations.Between 90% and 100% of patients affected by BMS are Caucasian.,4,17Patients with BMS were predominantly postmenopausal women in their fifth to seventh decade of life, with an average age of 69 to 73 years. The onset of pain syndrome was more common during the interval of 3 years before and 12 years after menopause.,14 The co-occurrence of vulvodynia and stomatodynia appears to confirm this information, with a preponderance of patients around the age of 60 years.,6Patients with vulvodynia are essentially peri-menopausal and postmenopausal. However, some articles reported ages ranging from 20s to the late 60s.Regarding penoscrotodynia, pain can begin in adolescence as well as in old age, with the majority of patients aged between 35 and 40 years. The co-occurrence of this pain syndrome with BMS was consistent with previous data, with a mean age of 44 years.Globally, the age of onset of BMS and vulvodynia in women is the same. However, penoscrotodynia occurred earlier in men than in those with BMS.,4 Eight percent of women were affected by pelvodynia, but only half of them consulted for treatment and only 1.4% had a diagnosis. The lack of data concerning penoscrotodynia in the literature prevents an estimate of its prevalence, but case studies have reported many more cases of penodynia than scrotodynia.BMS affects 1.5% to 5.1% of the global population, with a high prevalence in women.,16Based on 2 cohorts studied, 1.3% to 13.3% of women presented with both BMS and vulvodynia.BMS and vulvodynia affected a non-negligible proportion of the population and there was a difference in the number of real chronic pain versus diagnosed chronic pain cases. Data on penoscrotodynia are poorly documented in literature.,5,13 Only one study described the co-occurrence of genital and oral pain in Parkinson disease.The dynias considered in this study often correlated with a history of depression and even more commonly anxiety. While fear of cancer is a redundant trait in chronic pain, patients experiencing chronic pain appear to be in good health.,11,14,17BMS symptoms are burning and/or itching sensations, most often localized on the tongue but capable of extending to the entire oral cavity. They decrease and even disappear with eating and drinking, worsen after swallowing and increase throughout the day. They dramatically impair quality of life and some women describe the symptoms at their peak as worse than those of shingles or childbirth.,11 These symptoms may be accompanied by an increased urination frequency, vaginal dryness, and dysuria.The complaints of vulvodynia included pain (70%), burning (64%), tingling (56%), and dyspareunia (58%). The pruritus indicates another disorder. Penoscrotodynia may be associated with red scrotum syndrome, which is a vascular change with hyperemia in the anterior half of the scrotum that may extend to the other half and the base of the penis.For penoscrotodynia, a burning sensation and/or pain was described in the penoscrotal region, sometimes with intolerance to the friction of clothing as well as touch, which considerably affects patients’ quality of life.Despite different anatomical localizations, patient complaints predominantly share the context of pronounced depression and/or anxiety. This finding supports the hypothesis that BMS, vulvodynia, and penoscrotodynia share common etiological mechanisms, at least in part.,10The mechanisms of dissociation and conversion may play a central role in the pathogenesis of cutaneous sensory disorders. Dissociation usually occurs in the context of extreme psychosocial stress and history of severe abuse or neglect early in life. Dissociative patients can experience a sense of detachment from their body and present a state of extreme self-neglect, including the denial of serious skin disorders. Dissociation is characterized by a discontinuity or disturbance in the normal integration of consciousness, identity, memory, bodily representation, perception , motor control and behavior. Conversion is its somatic component.For each of the investigated dynias, the primary patient characteristic was anxiety and depression. Somatization generally refers to bodily symptoms that arise as an expression of an underlying psychological factor or distress. Therefore, somatization is likely to be an important factor in patients with cutaneous sensory disorders and diagnosable psychiatric disorders. For a person who has experienced psychological trauma, this could lead to dissociation (and conversion) mechanisms, turning psychological disorders into physical ones. Literature has reported that the number of traumatic events experienced during a patient’s lifetime is directly related to several idiopathic skin disorders and that the intrusive re-experience of emotional trauma could be experienced as sensory flashbacks to the skin.In the case of vulvodynia, a psychosexual explanation could be that psychological or sexual abnormalities  initially present with sensitization of the central nervous system, leading to allodynia and hyperalgesia. Women with chronic pain are cautious, attentive, pessimistic and vulnerable in their intimate relationships. Therefore, catastrophism in these patients negatively affects their mechanisms of adaptation to pain. Thus, vulvodynia is influenced by both cognitive and affective factors.,18,19Notably, many patients with BMS and/or vulvodynia also exhibit psychological fragility. Almost 80% of patients with BMS had alexithymia, which is a personality trait involving dysregulation of negative effect. A history of childhood abuse significantly affected vulvodynia, in that women who were sexually abused in childhood were more likely to develop this condition. Moreover, women with vulvodynia can experience greater pain catastrophizing, namely, a tendency to hold exaggerated negative thoughts and feelings about pain, which can also be described as rumination, helplessness, and magnification.,10The oral cavity, vulvar region and penoscrotal region are characterized by a high density of nerve endings, which makes them ideal sites for the development of cutaneous sensory disorders.Regarding the itchy sensation, histamine-specific pruritus transmission neurons have been found in the dorsal horn of the spinal cord, suggesting the existence of a distinct neural pathway from the classic pathways transmitting itchy sensations and which could be involved in itching neuropathic pain. QST is a technique used to evaluate peripheral and central nervous system disorders associated with chronic pain through the administration of calibrated stimuli to measure detection and pain thresholds. Therefore, it can be concluded that the patients presented with somatosensory impairments.Neurogenic hypotheses include autonomic nervous system disorders, sensory dysfunction associated with sensory fiber neuropathies, disruption of sensory pathways caused by endocrine changes during menopause, disruption of the central nervous system, and modulatory pathways involving the trigeminal nucleus and striatum. Recent advances in this field suggest that BMS is a peripheral sensory small-fiber neuropathy. These findings are based on quantitative sensory testing (QST), which revealed that sensitivity thresholds were disturbed in 76% of patients with BMS.Studies examining BMS using QST have shown that warmth detection and heat pain thresholds can be decreased, suggesting an increase in heat sensitivity in these patients. Conversely, no study has detected a decrease in pain thresholds with the application of cold or mechanical pressure. Generalized pain sensitivity disorders have also been observed in women with a lowered pressure threshold and pain in the vulva, shoulder, chin and thumbs. These women experience significant increases in the number of pain points, intensity of pain and anxiety induced by pain, which suggests generalized hypersensitivity to pain and pressure. Hyperesthesia in the pudendal dermatome has also been detected in patients with penoscrotodynia, supporting the hypothesis of small-fiber neuropathy.However, the use of QST in the vulvar region has resulted in decreased pain thresholds for the topical application of acetic acid in women with vulvodynia.Further research has revealed that the total number of epithelial nerve fibers and innervation density in the fungiform papillae and connective tissue are reduced in patients with stomatodynia associated with axonal degeneration. This finding supports the hypothesis that BMS is a peripheral small-fiber neuropathy.One explanation for vulvodynia is that initial peripheral neuropathy leads to a central sensitization process involving the system, which amplifies pain and causes psychological and sexual problems.Moreover, in vulvodynia, an increase in interleukin-1β, tumor necrosis factor-α and peripheral nerves has also been observed, which could cause neurogenic regional inflammation. Moreover, patients’ pelvic muscles exhibited increased sensitivity to emotional stimuli. A recent study showed an increase in the number of nociceptive vanilloid receptors in the vestibular region of patients with vulvodynia.Furthermore, an increase in the expression of the vanilloid capscain receptor has been highlighted in the context of BMS, which supports the hypothesis that capscain receptor is involved in the pathophysiology of this dynia.Nevertheless, elements that highlight the neurogenic or psychogenic components should not be opposed. They form 2 complementary explanations: one catalyzes the other in the appearance of symptoms.,6,10Depending on the study, the patients were classified according to the classification of Lamey and Lewis Table , based oHelicobacter pylori, autoimmune disorders, poorly fitting dentures, contact hypersensitivity, and other causes of peripheral neuropathy. Primary BMS was diagnosed after excluding the listed factors. The authors of the examined studies agreed that BMS was primary when no organic cause could explain the pain.,9,10,17Secondary BMS is associated with local or systemic oral causes, such as excessive use of mouthwashes, oral candidiasis, xerostomia, nutritional neuropathy , dysgueusia, mechanical factors, parafunctional habits, endocrine disorders, psychological disorders, Additional examinations of the visual examination included iron, ferritin, vitamins B1, B6, B12, folate and zinc levels, complete blood count, liver function tests, renal function tests, thyroid function, autoantibody profile (extractable nuclear antigens and antinuclear antibodies), and glycated hemoglobin.Additional avenues of investigation included candida infection (candida count), hormone imbalance  and depending on the clinical history, gastrointestinal disease (antibodies to H. pylori), allergies , and xerostomia .–11,14,17Vulvodynia was most often diagnosed by a gynecologist, who ensured that the vulvar area was normal and without any sign of infection or active dermatosis. It is also based on the exclusion of local or systemic factors that might explain pain. These factors were mainly allergens, such as soaps, spermicides, and drugs. The most common sign found on the vulvar mucosa is erythema; however, it is not pathognomonic because it is not present in many asymptomatic women.,15A cotton swab or Q-tip test was useful for diagnosis; this test consisted of gently touching all vulvar areas with a cotton swab, starting from the outside and ending with the trigger zones, which are the Bartholin glands.,9Laboratory examinations, such as blood and microbiological samples or biopsies, can be performed to eliminate any systemic or local cause.The authors classified penoscrotodynia according to either the intensity of pain  or mode of onset . The diagnosis of penoscrotodynia was also based on burning sensations and/or pain in the penoscrotal region without an apparent cause detected by visual examination. Erythema was frequently observed in the patient. Therefore, it is necessary to eliminate all secondary causes, such as infection, tumor, testicular torsion, variocele, hydrocele, spermatocele, or a history of surgery or allergens such as soaps.,13Performing penoscopy or biopsy is not reasonable if the skin looks healthy.It is important to emphasize that primary BMS, vulvodynia and penoscrotodynia are diagnosed based on exclusion. A diagnosis of chronic pain can only be made after eliminating all possible local and systemic causes that could lead to a differential diagnosis. The first step consisted of visual examination of erythema. This initial examination can be deepened by laboratory examinations or even biopsies, if this option remains reasonable. Several authors agree on the need to resort to cognitive behavioral therapy in the context of BMS or pelvodynia because of the significant psychogenic component of these pains.,4 In addition, patients could also consult a sex therapist.,11All authors agreed that it was necessary to recognize and name these pain syndromes in order to reassure patients. It is important for patients to understand that their symptoms are not indicative of a serious underlying disease. It would then be relevant to invite the patient to consult a psychologist or psychiatrist, preferably trained in pain management.In many instances, there is an underlying condition of anxiety or depression that must be treated before treating the symptoms to obtain lasting results. A Swedish study noted that this psychological approach would improve quality of life in 79% of patients.,11,13,14Several local treatments have been used in patients with BMS or pelvodynia with varying degrees of success. In some cases, the application of topical anesthetics, such as lidocaine ointments, to the painful sites was slightly relieved but did not eliminate the symptoms and helped improve the patient’s sexual life. Ointments based on corticosteroids such as beclometasone dipropionate are useless or even dangerous in the absence of a diagnosis of progressive inflammatory dermatosis. In addition, local antibacterial, antifungal, and antiviral agents seemed to be ineffective. Some authors have recommended desensitization to capsaicin using mouthwashes containing hot peppers diluted in water. Potential recommendations for patients with pelvodynia include wearing loose clothing, washing with mild soaps, or eliminating detergents by rinsing clothes twice. Transcutaneous electrical nerve stimulation (TENS) might relieve pain in patients with penoscrotodynia. For vulvodynia, some authors have recommended local estrogen therapy, whereas others have suggested vaginal physiotherapy with biofeedback. The results of the latter ranged from 71.4% to 85.7% of patients, indicating an improvement in symptoms. A final option of injecting botulinum toxin into the bulbospongiosus muscles demonstrated significant results at 3 and 6 months.,11,14In BMS, mouthwashes with clonazepam are effective.,18,22,23The results of all aforementioned treatments correspond to the latest scientific data on local treatments. However, they can be supplemented with capsaicin desensitization and low-level laser therapy, which involves applying a low-power laser to areas of vulvodynia pain. These latest therapies have shown encouraging results and can be explored in the context of penoscrotodynia. Furthermore, TENS can be used to treat vulvodynia. Finally, some authors have proposed alternative treatments, such as acupuncture or hypnosis, but more studies are needed to prove their effectiveness.–14 Therefore, these are the therapies of choice for patients with BMS and pelvodynia. However, some treatments that succeed in BMS and vulvodynia, such as dosulepin (75 mg/day), α-lipoic acid (800 mg/day), clozapine, duloxetine (20–60 mg/day), and clonazepam (3 mg/day), could be used for patients who have a co-occurrence of these 2 pain syndromes.,11,14,17 These treatments have yet to be studied in patients with penoscrotodynia. None of the selected studies explored whether drugs effective for BMS, such as the combination of gabapentin and nortryptiline or gabapentin and α-lipoic acid, diazepam and olanzapine, were also effective for pelvodynia.,10 The remaining treatments covered in the studies  did not appear to effectively improve symptoms.,11,14,17Figure An association between α-lipoic acid and gabapentin or pregabalin is a concept that clinical studies have proven relevant.,11,13Surgical treatment can be envisaged only in the context of pelvodynia. The response rate for vestibulectomy is 61% to 94%. However, there is no evidence that orchiectomy or epididymectomy improves the pain. In contrast, testicular denervation presents encouraging results.Based on these results, a therapeutic gradient can be established for treating patients with BMS and pelvodynia. First, it is essential to prescribe CBT to patients cognitive behavioral therapy. The next step is to administer local treatments such as lidocaine-based ointments, painful sites, TENS sessions and/or low level laser therapy sessions. If these measures are insufficient and the pain still affects the patient’s quality of life, it is possible to prescribe systemic treatment, beginning with gabapentin or pregabalin. If a patient remains unsatisfactory, the benefit of surgery must be assessed, primarily in the case of vulvodynia.Although BMS, vulvodynia and penoscrotodynia (pelvodynia) affect different organs, they share some similarities. First, from an epidemiological perspective, BMS and vulvodynia occur at similar ages and have similar clinical presentations. Similar neurobiological and psychogenic mechanisms have been implicated in this etiology. Neurobiological and psychogenic factors complement the pathophysiology of pelvodynia. Diagnostically, all of these conditions were based on exclusion criteria.This article highlights common treatments that are valuable in the case of co-occurrence of BMS and pelvodynia, which combine cognitive behavioral therapy with local and systemic treatments, and pregabalin and gabapentin, which have proven effective against all types of pain discussed. However, the effectiveness of drugs such as dosulepin, α-lipoic acid, duloxetine, and clonazepam remains unclear in the context of penoscrotodynia because of the lack of documentation of this chronic pain and merits clinical trials to complete the therapeutic arsenal provided in this article.Analysis of papers: B. Hamon.Bibliographical research: B. Hamon.Conceptualization: S. Boisrame.Methodology: S. Boisrame.Project administration: S. Boisrame.Selection of papers: S. Boisrame, B. Hamon.Supervision: S. Boisrame.Validation: S. Boisrame.Writing – original draft: B. Hamon, S. Boisrame.Writing – review & editing: B. Hamon, M. Orliaguet, L. Misery, S. Boisrame.


To estimate long-term efficacy and safety for maxillary trigeminal neuralgia (TN) using radiofrequency thermocoagulation (RFT) targeted on Gasserian ganglion, and to identify the factors which may influence outcomes after procedure.From 2006 to 2019, 1070 patients underwent RFT for the treatment of medically refractory maxillary TN was included. All patients were followed up for at least 2 years. Outcomes and complications were recorded and analysed. Logistic regression analysis was employed to identify risk factors of long-term pain recurrence. Prognostic value was calculated from receiver-operating characteristic curve (ROC).p < .001), previous facial numbness  and poor initial response to medication  were independently associated with long-term pain recurrence. Patients with prognostic index (PI) > 0.25 were identified as high-risk for recurrent TN . New and worsen facial hypoesthesia was recorded in 77.9% of patients corresponding with BNI score II–IV, and 18.7% reported improved sensation. Severe complication incidence including troublesome dysesthaesia, keratitis and masseter weakness was higher in 80 °C group.Longitudinal analysis was taken place for 97 non-responders (9.1%) with ineffective pain relief, 253 responders (23.6%) with pain recurrence and 720 responders (67.3%) without pain recurrence. The median pain-free survival (PFS) was 112.0 months . The pain-free rates were 89.9% (95% CI: 88.0–91.8%) at 1 year, 83.8% (95% CI: 81.5–86.1%) at 2 years, 75.4% (95% CI: 72.7–78.1%) at 5 years and 70.2% (95% CI: 67.4–73.0%) at 10 years. Atypical facial pain  targeted on Gasserian ganglion for the treatment of maxillary trigeminal neuralgia (TN) during long-term follow-up. Recurrence-free survival among a large sample was assessed and risk factors associated with long-term pain recurrence was identified. It has been verified that inadvertent damage of ophthalmic and mandibular division causes ophthalmic and masticatory complications. Therefore, a more precise needle tip position and thermocoagulation using a relatively low temperature was recommended.Favourable outcomes were achieved in terms of long-term pain relief and complications rate after RFT for maxillary TN. Patients with typical facial pain, normal facial sensation, and good initial response to medications may have favourable long-term outcomes. Pain recurrence was pre-defined as change from BNI Class I or II to a lower-outcome class (BNI Class III–V). Pain-free survival (PFS) was defined as the period of maintaining effective pain relief without medication from RFT procedure to the date of TN recurrence. BNI facial hypaesthesia scale was used to assess the degree of ipsilateral facial numbness [Pain intensity was assessed using the numeric rating scale (NRS) which consists of 0–10 pain . The Barrow Neurological Institute (BNI) scale was used to estimate the degree of pain after RFT . If the numbness . Class IThe primary study endpoint for this study was PFS over long-term follow-up period. For patients with bilateral pain, only their primarily unilateral RFT in the more symptomatic side was included. To avoid repeat measurements, for patients who underwent RFT for TN in the same division for several times in our hospital, only the first RFT procedure was included.All RFT procedures for the treatment of maxillary division TN were performed in the operating room under fluoroscopic guidance by the same skilled pain surgeon, who demonstrated expertise in performing neurosurgical interventions of the Gasserian ganglion. Atropine (0.01 mg/kg), fentanyl (50 μg) and droperidol (2.5 mg) were administered 1 h before procedure. Electrocardiogram, blood pressure, and pulse oximetry were monitored. Patients lied in the supine position with the head in a reverse occipitomental position. The FO was visualized by rotating C-arm with 15–25 degrees in the coronal plane and 20–30 degrees in the sagittal plane. After sterilization and local infiltration of 10 mL 0.5% lidocaine, a 22-gauge, 15 cm radiofrequency needle with a 5 mm active tip  was advanced directly towards FO using the Hartel anterior approach. Once the tip of the needle reached approximately 3 mm into FO, examinations were repeatedly conducted under the guidance of fluoroscopy in coaxial and lateral view. The location of the needle tip should be confirmed to be in the middle third between the clivus and the skull base in the lateral images . MultiplAll statistical analyses were conducted using SPSS for version of 22.0 . Differences were considered statistically significant at the 5% level with 2-tailed test.Quantitative data were described in the median with interquartile range (IQR). Categorical variables were reported in frequencies and proportions, and compared with Chi-square test or Wilcoxon rank sum test. The Kaplan–Meier curves with 95% confidence interval (CI) were calculated to explore the probability of PFS. The censored point was considered as pain-free surviving at the last follow-up and at the last contact. For patients who were lost to follow-up or patients who died of other diseases, data obtained at the time of the last contact was used. Univariate regression analysis and multivariate analysis based on binary logistic regression was used to identify and predict independent risk factors for pain recurrence in the long-term follow-up. The receiver-operating characteristic curve (ROC) was employed to determine the optimum cut-off value of prognostic index (PI) to discriminate patients with high and low risk for recurrent TN. Differences between PI-dependent survival were compared using the log-rank test.This study comprised a total of 1705 patients receiving RFT for medically refractory maxillary TN. A cohort of 1070 patients (62.76%) met the inclusion criteria . Longitup = .046). Before RFT procedure, facial hypaesthesia existed in 6.2% of patients with immediate effective pain relief, and 12.4% of them was noted in patients without satisfactory immediate pain relief preoperatively (p = .020).Baseline characteristics were not balance between patients with effective and ineffective initial pain relief in p < .001), facial hypaesthesia , and initially refractory response to medication  were significant risk factors associated with long-term pain recurrence. Additionally, no significant association with pain recurrence was observed on variables including age, gender, co-morbidity, disease duration, baseline NRS score, affected side, NVC on MRI/MRA, history of previous neurosurgical intervention, RFT temperature, NRS post-RFT at discharge day, initial efficacy, BNI facial hypaesthesia score post-RFT, ophthalmic complications post-RFT and masseter weakness post-RFT.Univariate analysis results are shown in p < .001), 5.224  for facial hypaesthesia assessed by BNI scale (p < .001), and 3.185  for no initial improvement in response to medication (p < .001). The contribution of all the other variables to prediction was trivial in this study  for atypical facial pain (is study . The indp < .001). The median recurrence free survival of high-risk was significantly lower than that of low-risk group (57.33 (95% CI: 48.80–65.87) vs. 130.61 (95% CI: 126.08–135.13)  were identified as high-risk for long-term pain recurrence  .p = .004).Adverse events after RFT procedure are demonstrated in In this study, there was a sufficient sample size to analyse the long-term outcomes and influence of various factors including patient special characteristics and surgical parameters on the recurrence after RFT of Gasserian ganglion for the treatment of maxillary division TN. We showed that the recurrent rate was approximately 23.6%. The predictive model identified three risk factors including atypical facial pain, facial hypaesthesia and initial refractory response to medication were associated with long-term pain recurrence. In addition, PI > 0.387 could lead to a relatively higher risk for recurrence. These results might provide convincing evidence of the long-term recurrent rate and risk factors associated with the impact of relapse.2 division TN obtained the best excellent pain relief after RFT procedure with pain relief rate 91, 89, 80, 72, 60 and 54% at 1, 3, 5, 7, 9 and 11 years, respectively [2 without affecting the normal area due to its pure sensation conduction component.Due to its relatively balanced efficacy and safety profile, percutaneous RFT of Gasserian ganglion through FO route has been extensively used to treat TN since 1974 . It was ectively . In our p = .046) and an almost 5.373-fold increase in recurrent risk was estimated during long-term follow-up . Meanwhile, several previous studies found that a better long-term efficacy was observed in patients who had not undergone a previous neurosurgical intervention [p = .105). But the high recurrence rate could be increased by facial hypaesthesia which was mostly remaining side effects from the previous ablative neurosurgical interventions, such as RFT, PBC, SRS and peripheral neurectomy. In our study, patients with remained facial hypaesthesia were more likely to experience a failure immediately after RFT (p = .020), which might be explained by lack of a clear response to electrical stimulation tests. And these patients had a 5.224-fold increased risk for recurrence  according to the multivariable analysis. For parts of these patients, their TSEP results before RFT procedure in this study illustrated a prolonged latency of P1 and N2 or a reduced amplitude of some waveforms. Results were better in patients with good initial response to medication, patients whose medication had initially failed had a 3.185-fold increased risk for recurrence over the long-term follow-up . By ROC analysis, patients were discriminated into high-risk group for recurrence with PI > 0.387, they had a 5.575-fold increase in recurrent risk . The prediction model with sensitivity= 70.6% and specificity = 83.7% could be expected to provide a helpful and clear contribution to decision-making in the routine clinical patients selection before RFT procedure.Atypical facial pain was characterized more by constant aching or burning aspects, and could appear along with recurrent paroxysmal typical TN. There was the evidence that as opposed to typically paroxysmal pain, atypical pain consisting of continuous component might improve differently after MVD ,23. Addirvention ,25. We s1 (10%), V1 + V2  of TN. 97.5% patients experienced tolerable numbness, 17.5% patients experienced mildly decreased corneal reflex, 2.5% patients felt a foreign body sensation [versus FO for the treatment of V2 TN and reported that the incidences of facial numbness and swelling did not differ significantly between the 2 groups . There was no postoperative corneal involvement or masticatory weakness in the FR group. However, corneal involvement and masticatory weakness occurred postoperatively in 55% patients and 77.5% patients in the FO group. They were unable to avoid the V1 and V3 branches, despite multiple adjustments of the needle position in FO group in 87.5% patients [2 or V3 TN could effectively ablate the conduction of pain fibres and spare the motor nerve. Generally, in this study, the needle tip was precisely adjusted according to the patients’ response to electrical stimulation tests after verification via fluoroscopic imaging. Multiple electrical stimulation tests were needed to elicit paraesthesia in the maxillary dermatome, while minimizing it in the dermatome of ophthalmic division and mandibular division. If paraesthesia was elicited in the affected V2 dermatome at > 0.5V, the position of the trocar tip should be continuously adjusted. If rhythmic myoclonus was elicited in mandible angle that indicated the needle tip was at motor fibre of V3, thus the position should also be adjusted. If paraesthesia could be elicited by <0.1 V sensory stimulation in the restrained V2 dermatome, patients would receive RFT at 70 °C for 90 s. If paraesthesia could be elicited by 0.1–0.3V sensory stimulation in the restrained V2 dermatome, patients would receive RFT at 75 °C for 90 s. During the thermocoagulation, patients should be repeatedly awakened for confirmation of the needle tip position according to appropriate response to intra-op electrostimulation. Additionally, corneal reflex and masseter function should be carefully monitored. If the ipsilateral corneal reflex was decreased which demonstrated V1 was being damaged, the procedure should be immediately halted. If the pain corresponding to the affected division disappeared completely and the tactile sense was blunt, the needle should also be pulled out. After RFT for maxillary TN, corneal reflex test should be taken place for each patient at discharge day. If there were decreased corneal reflex or other uncomfortable eye symptoms, ophthalmology consultation was immediately recommended for patients to avoid keratitis or permanent blindness eventually. In conclusion, ophthalmic complications and masseter weakness after RFT procedure of Gasserian ganglion for maxillary TN should be seriously taken into consideration, the above-mentioned protocol suggesting a more precise needle tip position and thermocoagulation using a relatively low temperature was recommended in purse of long-term pain relief as well as low risk for ophthalmic complications and masseter weakness after thermocoagulation.Heat could be produced by vibration and friction of radiofrequency electricity leading to thermocoagulation and denaturation of targeted nerve. Hence, various complications related to thermocoagulation could be developed and prevent the widespread use of RFT . An obseensation . As our 1 %, V1 + Vensation . Recentlpatients . Accordipatients . To decrThere were several limitations in this study. First, undetected confounders and probable bias were inevitable problems due to the retrospective analysis with observational data. Second, participants bias including different mood, possible suggestibility and hearing loss might be carried while conducting phone or e-mail interview. However, potential methods of prevention, such as indirect, craft open-ended questions and neutral stance were not used in the study. Third, the follow up was not by an independent observer, this oversight might bias the results of the study. Future large-scale, long-term randomized studies would be needed to validate our findings.Our results indicated that patients would attain a long-term pain-free after RFT of Gasserian ganglion for the treatment of maxillary division TN. The predictive model identified three risk factors including atypical facial pain, facial hypaesthesia and initial refractory response to medication were associated with long-term pain recurrence. Additionally, more precise and accurate position of radiofrequency trocar tip in the restrained distribution of V2 division was necessarily required in order to decrease the occurrence of ophthalmic and masticatory complication.


Patients with an optimal CPM result tended to be prescribed fewer antidepressants , and patients with signs of allodynia and/or temporal summation tended to be prescribed fewer NSAIDs . There was no difference in the duration of the treatments between the groups. QST/CPM testing appears to provide more targeted therapeutic options resulting in the overall drop in polypharmacy and reduced use of interventional treatments while remaining at least as effective as the standard of care.The evidence supporting the use of pharmacological treatments in pediatric chronic pain is limited. Quantitative sensory testing (QST) and conditioned pain modulation evaluation (CPM) provide information on pain phenotype, which may help clinicians to tailor the treatment. This retrospective study aimed to evaluate the association between the use of QST/CPM phenotyping on the selection of the treatment for children with chronic pain conditions. We retrospectively analyzed the medical records of 208 female patients (mean age 15 ± 2 years) enrolled in an outpatient interdisciplinary pediatric complex pain center. Pain phenotype information (QST/CPM) of 106 patients was available to the prescribing physician. The records of 102 age- and sex-matched patients without QST/CPM were used as controls. The primary endpoint was the proportion of medications and interventions prescribed. The secondary endpoint was the duration of treatment. The QST/CPM group received less opioids (7% vs. 28%, respectively,  Chronic pain in children and adolescents has a prevalence of 10–25% and often persists into adulthood ,4. ThereChronic pain can be dichotomized into chronic primary pain and chronic secondary pain. Chronic primary pain is defined as “pain in one or more anatomical regions that persists or recurs for longer than 3 months and is associated with significant emotional distress or functional disability and that cannot be better accounted for by another chronic pain condition”. Examples of chronic primary pain include widespread chronic pain, complex regional pain syndrome, chronic primary visceral pain, chronic primary musculoskeletal pain, chronic primary headache, and orofacial pain . ChronicQuantitative sensory testing (QST) and the conditioned pain modulation (CPM) evaluation are tools that can be used in the research setting to predict treatment responses in various pain conditions ,10. QST/We hypothesized that patients with a QST/CPM assessment could be prescribed medical treatments  in different proportions compared to those patients that have not been assessed using QST/CPM. This hypothesis was built on the premise that a treatment plan based on the sensory phenotype allows physicians to tailor the treatment without deterioration of patient outcomes while reducing the number of medications prescribed. Therefore, we aimed to describe and compare the prescription patterns of patients with and without the QST/CPM assessment. The main objective of this retrospective study was to evaluate if the use of QST/CPM assessments in a pediatric chronic pain interdisciplinary program has an impact on the selection of pharmacological or interventional treatment. The secondary objective of the study was to evaluate and compare the duration of the treatment.Patients aged 9 to 17 years referred to the ambulatory program of the Edwards Family Interdisciplinary Center for Complex Pain were included in the study. We used the Center for Complex Pain database to identify potential candidates for the analysis. The initial selection included patients between 9 and 17 years old, reporting persistent or recurrent non-cancer pain for at least three months from September 2015 to October 2018. The second screening included patients with complete psychosocial and physical function evaluation and complete information regarding the treatment and cause of the end of treatment. As female individuals represented over 83% of the sample, we excluded male subjects to avoid gender variations during the analysis. In addition, we excluded patients who would not be candidates for QST/CPM testing , patients who did not understand English or French, and patients with a cancer diagnosis. Finally, patients who had a QST/CPM assessment before their first evaluation were matched according to age and diagnosis using a computerized randomization method to patients who did not have a QST/CPM assessment (“standard of care control group”) in a 1:1 ratio. The Center for Complex Pain has used a comprehensive QST protocol to assess mechanisms of pain as well as a CPM protocol to evaluate the endogenous descending pain inhibitory control of patients before the initiation of a treatment since early 2016. The evaluation was systematically offered to patients starting in September 2017.Chronic pain conditions were categorized retrospectively for the purpose of this study using the ICD-11 classification of chronic pain using the categories of (1) chronic primary pain and (2) chronic secondary pain .The interdisciplinary outpatient program of the Center for Complex Pain focuses on optimizing physical and psychological function, normalizing sleep and social function, and increasing levels of activity while assisting with the management of the pain. The core team at each evaluation includes a nurse clinician, psychologist, social worker, physiotherapist, clinical fellow, and a pain physician. The clinical team of the Center for Complex Pain remained constant during the study period, excluding the change of one social worker, one nurse clinician, and the rotation of clinical fellows. At baseline, the team evaluates sleep quality, physical function, and psychological function using the Pittsburgh Sleep Quality Index  (PSQI), The full evaluation is termed QST/CPM evaluation but may be abbreviated to “QST” only for short in the tables/figures. The QST protocol was based on previous comprehensive studies and includes assessments of mechanical detection threshold, vibration detection threshold, dynamic mechanical allodynia, pain pressure threshold, heat pain threshold, and mechanical pain summation. QST/CPM evaluations were offered as a clinical service at the first appointment at the clinic, and parents were not present in any of the evaluations. The procedures were standardized and performed in triplicates by a single QST/CPM technician. The results were evaluated and compared to reference values from the literature, when available, with respect to protocol and test sites ,24. TestThe pain pressure threshold (PPT) was measured using a hand-held digital pressure algometer (Jtech) with a display in Newtons. If the PPT was significantly below the lower bound of the 95% CI of the reference values at a control site  or signThe presence of dynamic mechanical allodynia was reported using a standardized brush (Somedic SENSELab—Brush-05). Allodynia is defined by the IASP as “pain due to a stimulus that does not normally provoke pain” . On a meThe presence of temporal summation was evaluated both mechanically and thermally. Mechanical temporal summation was evaluated using the difference in the self-reported pain between one and ten stimulations with a Neuropen (Owen Mumford) with a standardized 40 g Neurotip at a rate of 1 per second. Mechanical temporal summation was evaluated at a control site  as well as the painful site within the individual, but not to external reference values due to the difference in the tool used. Thermal temporal summation was measured on the medial forearm during a constant heat stimulus over a period of 2 min at a pre-determined temperature self-reported to cause ≥ 5/10 pain and interpreted as the difference in pain intensity between the numerical rating score at 60 s and at 120 s of the test . If a paMechanical detection threshold and vibration detection thresholds were investigated using Von Frey Filaments and a 64 Hz tuning fork (Rydel-Seiffer), respectively, and compared to reference values for the zygomatic bone, processus styloideus ulnae, or malleolus internus . These mThe endogenous descending pain inhibitory pathway control was quantitatively evaluated using the CPM paradigm developed by Marchand and colleagues  and simpAfter the physical examination, the team proposed an individualized treatment program for the patient and their family, including non-pharmacological as well as pharmacological and interventional treatments. The cost of the evaluations, treatment, and follow-up provided by the Center for Complex Pain is entirely covered by the Quebec public health system and by unrestricted grants from the Montreal Children’s Hospital Foundation, the Louise and Alan Edwards Foundation, and the Pathy Family Foundation.The multidisciplinary program included cognitive behavioral therapy  and outpatient physiotherapy once a week or twice a month, depending on the patient’s needs. The medical treatment varied based on the information available during the clinical evaluations. When the QST/CPM evaluation results were not available, the clinicians chose the medical treatment using treatment guidelines for specific conditions . In addition, they selected the treatment based on the findings of the physical examination  or on the type of pain .When clinicians had the results of the QST/CPM evaluation, they used a simplified protocol in addition to the findings of the physical examination . The treThe primary outcome measure was the number and type of medical treatments prescribed by the team to treat pain. Medical treatments were grouped into six categories: antidepressants; opioids; non-steroidal anti-inflammatories (NSAIDs), including diclofenac topical cream; anticonvulsants; other drugs ; and interventional treatments. Most interventional treatments consisted of ultrasound-guided peripheral nerve blocks with very few ablative procedures (mainly radiofrequency), as previously described by Vega and colleagues .The initial treatments prescribed to patients with primary and secondary pain conditions were independently analyzed. We also analyzed the duration of treatment as an independent variable. We defined the duration of treatment as the time between the first ambulatory evaluation and the completion of the treatment. Patients were considered to have completed the treatment when they reported minimal (NRS < 3/10) or no pain, were not taking pain medication, and were presenting normal physical and role functioning (school attendance). Other reasons for early termination of the treatment included transfer to another specialty, transfer to adult care on their 18th birthday, or loss to follow-up.t-test for the difference of means of continuous variables or Mann–Whitney’s U test for non-parametric variables was performed to compare baseline characteristics between groups in terms of mood, function, pain intensity, and sleep. In order to address the main hypothesis, binary logistic regression analysis was performed to compare the number of patients prescribed different drug treatments (dependent variable) between the QST/CPM evaluation group (“QST group”) and standard treatment group (independent variable). The results were reported for pooled data, by diagnosis category, and by QST/CPM results. Finally, plots of Kaplan–Meier estimates with log-rank tests were produced to compare the duration of treatment of patients (time between first ambulatory visit and completion of treatment). Reasons for missing data included transfer to another specialty, transfer to adult care on their 18th birthday, or loss to follow-up. In those cases, the data were entered as “censored” in the Kaplan–Meier model and log-rank test. The significance level was established at 0.05. Bonferroni corrections for multiple comparisons were applied where appropriate. Statistics were performed using IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY, USA: IBM Corp.Descriptive statistics were computed to describe the patient sample included in the study. An independent samples n = 106) and the standard treatment group (n = 102) with regard to age, diagnosis, pain intensity, sleep quality, function, and mood at baseline , and 100 had a chronic secondary pain diagnosis. There were no differences between the QST/CPM group , 61% presented with sub-threshold pressure pain sensitivity (phenotype B), and 55% had a suboptimal or inefficient endogenous pain modulation (phenotype C). A total of 26% presented with all three abnormal sensory processing phenotypes .There were significant differences in the number and type of medications prescribed when patients were tested with the QST/CPM compared with patients without testing. Patients in the QST/CPM group received fewer opioids, fewer anticonvulsants, and more frequently other drugs . Patients in the QST/CPM group also tended to receive less interventional treatments .p < 0.001). Patients with an efficient endogenous pain inhibitory response were prescribed fewer antidepressants ; however, after Bonferroni correction for multiple comparisons (significance level of 0.008), this result was not significant. Patients with a positive sign of allodynia and/or temporal summation were prescribed fewer NSAIDs ; however, after Bonferroni correction (significance level of 0.008), this result was not significant . Twenty-five individuals were censored  from the treatment duration model because they had left the clinic due to a transfer to adult care on their 18th birthday (n = 15), transferred to another specialty (n = 3), or loss to follow-up (n = 7).There was no significant difference in duration of treatment between the QST/CPM and standard assessment control group, regardless of diagnosis . OverallThe efficacy and side effects of each treatment were not assessed in this retrospective chart review. If at follow-up, a patient reported no improvement in pain or significant side effects, the clinical team offered an alternative treatment and continued offering individualized care to each patient, including psychotherapy and physiotherapy.In this study, we examined the effect of using an exhaustive pain phenotyping protocol based on mechanical and thermal QST and a CPM evaluation in an interdisciplinary center for complex pain. A single physician was in charge of the medical treatment of the patients included in this study, along with four rotating fellows under his supervision, thus limiting differences in physician preferences of treatment modalities. When QST/CPM evaluations were available, the physicians prescribed less opioids and other medications and tended to perform fewer interventional procedures, especially among patients with chronic secondary pain. Overall, the use of the QST/CPM evaluations did not change the length of the treatment.Patients who demonstrated an efficient endogenous pain inhibitory control tended to be prescribed fewer antidepressants. Moreover, patients with dynamic mechanical allodynia and/or temporal summation tended to be prescribed fewer NSAIDs. The clinicians in this study followed treatment protocols based on previous studies and recommendations for the treatment of adults and children ,48,49,50Eccleston and colleagues stated that “given the widespread use of off-license prescribing in pediatric pain medicine and the absence of data concerning pain and its management, we need to focus on benefits of drugs as well as harms and harm reduction” . Our mecA trend was observed where children between 7 and 14 years old seemed to recover faster compared with those between 15 and 18 years. This might be explained by the temporality of the progression of chronic pain conditions. Individuals who suffer from pain for a prolonged period without treatment may experience long-term neuroadaptations that further promote pain and disability ,29,52.Female individuals represented over 83% of the patients in the clinic, which is reflective of the higher prevalence of chronic pain conditions in females in the population . Due to The present study presented limitations. The study consisted of a retrospective analysis of female patients at a single institution, and it is uncertain how generalizable the current results are. Future multicenter randomized studies should evaluate the weight of QST/CPM evaluations in the efficacy of treatments and in the prevention of the disability associated with complex pain conditions. The pharmacological and interventional treatments are only a part of the different therapeutic options offered within an interdisciplinary program. As part of a comprehensive multidimensional pain treatment program, it is not easy to interpret the weight of potential benefits of individual therapies. However, a meaningful reduction in the number of medications prescribed was observed after the implementation of the QST/CPM evaluations, which is considered a positive effect due to the reduction in polypharmacy. Side effects were not analyzed specifically in this study. The QST/CPM protocol was performed on appointment, without regard to pain episodes. This means patients may have received the QST/CPM evaluation during a period when their pain was less intense or more intense.Although we found some encouraging results in our study, the use of a comprehensive QST/CPM protocol remains complex and increases the costs of the consultations. Moreover, pain phenotyping protocols need to be simplified to be used in daily clinical practice. The QST/CPM protocol used in this study required between 75 and 90 min to complete and document. This research group is working on the creation of a simplified version for future studies.The sensory assessment may guide clinicians in selecting different treatment options for their patients. A mechanistic approach may reduce the use of potentially unnecessary treatments without affecting the clinical outcomes of children with complex pain conditions.


Analgesia after thoracotomy is challenging but important as inadequate pain control may result in early postoperative complications and a higher risk for post-thoracotomy pain syndrome. The authors report the successful utilization of an erector spinae plane (ESP) catheter for post-thoracotomy analgesia in a 40-year-old female with two dual-leaded spinal cord stimulators (SCS) in the cervical and thoracic levels. Although thoracic epidural analgesia is the current standard, epidural catheterization may present with obstructive, mechanical, or infectious concerns in patients with SCS. The ESP block may be a preferable approach to postoperative analgesia after thoraco-abdominal surgery over the thoracic epidural for patients with SCS. Pain associated with thoracotomy is widely known for its intensity as well as its persistence long after the operation is completed . AdequatThe current gold standard for post-thoracotomy pain is thoracic epidural analgesia ; howeverFor our patient, the presence of indwelling SCS precluded a thoracic epidural or paravertebral block as viable options due to the risk of mechanical damage to SCS leads. Bacteremia and infection seeding to the device, as well as patchy or incomplete analgesia, are other significant risks. In addition, we chose to avoid opioid monotherapy for postoperative analgesia to mitigate the numerous dose-dependent adverse effect of opioids including but not limited to respiratory depression, sedation, ileus, and risk for prolonged opioid use after surgery . With thA 40-year-old wheelchair-bound American Society of Anesthesiologists (ASA) physical status III patient with a history of cerebral palsy, esophageal spasms, cervical and thoracic SCS devices for chronic chest and epigastric pain, presented for surgical repair of recurrent paraesophageal hernia, fundoplication takedown, and partial gastrectomy via a left thoracotomy approach. She presented with moderate extremity contractures and was able to verbalize and speak appropriately though with apparent developmental delay. She quantified her baseline pain as 4/10 using the Numeric Rating Scale. Our Acute Pain Team was consulted for assistance in postoperative pain management. According to the patient and her mother, the SCS devices were deactivated for many years and were not being actively managed by her current pain physician. Re-activation or further outpatient follow-up was neither desired nor pursued at the time. Her daily pain medications included duloxetine 20 milligrams, gabapentin 100 milligrams, amitriptyline 100 milligrams, and naproxen as needed.There were no available records of either SCS device, but both were visualized on a preoperative chest radiograph upon chart review. The cervical SCS leads were midline, extending to the C2 vertebral body proximally and tunneled to a right-sided generator. The thoracic SCS leads were midline and located at the superior endplate of the T7 vertebral body with its distal lead tunneled inferiorly towards a left-sided generator. An upper thoracic epidural placement would be needed for post-surgical analgesia; however, due to the proximity of the two SCS and respective paired leads within the cervical and thoracic spaces, a left-sided ESP block and catheter was offered instead of a thoracic epidural catheter. After a discussion of risks and benefits with the patient and her mother, informed consent was obtained.After induction of general anesthesia, the patient was placed in the right lateral decubitus position. Her back was cleansed with 2% chlorhexidine skin prep and sterile draping was placed. A 15-4 MHz linear ultrasound transducer  was placed in the sagittal orientation at the most lateral aspect of the T6 transverse process on the left side. The erector spinae muscle complex was identified superficial to the transverse process. The 18-gauge Tuohy needle  was advanced in-plane in a cephalad direction and injection of 20 milliliters of 0.25% bupivacaine was accomplished easily with dissection of the erector spinae muscle from the transverse process. A 20-gauge polyamide nylon closed-tip catheter  was then inserted with its tip visualized under ultrasound between the T3-T4 transverse processes and the catheter was secured. The patient remained hemodynamically stable under general anesthesia throughout the procedure, and a postoperative chest X-ray was reviewed  one, the patient self-described her pain as “great” since she was mostly experiencing her baseline (4/10) pain at rest, though it did increase to 6/10 with deep inspiration and cough. She used 48 morphine milligram equivalents (MME) from her hydromorphone PCA. Her mood was good, and she did not complain of issues with sleep overnight. On POD two, she started physical therapy so that she could transfer into her motorized wheelchair, which caused higher pain scores and opioid use. She reported 6/10 pain at rest and 8/10 with activity, with 68 MME use. She required a 10 milliliter 0.375% bupivacaine bolus twice over 12 hours apart. While sensory testing was precluded by surgical dressings and her contractures, the significant relief reported solely after bolus administration and correlating improvement in vital signs strongly suggested catheter efficacy. This allowed her to sleep well overnight. On POD three, her pain was 4/10 at rest and 7/10 with activity and participation in physical therapy, and without opioid utilization from the available PCA. Her chest tube was removed on this day, followed by the removal of the ESP catheter. She continued to sleep comfortably overnight. Her pain was managed with non-opioid analgesics thereafter (scheduled acetaminophen and methocarbamol) and she was discharged to home on POD six. On subsequent follow-up with her cardiothoracic surgeon after discharge, the patient did complain of any thoracotomy pain.  SCS have gained wider application in patients with chronic neuropathic pain conditions such as failed back surgery syndrome, complex regional pain syndrome, peripheral neuropathy, refractory angina pectoris, and phantom limb pain . There iThere are several considerations to epidural placement in a patient with SCS. Bull et al. advocate absolute contraindication of neuraxial procedures in such cases because they can cause direct damage to SCS leads as well as possibly introduce infection . Harned Also, while unlikely for epidurally-administered medications to cause indirect damage due to the protective fibrosis that is known to develop around the leads, that same fibrosis may compromise epidural spread and lead to patchy or incomplete coverage ,14. In tAt the time of this manuscript, the authors could not find any reports on thoracic epidural placement in patients with SCS. This may reflect hesitancy with epidural placement, usually inserted at the T6 to T10 levels for incisional coverage, since SCS placement for low back and leg pain would coincide with those levels as well . PublishThe ESP block is an interfascial plane injection between the transverse process and the erector spinae muscle . At the  demonstrated efficacy in a combined erector spinae plane block plus thoracic paravertebral block for patients undergoing video-assisted thoracic surgery [Several studies have demonstrated the utility of ESP blocks in the treatment of pain from thoracic surgery and reduced opioid use. In a 2020 randomized, blinded clinical trial of 60 patients undergoing thoracotomy, there was decreased morphine use and lower pain scores in subjects who received an ESP single-shot block plus conventional opioid analgesia for postoperative pain compared to subjects who only used conventional opioid analgesia . In a ca surgery . This st surgery .In addition to analgesia for acute surgical pain, the ESP block is a viable treatment for post-thoracotomy pain syndrome (PTPS), which is surgical pain that persists more than two months after surgery. In one case series, five patients with PTPS approximately three to seven months after surgery were successfully treated with a single injection ESP block .There is a paucity of studies on ESP blocks performed on patients with SCS for postoperative analgesia after thoraco-abdominal surgeries. We found only one published report of successful ESP block utilization for a patient with a cervical SCS; however, the block was to provide analgesia from the acute pain caused by the tunneling pathway created in the subcutaneous layer to connect the newly placed SCS to its implantable pulse generator .With expanding application of SCS to reduce opioid reliance in patients with chronic pain, there is a higher likelihood of evaluating these patients for regional analgesic options in the operative, traumatic, or obstetric setting. Thoracic epidural catheterization may not be an appropriate modality for selected patient populations due to varied risks. Alternatively, the ESP block is efficacious while offering distance from the device regardless of implanted level, technical ease in placement, and the ability for continuous infusion via catheterization. Perhaps with these considerations, ESP block and catheterization should be considered as a regional analgesic option for acute postoperative analgesia after thoracic and abdominal surgeries in patients with indwelling SCS.