This study compared the effect of endourological procedures with or without the Amplatz sheath (AS) on cystolithotripsy. We retrospectively analysed 18 patients who underwent treatment for bladder stone over 30 mm. This study consisted of two groups, namely, patients who underwent cystolithotripsy with an AS (AS group) and those who underwent standard procedure without an AS (SP group). The stone-free rate, total energy used for operation, operation time, days of admission after operation, and complication of both groups were compared. The number of patients in the AS and SP groups was 10 and 8, respectively. Significant differences were not found between these two groups with regard to age, stone burden, stone volume, number of stones, and history of neurogenic bladder. All patients in both groups achieved a stone-free state. Total energy was significantly increased and operation time was shorter in the AS group. No significant difference was observed in terms of days of admission after operation. Any complications were not increased by the use of AS. Struvite was the most common stone component in both groups. Use of an AS can shorten the operation time of cystolithotripsy without increasing perioperative complication. A number of treatment options are available for bladder stones including shock wave lithotripsy (SWL), transurethral cystolithotripsy, percutaneous lithotripsy, and open surgery. Endoscopic transurethral cystolithotripsy is among the most well-known procedures for the majority of urologists. However, disintegrating and extracting stones from the bladder, particularly in cases of large stones, take a considerable amount of time with usual cystolithotripsy.Maheshwari reported a novel technique in 1998 . Based oWe retrospectively analysed 18 female patients who underwent treatment for bladder stone over 30 mm diameter between May 2009 and December 2014 at the Ohguchi Higashi General Hospital, Yokohama, Japan. We routinely utilised the AS for cystolithotripsy of large bladder stone since November 2011. This study consisted of patients who underwent standard procedure with an AS (AS group) and those without an AS (SP group). The stone-free rate, total energy used for operation, operation time, days of admission after operation, and complication of both groups were compared. Postoperative pain was compared by usage of analgesic until hospital discharge.π/6 × 1/1000. Each diameter was measured in preoperative computed tomography. Stone-free status was assessed with a plain KUB film at postoperative day 1. This status was defined as no visible fragments on the film.Stone burden was defined as the sum of the stones' maximum diameter on radiography of the kidneys, ureters, and bladder (KUB) films. Stone volume was calculated using the ellipsoid formula: height (mm) × width (mm) × depth (mm) ×  Written informed consent was obtained from all individual participants included in the study.This study was conducted according to the Helsinki Declaration. The ethics committee of Kanagawa Prefecture Medical Association approved this study.μm laser fibre covered with a cut 5 Fr ureteral catheter into the work channel. Stone fragments were disintegrated using 100 W laser generators  and then were removed by an irrigation flow through the AS. The irrigation flow was fixed at 100 mmHg after detaching the 26.5 Fr outer sheath . Statistical significance was set at P < 0.05. Statistical analyses were carried out using the SPSS version 19 software package .Mann–Whitney test and P = 0.015; operation time: 58.50 minutes versus 112.0 minutes P = 0.015). No significant difference was found in terms of days of admission after operation. Complications such as mucosal injury, incontinence, and pain after operations were not observed. One patient in SP group experienced postoperative fever that was treated conservatively. Struvite was the most common stone component in both groups. No recurrence has been found although 7 of 18 patients were lost to follow-up.The characteristics of patients are shown in Bladder calculi represent 5% of all urinary stones in developed countries . The majSeveral treatments are available for bladder stones including open surgery, SWL, percutaneous lithotripsy, and transurethral cystolithotripsy. Open surgery remains a standard treatment for paediatric bladder stone . HoweverSWL is sometimes performed because of its tolerance for high-risk patients . HoweverAccording to a study that compared the two aforementioned treatments, open surgery can completely remove stones, but it requires longer hospitalisation compared to SWL . In contEndourological treatment is safe and effective alternative treatment for bladder stone. This treatment was first reported in 1963 . TransurIn endourological treatment, several modalities are available, including ultrasonic lithotripsy, electrohydraulic lithotripsy, pneumatic lithotripsy, and a holmium:yttrium aluminium garnet (Ho:YAG) laser, to integrate stones . MaheshwThe limitations of this study are as follows. First, the number of patients enrolled in this study was 18; this sample size may not be adequate to reach a definite conclusion. However, the difference between the two groups was remarkable, indicating that the AS affects cystolithotripsy. Second, the recurrence rate was poorly investigated. Patient follow-up after discharge was poor because 13 of 18 patients had general diseases that affected performance status. Thus, most of these patients had difficulty in visiting the hospital. We need further investigation with regard to recurrence of bladder stone after using this method.Using an AS can shorten the operation time of cystolithotripsy without increasing perioperative complication.


Cervical radiculopathy has become an increasing problem worldwide. Conservative treatment options have been recommended in many reviews on cervical radiculopathy, ranging from different types of physiotherapy to waiting for remission by natural history. No multimodal pain management concept (MPM) on an inpatient basis has been evaluated. This study aimed at showing the positive short-term effects of an inpatient multimodal pain management concept with focus on cervical translaminar epidural steroid injection for patients with cervical radiculopathy. 54 patients who had undergone inpatient MPM for 10 days were evaluated before and after 10-days treatment. The NRS (0–10) value for arm pain could be reduced from 6.0 (IQR 5.7–6.8) to 2.25 (IQR 2.0–3.1) and from 5.9 (IQR 4.8–6.0) to 2.0 (IQR 1.7–2.6) for neck pain. Neck pain was reduced by 57.4% and arm pain by 62.5%. 2 days after epidural steroid injection, pain was reduced by 40.1% in the neck and by 43.4% in the arms. MPM seems to be an efficient short-term approach to treating cervical radiculopathy. Cervical translaminar epidural steroid injection is an important part of this concept. In the absence of a clear indication for surgery, MPM represents a treatment option. Cervical radiculopathy has become an increasing problem over the last years. E.g. in Germany, the number of patients with cervical radiculopathy and inpatient treatment doubled from 2005 to 20158.The incidence of neck pain in clinical studies ranges between 10.4% and 71.5%, and the annual prevalence is estimated to vary between 30% and 50%9. In addition, there may be other reasons for upper extremity pain than radiculopathy. Muscles, ligaments or cervical facet joints may be responsible for pain in the neck or in the upper extremities11. ‘Clinically, it is characterized by arm pain, in some cases paraesthesia and eventually reduced muscle strength, altered sensation and impairment of deep tendon reflexes’13.The degenerative changes mainly affect the lower levels of the cervical spine, in particular C5/C6 as well as C6/C7 and rare C7/Th1 or C4/C5. In our clinical experience, radiologically elevated findings in native and sectional image diagnosis  correlate only partially with clinical findings. Cervical radiculopathy is resulting from nerve root dysfunction, which may be caused by several reasons, most commonly by disc herniation and spinal foraminal stenosis14.The age group with the highest risk of developing cervical radiculopathy in the USA and European countries is that of people aged between 35 and 49 years14.Most authors have viewed pain episodes over a person’s lifetime as common relapses. Women and residents of high-income countries or urban areas have a higher risk of developing cervical radiculopathy17. A report describing the U.S. health status regarding diseases and risk factors, neck pain ranked number 4 between 1990 and 201015.Furthermore, neck pain has a significant impact on socioeconomic factors and on costs of public health serviceset al. proposed that neck pain contributes to poor physical quality of life in the future17. The costs of public health services are steadily increasing, while the number of effective treatment options is still limited; therefore, it is very important to find the right treatment for each individual patient as soon as possible18.In addition, Nolet 20.The number of surgical interventions for cervical radiculopathy and degenerative conditions have grown rapidly in the United States21. The mostly non-surgical intervention described in the literature so far is epidural steroid injection, which is still listed as ‘off-label’ use22. Nevertheless, literature reports have often described the success of this treatment method for pain relief from radicular symptoms31. Injection techniques have become an important tool for treating spinal pain24.This increase may be due to the low reimbursement of conservative treatments by health care providers and the lack of sufficient evidence for conservative treatment options for neck and arm pain. In Germany for example, the inclusion criteria for an inpatient multimodal pain management concept (MPM) are so tight, that in our daily clinical experience only 20% of patients can benefit from it. The therapeutic concepts available are very heterogeneous and can hardly be compared. In our opinion, in the absence of a clear indication for surgery, intensive conservative treatment should be provided, and all conservative treatment options should be exhausted prior to any spine surgery32. MPM has been shown to be a very beneficial treatment option for avoiding surgery and reducing pain in patients with radicular nerve root compression35. Beside the injections, conservative treatment options have been recommended in many reviews on cervical radiculopathy, ranging from different types of physiotherapy to waiting for remission by natural history. There are studies to show the efficacy of training programs on upper extremity pain in patients with chronic neck in the short and long term38.In the case of low back pain, injection therapy is often accompanied by multimodal treatment such as physical therapy and psychological counselling to avoid pain chronification40. Only little is known about the use of multimodal pain management concepts in the case of cervical radiculopathy. Therefore, it is important to show the effectiveness of a multimodal pain management concept and particularly the benefits of epidural steroid injection within this concept. Due to the nerve root injections, pain and symptoms can be reduced faster and the patient can benefit from the exercise programs and the behavioural approach within the hospital stay. The multimodal approach including orthopaedic and psychological interventions helps to stop the vicious circle.However, no multimodal treatment concept on an inpatient basis has yet been evaluatedThis study aimed at showing the short-term effect of an inpatient multimodal therapeutic concept based on drug injections – with particular focus on cervical translaminar epidural steroid injection – for patients with cervical radiculopathy.41. In addition, to be included in the follow-up, patients had to have participated in at least two psychological sessions during therapy. An absolute indication for surgery had to be excluded and a clear indication for MPM was required. That means at least 6 weeks of pain and failed outpatient treatment. Exclusion criteria were cervical surgery before treatment, myelopathy, tumours with spinal involvement, and congenital spinal deformities. In addition, patients had to speak German language to be able to take part in the psychological behavioral education lessons. Since this was a single-arm study, no control group was available. Cervical nerve root injections may have some severe side effects; therefore, placebo injections cannot be justified42. The study was approved by the Ethics Commission of the University of Regensburg  and carried out in accordance to the approved guidelines of the Helsinki Declaration of 1975. A written informed consent was obtained from all study participants. The study is registered on 22.02.2017 in the German Clinical Trials Register  under the number DRKS00011788 (WHO register).This non-randomized, unblended, prospective, clinical study included male and female patients with cervical radiculopathy, who had been treated according to a multimodal therapeutic concept at the Department of Orthopaedics of the University Medical Centre Regensburg between March 2015 and September 2015. Participation in the study was voluntary. Inclusion criteria were neck and arm pain >4 on a numeric rating scale (NRS 0–10) and clear signs of radiculopathy, which means radiating arm pain, positive Spurling test and according MRI findingsThe patients were recruited for MPM treatment in our outpatient clinic when fulfilling the described criteria. The inclusion in the study was done on their first day of hospital stay by the first author. 54 of initially 69 patients remained after evaluating the exclusion criteria. 6 of the 11 excluded patients had received primary surgery, 4 showed myelopathy in the MRI, and 5 declined participation. , so that injection-based therapy represented an appropriate treatment option. The age of the included patients was between 29 and 79 years. The relevant demographic data can be seen in Table 32 and has now been adapted for patients with cervical radiculopathy.This multimodal pain management concept has already been published several times by the author for low back pain43. Additional treatment consisted of 1 cervical epidural translaminar injection per hospital stay conducted in ‘loss-of-resistance technique’ under X-ray control in 2 planes in the operating theatre44. Cervical epidural translaminar injections contained 40 mg of triamcinolone and the contrast agent solutrast 250 , which was injected into the affected nerve root in ‘free-hand technique’46 was assessed at the beginning and at the end of therapy. Minimal clinically significant pain reduction was set to NRS 2.049. Treatment success was defined as NRS < 50% of the initial pain at the end of hospitalization50. Using the NDI, a score of < = 8% means patients with hardly any symptoms, whereas a score >40 stands for patients with severe problems and a higher risk of pain chronification55. The minimal clinically relevant change has ranged from 3.5% to 9.5% depending on the respective author54. We used the percentage of 8.4% applied by Jorritsma et al.55. The Hospital Anxiety and Depression Scale-German version (HADS-D) were evaluated only on the first day of therapy, because no changes were expected during hospitalization. Scores from 0 to 7 are normal, scores from 8 to 10 borderline abnormal, and scores higher than 10 are abnormal for both anxiety and depression57.Data were recorded daily in a standardized manner. The data obtained before, during, and after treatment were compared to assess the treatment success at the end of hospitalization. Besides the numerical rating scale (NRS) for neck and arm pain as a main evaluation criterion, the validated German version of the Neck Disability Index (NDI)58. Because these injections were only given on Tuesdays or Fridays, some sort of randomisation was provided on what day of hospitalisation the epidural injection was given. Patients were admitted to hospital from Monday to Friday. At the end of the stay all collected data were pseudonymized saved. Primary outcome was pain reduction >NRS 2 for arm and neck pain.To assess the effect of cervical epidural injection as conducted for triamcinolone without any local anaesthetics, pain reduction was evaluated 2 days after injectionStatistical analysis was done with SPSS . Metric variables were reported descriptively as mean and standard deviation. Statistical data were not normally distributed. Data were compared with the non-parametric Wilcoxon test. The level of significance was set at p < 0.05. A sample size of n = 54 resulted in 80% power to detect a significant effect, if the true effect size of the total population was d = 0.39, which can be considered small.The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.The Neck Disability Index (NDI) is used to measure everyday impairment. The mean value at the initial examination on day 1 was 37.1%. As described above, the minimal clinically relevant change was set at 8.4%. There was a significant improvement (p < 0.001), 57.4% of the patients described pain reduction of more than 8.4%. The mean changes were 11.24% but started at −8, which means pain increase in one patient and pain reduction in 52% of patients.56. The results for anxiety and depression can be seen in Table The Hospital Anxiety and Depression Scale (HADS-D) was additionally used to detect possible psychological abnormalities50.The median NRS value for neck pain was 6.0 (5.7–6.8) before treatment and 2.25 2.0–3.1) at discharge. The NRS value for arm pain could be reduced from 5.9 4.8–6.0) to 2.0 (1.7–2.6).  patients described some dizziness as a side effect, but no severe adverse events were reported.The study aimed at showing the positive short-term effect of an inpatient multimodal therapeutic concept based on drug injections for patients with cervical radiculopathy with particular focus on cervical translaminar epidural steroid injection.Within this concept, we showed that neck pain improved from NRS 6.0 to 2.25 and arm pain from 5.9 to 2.0, and both values represent significant pain reduction (p < 0.001).68.5% (37) of the treated patients had experienced pain for more than 3 months. Thus, avoiding pain chronification or trying to reverse the effects is all the more important. The NDI score as a value for every day impairment had also improved during hospitalization.59 or the type of injection65. Conservative treatment options have been recommended in many reviews on cervical radiculopathy, ranging from different types of physiotherapy to waiting for remission by natural history. However, no multimodal treatment concept on an inpatient basis has been evaluated so far40.Only single methods are usually described as treatment options. Most studies have either compared different surgical approaches32.In times of low frequency outpatient treatment, first pain relief takes longer, bearing a high risk of pain chronification. In this study, the period of the first clinically relevant success with regard to pain reduction of more than NRS 2 was 4.4 days for neck pain and 4.1 days for arm pain. Because of the combination of several types of conservative treatment and 2 injections per day, patients receive different conservative treatments over a very short period of time, which leads to quick pain relief and thus − in combination with psychological lessons – tries to avoid chronification32. While reducing pain through injections, patients may take part in activating treatments as mentioned above. ‘Besides direct physical effects, the accompanying therapies also help to improve the affective-emotional level as well as the motor-psychomotor level by learning physically regulating movements. The focus is on activating methods, not on passive methods’32.Particularly physical activation is the key to successful conservative treatment. ‘The aim of the accompanying methods is to preserve or restore the full capacity of the spine-stabilizing muscles, to train coordination skills and to learn spine friendly behaviour. Risk factors that can lead to chronic pain must be eliminated. All methods serve to interrupt the vicious circle of “pain−stress−malposition−pain”With this study, we showed that there is the wanted effect on neck and arm pain. Therefore, these data also support our concept of interrupting the vicious circle of ‘pain–stress–malposition–pain’. It is clear, that a restauration of the full capacity of the spine-stabilizing muscles cannot be achieved after just 10 days, but this intensive treatment should be the cornerstone for further exercises.66. This supports our idea of reducing pain by injections first. Cervical traction and immobilization has been supported in some studies to calm the symptoms associated with cervical radiculopathy67. Also cervical traction may increase the dimensions of the neuroforamen by distraction. A recent prospective randomized clinical trial found that adding mechanical traction to an exercise protocol in patients with cervical radiculopathy resulted in superior outcomes  when compared with exercise plus over door traction, or exercise alone68. As traction was not included in our therapy yet, further investigation of this effect within our concept will be interesting. It has also been shown that neck-specific exercises with and without behavioral approach has better results than general physical activity36.Many studies show positive effects of different types of exercises. Cervical range of motion and strengthening exercises are typically not recommended when patients are symptomatic as these movements may exacerbate symptoms69.Another important part of the MPM are the psychological lessons. Psychosocial interventions should be offered in addition to the medical treatment to patients to reduce the risk of chronic pain. The efficacy of such an interdisciplinary care has been shown22. In addition, many reports have described severe complications, but Pountos et al. stated in their review that ‘the true incidence of such complications remains unclear.’ The most devastating complications such as paralysis are very rare and have been limited to case reports64. Minor adverse events have an incidence of less than 1% and are generally transient42. But controversial discussions are still part of the scientific literature. There even was a Food and Drug Administration (FDA) warning on April 23, 2014, with regard to injecting corticosteroids into the epidural space of the spine71. Other reviews have described cervical epidural steroid injections as ‘effective in easing pain and reducing the need for surgery’, although ‘the evidence of effectiveness is of very low quality, and the benefits of the procedure are compromised by the risks of serious complications’61. Furthermore, the use of non‐particulate vs. particulate steroids has been discussed. In our opinion, particulate steroids, similar to triamcinolone, remain locally effective far longer because the particles remain at the site of the injection72. On the other hand, this mechanism may lead to the described severe complications because of intravascular injection73. In addition, Shakir et al. showed that transforaminal epidural steroid injections have similar benefits, independent of the type of corticosteroid formulation used (triamcinolone or dexamethasone)58. After analysis of the complications, the FDA recommended an interlaminar approach instead of a transforaminal approach as well as the use of non-particulate steroids to minimize the risk of accidental arterial uptake and neurological damage71. In our therapy concept, we always use the interlaminar approach as described by Grifka et al.21. Over the past 16 years, we have always used triamcinolone as particulate steroid without any severe complications. In our study population, 4 patients described some dizziness for a few hours after the injection. Because these injections are given in our operating theatre, we often observe this phenomenon that is mainly caused by higher blood pressure due to the agitation of the patients. Thus, in our multimodal pain concept, epidural steroid injection has been a very effective tool for reducing pain in addition to the ‘normal’ daily injections.In this study, special focus was placed on the effect of cervical translaminar epidural steroid injection. Although, epidural injections have now been used for many years and are the only effective, non-operative tool for managing cervical radiculopathy, the use of corticosteroid is still ‘off-label’ worldwideThe biggest limitation of this study may be the lack of a general control group. However, implementation of a control group is difficult when evaluating the overall concept of MPM and not just the sub-item ‘injections’. Moreover, study populations may have some selection bias because patients are only included after failed outpatient unimodal therapy. Therefore, study populations may have a trend towards chronification. Another possible bias might be, that the data collection was not anonymous and therefore the patients might want to please their caregiver. Another limitation is the short follow-up and the effect after discharge is not known. Future studies will have to show the mid- and long-term effect of this therapy.In summary, this study showed MPM based on injections to be an efficient treatment option for cervical radiculopathy. Despite several reports on severe complications published in the literature, MPM appears to be a safe procedure, and transforaminal epidural steroid injection may be an important factor of this concept. In the absence of an absolute indication for surgery, this is a treatment option that could be tried before surgery.The study was approved by the Ethics Commission of the University of Regensburg and carried out in accordance with the approved guidelines. Registration in Deutsche Register Klinischer Studien (DRKS), German Clinical Trials Register DRKS00011788.


A small subset of patients who underwent successful vertebral compression fracture (VCF) augmentation procedures may develop subsequent pain requiring spinal injections. In a retrospective analysis, we determined whether the pain was related to the original fracture site or to another area within the lumbar or thoracic spine. The pain occurred either at the same/adjacent level and/or non-adjacent level as the VCF. Interventional treatments primarily targeted the facet joints, specifically in the form of facet joint blocks and/or radiofrequency ablation to the medial branches. The pattern of facet injections relative to the original fracture level was studied. Additionally, the elapsed time between the vertebral augmentation and the subsequent interventional blocks was also evaluated.A total of 56 patients sustained VCFs. 12 of these patients underwent interventional procedures after vertebral augmentation procedures. The level(s) of same/adjacent level and non-adjacent level pain were determined via physical examination and/or imaging studies. These levels were subsequently treated with interventional procedures primarily focused on the facet joints. The time period of the injections varied from two weeks status post-vertebral augmentation to as late as 304 weeks (5.8 years) status post-vertebral augmentation.We performed 25 vertebral augmentation procedures on these 12 patients. 15 lumbar, eight lower thoracic, and two mid-thoracic VCFs were augmented. 9/14 cases of blocks included those performed at non-adjacent levels, whereas 5/14 cases of blocks were performed only at the same and/or adjacent levels as the VCF. For the events in which thoracic VCFs were augmented, 6/7 (or 86%) had developed non-adjacent level pain in areas of the lumbar spine. The time from vertebral augmentation procedure to subsequent pain procedure ranged from two weeks to five plus years. The average time elapsed was 83 weeks. Only one case required blocks performed within the first six weeks after vertebral augmentation. In this case, the blocks included those at non-adjacent levels. A total of 4/12 cases (33%) had a block within 12 weeks of the original vertebral augmentation procedure.Lumbar spine imaging showed that at least 9/12 patients had pre-existing significant lumbar pathology at the time of fracture treatment. This may have contributed to the later development of pain.Pain after a successful vertebral augmentation is typically non-acute . Mechanisms other than the primary VCF are usually responsible for non-adjacent level pain, which are present a majority of the time on reviewing the patients' diagnostic studies. These mechanisms usually take many weeks to develop and subsequently elicit pain that requires additional interventional pain procedures. In our study, the pain is usually related to the pre-existing degenerative spondylosis and stenosis rather than the fracture site. This study shows that the facet joints in closely related lumbar degenerative changes are the cause of pain in this patient group. These procedures should be explored with pain after vertebral augmentation, especially in those patients with known or suspected spinal degeneration and/or poor biomechanics. In 2007, Georgy reviewed a subset of patients from a larger group who underwent vertebral compression fracture (VCF) augmentation procedures and subsequently required spinal injections to reduce pain . He statWe performed a retrospective analysis of our patient database, reviewing all patients who underwent vertebral augmentation and later had some post-procedure pain, requiring another interventional pain procedure. We documented whether the pain was related to the original fracture site or related to another area within the lumbar or thoracic spine either at the same/adjacent level and/or non-adjacent level. The elapsed time of the pain in relation to when the fracture was treated was also evaluated. The normal post-operative period was considered six weeks. Interventional pain management targeted the facet joint rather than the epidural space as the major source of pain. Interventional treatments consisted of primarily facet joint blocks and/or radiofrequency ablation to the medial branches in the majority with several patients also having epidural or sacroiliac joint blocks. The pattern of facet injections relative to the original fracture level was then analyzed showing that pain procedures in the first six weeks post-operatively were actually the exception. The later pain was related to chronic spinal pain often delayed by many months or years due to associated general spinal degenerative changes, poor body mechanics, and lack of exercise in this age group rather than specifically as a result of the treated fracture.Informed consent was obtained from the patients for this study. We analyzed the data of 56 patients who sustained VCFs. We included only those patients who underwent interventional blocks after vertebral augmentation procedures. 12 patients fulfilled this criterion. 10 of the 12 only had one interventional procedure while 2/12 had a second procedure, thus there were 14 different events. For those patients with persistent pain, we determined the level(s) of same/adjacent level and non-adjacent level pain via physical examination and/or imaging studies which included plain radiographs, computed tomography (CT), magnetic resonance imaging (MRI), and/or bone scan. We subsequently performed interventional procedures primarily focused on the facet joints. The time period of the injections varied from two weeks status post-vertebral augmentation to as late as 304 weeks (5.8 years) status post-vertebral augmentation. If the pain location after vertebral augmentation was at the same and/or adjacent levels as the previously augmented vertebra, we then treated the same and/or adjacent levels with interventional blocks, primarily at the facet joints above and below the level fractured, as well as at the level of the fracture. If patients had non-adjacent level pain, then the areas of subsequent pain generation were effectively treated with interventional blocks based on both clinical examination and radiologic studies. Office follow-ups were scheduled two and six weeks post-procedure.Please refer to Table 21% (or 12/56) of the total group of patients reviewed after vertebral augmentation had sufficient pain requiring interventional pain management and fit the study inclusion criteria. The average age of the 12 patients in our inclusion group was 78 years old. 10 patients were female and two were male. 12 patients had one interventional event, while two had two separate events. We performed 25 vertebral augmentation procedures  on these 12 patients. 15 lumbar, eight lower thoracic, and two mid-thoracic VCFs were augmented. The time from vertebral augmentation procedure to subsequent pain procedure varied from two weeks to over 306 weeks (or 5.8 years). 9/14 cases (66%) of blocks included those performed at non-adjacent levels while 5/14 cases (33%) of blocks were performed only at the same and/or adjacent levels as the VCF. For the events in which thoracic VCFs were augmented only one had a subsequent facet injection for pain adjacent to the thoracic fracture, while 6/7 (or 86%) had developed non-adjacent level pain in areas in the lumbar spine.The average time elapsed between the patients undergoing vertebral augmentation and subsequent interventional blocks was 83 weeks (1.6 years). Only one case (event #1) had blocks performed within the first six weeks status post-vertebral augmentation. If we consider the entire group of 56 cases, this suggests that significant pain after vertebral augmentation requiring an interventional pain procedure is very uncommon . In this case, the facet blocks performed included those at non-adjacent levels. A total of 4/12 cases (33%) had a block within 12 weeks of the original vertebral augmentation procedure. Of note is that 3/5 ESIs were performed on the patients who required interventional procedures within the first 10 weeks after the vertebral augmentation. The average pre-procedure visual analog scale (VAS) was eight, while the average post-procedure VAS was 4.5 on their first follow-up visit (two weeks post-procedure) and 2.5 on their second follow-up visit (six weeks post-procedure).When reviewing other lumbar pathology seen on MRI or CT of these patients at the time of VCF diagnosis, 3/12 had L4-5 degenerative spondylolisthesis, 3/12 had lumbar stenosis (not including patients with L4-5 spondylolisthesis) and 2/12 had degenerative lumbar scoliosis. Therefore, at least 8/12 (67%) had significant spinal stenosis or lumbar degenerative disease. Additionally, 1/12 had L3-4 anterolisthesis and 1/12 had multiple previous lumbar fractures. Thus, in our group, at least 10/12 had pre-existing significant lumbar pathology on MRI/CT scans at the time of fracture treatment. This may have been a major factor in the later development of pain.In Georgy's study, over a 12 month period, 144 patients underwent vertebral augmentation and 24% of these patients required interventional pain procedures afterwards [We found a very similar percent, 21%, requiring interventional pain procedures after vertebral augmentation. Less than 2% of the entire group required interventional pain procedures within the first six weeks; however, 86% of interventional blocks after thoracic VCFs were in the lumbar spine. In reviewing imaging at the time of the fracture, 10/12 (83%) had significant lumbar degenerative disease characterized by lumbar stenosis, scoliosis, or spondylolisthesis. Lumbar ESIs are usually indicated in the presence of a herniated disc and/or nerve root compression/inflammation, which may result in radicular pain down the leg. We only found ESIs to be appropriate in 5/14 events, representing patients with spinal stenosis, spondylolisthesis, and/or herniated nucleus pulposus (HNPs). On the contrary, the facet joints are typical generators of axial back pain, which may cause a referred pain. Actually, facet blocks were the mainstay of interventional pain treatment prior to the existence of vertebral augmentation techniques. We performed facet interventions in all 14 events, as the pain represented a more specific axial location and possible pain referral pattern, which was applicable in all 14 events. Our interventions were more focused on targeting specific pain generators based on the location of pain and follow-up CT and MRI scans for more specific results of pain relief.Pain after a vertebral augmentation procedure could either be residual from the procedure, however new, or increasing pain could develop and needs to be evaluated regarding the known complications of osteoporotic fractures and vertebral augmentation . GaughenIn our group, only one patient out of the 12 required a pain intervention within the first six weeks after vertebral augmentation. This could actually be extrapolated to include all 56 of our patients who sustained VCFs and had vertebral augmentation procedures, as only one out of 56 patients (or less than 2%) had a pain procedure within six weeks after vertebral augmentation. This one patient had multiple interventions, one of which included a non-adjacent level. Out of the remaining cases, all of which took longer than six weeks to undergo subsequent interventions, the majority of them, specifically 9/13 (70%), had interventions performed at non-adjacent levels. The majority of these events had concurrent lumbar spine pathology documented on imaging studies, as noted in Table Please refer to Figure Prior to proceding with interventional treatment, conservative treatment is paramount in preventing future injury and pain with VCFs. Physical therapy mainly consists of extension-based exercises to strengthen the surrounding musculature. Flexion of the thoracolumbar spine is typically contraindicated. Huntoon, et al. (2008) demonstrated that patients who underwent vertebral augmentation and subsequently participated in an extension-based strengthening exercise program had a significantly longer median time to re-fracture than those who only underwent vertebral augmentation . Additio21% of patients after vertebral augmentation had post-procedure pain that required an interventional pain procedure. This is similar to other previous reports; however, the majority of patients in our study had delayed pain greater than three months after the initial vertebral augmentation that was related to other spinal pathology. If the patient develops pain at a later time, it is often distinguishable from the fracture site pain and, as we show, is usually related to the pre-existing degenerative spondylosis and stenosis rather than the fracture site. If routine conservative treatment, including medications and therapy, is ineffective, this study shows that interventions targeting the facet joints based on the pain location are effective. ESIs with non-specified levels do not allow for the same specificity of interventional pain relief as do facet joint interventions. This study shows that lumbar degenerative changes are closely related to the pain in elderly patients with residual or new pain after previous vertebral augmentation. The facet joints should be the focus of treatment in those patients with known or suspected spinal degeneration.


Background. Because of economic reasons, day surgery rates have steadily increased in many countries and the trend is to perform around 70% of all surgical procedures as day surgery. Literature shows that postoperative pain treatment remains unfulfilled in several fields such as orthopedic and general surgery patients. In Italy, the day surgery program is not yet under governmental authority and is managed regionally by local practices. Aim. To investigate the trends in pain intensity and its relation to type of surgeries and pain therapy protocols, in postoperative patients, discharged from three different Ambulatory Surgeries located in North West Italy (Piedmont region). Method. The present study enrolled 276 patients who undergone different surgical procedures in ambulatory regimen. Patients recorded postoperative pain score twice a day, compliance with prescribed drugs, and pain related reasons for contacting the hospital. Monitoring lasted for 7 days. Results. At discharge, 72% of patients were under weak opioids, 12% interrupted the treatment due to side effects, 17% of patients required extra drugs, and 15% contacted the hospital reporting pain problems. About 50% of patients experienced moderate pain during the first day after surgery. Results from our study show that most of the patients experienced avoidable pain after discharge. To enable rapid discharge and more efficient use of beds, many surgeries are performed in ambulatory regimens; in the near future, advances in techniques and methods will allow 50 to 75% of all surgical conditions to be treated on a day basis .Italy is currently performing about 29% of all surgery in ambulatory regimen and since only larger hospitals have dedicated units, it is mainly carried out in hospital facilities .Day surgery requires patient safety and satisfaction with care: good analgesia is said to be one of the key factors for successful ambulatory surgery . PostopeThe level of pain 48 hours after surgery is a good predictor for returning to work; the more severe reported pain at 48 hours, the greater risk for the patient to resume normal activity within one week . Even miPostoperative pain assessment and treatment are also clinically important since pain is related to increased vascular resistance and cardiac workload, particularly in the elderly . FurtherBefore the year 2010, studies reported moderate-to-severe pain scores in more than 30% of day hospital patients 24 hours after surgery , 10, andRecently, studies reported moderate-to-severe pain after hospital discharge  in 50% of patients after 48 hours and in 40% still after one week; moderate-to-severe pain can persist in 20 to 30% of patients after 3 to 4 months , 13.One of the strongest unique predictors of satisfaction with treatment is patients' belief that their pain has been thoroughly evaluated  but studA large survey showed that even anesthesiologists believe that postoperative pain in day surgery still seems to be a problem and that almost half of the ambulatory patients experience high pain scores at home .Several studies carried out in countries with high rates of day surgery activities and standardized procedures have shown that day surgery procedures vary greatly across European countries  and the The recent large POPSI and POPSI-2 studies  have indicated that the management of postoperative pain in Italy is still suboptimal and below European standards , 20.Italian care settings, perioperative therapies, and home prescriptions after day surgery vary among different hospitals. In 2012 about 55% of Italian anesthesiologists stated that they used hospital protocols and 13% did not use any protocols; this was more likely to occur in Northern Regions [The aim of this paper is to investigate the incidence and the course of postoperative pain one week after ambulatory surgery and patients home habits related to prescribed therapy. To our knowledge there are no Italian studies on postoperative pain after day surgery and patients' behavior towards drugs after discharge.A prospective 3-month observational study was carried out in a convenience sample of 3 different day surgery units in Piedmont Hospitals  in 2012. All patients over 18 years of age, being able to fluently speak in Italian and undergoing surgery in ambulatory regimen, were included.http://dx.doi.org/10.1155/2016/6104383) at discharge in which they recorded twice daily (8 am and 8 pm) for 7 days the pain experienced on a numeric scale (NRS) from 0 (no pain) to 10 (maximum pain). Patients were asked to report compliance with prescribed drugs and reasons for stopping drug use, any other pain treatment, and reasons for contacting general practitioners or hospital staff.Demographic data, type of surgery, anesthesia modality, prescribed drugs and other treatments, pain killers in the first 24 hours, and treatment compliance were collected. Survey started on day of surgery (day 1), ending on day seven. Patients received a diary ; (ii) weak opioids ; and (iii) strong opioids . Intravenous infusions were positioned at the exit of the operating room and maintained up to the time of discharge.In the three examined settings, perioperative therapy and home prescriptions after day surgery vary and they are prescribed on the basis of hospital protocols or on the basis of anesthetists or surgeons' experiences and preferences. Due to the heterogeneity of these hospitals, drugs were coded for data analysis on the WHO ladder as follows , 22: (i) opioids (500 mg of acetaminophen with 30 mg of codeine) on a regular basis or PRN.Analgesic protocols consisted of oral tablets; agents, doses, and administration frequency were prescribed at discharge by ward surgeons. For the descriptive analysis drugs were coded on the WHO ladder as follows , 22: (i)Continuous data were analyzed as means (standard deviations) or median (range) according to the type of distribution. Discrete data were analyzed as counts and percentages. A threshold of NRS ≥ 4 was used to discriminate between mild and moderate-to-severe pain of postoperative average pain intensity . NRS scoTherapy at discharge and type of anesthesia were analyzed using mixed-effects regression models to identify associations between NRS scores over time and type of surgery. A compound symmetry structure for repeated measurements of the same patients (at 24 and 48 hours and 7 days) corresponding to a constant correlation over time resulted in the best model fit based on Akaike Information Criterion (AIC) values. Adjustment for sex and age was considered.All analyses were performed using R  version 2.15.Institutional Review Board of each hospital approved the study. Patients were identified only by the nurses on duty, and data collection forms were stored in a locked area accessible only by authorized personnel until data entry was completed. All patients signed an informed consent form.A total of 276 patients were recruited  with a mAround 84% of patients received regional anesthesia and 16% general anesthesia. Analgesia techniques  varied aPain therapy after surgery in the recovery room included intravenous nonopioids (48%), weak opioids (39%), and strong opioids (13%). During the postoperative hours , 59% of At discharge , prescriPostoperative pain varied across surgeries . ModeratAlthough numbers were limited, about 30% of patients who were prescribed weak opioids on a regular basis and about 70% of patients who were prescribed weak opioids drugs PRN experienced moderate-to-severe pain at 24 and 48 hours .p < 0.001) and 2.91 . Patients who took extra drugs, at home, have significantly higher level of pain . Pain is decreased by a further 0.89 points (orthopedic surgery) and 0.77 points  every 12 hours, p < 0.01. Hand surgery was significantly less painful than valgus toe surgery as well as tumor/cyst removal as compared to laparoscopic cholecystectomy. The hospital effect is negligible for both orthopedic and general surgery.Regression analysis  shows a Overall 11% of patients took no analgesics at home; about 76% of them had no or only mild pain, but the other patients experienced moderate-to-severe pain.About 15% of patients contacted health care professionals because of pain: the general practitioner, the emergency department, or the surgical ward. Eight of these patients had mild pain, 16 patients had moderate pain, and 13 patients had severe pain.Forty-six patients (16.7%) took extra analgesics: half of them underwent valgus toe surgeries and knee arthroscopies and half of these patients underwent herniorrhaphies, hemorrhoidectomies, and exercises.Nonpharmacological interventions for pain control at home were reported by 17.8% of patients; 83% used ice bags, and the other used massage.Early discharge is increasingly being adopted and demands a rapid recovery and low incidence and intensity of surgery and anesthesia related side effects to guarantee feasibility of self-care at home.The present study demonstrates, in accordance with the literature, that postoperative pain is an important factor complicating recovery and discharge of patients after day surgery procedures.Prevalence of pain after orthopedic and general surgeries is consistent with recent studies in other countries , 23–25.After one week, patients who had undergone hemorrhoidectomy and valgus toe surgery still experienced moderate-to-severe pain. This is an unmanaged problem that even affects long-term outcomes. High levels of pain 4 days after surgery were associated with a worse quality of life at 6 months . ViñolesPain management strategies show some differences among patients that could be explained with the different prescriptions protocols adopted by each surgeon. The literature shows different sight on pain intensity and duration related to surgical procedure. A recent study demonstrated that inpatients undergoing minor surgeries reported high pain score but often were ignored or not taken seriously, so that analgesic administration was delayed and/or insufficient .The general strategy for perioperative pain control is fundamentally founded on the use of systemic analgesics, by intravenous or oral route, with few targeted to the individual patient's needs. Many anesthesiologists preferred this approach because it is easy to use and can be managed by nurses as well as being considered cheaper .Although not recommended, PRN drugs are prescribed as the primary pain therapy for all surgeries except for laparoscopic surgery , 27.Several alternatives that seem to provide better pain relief, such as patient controlled regional analgesia (PCA) and regional blocks with catheters in situ, are reported in guidelines . HoweverIndividual patient variability is a well-known topic: for the same surgical intervention and painkillers administered, patients report different levels of pain and response. This problem seems to be unsolvable but surely manageable if the patient could be monitored more closely and fastened follow-up after discharge .Only 50% of all Italian hospitals have an active APS (Acute Pain Service), and improving postoperative pain control is affected by organizational and cultural barriers . No hospPatient behaviors at home confirm that pain is a multifactorial experience not just a symptom, and patient tends to manage it in “his/her own way.” Some patients take analgesics only when “really needed” while others take nothing “even when it is needed.” This suggests that informing a patient does not mean involving a patient and that preoperative and postoperative care should be improved .Furthermore, clinical information provided by physicians and nurses before surgery during few minutes session often overload patients with details which are difficult to process and retain .We observed that ice bags were used only by 20% of patients while they were routinely recommended after each orthopedic procedure, and the reasons for lack of compliance should be explored. Other studies demonstrated that only a limited number of patients (3% of shoulder and 4% of hand surgery patients) used cold treatment . PatientDespite the data being collected in 2012, the anesthesiology procedures and pain treatment strategies have remained substantially the same, so they are still up-to-date.t-test.There are some limitations in the study. First, it was carried out on a convenience sample without a formal sample calculation because of the explorative nature of the study. On the basis of a posterior power analysis, the sample size of 276 patients allows for a power of 79% to assess a difference of 1 point in pain score over time, considering a standard deviation of 3 points and a I-type error of 5% on the basis of a paired In the study we gave priority to the simplicity of compilation tools and we did not consider other important outcomes factors like pain during ambulation. This is probably one of the most important pain factors for ambulatory patients since they have to cope with pain during movement at home with limited additional aid.We have not investigated the surgical technique because of hospital organizational settings.Several patients in this study received a local or spinal anesthesia, so pain intensities collected in this cohort study may differ from those obtained with other patients group.Awareness of postoperative pain intensity after day surgery procedures may contribute to improving postoperative care by implementation of specific pain treatment protocols and home follow-up.One of the key elements of a safe discharge home of day surgery patients is good knowledge of the postoperative course, including pain management. Our data indicate that pain varied widely across patients and surgeries, emphasizing the need for personalized pain treatment. Preoperative screening for patients who are at risk of postoperative pain would enable personalized pain control interventions and closer patient follow-up allowing management of tailored therapy based on the real need. Management of pain and side effects of painkillers should be a priority for quality improvements of day surgery program.The data collection form was filled in by nurses while the diary was completed by patients from the time of surgery until the end of the seventh day after surgery and returned to the follow-up visit.


The purpose of this study was to explore the neural mechanism in Chronic prostatitis/Chronic pelvic pain syndrome (CP/CPPS) using resting-state functional magnetic resonance imaging. The functional magnetic resonance imaging was performed on 31 male CP/CPPS-patients and 31 age and education matched male healthy controls on a 3-T magnetic resonance imaging unit. A two-sample t-test was adopted to reveal the regional homogeneity between the patients and healthy controls. The mean regional homogeneity values in the alerted brain regions of patients were correlated with the clinical measurements by using Pearson's correlation analyses. The CP/CPPS-patients had significantly decreased regional homogeneity in the bilateral anterior cingulate cortices, insular cortices and right medial prefrontal cortex, while significantly increased regional homogeneity in the brainstem and right thalamus compared with the healthy controls. In the CP/CPPS-patients, the mean regional homogeneity value in the left anterior cingulate cortex, bilateral insular cortices and brainstem were respectively correlated with the National Institutes of Health Chronic Prostatitis Symptom Index total score and pain subscale. These brain regions are important in the pain modulation process. Therefore, an impaired pain modulatory system, either by decreased descending pain inhibition or enhanced pain facilitation, may explain the pain symptoms in CP/CPPS. Chronic prostatitis/Chronic pelvic pain syndrome (CP/CPPS), the most frequent form prostatitis in men , has a pRegional homogeneity (ReHo) has been developed to explore the regional spontaneous activity with similar or synchronous hemodynamic characteristics in the voxelwise analysis . ReHo waIn this study, we thereby applied the functional magnetic resonance imaging (fMRI) with ReHo method to investigate the neural mechanism of CP/CPPS in the patients without spontaneous pelvic pain during resting-state. We hypothesized that the altered ReHo would be found in the certain brain regions, especially related to the ACC and INC in CP/CPPS.31 male CP/CPPS-patients and 31 age and education matched male healthy controls were enrolled between October 2013 and May 2016 in this study. Both of the patients and healthy controls were right-handed. The inclusion criteria for CP/CPPS-patients were as follows: (a) the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) total score 15 or greater ; (b) patThe resting-state fMRI data and high resolution T1-weighted magnetic resonance images were obtained by using a 3-T MRI unit  with an eight-channel phase array head coil. The fMRI images were acquired with an echo-planar imaging sequence . The high resolution T1-weighted magnetic resonance images were acquired with a three-dimensional fast spoiled gradient-echo dual-echo sequence . The authors had access to information that could identify individual participants during or after data collection in this case-control study.http://www.fil.ion.ucl.ac.uk/spm/software/spm5) and Data Processing Assistant for Resting-State Functional MRI V2.2 Basic Edition (http://www.restfmri.net) softwares. We discarded the first 10 volumes of each functional time series. The remaining images were corrected for acquisition time delay between different slices and realigned to the first volume. The head motion of each participant was less than 2 mm translation in any cardinal direction and 2 degrees rotation in x, y or z axe. The resting-state fMRI data were then spatially normalized to the Montreal Neurological Institute space. The linear drift and the average blood oxygen level-dependent signals in ventricular and white matter regions were removed. A band-pass filtration (0.01–0.08 Hz) was performed to reduce the noise. The Kendall coefficient of concordance was used to measure the correlation of the time series with its 26 nearest neighboring voxels. Individual ReHo maps were generated by calculating the Kendall coefficient of concordance. After the ReHo calculation, a Gaussian kernel with a full width at half-maximum of 4 mm was used to smooth the ReHo image in order to reduce noise and residual differences. The mean ReHo value of the voxels in the alerted brain regions was extracted for each patient.The resting-state fMRI data were processed by the Statistical Parametric Mapping 5  standard score  and ZungTwo-sample t-tests were used to identify the differences in the whole brain ReHo maps between the CP/CPPS-patients and the healthy controls. Results were thresholded at p < 0.05 . The mean ReHo values in the alerted brain regions of patients were correlated with the NIH-CPSI total score and NIH-CPSI pain subscale by using Pearson's correlation analyses. Results were thresholded at p < 0.05/8 (Bonferroni corrected). The age, SAS standard score and SDS standard score were considered as covariances of no interest. The education was not included as a covariate due to its matching between the CP/CPPS-patients and the healthy controls.In comparison with the healthy controls, CP/CPPS-patients had significantly decreased Reho in the bilateral ACCs , INCs F and righIn the CP/CPPS-patients, NIH-CPSI total score had significantly negative correlations with the mean ReHo value in the left ACC  , left INIn the present study, our results showed that the CP/CPPS-patients had significantly decreased ReHo in the bilateral ACCs, INCs and right mPFC, while increased ReHo in the brainstem and right thalamus compared with the healthy controls. These findings may be helpful for further revealing the neural mechanism of CP/CPPS.A number of previous studies have shown that the ACC ,16 and IIn addition, we found that the mean ReHo value of left ACC and bilateral INCs was inversely correlated with the NIH-CPSI total score. Therefore, we suggest that the impaired descending pain inhibition lead to insufficiently suppressing nociceptive input in CP/CPPS. Moreover, the left ACC in the dominant hemisphere may have a closer relationship with the regulation than the right ACC in CP/CPPS. It was consistent with the results of a previous study reported by Mordasini et al  that theThe mPFC, especially in the right hemisphere, is also involved in the descending pain regulation . The actThe ascending pain pathways also play important roles in the pain modulation . There eBrainstem is also important in the descending pain regulation that could be disrupted by the chronic pain . In thisThis study had some limitations. First, we only used the volume-based ReHo method to examine the neural mechanism of CP/CPPS in the current study. However, the partial volume effects were salient in the voxels close to the boundary between the gray matter and white matter . The surIn conclusion, an impaired pain modulatory system, either by decreased descending pain inhibition or enhanced pain facilitation, may explain the pain symptoms in CP/CPPS.


To assess the influence of the body weight in functional capacity and pain of adult and elderly individuals with knee osteoarthritis.t test, with significance level set at 5%. The sample consisted of 107 adult and elderly patients with knee osteoarthritis divided into two groups (adequate weight/adiposity and excessive weight/adiposity) according to body mass index and percent of body fat mass, assessed by electric bioimpedance. Subjects were evaluated for functional mobility (Timed Up and Go Test), pain, stiffness and function (Western Ontario and MacMaster Universities Osteoarthritis Index − WOMAC), pain intensity  and pressure pain tolerance threshold . Data were analyzed with Statistical Package of the Social Sciences, version 22 for Windows. Comparisons between groups were made through Student’s  There was predominance of females in the sample (81.3%), and mean age was 61.8±10.1 years. When dividing the sample by both body mass index and adiposity, 89.7% of them had weight/adiposity excess, and 59.8% were obese. There was no difference between groups regarding age, pain intensity, pressure pain tolerance threshold, functional mobility, stiffness and function. However, pain (WOMAC) was higher (p=0.05) in the group of patients with weight or adiposity excess, and pain perception according to VAS was worse in the group of obese patients (p=0.05). Excessive weight had negative impact in patients with osteoarthritis, increasing pain assessed by WOMAC or VAS, although no differences were observed in functionality and pressure pain tolerance. It impairs the knees of around 10% of women and 13% of men above 60 years of age. The proportion of symptomatic individuals is increasing due to population ageing and a rise in obesity rates in many countries.Osteoarthritis (OA), one of the most prevalent chronic diseases worldwide, is the most common articular disorder and affects 50% or more elderly individuals.,2 It(-) Among the etiological factors of the disease, increased body weight must be highlighted since it causes more articular pressure, contributing to cartilage degeneration, sclerosis of the subchondral bone and formation of osteophytes. This probably explains the fact that obese individuals present three times more risk of developing OA when compared to the ones with a healthy weight.Osteoarthritis is the main cause of pain, incapacity and decreased quality of life of the elderly.-6 Am Body weight reduction has been recommended as an important component of OA treatment. There are reports of reduction in pain and physical disability in patients with OA and weight excess after moderate reduction in body weight. In addition to the mechanical overload produced by the excessive weight, there is a possible influence of adipocytokines and altered carbohydrate and lipid metabolism, that may generate characteristic changes of a chronic inflammatory state observed in these patients.Weight excess is considered to be a modifiable risk factor for OA.4 Body Nonetheless, the sample was relatively small (n=35), and the authors recognized that a body composition assessment could bring more accurate results, since the isolated use of the BMI does not allow differentiation between fat and lean mass.A recent study compared obese and non-obese elderly individuals with knee OA based on the body mass index (BMI), and showed the obese ones presented less functional mobility, slower gait speed, higher pain intensity, and difficulty in performing daily living activities when compared to those with a healthy weight.13 Non acknowledging and understanding the factors that may interfere in functional capacity and pain in individuals with OA may contribute to the development of novel treatment and prevention strategies of such prevalent disease.Besides BMI, other more accurate ways to assess body composition may contribute to a better understanding about the impact of weight excess in OA. Since knowledge about the relation between weight excess and pain, especially in patients with OA, is limited,12 ackTo assess the influence of the body weight in functional capacity and pain of adult and elderly individuals with knee osteoarthritis.This was an observational transversal study of 107 adult and elderly individuals with knee OA. The research was conducted between August 2013 and November 2014. Participants were recruited by means of a screening among patients referred to the physical therapy department of a private university in São Paulo (SP), Brazil. Phone contact was made to the patients who had diagnosis of OA, and those interested in participating in the research were invited to attend a session to receive information about the investigation. All patients received physical therapy treatment after participation.Patients who met the following inclusion criteria were included in the study: diagnosis of OA, medical recommendation to participate in a physical therapy program, no chronic use of any medication (except the drugs prescribed for OA). Individuals with total or partial prosthesis in one or both knees or hips, decompensated hypertension or other heart diseases, rheumatoid arthritis, fibromyalgia or neurological disorders that could affect locomotion were excluded from the study.Patients who agreed in participating the research underwent the following assessments: anthropometry, body composition, pain, joint stiffness and functionality, as well as pressure pain tolerance threshold.2) was calculated from the weight and height, and participants were classified as having adequate body weight (BMI <25kg/m2) or excessive weight (BMI ≥25kg/m2).The anthropometric evaluation consisted of measures of weight and height. Body weight (kg) was assessed with the participants barefoot and with light clothes, in a digital scale, graduated in 0.1kg. Height (cm) was measured with a stadiometer graduated in 0.1cm. Body mass index . Participants were instructed not to eat for 4 hours before the test, to drink plenty of water , not to drink alcoholic beverages or substances containing caffeine 48 hours prior to the test, and not to perform strenuous physical activities 24 hours before the exam. Prior to the examination, volunteers were instructed to empty the bladder and remove metallic objects from the body. Participants remained at rest for 10 minutes before the evaluation. The classification of results regarding adiposity (%F) was made in accordance with the American College of Sports Medicine (ACSM) recommendation,15 bas was used to assess pain intensity. To evaluate pain, joint stiffness and functionality, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was employed in its Portuguese version. The WOMAC scores are presented in Likert scale, in which each question has a score ranging from zero to 100, distributed as follows: zero, if none; 25, little; 50, moderate; 75, severe; 100, very intense. Each of the dimensions  receives a score, transformed into a scale from zero  to 100 points .The Visual Analogue Scale (VAS)16 wasTo measure functional mobility, the Timed Up and Go (TUG) test was used. It consists of measuring in seconds the time spent by the individual to get up from a chair, walk 3m, go back and sit again. The test was repeated three times and the shortest time obtained was selected for the analysis.19 The pressure of 1kg/cm2 was applied at constant speed, at a 90° angle between the stimulation surface and the stimulated point, over all points to the extent the participant reported pain or discomfort. Reading was expressed in pounds and later converted into kilograms. During the evaluation, each participant was instructed to say “stop” as soon as the feeling of pressure went from unpleasant to painful. Some points in the vastus medialis and vastus lateralis muscles were assessed, as previously described.(22)Algometry was employed to evaluate the pressure pain tolerance threshold . The algometer is a hand device formed by a piston that contains a 1cm diameter rubber in one end, which is capable of recording, through its electronic device, the pressure applied on a given surface. Its reliability was previously demonstrated.,21 Tt test, with significance level set at 5% (p<0.05).Data were analyzed using the Statistical Package for the Social Sciences (SPSS), version 22, for Windows, and the results were expressed as means±standard deviation. The distribution of the data was analyzed using D’Agostino Pearson test. Comparisons between groups  were made through Student’s Centro Universitário Adventista de São Paulo, under protocol number 243,745, CAAE: 15199713.2.0000.5377. All research participants signed the informed consent form.The present study was approved by the Research Ethics Committee of The sample comprised 107 individuals with knee OA, predominantly females with mean age of 61.8±10.1 years . Most paData on pain  and functionality (TUG and WOMAC) of the total sample are shown in  in both cases, 89.7% of sample (n=96) had excessive weight/excessive adiposity. The predominance of women was significantly higher in the group with BMI ≥25 than in the group with BMI <25 (p=0.016). The same was observed for the adiposity groups: there was significantly more women in the group with excessive adiposity than the in group with adequate adiposity (p=0.001).When dividing the group by BMI (<25 and ≥25) and by %F ,15 in The group with BMI <25 had a mean BMI of 23.5±1.8, whereas in the group of patients with BMI ≥25, the mean BMI was 32.6±4.9. When divided by adiposity, the group that presented adequate adiposity had a mean BMI of 25.1±2.8, and in the group with excessive adiposity, the mean BMI was 32.5±5.2. Comparison between groups revealed that both the heavier BMI and those with higher adiposity (%F) presented significantly more pain when evaluated by WOMAC. However, there was no difference between groups regarding duration of pain, pain assessed by VAS, algometry and functionality .2) and non-obese (BMI ≥30kg/m2), as shown in Patients were also classified as obese (BMI <30kg/mIn both forms of classification used in this study (BMI and adiposity), individuals with OA who presented excessive weight or excessive adiposity differed in WOMAC pain results in relation to those who presented adequate weight and adiposity. However, contrary to this assumption and to the findings by Gomes-Neto et al., (who verified greater pain and disability in patients with BMI>25), the sample of the present study showed differences only in pain assessed by WOMAC, but none in functionality and stiffness evaluated by the same instrument. When classified as obese (BMI ≥30 and non-obese (BMI <30), groups were different regarding pain perception only (VAS).The literature reports that obese individuals are likely to overload their joints more and, therefore, have greater disabilities.23 How however, despite the lower absolute tolerance observed in individuals with excessive weight/excessive adiposity, no statistically significant differences were found between groups. This probably reflects the fact that the increase in body weight is related to the increase in pain.In addition to BMI, excessive adiposity may also be related to increased pain sensitivity,24 howRegarding the other forms of pain assessment employed in this study, although values of VAS and algometry were worse in the excessive weight/excessive adiposity or obese groups and better in the groups with adequate weight/adiposity and non-obese patients, no significant differences were found between them. In our sample, WOMAC was a more sensitive instrument to assess pain when weight or adiposity excess was the criteria to split groups. However, VAS was efficient in discriminating pain perception when patients were classified as obese or non-obese. in this study, unexpectedly, there was no difference between groups in the TUG test, which evaluates functional mobility by means of an activity involving standing up, walking and sitting down.Although pain intensity may influence the performance of functional activities in obese individuals with knee OA,26 in 2 and 15 with morbid obesity, BMI >40kg/m2), Vasconcelos et al., found that the degree of obesity had no impact on the symptoms of pain, stiffness and functional difficulties . The authors concluded that other factors should influence functional performance of obese women with knee OA. This may explain the fact that we found no difference in the time to perform TUG between the groups of this study. The mean differences of 0.3 seconds found between groups when separated by BMI (≥25 or ≥30), and 0.7 seconds when separated by adiposity, were not significant but show that these individuals probably have already experienced functional mobility problems, since their mean time to perform the test was higher than 10 seconds. However, a previous study showed even higher values in TUG of individuals with knee OA, and BMI similar to those of the patients in this study.When comparing women with bilateral knee OA  resulted in data very similar to those obtained when categorizing by adiposity (adequate or excessive).In the present study, besides using BMI as a classification criterion, as already done by other authors,13 we  This highlights the magnitude of the problem represented by excessive weight in OA patients, besides raising and reinforcing the thesis that only therapeutic exercises may not be fully effective for treating the disease. Likewise, the control of body weight and adiposity, education about the disease, cognitive-behavioral therapy, among other approaches, seem to be associated with a better management of chronic diseases, such as OA.It should also be noted that, in this study, weight or adiposity excess were very prevalent conditions in patients with knee OA. In the group of 107 patients studied, 89.7% presented excess of weight or adiposity when evaluated by BMI or %F, respectively, and 59.8% of them were obese (BMI ≥30). It is known that obesity, besides being widely recognized as a risk factor for OA, contributes to enhance severity of the disease.29 ThiFuture research with even more accurate methods of body composition assessment, such as computed tomography, can confirm the results of the present study, as well as establish relations between body composition and other variables that may influence the quality of life and functionality of individuals with knee OA.Participants from this study were recruited among individuals referred to a physical therapy department, and their weight and adiposity were evaluated along with other assessments prior to referral to treatment. All volunteers had diagnosis of OA, but no classification of the degree of the disease, which limits our conclusions. Although this form of selection has resulted in discrepant number of participants in both groups, this distribution probably reflects the actual condition of the body composition in patients with OA in the daily medical and rehabilitation practices. The low number of participants in the groups with adequate BMI and %F may have prevented the observation of some significant differences between groups. Despite these limitations, our results provide important new pieces of information on the influence of body weight and body composition in individuals with knee OA.Weight and adiposity excess or obesity had a negative impact in patients with osteoarthritis, increasing their pain perception. Although mean results of functional capacity and pressure pain tolerance were worse in patients with weight excess or adiposity excess, differences in these parameters did not reach statistical significance when compared with the adequate weight or adiposity groups.


On July 22, 2016, President Barack Obama signed a bill into law that could have the potential to impact our practice. The Comprehensive Addiction and Recovery Act (CARA) is aimed at curbing the national opioid epidemic, a troubling phenomenon leading to increased deaths from drug overdoses. The Centers for Disease Control and Prevention (CDC) report that almost 500,000 people died of drug overdoses from 2000 through 2014 , clearlyHowever, pain is a feared and fearsome symptom often experienced by patients with cancer. In oncology, advanced practitioners (APs) have struggled for decades with developing and implementing optimal and comprehensive ways to assess and effectively manage the significant pain that can often be associated with this disease.The new law authorizes $181 million in funding for state programs to fight opioid addiction and includes the following components :(1) A requirement that the US Department of Health and Human Services (HHS) create a task force for the study of best practices for chronic and acute pain management(2) A requirement to make naloxone more available and expand potential grants to states for the implementation of "standing orders" for the drug(3) Reauthorization of the National All Schedules Prescription Electronic Reporting (NASPERS) Act and grants for state drug-monitoring programs(4) Grants to states to combat the opioid epidemic and expansion of treatment for addiction(5) "Partial fills" for opioids, giving patients less than the original prescriptionObviously, the recreational use of opioids is dramatically different from their use in cancer pain. Additionally, the use of opioids for chronic, non–cancer-related pain can be a difficult and complicated issue. However, it is reasonable for APs working in oncology to be wary of new legislation that could potentially affect the optimal pain management for our patients that we strive for.This past May, ASCO released a policy statement on opioid therapy for patients with cancer. The policy focuses on this population and their unique needs, providing principles to address both the public health concerns and the mandate we have to provide appropriate pain management of our patients . A parti(1) Patients with cancer are a special population and should be mostly exempt from restrictive regulations or limited doses of opioids(2) Provider education is recommended and should be evidence-based and by specialty(3) Prescription limits should not be enacted for patients with cancer if allowed to impact their access to medication(4) Prescription drug-monitoring programs must consider the provider who is prescribing for cancer pain and the specialty, patient population, and additional factors that are appropriate in treating cancer pain(5) Patient screening and assessment before and during opioid treatment should be determined by the treating physician(6) Wider availability of naloxone is supported by ASCOJudy Paice, PhD, RN, an AP and champion of cancer pain management in patients for many years, is the lead author of ASCO’s most recent guideline for the management of chronic pain in survivors of adult cancers. The guideline notes that with our incredible advancements in cancer diagnosis and treatment, more individuals are living with a history of cancer than ever before . AlthougIt is my hope that the passage of CARA will not have the undesired effect of impacting our ability to appropriately manage pain in our patients with cancer. It is true that the opioid epidemic is causing opioid-related deaths in record numbers and that at least half of all opioid overdose deaths implicate a prescription opioid. The management of non–cancer-related chronic pain is a complex issue and is not the focus of this editorial.However, APs should stay informed on the repercussions made possible by the passage of CARA. We have wrestled for years with how to best manage cancer pain in our patients. We’ve celebrated the development of new agents and formulations of opioid medications, noting that pain management has become easier and more acceptable to patients when given in long-lasting preparations. We’ve educated ourselves on the optimal way to assess and address cancer pain in our unique population of patients. I would hate to see us backslide in our approach and ability to care for our patients’ pain—a serious and potentially debilitating symptom.


Pain drawings have been frequently used in the preoperative evaluation of spine patients. For lumbar conditions comprehensive research has established both the reliability and predictive value, but for the cervical spine most of this knowledge is lacking. The aims of this study were to validate pain drawings for the cervical spine, and to investigate the predictive value for treatment outcome of four different evaluation methods.post hoc analysis of a randomized controlled trial, comparing cervical disc replacement to fusion for radiculopathy related to degenerative disc disease. A pain drawing together with Neck Disability Index (NDI) was completed preoperatively, after 2 and 5 years. The inter- and intraobserver reliability of four evaluation methods was tested using κ statistics, and its predictive value investigated by correlation to change in NDI.We carried out a Included were 151 patients, mean age of 47 years, female/male: 78/73. The interobserver reliability was fair for the modified Ransford and Udén methods, good for the Gatchel method, and very good for the modified Ohnmeiss method. Markings in the shoulder and upper arm region on the pain drawing were positive predictors of outcome after 2 years of follow-up, and markings in the upper arm region remained a positive predictor of outcome even after 5 years of follow-up.Pain drawings were a reliable tool to interpret patients’ pain prior to cervical spine surgery and were also to some extent predictive for treatment outcome. Pain drawings have been a common tool allowing patients to communicate pain without the necessity of an elaborate language for quite some time. In low-back-pain patients, pain drawings have been analysed qualitatively into organic or non-organic drawings by penalty point systems or general impression . SeveralCervical radiculopathy is caused by degenerative changes such as disc herniation or foraminal narrowing due to decreased disc height, pleated ligament, and osteophyte formation in the uncovertebral- and or facet joints. The most commonly affected nerve root is the C7, secondly the C6. The symptoms are neck pain with arm pain in the same distribution area as the affected nerve . To our This study was designed to validate pain drawings of neck pain patients in terms of inter- and intraobserver reliability of four different interpretation scores and to evaluate whether these interpretation scores are predictive for treatment outcome.post hoc analysis of a prospective randomized controlled trial (RCT) of 151 patients from three hospitals in Sweden during 2007 through 2010. The patients suffered from radiculopathy due to DDD and were randomized after exposure and decompression to either artificial disc replacement (ADR)  or plated fusion using autologous iliac crest graft. Inclusion and exclusion criteria as well as 2-year results have been published previously . Patient informed consent was obtained before randomization. The study was registered at ISRCTN (registration number: 44347115).The pain drawing developed by Spangfort , which iThree spine surgeons—one with <5 years of experience, one with 10 years of experience, and one with >30 years of experience—scored the pain drawings independently to determine the interobserver reliability. The less experienced observer performed a second scoring 1 month after the first scoring, blinded from the previous results of the first scoring, to determine intraobserver reliability. For evaluation of the pain drawings we used the penalty point system by Ransford , the griPenalty point system by Ransford. The pain drawing was assigned points for the following characteristics: unreal drawings (indications of pain in patterns inconsistent with radicular symptoms), drawings showing ‘expansion’ or ‘magnification’ of pain (indicating pain outside the drawing of the body), ‘I particularly hurt here’ indicators (using arrows or extra words to emphasize pain intensity), ‘Look how bad I am’ indicators . A score of two points or less was regarded as normal —the pain drawing shows pain in the arm and/or shoulder as in typical nerve root pain.Possible neurogenic (PN)—the pain drawing shows some aberrations from a classic nerve root syndrome.Non-neurogenic (NN)—the pain has a distribution that could not be explained by radiculopathy.Possible non-neurogenic (PNN)—the pain drawing shows very little resemblance with a nerve root pain and is therefore hard to categorize into the other groups above.The visual inspection method by Udén is henceforth nominated the modified Udén method.Grid assessment method by Gatchel. The pain drawing was divided with bilaterally symmetrical grids with small boxes of approximately equal area. The grid over the human figure was copied onto a transparent plastic template and placed over each completed pain drawing for scoring. The number of boxes filled in by markings was counted.Scoring into body surfaces by Ohnmeiss. The method was modified for cervical use, hence the pain drawing was divided into the following five regions: neck, head, upper trunk (scapula region), upper arm, and lower arm. Markings on the elbow or wrist non-contiguous with neck or arm pain were disregarded because they may indicate joint problems ..17).Reliability. For each dichotomous method, reliability was assessed in the following ways: The percentage total agreement between the three observers was computed. This is simply the per cent of the patients for which all three observers gave the same result. Light’s κ (kappa) ( (kappa)  was comp (kappa)  was compκ ≤ 0.20 is considered to be poor agreement, κ 0.21–0.40 is fair agreement, κ 0.41–0.60 is moderate agreement, κ 0.61–0.80 is good agreement, and κ 0.81–1.00 equals very good agreement.Validation. The following values were correlated to the pain drawings: preoperative NDI and absolute change in NDI .The inferential part was done only for the dichotomous/dichotomized methods. For each such method and observer , the endpoint values for the N and NN groups were compared. The endpoint mean for the N group was subtracted from the endpoint mean in the NN group. For the modified Ohnmeiss method, the comparison was instead between groups 0 (no pain markings) and 1 (with pain markings) separately for each body surface region. The endpoint mean for the group 0 was subtracted from the endpoint mean in group 1. Positive values correspond to larger values for the NN group or, for the modified Ohnmeiss method, for group 1. For the endpoints representing a change (ΔNDI) this typically means less negative values, i.e. closer to zero, suggesting that the NN group (or group 1) performed ‘worse’. That is because the patients that improve after surgery get a negative ΔNDI, i.e. the preoperative NDI value is high and is subtracted from the postoperative NDI value that is low. The more negative ΔNDI value, the greater is the patient’s improvement.P values were computed using bootstrap with B = 10,000 bootstrap replicates and the percentile method  rather than individual values, reflecting the dependence between values for the same patient.The target parameter was the difference in means. Confidence intervals (CI) and e method . P valueMissing data were handled using ‘available cases’. Hence only patients without missing values for the variables used in the analysis at hand were included. Consequently, the populations the various analyses were based on are not the same.No correction was done for multiple testing/estimation.All statistical analyses were performed in R , versionOf the 151 patients included in the RCT, 20 patients had missing data for pain drawings. One pain drawing was incorrectly given after the operation. Three patients were lacking preoperative NDI, five were lacking 2-year NDI, and 12 were lacking 5-year NDI.The distributions of N and NN pain drawings were equal for the modified Ransford and Gatchel methods, with ∼50% of the patients in each group compared to the modified Udén method . There was an uneven distribution in the modified Ohnmeiss regions, where 80% had marked pain in the neck, 95% in the shoulder, 91% in the upper arm, and 97% in the lower arm .The agreement between all three observers was fair in the modified Ransford and Udén methods , good in the Gatchel method , and very good in the modified Ohnmeiss method . The re-evaluation by the same observer was good in the modified Ransford method , moderate in the modified Udén method , and very good in the Gatchel and modified Ohnmeiss methods  .Preoperative NDI was higher in the NN groups compared to the N groups in the modified Ransford , Udén , and Gatchel methods . In the modified Ohnmeiss groups, the preoperative NDI was higher among the patients who had marked pain in the head region compared to those who did not  .The patients with markings in the shoulder region  and upper arm region  improved more from surgery at the 2-year follow-up than the patients with no markings in these regions. At the 5-year follow-up there were no remaining differences in improvement for those with markings in the shoulder region. For the patients with markings in the upper arm region the greater improvement was sustained even after 5 years  .The preoperative NDI differences between the N and NN groups had no effect on the clinical outcome 2 and 5 years after surgery. ΔNDI improved above the minimum clinically important difference (MCID) of 17% for NDI , in bothThis validation study documented for the first time the reliability of cervical pain drawings and the associations between cervical pain drawings and surgical treatment outcome. In our study the agreement between two observers of the modified Ransford and the Udén methods was moderate. This contradicts the validation of the original methods by Ransford and Udén on low-back pain patients. Von Baeyer et al.  presenteHayashi et al.  presenteIt seems arbitrary if we can read something valuable out of the patients’ pain drawing or not. Mann et al.  let low-To avoid bias by influencing each other, the three spine surgeons that scored the pain drawings in our study did not discuss the written directions beforehand. Such discussions, or a trial period on ‘dummy patients’ to coordinate the interpretations, could possibly have made the assessors more uniform, which may have improved the interobserver agreement. On the other hand, our scenario reflects more how the methods would be used in practice, how interpretations between different assessors would in fact be spread.Markings in the arm region on the pain drawing have previously been well associated to the presence of herniated nucleus pulposis on MRI  . In our The statistical calculations were done without correction for multiple testing/estimation. We hereby accept the risk of making a type one error. Since we did not compute so many variables we estimated that with a correction for multiple testing the results would be too conservative, hence carrying the risk of making a type two error. According to false discovery rate, we had only approximately 1% risk of making a type one error, which we appraised to be a small risk .Scoring pain drawings with the modified Ohnmeiss method had very good inter- and intraobserver reliability. This method was also valuable in predicting surgical treatment outcome in patients with nerve root compression in the cervical spine. Preoperative markings in the shoulder and upper arm region on the pain drawing had superior outcome 2 years after surgery compared to no pain markings in those regions. Preoperative markings in the upper arm region on the pain drawing remained a positive predictor for superior treatment outcome even 5 years after surgery.