Background: Surgical incision pain, rebound pain, and recurrence can manifest themselves in different forms of postoperative pain after full endoscopic lumbar discectomy (FELD). This study aims to evaluate various postoperative pains after FELD and summarize their characteristics. Methods: Data about the demographic characteristics of patients, pain intensity, and functional assessment results were collected from January 2016 to September 2019. Clinical outcomes including Oswestry Disability Index (ODI) and visual analog scale (VAS) scores, were obtained. Results: A total of 206 patients were enrolled. ODI and VAS of the patients significantly decreased after FELD at 12-month follow-up. A total of 193 (93.7%) patients had mild surgical incision pain after FELD and generally a VAS < 4, and it mostly resolved on its own within 3 days. A total of 12 (5.8%) patients experienced rebound pain, which was typically characterized by pain (mainly leg pain with or without back pain), generally occurring within 2 weeks after FELD and lasting < 3 weeks. The pain levels of rebound pain were equal to or less than those of preoperative pain, and generally scored a VAS of < 6. The recurrence rate was 4.4%. Recurrence often occurs within three months after surgery, with the pain level of the recurrence being greater than or equal to the preoperative pain. Conclusions: Different types of postoperative pain have their own unique characteristics and durations, and treatment options are also distinct. Conservative treatment and analgesia may be indicated for rebound pain and surgical incision pain, but recurrence usually requires surgical treatment. Full endoscopic lumbar discectomy (FELD) has evolved rapidly in the treatment of degenerative lumbar spine disease ,2,3,4. CThus far, there is no specific research about transient rebound pain. Hence, some studies have retrospectively analyzed the recurrence of transient pain in some patients who underwent FELD. On this basis, the current study aimed to assess various postoperative pains that appears after FELD, and summarizes the characteristics of various postoperative pains. We also sought evaluate the incidence, clinical features, and long-term clinical effects of rebound pain after FELD, to assess the risk factors of rebound pain, and to provide appropriate clinical diagnosis and treatment.This is a retrospective study. The current study was approved by the institutional review board of Changhua Christian Hospital (CCH No.190905). After a cautious review of the data, we retrospectively selected 328 consecutive patients who underwent FELD from January 2016 to September 2019. The inclusion criteria were as follows: (1) patients with disc herniation with unilateral radiculopathy, with/without mild stenosis (2) those with single-level symptoms, and (3) those who received failed conservative treatment for more than 3 months. Patients with spinal instability, multilevel symptoms, spondylolisthesis or scoliosis, moderate/severe spinal stenosis, infection, trauma, neoplasm, recurrence, or a history of prior spinal surgery at the index level were excluded from the research. In addition, based on the presence of recurrent transient pain after FELD, the patients were divided into rebound and non-rebound pain groups.Using the transforaminal approach, the patients received epidural anesthesia while in the prone position under fluoroscopic guidance to confirm the surgical level. The working channel was inserted over the dilator and along the guide wire after a skin incision was made. An endoscope  was inserted into the working channel. In some cases, foraminoplasty was required to enlarge the working space via the removal of some bony tissues using a reamer, trephine, or high-speed burr. Then, the disc fragments were removed, and an annuloplasty was performed.Postoperative dehydration and neurotrophic drugs were routinely administered. Patients were monitored for 24 h postoperatively, and they moved freely on the bed. One day after FELD, patients with a waist brace performed back muscle exercises. Simultaneously, we instructed our patients to minimize strenuous activity  for 3–4 weeks after surgery and to wear a lumbar brace for at least 4 weeks after surgery. Demographic data, including age, sex, smoking, body mass index (BMI), diagnosis, and surgical level, were collected. In addition, information regarding the operative time and complications was obtained.Data about patient-reported functional outcomes, including visual analog scale (VAS) scores for back and leg pain and the Oswestry Disability Index (ODI) at each follow-up time, were prospectively collected. Moreover, VAS scores for surgical incision pain were monitored daily until 3 days postoperatively. The rebound pain group underwent weekly monitoring until 1 month and at 3, 6, and 12 (last f/u) months after surgery. The satisfaction rate was assessed based on the modified Macnab criteria (excellent or good outcomes) . After discharge, we regularly conducted telephone follow-ups with patients to collect data on outcomes, including characteristics of pain, the occurrence of rebound pain, functional changes, and treatment efficacy. All of the data were collected by one research assistant.Preoperative magnetic resonance imaging (MRI) was performed to assess for Modic change and Schmorl’s node. The herniated disc size and location were evaluated using the Michigan State University classification  12]. Lu. Lu12]. t-test or the Kolmogorov–Smirnov test as well as the x2 test or the Fisher’s exact test were used to analyze continuous and categorical variables, respectively. The logistic regression model was used to assess the risk factors for rebound pain. Statistical analyses were performed using the Statistical Package for the Social Sciences software, version 24.0 . A p-value of <0.05 was considered statistically significant.Quantitative variables were expressed as mean ± standard deviation. The two-sample 2, respectively. Moreover, there were 37 (17.9%) smokers, including 12 with lesions at the L3/4 level, 120 at the L4/5 level, and 74 at the L5/S1 level, presented with single-level lumbar disc herniation without stenosis. Only 11 patients exhibited Modic change at the index level, and 8 (3.9%) presented with Schmorl’s node at the index level. According to the Pfirrmann grading system, 63 presented with a grade I lesion, 130 with a grade II lesion, and 13 with a grade III lesion. The average operative time was 40.4 ± 7.0 (range: 25–54) mins.122 patients were lost to follow-up. Finally, a total of 206 patients, including 99 men and 107 women, were enrolled in this study. The mean age and BMI of the participants were 36.7 ± 7.6 (range: 20–57) years and 22.1 ± 2.6 (range: 17.8–30.6) kg/mIn the current study, 193 out of 206 patients (93.7%) had mild surgical incision pain after FELD, and most of them could relieve the pain by themselves with appropriate analgesic drugs. The mean VAS for surgical incision pain decreased from 3.02 ± 0.68 on postoperative day-1 to 1.48 ± 0.59 on postoperative day-2 and 0.61 ± 0.69 on postoperative day-3. It seems that the surgical incision pain lasts about 3 days after FELD. In addition, most patients have VAS scores of less than 3, and a few patients reach 4.p < 0.05). Further, the ODI scores significantly improved from 49.3 ± 11.5 to 13.8 ± 5.5 (p < 0.05). One year after surgery, the VAS scores for back and leg pain significantly decreased from 5.6 ± 1.8 to 1.3 ± 1.1 and from 6.9 ± 1.5 to 1.2 ± 1.1, respectively  with rebound pain. There were three men and nine women, with an average age of 38.4 ± 2.4 (range: 26–46) years. Patients commonly presented with single-level lumbar disc herniation without stenosis (n = 11 [91.7%]), and these included five patients with lesions at the L4/5 and seven at the L5/S1. Rebound pain often occurred within 2 weeks after surgery, and it lasted less than 3 weeks. In most cases, the pain level of rebound pain was less than or equal to the preoperative pain, and a high proportion of patients had VAS scores of <6  patients experienced rebound pain. es of <6 . Accordip > 0.05) (p > 0.05)  . Table 5 > 0.05) . In the  > 0.05) .At present, with the development of FELD and the accumulation of cases, increasing attention has been directed toward the treatment and prevention of complications. Previous studies have shown that this technique is associated with some complications, including nerve root injury, residual remnants, prominent recurrence, and postoperative transient/persistent pain ,15. PostIt is common to experience pain at the site of the incision. As the wound heals, the pain will decrease. Most of the pain and soreness will disappear when the wound is completely healed and the sutures or staples are removed. In open surgery, deep tissue soreness and pain usually last for one to two weeks. Similar to our study, most patients (93.7%) had mild surgical incision pain after surgery. However, it mostly resolved on its own within 3 days, which is a benefit of FELD’s lower trauma.Previously, some experienced spine surgeons considered rebound pain only an empirical finding, and it was even disregarded by several surgeons. To date, there is no relevant study about this unique condition, and standardized diagnostic criteria are not available. The pathogenesis of rebound pain has not been fully elucidated, and it may be correlated with several factors. Although the nerve roots have good activity after adhesion release and decompression via FELD, they remain in an inflammatory edematous state due to surgical trauma and self-repair. Moreover, insufficient blood supply in the local vasculature can further aggravate inflammatory edema . In our In the current study, the incidence rate of transient rebound pain is 5.8%. This is not lower than the incidence of various postoperative complications after FELD. Interestingly, rebound pain mostly occurs in the early postoperative period, and the pain is not too severe. We did not identify the precipitating factors of rebound pain based on the survey indexes of age, sex, BMI, diagnosis, surgical level, Modic change, disc degeneration, operative time, and preoperative VAS score and ODI in the logistic regression analysis. Regarding clinical efficacy, our study compared pain intensity and functional assessment results at least during the 1-year follow-up between the rebound and non-rebound pain groups. There were no significant differences between the two groups. Thus, postoperative rebound pain is a short-term symptom, and it has no significant effect on the final efficacy of FELD.According to previous studies, the prevalence of recurrence after FELD can reach 2.8–11% ,20. In oBased on the findings of this study, the characteristics of postoperative pain are summarized as follows: (1) Most patients have mild surgical incision pain after FELD, and it mostly resolves on its own within 3 days, and VAS scores are generally lower than 4. Most of them can relieve pain on their own, and appropriate analgesics can be given when necessary. (2) Postoperative rebound pain has a distinct pathological process of regaining pain after relief, and its pain level is less than or equal to the preoperative pain (a high proportion of patients had VAS scores of <6). Rebound pain is typically characterized by pain (mainly leg pain with or without back pain) and usually occurs within 2 weeks after surgery and lasts <3 weeks. Rebound pain does not require surgical intervention; most of it can be relieved by adequate bed rest, and if necessary, analgesics and physical therapy are used to relieve the pain. Also, rebound pain did not affect long-term surgical outcomes. (3) Recurrence often occurs within 3 months after surgery, and the pain level is greater than or equal to the preoperative pain. Most patients require surgical intervention for recurrence.In addition, several other complications of postoperative pain, such as residual remnants, hematomas, and nerve root injuries, should also be noted ,23. SpecThe current study had several limitations. That is, it was retrospective in nature, had a small sample size, and a short-term follow-up duration. Patient data that was lost during the follow-up may affect the results. In addition, there were no power calculations for our samples. Moreover, the definition of rebound pain after FELD is uncertain due to its diverse features, unclear etiology, and limited cases. Therefore, large multicenter prospective studies must be conducted in the future.Different types of postoperative pain have their own unique characteristics and durations. Most patients gave feedback on the pain of the surgical incision, which could be relieved by themselves or by using analgesics appropriately to relieve the pain, and its duration, usually about 3 days. Approximately 5.8% of patients experienced rebound pain, and its level is less than or equal to the preoperative pain, as well as being mitigated by conservative treatment, sufficient bed rest, and analgesics. Rebound pain does not affect the final efficacy of FELD. Recurrence often occurs within three months after FELD, and the pain level is greater than or equal to the preoperative pain. In addition, most cases required surgical intervention. Careful differentiation between the various types of postoperative pain is needed to contribute to better patient relief.


To examine the association between dispositional optimism and all-cause mortality after esophageal cancer surgery and whether pathological tumor stage and the COVID-19 pandemic modified this association.This nationwide, population-based prospective cohort study included 335 patients undergoing esophageal cancer surgery in Sweden between January 1, 2013, and December 31, 2019. Dispositional optimism was measured 1 year post-surgery using Life Orientation Test-Revised (LOT-R). A higher LOT-R sum score represents higher dispositional optimism. Mortality information was obtained from the Swedish Register of the Total Population. All patients were followed up until death or until December 31, 2020, whichever occurred first. Cox regression with adjustments for confounders was used.The median follow-up was 20.8 months, during which 125 (37.3%) patients died. Among the included 335 patients, 219 (65.4%) patients had tumor pathologically staged Tis-II, and 300 (89.6%) patients entered the cohort before the COVID-19 pandemic. Both tumor stage and the COVID-19 pandemic were effect modifiers. For each unit increase in LOT-R sum score, the risk of all-cause mortality decreased by 11%  among patients with tumor staged Tis-II before the COVID-19 pandemic. This association was non-significant in patients with tumor staged III–IV  and during the COVID-19 pandemic .Assessing dispositional optimism may help predict postoperative survival, especially for patients with early and intermediate esophageal cancer. Increasing dispositional optimism might be a potential intervention target to improve survival after esophageal cancer surgery.The online version contains supplementary material available at 10.1007/s00520-022-07311-z. Esophageal cancer is the seventh most commonly diagnosed cancer worldwide , which cDispositional optimism is a personality trait defined as generalized positive expectations for the future . It is rThe present study aimed to use a Swedish nationwide, population-based, prospective cohort to examine whether dispositional optimism predicted all-cause mortality after esophageal cancer surgery. In addition, given that esophageal cancer is an aggressive tumor and the COVID-19 pandemic severely affects the society and healthcare system, the effect of dispositional optimism on survival might be overridden by the effect of the strongest prognostic factor, tumor stage, and of the hazard event, the COVID-19 pandemic. Therefore, we also aimed to examine the potential effect modifications by pathological tumor stage and the COVID-19 pandemic.Data for the present study were drawn from a prospective, ongoing, Swedish nationwide, and population-based cohort study entitled Oesophageal Surgery on Cancer patients-Adaptation and Recovery (OSCAR). Details of the OSCAR study have been described elsewhere , 27. In The present study included OSCAR study participants undergoing esophageal cancer surgery in Sweden between January 1, 2013, and December 31, 2019. Patients with a psychiatric history were excluded.After consenting to participate in the OSCAR study, patients self-reported their dispositional optimism on the Swedish version of Life Orientation Test-Revised (LOT-R) , 29 duriGiven the inconclusive dimensionality of LOT-R  and the A sum score of the remaining five items was computed with a higher score representing higher dispositional optimism. The internal reliability estimated by McDonald’s omega was 0.49, with 95% bootstrapped confidence interval (CI) 0.31 to 0.62 [All patients were followed from 1 year post-surgery (identified as the date of the first interview after consenting to participate in the OSCAR study) and until the date of death or December 31, 2020, whichever occurred first. Mortality information was obtained from the Swedish Register of the Total Population, which has 100% complete ascertainment of death .Four sociodemographic variables including age at surgery (continuous), sex , education level , and cohabitation status (non-cohabitating or cohabitating) were considered as confirmed confounders because they are associated with both dispositional optimism and mortality , 33. TheThe sociodemographic data were collected from the patient-reported questionnaires and the Swedish Longitudinal Integration Database for Health Insurance and Labor Market Studies. Clinical data were obtained from medical records, the Swedish Patient Register, and the Swedish Cancer Register.t-test or analysis of variance. Multivariable Cox proportional hazards model was used to calculate the HR with 95% CI for the all-cause mortality with one unit increase in the LOT-R sum score. Time since surgery was used as the time scale. The four sociodemographic variables were adjusted for in all Cox models because they were confounders based on prior knowledge [The overall mean of the LOT-R sum scores between patients with different characteristics were compared using nowledge , 33. GivWe treated the COVID-19 pandemic as a time-varying variable, and the period from March 1, 2020, was regarded as within the COVID-19 pandemic in Sweden. Given that most person-time in this study was before the COVID-19 pandemic, we might only have statistical power for the analysis involving period before the COVID-19 pandemic but not period within the COVID-19 pandemic. Therefore, we conducted a subgroup analysis limiting the follow-up ending date before the occurrence of the COVID-19 pandemic in Sweden  to further examine the association during the period without the COVID-19 pandemic.In addition, to account for the potential reverse causality that approaching death might affect dispositional optimism, we excluded patients who survived less than 2 months after the dispositional optimism measurement and re-estimated all Cox models.The assumption of proportional hazards was tested in all Cox models using Schoenfeld residuals and it was met for all analyses. All hypothesis tests were two-sided with significance level 0.05. Stata 13  and SAS 9.4  were used for the statistical analyses.In total, 921 patients underwent esophageal cancer surgery between January 1, 2013, and December 31, 2019, in Sweden. After excluding 221 patients who died within 1 year after surgery and 131 patients who were uncontactable, 569 patients were invited to participate in the OSCAR study. Of these, 376 patients consented to the participation and accomplished the first interview. Non-participation was mainly associated with poor health, cancer recurrence, and unwillingness . After fTable Among the 335 patients included in the whole cohort with follow-up until December 31, 2020, 125 deaths occurred. Patients were followed up for a median of 20.8 months (interquartile range 10.9 to 43.7 months) with a total of 9305.0 person-months.p-value for the interaction term was 0.24. The model containing an interaction term between dispositional optimism and the COVID-19 pandemic showed that HR for the period before the COVID-19 pandemic was 0.94 . The model containing an interaction term between dispositional optimism and pathological tumor stage showed that HR for patients with tumor staged Tis-II was 0.93 , 300 patients were included, of which 102 patients died during the follow-up with a median of 18.0 months (interquartile range 9.4 to 36.1 months) and a total of 7221.0 person-months.. The p-value for the interaction term was 0.08. Figure The model without any interaction terms showed that the overall HR was 0.94 (95% CI 0.89 to 1.00). The model with an interaction term between dispositional optimism and pathological tumor stage generated similar results as the above model using the whole cohort. Higher dispositional optimism was significantly associated with lower all-cause mortality for patients with tumor staged Tis-II , but not for patients with tumor staged III–IV In the sensitivity analyses excluding patients who survived less than 2 months after entering the OSCAR study, the association between dispositional optimism and all-cause mortality remained almost unchanged (results not shown).This Swedish nationwide population-based cohort study found that in the period before the COVID-19 pandemic, higher dispositional optimism was associated with lower all-cause mortality after esophageal cancer surgery among patients with tumor staged Tis-II. However, among those with advanced tumor stage (III–IV) and during the COVID-19 pandemic, non-significant associations were observed.The current study adds to the growing evidence of the beneficial effect of dispositional optimism on survival –24. SeveThe prognosis for advanced esophageal cancer is much less controllable compared with early and intermediate stages of cancer, which may explain the observed effect modification by tumor stage. It is difficult for patients with advanced esophageal cancer to prolong survival due to the aggressive tumor itself  . HoweverThe observed predictive effect of dispositional optimism on survival may be beneficial, especially for patients with early and intermediate stages of esophageal cancer. Assessing dispositional optimism may help identify patients with a higher risk of premature death, thus leading to timely and tailored interventions. Also, given that dispositional optimism can be improved via psychological interventions like Best Possible Self exercise and cognitive behavioral therapy , it mighWe did not find a statistically significant association between dispositional optimism and all-cause mortality for the period within the COVID-19 pandemic. The analyzed person-time within the COVID-19 pandemic in this study was limited, which led to unstable point estimates and wide confidence intervals. Thus, this result should be interpreted with great caution and needs to be examined further by future studies using larger sample sizes. However, it makes conceptual sense that the protective effect of dispositional optimism on survival disappeared during the COVID-19 pandemic. It has been reported that individuals aged above 60 have up to 70% excess mortality during the first wave of the COVID-19 pandemic in Sweden, compared with corresponding calendar weeks in previous years . PatientThis study has several strengths. First, to the best of our knowledge, it is the first study examining the association between dispositional optimism and all-cause mortality after esophageal cancer surgery. Second, the comprehensive data collection allowed for adjustments for confirmed confounders as well as a selection of potential but unproven confounders, which reduced the risk of confounding bias. Third, the predefined interaction and subgroup analyses addressed the effect modifications by pathological tumor stage and the COVID-19 pandemic, and thus presented a more comprehensive picture of the association between dispositional optimism and postoperative survival. Fourth, complete follow-up based on register reduced the risk of selection bias. Lastly, the nationwide population-based prospective cohort study design enhanced the generalizability of the results.This study also has some limitations. Because the OSCAR study focuses on patients who have survived for at least 1 year after esophagectomy, all patient-reported outcomes were started to be collected at 1 year after surgery. The results of this study might not be applicable to the period within 1 year after surgery and should be interpreted in light of the measurement time point of dispositional optimism. However, previous studies have shown that dispositional optimism keep almost unchanged before and after cancer diagnosis and surgery , 35. AddIn conclusion, this study showed that higher dispositional optimism was associated with lower all-cause mortality after esophageal cancer surgery in patients with early and intermediate tumor stages in the period before the COVID-19 pandemic. Future studies with larger sample sizes are needed to validate the predictive effect of dispositional optimism and to identify the underlying mechanisms. Intervention studies are warranted to examine whether dispositional optimism could be a modifiable target to help improve survival after esophageal cancer surgery.Supplementary file1 (PDF 159 KB)Below is the link to the electronic supplementary material.


Background and Objectives: This study tested the hypothesis that treatment of myofascial trigger points (MTrPs) in the upper trapezius muscle (UTM) with repeated injection of 1% lidocaine results in better alleviation of muscular stiffness and soreness as well as improved metabolism in the hypercontracted MTrP area than treatment with radial extracorporeal shock wave therapy (rESWT). Materials and Methods: A single-blinded, prospective, randomized controlled trial was conducted on patients suffering from MTrPs in the UTM. Thirty patients were treated with repeated injection of 2 mL of 1% lidocaine . Another 30 patients were treated with rESWT . The primary outcome measure was pain severity using the VAS score. The secondary outcome measures included muscle elasticity index, pressure pain threshold and neck disability index. Evaluation was performed at baseline (T1), 15–30 min after the first treatment in order to register immediate treatment effects (T2), before the second treatment  (T3) and one week after the third treatment  (T4). Results: There were no statistically significant differences in the primary and secondary outcome measures between the patients in the lidocaine arm and the patients in the rESWT arm at T1 and T4. Within the arms, the mean differences of all outcomes were statistically significant (p < 0.001) when comparing the data obtained at T1 with the data obtained at T3 and the data obtained at T4. Conclusions: The results of this pilot study suggest that the use of rESWT in patients with MTrPs in the UTM is safe and leads to reduced pain and improved muscle elasticity, pressure pain threshold and neck disability index, without adverse effects. Larger trials are necessary to verify this. Clinicians should consider rESWT instead of injections of lidocaine in the treatment of MTrPs in the UTM. The most widely accepted hypothesis regarding the pathogenesis of MTrPs is sustained sarcomere contraction due to excessive acetylcholine release at the neuromuscular junction on the basis of overuse or muscle injury ,3,4,5,6.nephrine ,8,9.Upon palpation, active MTrPs induce spontaneous discomfort, referred pain and motor or autonomic symptoms, including diminished range of motion, muscular weakness and lack of coordination ,4,5,6,8.Imaging techniques such as ultrasonography (US), magnetic resonance elastography (MRE) and ultrasono-elastography (UE) were used to study the physical characteristics of taut bands of skeletal muscle fibers and MTrPs ,13,14. TRepeated injection of local anesthetics is an established procedure for treating MTrPs ,16,17. HThis study tested the hypothesis that treatment of MTrPs in the UTM with repeated injection of 1% lidocaine results in better alleviation of muscular stiffness and soreness as well as improved metabolism in the hypercontracted MTrP area than treatment with radial ESWT (rESWT). Treatment success was assessed using objective (elasticity index (EI)) and subjective  of pain, pressure pain threshold (PPT)) outcome measures.This study was a randomized, controlled trial (RCT) with blinded assessors and statisticians. The study was carried out in compliance with the Declaration of Helsinki of the World Medical Association (WMA). It was approved by the Institutional Review Board of the Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand , and was registered with the Thai Clinical Trials Registry (Identifier TCTR20160330003). At any time, all patients had the option to withdraw their informed consent to participate in this study. There was no commercial support for this research.Patients were enrolled in this study from January 2016 through June 2019 at the Department of Rehabilitation Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand. Patients with MTrPs who were diagnosed by A.S. using the criteria specified in [Neither the UE outcome assessor nor the outcome assessor for pain severity  and the neck disability index (NDI) were blinded to group randomization, and did not participate in the implementation of interventions. The statistician was also uninformed about the group assignment.Injections of lidocaine and rESWT were administered by a single, skilled physiatrist (A.S.).Patients in the lidocaine arm received intramuscular injections of 2 mL of 1% lidocaine at the site of the MTrP using a 25 Gauge needle . A local twitch reaction when the trigger site was injected confirmed the MTrP.2; frequency of the rESWs set at 12 Hz).Patients in the rESWT arm were treated with a Swiss DolorClast rESWT device , EvoBlue handpiece and 15-mm convex applicator  per treatment session; air pressure of the device set at 2.5 bar, resulting in a positive energy flux density of 0.1 mJ/mmIn addition, all patients were taught a simple home exercise routine of UTM stretching during the first visit. The patients received a video file of the UTM stretching exercise on their mobile phones. Patients had to finish 10 sessions of UTM stretching twice a day. For ethical concerns, patients were allowed to take acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) if the discomfort became intolerable, depending on the pain severity. The amount of acetaminophen and NSIADs was recorded.The primary outcome measure was pain severity using the VAS score. The secondary outcome measures included muscle elasticity index (EI), pressure pain threshold (PPT) and neck disability index (NDI). Evaluation was performed at baseline (T1), 15–30 min after the first treatment session in order to register immediate treatment effects (T2), before the second treatment session  (T3) and one week after the third treatment session  (T4).The VAS score was assessed by letting the patients select a point on a 10 cm scale ranging from 0  to 10  that best reflected their level of pain at the time of assessment. A clinically significant difference in pain severity was represented by a mean reduction in VAS of 2.0 cm, which correlates to effective therapy ,41,42.The UE elasticity index was acquired using a LOGIQ S7 Expert ultrasound scanner , with ML6-15 high-frequency linear ultrasound transducer, and Elasto-Q dedicated quantitative software, Power, intensity and edge enhancement were set before data collection for image correction, and were maintained the same for all pre- and post-treatment assessments (a lower EI implies better elasticity of the muscle). After the patient’s head was placed in a neutral position, the UTM was detected using the 2D ultrasound mode of the device. Then the examiner performed an elasticity index measurement of the UTM by rhythmic tissue compression and decompression, adhering to the equipment criteria for standardization of the process c.f. ,13,14). ,14. 13,1A digital pressure algometer  was used to determine the least amount of pressure that was required to cause pain . To thisThe NDI is a widely used self-rating scale for assessing how pain affects everyday activities . Pain seAny unexpected events that happened throughout the experiment were recognized and recorded as adverse effects.p values smaller than 0.05 considered statistically significant. Independent t-tests or Mann–Whitney U tests for continuous variables  were used to compare baseline characteristics between the arms; Fisher’s exact test was used to compare baseline characteristics for the categorical variable Gender between the arms. A 2 × 3 repeated measures analysis of variance was used on the outcome measures, with time  as the within-subject component and treatment  as the between-subject factor. When the sphericity assumption was broken, the Greenhouse-Geisser correction was used. The significance values were adjusted using the Bonferroni correction.Statistical analysis of all data was performed using the Statistical Program for Social Sciences (SPSS) version 17 , with The study’s power was calculated based on the assumption that 70% of the patients in the Lidocaine arm would achieve a reduction in VAS pain by more than 2 cm at T4, but only 30% of the patients in the rESWT arm . With a type I error rate of 5%, a power of 80%, and at least 10% follow-up losses, 25 patients per arm were required. We expanded the sample size to 30 patients per arm to strengthen the power of this study. The power analysis was performed with the tool, OpenEpi .The characteristics of the patients at baseline (T1) are summarized in Compared to rESWT, injection of 1% lidocaine resulted in statistically significantly smaller mean VAS score, mean EI, mean PPT and mean NDI at T2  and T3 , but not at T4 . Within the arms, both treatments resulted in statistically significantly smaller mean VAS score, mean EI, mean PPT, and mean NDI at T3 and T4 compared to T1.Pain and reddening of the skin were noted in a few cases, but the patients did not drop out. There were no severe adverse effects and no long-term negative consequences.No patient experienced pain that would have required acetaminophen or NSAIDs.A recent systematic review and meta-analysis on treatment of myofascial pain syndrome with ESWT  listed eAnother recent study compared rESWT with rESWT + injection of 3 mL of 0.5% lidocaine  . The autTreatment of MTrPs with ESWT was also applied in a number of other studies that were not considered in the systematic review and meta-analysis performed in ,33,37,38Our study had two major results: (1) All outcome measures were statistically significantly improved after the first injection of lidocaine compared to the situation after the first rESWT session . Accordip, a pain neurotransmitter, may be abundant in active MTrPs [p levels [Altered flexibility of the UTM following rESWT could be one of the mechanisms mediating the beneficial effects of rESWT on MTrPs. However, this is only one of many potential mechanisms that may explain the outcome of this study. Other potential mechanisms are briefly summarized in the following. (i) rESWT improved the NDI, which is consistent with previous findings ,27,36. Op levels . (iv) Acp levels , mechanip levels . (vi) Anp levels . DecipheCollectively, the studies on ESWT for MTrPs of the UTM published so far ,35,36,37Our study has some limitations. First, the patients were not blinded to the therapy, which may have caused some subjective bias. Second, there were no subgroups with variable rESWT intensities, intervals, or frequencies because total energy is dose-dependent, which could alter therapy benefits and cost-effectiveness. Identifying appropriate regimens and conducting cost-effective assessments should be a priority in the future. Third, this study was not a non-inferiority trial. Accordingly, this study could not establish that rESWT is as effective as injections of lidocaine in treatment of MTrPs of the UTM. Fourth, this study’s target demographic was individuals aged 20 to 25 years, avoiding MPS in combination with degenerative joint issues, which is typical in the elderly.The results of this pilot study suggest that the use of rESWT in patients with MTrPs in the UTM is safe and leads to reduced pain and improved muscle elasticity, pressure pain threshold, and neck disability index, without adverse effects. Larger trials are necessary to verify this. Clinicians should consider rESWT instead of injections of lidocaine in the treatment of MTrPs in the UTM.


Limited efficacy has been observed when using opioids to treat neuropathic pain. Lidocaine patches reduce neuropathic pain in postherpetic neuralgia, but their benefits for cancer-related neuropathic pain remain unclear. This study aimed to investigate a treatment for cancer-related neuropathic pain.We conducted a prospective, open-label, single-arm study to assess the efficacy and safety of lidocaine transdermal patches in patients experiencing localized, superficial, neuropathic cancer pain. Terminal cancer patients already receiving opioid treatment participated in the 3-day study. The primary endpoint was pain intensity evaluated by the numerical rating scale (NRS). The secondary endpoints were the pain relief score and the quality of analgesic treatment.p < 0.0001). The median NRS pain intensity from Day 1 to Day 3 was 4.0 with 95% C.I. , 3.0 , and 2.6 , respectively. The difference between the median NRS pain intensities of any 2 days was significant . The generalized estimating equation (GEE) estimation model showed significant differences between the NRS pain intensities on any 2 days. There was no significant difference in the pain relief score or the quality of analgesic treatment.The results showed a significant difference in the median NRS over 3 days (Kruskal–Wallis test, In this study, the 5% lidocaine transdermal patch reduced the NRS pain intensity in neuropathic cancer patients already receiving opioid treatment. Treatment of localized and superficial neuropathic pain caused by cancer was well tolerated and effective.The online version contains supplementary material available at 10.1186/s12904-023-01126-3. Although opioids are effective and safe in chronic cancer pain treatment, neuropathic pain (NP) is a common problem encountered in 40% of cancer patients –3. A canThere are several classes of pain medications that provide moderate relief, but they are unlikely to provide complete or near-complete relief. While antidepressants and anticonvulsants effectively treat neuropathic pain, adverse effects may prevent adequate analgesia. As an aminoethylamide local anesthetic, lidocaine inhibits voltage-gated sodium channels on excitable membranes, preventing nerve impulses from being generated and conduction , 8. A toIn March 1999, the Food and Drug Administration (FDA) approved a 5% lidocaine patch to relieve postherpetic neuralgia. However, it is unknown whether a lidocaine patch effectively treats NP cancer patients who are already receiving opioid treatment. The present study aimed to investigate the analgesic effect of a 5% lidocaine patch in patients with neuropathic cancer pain in hospice care. NP was assessed by pain intensity via the numerical rating scale, pain relief score, and analgesic treatment quality –13. The We conducted a prospective, open-label, single-arm study for pain control. A total of 96 terminal cancer patients with stage IV (advanced) malignant disease who were admitted to the hospice ward at National Cheng Kung University Hospital (NCKUH), were enrolled. The eligibility criteria were 18 years of age and above, male or female, who were treated with opioids for cancer-related pain and still experiencing neuropathic cancer pain evaluated by the LANSS Pain Scale . In addiIn this study, the first visit included screening and enrollment, and eligible subjects (with neuropathic cancer pain) received the study patch for 3 days Fig. . SubsequThe primary endpoint of the analgesic effect of the experimental patch was evaluated by the 11-point NRS pain intensity on Day 2 and Day 3. The secondary endpoints of efficacy were evaluated by the five-item pain relief score and analgesic treatment quality on Day 2 and Day 3. Pain intensity was evaluated using a horizontal line, with a total of 11 points, ranging from 0 to 10, on a numerical rating scale (NRS) , which iWe evaluated the safety of the lidocaine patches using vital signs, skin inspections, and skin examinations. The application area affected by the lidocaine patch was recorded. Under the same conditions, systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were measured. A brief examination of the skin under the patches was carried out at each visit to document skin redness, blanching, or irritation. Detailed adverse event data were recorded by the patient and summarized.p value less than 0.05 considered to indicate statistical significance. Safety parameters such as vital signs and skin inspection were also summarized and displayed with descriptive summary statistics. The analyses were performed using the R 4.0.2 version software package for Windows.The demographic data and the distribution of each variable were described using frequency distributions. Data analyses included descriptive and inferential statistics. A descriptive analysis was conducted, including the estimated mean and standard deviation for continuous variables and the percentages and frequencies for categorical variables. Because of violations of the normality assumption, the Wilcoxon signed-rank test and the Kruskal–Wallis test were used to compare whether the median values of the two/three groups were equal. To account for the correlation among repeated measures from the same cancer patient, a generalized estimating equation (GEE) was used to estimate the effect of covariates on the mean of the response variables. All statistical tests were 2-sided, with a A total of 96 terminal cancer patients in hospice wards were referred to our studies. The median age was 58 years old, and 50/46 patients were male/female. The most common types of cancer were as follows: head and neck cancer (HNSCC), 15 (15.6%); upper gastrointestinal (UGI) cancer, 14 (14.6%); colorectal cancer (CRC), 12 (12.5%); genitourinary (GU) cancer, 10 (10.4%); lung cancer, 10 (10.4%); breast cancer, 10 (10.4%); and hepatocellular carcinoma (HCC), 9 (9.4%). The cancer subtypes and patient characteristics are listed in Table p value < 0.0001). The average and median pain scores demonstrated a decreasing trend with increasing use time. The median NRS pain intensity from Day 1 to Day 3 was 4.0 with 95% CI , 3.0 , and 2.6 , respectively. The median NRS pain intensity of any 2 days was significant . We reported changes in the number of patients with different NRS pain intensities on any 2 days , 3.0 .5, 3.5, .0), 3.0 .5, 3.5, .0), 3.0 .5, 3.5, .0), 3.0 .5, 3.5, We also used the generalized estimating equation (GEE) model for the same patient with a three-day series assessed by NRS pain intensity Table . The GEEp value = 0.79). According to the Wilcoxon signed-rank test , there were no significant differences between the median pain relief scores for any 2 days. Based on the GEE model, the patch had no significant impact on the pain relief score.We evaluated the clinical impact of lidocaine analgesics over 3 days using a five-item pain relief score. The results showed no significant difference in the median of the three-day pain relief score. Supplementary Fig. p value = 0.77). There were no significant differences in the median analgesic treatment quality for any 2 days as assessed by the Wilcoxon signed-rank test . Based on the GEE model, the patch had no significant impact on the quality of analgesic treatment score.No significant difference was found in the quality of analgesic treatment. Supplementary Fig. The side effects were observed in the 96 terminal cancer patients. Minimal adverse events were noted, including cold sensation (6.3%), irritation (3.1%), itching (3.1%), rash (3.1%), and redness (1.0%), as shown in Table To treat neuropathic pain, we must select the appropriate approach, including the dosage and route of administration for hospice care. Most medications given to patients near the end of their lives are topical or subcutaneous . In thisHans G et al.  reportedThis study’s primary efficacy variable was the resting-pain intensity measured with a numerical rating scale (NRS). We planned to compare NRSs from any two groups using the Wilcoxon signed-rank test. To check whether the two medians were similar, if the true median difference between the two populations was set to 1 and the common standard deviation of the two populations was set to 1.5, the required minimum sample size was 67. In this setting, the type I error probability associated with this test of this null hypothesis was 0.05, and the study power was 0.95. As calculated by power calculations, we enrolled 96 patients with terminal cancer, which was greater than the 67 minimally required samples.The Kruskal–Wallis test considers the data collected over 3 days as coming from independent and different individuals. A generalized estimating model is used to address the issue of other correlated values of the same patient at different time points since the same patient completed the pain measurement form for 3 days, which is thus repeated measurement data. The GEE estimation demonstrated statistical significance for the pain reduction effect as measured by the NRS pain intensity in the time series and the Kruskal–Wallis and Wilcoxon signed-rank tests, which showed statistical significance in NRS pain intensity for any 2 days.Topical and local anesthetic patches are highly appealing therapies for allodynia due to their simplicity and safety, especially in hospice care. This appeal is based on the benefits of the patch formulation as a barrier to external stimuli and its lack of clinically significant systemic absorption, drug interactions, and severe side effects , 8. ThisA significant difference in pain relief or analgesic treatment quality was not found in the GEE estimates. Additionally, Derry et al. reviewed topical lidocaine for neuropathic pain in adults . There iThere are certain limitations to extrapolating our results. This was an uncontrolled, open-label, single-arm study and is subject to a significant risk of the placebo effect and recall bias. A short study period and lack of long-term follow-up data also limit the study. The lack of a neuropathic pain-specific tool for the primary outcome might also be a limitation. We did not set a standard dose of lidocaine patches in this study. The opioid doses for participating patients were not well documented in our study. A lidocaine patch would unlikely penetrate deep enough to have a pharmacological effect unless the patient’s neuropathic pain was cutaneous or superficial.In this study, a 5% lidocaine skin patch reduced NRS pain intensity in patients with neuropathic cancer pain. It was well tolerated and effective for treating localized and superficial neuropathic cancer pain.Additional file 1: Supplementary Table 1. 96 Patients’ Characteristics. Supplementary Table 2. 96 patients with Pain score .Additional file 2: Supplementary Fig. 1. The Kruskal–Wallis test showed significant differences in the median and mean pain scores over three days .Additional file 3: Supplementary Fig. 2. Effect on pain relief score and quality of analgesic treatment. A. a five-item pain relief score was assessed on Day 1, Day 2 and Day 3. The results showed no significant difference in the median of the three-day pain relief score . B. a five-item quality of analgesic treatment was assessed on Day 1, Day 2 and Day 3. The results showed no significant difference in the median of the three-day .


Low back pain is a heterogeneous disease. Myofascial pain and enthesopathy of the quadratus lumborum muscle are important causes of lower back and/or buttock pain. However, a concrete, safe, and effective injection technique for the treatment of trigger points and enthesopathy in the quadratus lumborum muscle has not yet been developed.We aimed to evaluate the importance of the quadratus lumborum muscle and introduce an effective landmark-based blind injection technique for treating quadratus lumborum trigger points and enthesopathy.n = 17) with lower back and/or buttock pain were placed in the lateral decubitus position. Next, we delicately palpated the quadratus lumborum muscle to accurately locate its lesions, including trigger points, taut bands, and tendon lesions, after five key landmarks had been identified. A newly designed 60–90-mm, 28G thin hypodermic needle was inserted at the tender points. The needle was typically advanced until its tip touched the transverse process to treat myofascial trigger points and tendon lesions in the iliolumbar and lumbocostal fibers, excluding superficial trigger points of the iliocostal fibers. Subsequently, lidocaine (0.5%) or a mixture of lidocaine (0.5%) and dextrose (12.5–15%) was injected.Adult patients  to 0–1/10 (mean 0.294) after completion of all treatments. The total number of treatments was one to four in acute and subacute cases and two to eight in chronic cases. The mean follow-up period was 73.5 days .Herein, we describe for the first time a landmark-based integrated injection technique for the treatment of trigger points and myofascial pain in the quadratus lumborum; this technique is safe, effective, and can be used with or without steroids, fluoroscopy, or ultrasound guidance. Low back pain is one of the most common diseases responsible for years lived with disability , and theMyofascial pain syndrome of the quadratus lumborum muscle is one of the most common musculoskeletal disorders among patients with low back and buttock pain, including failed back surgery syndrome . HoweverThe recently reported that a quadratus lumborum plane block using ultrasound is primarily used to manage perioperative pain or provide local anesthesia . HoweverTherefore, conventional TPI or quadratus lumborum block would not be a fundamental treatment to safely and effectively treat myofascial pain syndrome in the quadratus lumborum, which may account for a large proportion of nonspecific low back pain. The injection therapy known as prolotherapy, which uses a dextrose solution as the injectant, has been reported to effectively treat chronic musculoskeletal pain, including low back pain . ConsideHere, we introduce and describe a landmark-based quadratus lumborum muscle TPI and integrative injection technique combining TPI with prolotherapy to safely and effectively treat quadratus lumborum pain.Ethical approval for this retrospective chart review study was granted by the Institutional Review Board (IRB) of Wiltse Memorial Hospital Joint Research Ethics Committee in Suwon, Korea (2021-W11). The requirement for written informed consent was waived by the IRB owing to the retrospective study design. All procedures were performed in accordance with the Declaration of Helsinki.We included 17 patients  with a dPatients who underwent surgery or had radiological findings (including MRI) of nerve compression lesions, severe stenotic lesions, vertebral fractures, or infectious lesions requiring surgical intervention were excluded. Patients suspected of myofascial pain syndrome radiologically and clinically caused by other lower back, buttock, and thigh muscles, or patients refusing treatment were also excluded.After obtaining the history of the lower back and/or buttock pain, we performed physical examinations using standing tests to help narrow the differential diagnosis, including: forward bending (flexion), extension, and both sides lateral side-bending and trunk rotation. Subsequently, the patients were positioned in the lateral decubitus position with the affected or more painful side upward, the upper knee behind the other knee with slight knee flexion, and the affected side arm upward and comfortably stretched over the head. This posture made it easier to palpate the deeply located quadratus lumborum TrPs or lesions by maximally extending the space between the twelfth rib and the iliac crest.Patients were instructed to say “yes” or “ah” if they felt pain when the examiner's thumb pressure was applied to the quadratus lumborum. Those locations were set as target points. Tender points and symptom-related fibrous nodules, taut bands, or lesions were located and labeled with a marking pen. Subsequently, we considered the quadratus lumborum muscle fiber direction and location. When we targeted the superficial fibers , palpation was performed slightly obliquely anteriorly (10–20°). When we targeted the deep fibers  near the cleft, we palpated vertically toward the transverse processes of the lumbar vertebrae . We usedAdditionally, injection near the L2 and L3 transverse processes and cephalad of the L1 transverse process must be carefully undertaken to avoid kidney injury and pneumothorax by penetrating the diaphragm and pleura, directing the needle tip in a cephalad or cranial direction toward the twelfth rib. Pneumothorax may occur if treated without accurately confirming the twelfth rib.We did not apply post-isometric muscle relaxation or a moist hot pack over the muscle after injection.Newly designed 28G 60–90-mm thin hypodermic needles  were utiThe very thin 28G 60–90-mm needle with or without a hub cap would bend or could not penetrate the skin during the insertion process without a guide tube. Therefore, the guide tube was used to adjust the direction of the needle or provide directional guidance and then pulled sideways and removed when the upper part of the injection needle shaft remained 0.5–1 cm from the top of the guide tube.A patent for the newly devised needle (injection needle with a plastic needle hub cap) and guide tube has been registered with the Korean Intellectual Property Office; inventor, author, Hun Man Sirh. A patent for the guide tube (puncturing guidance tube) has also been registered with the United States Patent and Trademark Office.We used five easily identifiable and important landmarks  to treatWe retrospectively reviewed the electronic medical records from Dr. Sirh's Pain Clinic. We evaluated patients' self-reported pain intensity scores using a 0–10 point visual analog scale (VAS) score before and after the procedure, visible and invisible LTRs, and patients' pain report during the procedure as outcome measures. Treatments were administered one to three times per week for the first few treatments, depending on the severity of the symptoms and lesion complexity , and were subsequently tapered to once a week and once every two to three weeks as symptoms improved. We evaluated the number of treatments until the end of the procedure. Data in this brief report were analyzed descriptively due to small sample size.Patients were on average 47.35 years (range: 28–70); 11 were men and 6 were women. The duration of symptom onset ranged from three days to three years. The mean pain duration was 163.2 ± 296.6 days. Among the 17 patients, 10 had bilateral lesions and 7 had unilateral lesions. Patients were not treated bilaterally at each treatment session.Acute and subacute patients received an average of 3.6 (range 2–4) procedures; Chronic patients received an average of 4.9 (range 2–8). Treatments were repeated according to the severity and duration of the symptoms.All patients reported almost complete resolution of lumbar and/or buttock pain  and/or pThis brief research report describes the importance of the quadratus lumborum muscle TrPs and enthesopathy in nonspecific lower back and/or buttock pain and also describes a palpation-guided approach technique using five landmarks and its advantages for safely and effectively performing TPI and prolotherapy. This study suggests that landmark-based blind TPIs may be used for patients with intractable lumbar pain, buttock pain, and/or paresthesia due to quadratus lumborum muscle TrPs, fibrosis, calcification, and tears or other tendon lesions.We determined the diagnosis using six screening standing examinations, and treatment effectiveness using before-and-after treatment assessment of clinical symptoms and signs, loss of referred pain, improvement of the limited range of motion, and degree of symptom relief (decrease of VAS score). In almost all patients, tender spots in the quadratus lumborum muscle were identified prior to treatment. Injection was performed at tender points and/or palpable taut bands, and an LTR and immediate symptomatic improvement (limited range of motion and referred pain) were almost always confirmed during needling and immediately after treatment. In our study, most quadratus lumborum muscle lesions were tender and diagnosed as myofascial TrPs and enthesopathy or fibrosis with a tight or firm sensation, resulting in increased resistance to needling. Therefore, during injection, the needle tips must be in contact with the transverse process or iliac crest for the treatment of enthesopathy.When clinical history and physical examination are considered, myofascial lower back pain and patterns of quadratus lumborum TrPs are characterized by pain on coughing or sneezing with upper iliocostal fiber TrPs, vertical pain with a unilateral lesion and/or transverse pain with a bilateral lesion, and a limitation of motion, such as forward bending (mainly), turning, leaning to the opposite side, rolling onto the side from the supine position, climbing stairs, arising from the supine position, or standing up from a chair . QuadratPain due to myofascial pain syndrome and enthesopathy has received less attention than other lower back and/or buttock pain diagnoses regardless of thigh pain due to the lack of an appropriate and accurate diagnosis. Diagnosis of erector spinae and quadratus lumborum muscle lesions is vitally important in lower back pain. Considering the aforementioned characteristic pain and patterns of quadratus lumborum TrPs, a differential diagnosis considering the quadratus lumborum muscle and other back muscles, such as the erector spinae and iliopsoas, is required to accurately evaluate and treat quadratus lumborum lesions in back and/or buttock pain.Some reports , 16 haveFurthermore, in essence, the ultrasound-guided quadratus lumborum injection technique for pain management targets interfascial plane blockage or hydrodissection by identifying markers of muscle or bony landmarks, whereas quadratus lumborum myofascial pain syndrome primarily involves TrPs, fibrosis, calcification, and enthesopathy. These are also difficult to distinguish from the surrounding lesions by ultrasound. Lower back muscles, including the quadratus lumborum, are usually bulky and deeply seated. Therefore, to address the aforementioned lesions, treatment through physical examination and delicate palpation may be more important. Delicate palpation and anatomical knowledge based on five landmarks enable physicians to treat lower back myofascial pain syndrome easily, safely, and effectively with or without ultrasonography or fluoroscopy because quadratus lumborum TrPs cannot usually be visualized with image guidance. We have always confirmed and evaluated LTRs or patient reports of pain (jump signs) when inserting the needle into TrPs or taut bands.Although ultrasonography is known to be more helpful in identifying LTRs and guiding injections in deeper muscles , it mustIt should not be overlooked that landmark-based intramuscular TPI through a lateral approach could significantly improve quadratus lumborum myofascial pain. It can be performed easily even at the bedside in the emergency room or ward where ultrasound equipment is not available. For ligament and tendon lesions, bony contact of the needle with the lumbar transverse processes or iliac crest is required. Travell & Simons  describeDespite their advantages, MRI and ultrasound also have shortcomings, such as revealing findings unrelated to pain or symptoms. Furthermore, in ultrasound-guided TPI, it is difficult to accurately approach palpated tender points, and high-resolution devices and long-term learning curves are needed to improve treatment quality. In the future, additional studies are required to prospectively compare our palpation-guided, landmark-based integrated injection method with ultrasound-guided injection for low back pain, including quadratus lumborum myofascial pain syndrome.Additionally, we did not observe significant complications or side effects, such as infection or lumbar plexus and organ injury, except for negligible bleeding and bruising, because of the use of the newly devised 60–90-mm 28G needle and guide tube, and our approach method using five landmarks. However, potential side effects include infection, bruising, pneumothorax, lumbar plexus injury, hypotension, and nausea due to unintentional sympathetic ganglion block. Therefore, it is safer to treat the quadratus lumborum unilaterally in a single treatment session.This study had certain limitations. First, this study did not include an adequate number of patients for statistical comparative analysis. Second, the data were retrospectively reviewed. Third, as most patients with quadratus lumborum muscle problems typically also exhibit myofascial pain in other lower back muscles, lumbar facet joint problems, and hip joint problems, we did not enroll patients who were simultaneously receiving treatment for these issues. Fourth, our study is single-arm without a control group and did not assess differences between acute, subacute, and chronic cases. Fifth, the other limitation of our study was that it lacked long-term follow-up. A larger, controlled, prospective study is needed in the future to evaluate the effects of our TPI and integrated injection technique in patients with combined problems of various structures and the quadratus lumborum.In conclusion, myofascial pain and enthesopathy of the quadratus lumborum muscle are considerably more important as causes of lower back and/or buttock pain than is commonly realized and should be differentially diagnosed. Delicate palpation with proper pressure, position, and needling technique using the above-mentioned five landmarks are important for the diagnosis and treatment of quadratus lumborum muscle lesions. This study suggests that a safer and more effective treatment can be provided through a repeated and integrated injection method using palpation-guided technique based on five landmarks with the newly designed needle and guide tube, even without image guidance.


Although complex pain conditions require an interdisciplinary approach, employment services are rarely provided in pain centers. Individual Placement and Support (IPS) is an effective approach to increase work participation among patients with severe mental illness, and recent evidence suggests that this method can be successfully repurposed for new target groups. We aimed to investigate the effectiveness of IPS integrated with interdisciplinary treatment as usual (TAU) for patients with chronic pain in a tertiary pain center.A randomized controlled trial comparing IPS integrated with TAU (n = 38) with TAU alone (n = 20) was conducted. Participants were patients with chronic pain who were 18–65 years of age and currently on long-term sick leave or disability benefits or unemployed. The primary outcome was employment within 12 months after enrollment, with additional long-term follow-up after 24 months. Secondary outcomes included health and quality of life, measured at baseline, 6 months, and 12 months.During 12-month follow-up, 52.8% in the IPS group and 38.9% in the TAU group had attained employment. The difference increased during 24-month follow-up but did not reach statistical significance. Findings on secondary outcomes were generally nonsignificant.The IPS in Pain trial is the first study to evaluate the effect of IPS for patients with chronic pain conditions. It shows that IPS can be integrated into the daily practice of interdisciplinary pain treatment, with employment rates exceeding 50% in 1 year and a clear trend in favor of the IPS group. Results did not, however, reach significance. Larger randomized controlled trials are needed to draw clear conclusions about effectiveness. Chronic pain represents a large and growing international health problem , accountPeople with chronic pain can face many obstacles in finding employment or returning to work after a period of absence , 4. The competitive employment , while one participant dropped out of the study. Although findings from the pilot study were encouraging, there was a need to investigate the effectiveness of IPS for patients with chronic pain in a larger RCT.Individual Placement and Support (IPS) is an evidence-based intervention originally designed to help people with severe mental illness (SMI), e.g., schizophrenia, gain and keep employment. IPS has been shown to be effective in the original target group across 28 randomized controlled trials (RCTs), with mean employment rates of 55%, as compared with 25% in control conditions . Recent The present trial aimed to investigate whether IPS as an integrated part of the interdisciplinary treatment as usual (TAU) for patients with chronic pain in a tertiary pain center resulted in a higher rate of competitive employment (research question 1), higher job productivity (research question 2), or more improvement in health and quality of life (QoL) (research question 3) than did TAU alone.The IPS in Pain trial was an RCT comparing pain treatment with integrated IPS to TAU. The project was submitted to the Norwegian Regional Ethical Committee, and from there it was referred to the Data Protection Officer at Oslo University Hospital, who approved the study (project number: 2015/14224). The trial was registered at ClinicalTrials.gov (NCT02697656), and a detailed study protocol was published .Eligible participants were patients referred to the pain center at the Department of Pain Management and Research at Oslo University Hospital in Norway during the recruitment period (November 2015 through December 2017). The inclusion criteria were: eligible for interdisciplinary treatment, not employed , expressed desire to work, age 18–65 years, living in Oslo, and ability to answer questionnaires in Norwegian.All patients referred to the center were informed of the study and invited to participate. Eligible patients who wished to participate received additional information about the procedures and purposes of the study and their right to withdraw at any time, and they provided informed consent to participate.Participants were randomly assigned to either an intervention group (IPS) or a control group (TAU). The randomization process was described in the study protocol .The intervention group received job support according to the IPS model from an employment specialist, integrated with the usual interdisciplinary pain treatment provided at the pain center. Two employment specialists were hired at the center during the trial period, specifically in relation to the project. In addition to regular ad hoc meetings, the employment specialists and pain management team had meetings during which they discussed all participants. The employment specialists delivered job support to the participants according to the supported employment fidelity review manual , adherinBecause IPS was originally developed for people with SMI, some adaptations were necessary to serve the population in the present study. The adaptations were made in line with recommendations in the fidelity review manual . With reIPS services were provided for up to 2 years for the first included participants and for up to 1 year for participants included later in the project period. Fidelity to the IPS model was assessed at four time points during 2016–2017. The fidelity assessments were conducted by an independent and experienced evaluator using the established Norwegian translation of the 25-item IPS fidelity scale and are described in more detail in the study protocol  = 26.34, P < 0.001, OR = 5.65, 95% CI = 2.75–11.60).A significantly higher proportion of the IPS group attained competitive employment during the 12-month follow-up period , compared with the employment rate at the 12-month follow-up point among historical controls , and the adjusted analysis showed no overall difference between the two groups in any of the outcomes. Because of the large number of secondary outcomes, alpha inflation is a concern, suggesting that caution is needed in interpreting this single finding. Although the low sample size and relatively high attrition make it difficult to draw firm conclusions, the general lack of findings on health-related outcomes is in line with previous studies of IPS among the original target group with SMI .The present study evaluates the promising evidence-based intervention IPS for a new and important target group by using a mix of employment- and health-related outcome measures. The preceding pilot study  and the current employment status at 12 months used among patients in the historical control group is likely to be lower than the outcome of any employment during the 12-month follow-up period among the IPS group and is therefore not directly comparable. The results from the ancillary analysis comparing these rates should therefore be interpreted with caution.Because of the low sample size in the control group, data from a historical control group were collected to remediate this limitation to some extent. Meanwhile, the outcome of All patients who were referred to the pain center during the recruitment period and fulfilled the inclusion criteria were eligible for participation. However, we do not have information about the exact number of patients who were assessed for eligibility, how many declined participation, or reasons for declining. This could limit the generalizability of the results. Meanwhile, a screening among all patients at the clinic in 2018 showed that 61.5% of patients who are not currently in employment would like to work. Patients without a desire to work were not eligible for the study, and the criterion of living in Oslo further excluded many patients who live outside this area.The response rates on the primary outcome were reasonably high, ranging from 85% to 97% at the various follow-up points. The response rates on secondary outcomes were, however, relatively low, and it is possible that those lost to follow-up had different characteristics from those of respondents. Ignoring the missing data in unadjusted analyses could lead to biased and unreliable estimates. This was addressed through the use of mixed-effects regression models with maximum likelihood estimation, with adjustment for baseline characteristics and missing observations. Unadjusted and adjusted analyses yielded similar results, and results from both approaches were reported.The IPS in Pain trial is the first study to investigate the effect of IPS for people with chronic pain conditions. As a small study and the first of its kind, it should be regarded as a proof-of-concept trial exploring the potential of the IPS method for this new target group. The study shows that IPS can be integrated into the daily practice of interdisciplinary pain treatment and can lead to employment rates exceeding 50% in 1 year. There is a need for further research in the form of larger multicenter RCTs to shed further light on whether IPS is more effective than TAU for people with chronic pain conditions.The IPS in Pain trial also included process measures with detailed IPS fidelity reviews, participants’ satisfaction with the intervention, and possible predictors of employment. These are beyond the scope of this article and will be reported in a future process evaluation.The IPS in Pain trial is the first study to evaluate the effect of IPS for patients with chronic pain conditions, and it explores the potential of the IPS method for this new target group. The results show that IPS can be integrated into the daily practice of interdisciplinary pain treatment, with employment rates exceeding 50% in 1 year. Participants who received IPS had consistently higher employment rates than those of the control group, but these findings did not reach statistical significance, possibly because of low sample size. Findings on health-related outcomes were also generally nonsignificant. Larger RCTs are needed in order to draw clear conclusions about effectiveness.


Persistent or recurrent lumbosacral pain is a common symptom after spinal surgery. Several interventions have been introduced for failed back surgery syndrome; however, their clinical efficacy, safety, and cost-effectiveness are insufficient. Sympathetic ganglion block has been selected for pain associated with the sympathetic nervous system. In this study, we compared pain and quality of life in patients with failed back surgery syndrome who responded and did not respond to lumbar sympathetic ganglion block.We included 84 patients diagnosed with failed back surgery syndrome who had lumbosacral pain and underwent lumbar sympathetic ganglion block between January 2020 and April 2021. The patients’ data were retrospectively analyzed; clinical outcomes were assessed before (T0), 1 week after (T1), and 4 weeks after (T4) lumbar sympathetic ganglion block. Based on the pain difference from T0 to T1, we categorized patients into two groups: patients with ≥ 50% pain reduction (responder group) and patients with < 50% pain reduction (non-responder group). Demographic, clinical, surgical, and fluoroscopic data were evaluated and compared. The primary outcome was pain scores and the EuroQol-5D score from T0 to T4.Among the 84 patients analyzed, 41 (48.8%) experienced ≥ 50% pain reduction at 1 week after lumbar sympathetic ganglion block. Lumbar sympathetic ganglion block significantly improved pain at T1 and T4 compared to T0 in both groups. Lumbar sympathetic ganglion block improved the EuroQol-5D score at T1 compared to T0 in the responder group. The responder group had a significant decrease in pain at T1 from T0 and T4 from T0 and a significant decrease in the EuroQol-5D score at T1 from T0 compared with the non-responder group. Coldness of the leg over time did not differ between the groups. No serious adverse events occurred in either of the groups.Lumbar sympathetic ganglion block may improve pain at 1 and 4 weeks in patients with failed back surgery syndrome. Patients with ≥ 50% pain reduction at 1 week showed simultaneous improvement in quality of life and pain reduction at 4 weeks.https://cris.nih.go.kr/cris/index/index.do, identifier KCT0007236. The incc fibers , 14. Lumc fibers , 13. Patunicants . However1We retrospectively reviewed the electronic medical records of 87 patients with FBSS who had lower back and leg pain and underwent LSGB between January 2020 and April 2021 at two tertiary care hospitals in Seoul, Korea. The enrolled patients ranged in age from 32 to 86 years old. The inclusion criteria were as follows: (a) > 6 months from lumbar spinal surgery; (b) a primary diagnosis of lower back pain radiating to the lower limbs; (c) cross-sectional imaging (either computed tomography or magnetic resonance imaging) of the lumbosacral spine in patients diagnosed with spinal stenosis or herniated nucleus pulposus after lumbar spinal surgery; and (d) insufficient pain control 1 month after lumbosacral epidural block, medial branch block, facet joint block or sacroiliac joint block. The exclusion criteria included neoplastic, peripheral vascular diseases, or failed lumbar sympathetic block . The lesAll procedures were performed under fluoroscopic guidance and were standardized. A physician determined the block level and side. Patients were placed in the prone position, and anteroposterior and lateral view images were obtained using a C-arm  to ensure the proper entry site. Following the aseptic preparation and application of 1% lidocaine, a 21-gauge Chiba needle  was advanced to the anterolateral border of the vertebral body. Aspirations were routinely performed to assess the presence of blood. When the needle position was confirmed by fluoroscopic imaging, an aspiration test was performed, and a contrast medium was injected. We assumed a successful block, which the lumbar sympathetic ganglion spread when the contrast medium was shown to form a line at the anterolateral margin of the vertebral body in the lateral view. The target point was confirmed with the anteroposterior and lateral view . When thWe defined the responder group as patients who showed ≥ 50% improvement in pain at T1 from T0 and the non-responder group as patients who showed < 50% improvement in pain at T1 from T0.t-test, or Fisher’s exact test. The pain score, EQ-5D score, and coldness of the leg over time in each group and between groups were compared using the t-test, Mann-Whitney’s U-test, and Wilcoxon rank sum test. A p-value less than 0.05 was considered statistically significant.All data were analyzed using SAS 9.4 . Data are expressed as the mean ± standard deviation (SD), median (interquartile range), or number (proportion), as appropriate. Demographic data for the two groups were compared using the Wilcoxon rank sum test, Chi-square test, P < 0.001 and P = 0.000, respectively). The EQ-5D did not differ at T0, and the EQ-5D was lower in the responder group at T1 and T4 . Coldness of the leg did not differ between the groups. P = 0.046). In the non-responder group, EQ-5D and coldness of the leg scores did not differ over time . Moreover, the EQ-5D difference between T1 and T0 was significantly higher in the responder group than in the non-responder group (P = 0016). Coldness of the leg over time did not differ between the groups . Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.This study was approved by our departmental Ethics Committee  and registered with Clinical Research Information Service of the Korea National Institute of Health (JL and HP: conceptualization, data curation, formal analysis, investigation, methodology, and writing – review and editing. WS, JK, SY, HR, CK, and SK: data curation and investigation. All authors contributed to the article and approved the submitted version.


Chronic pain has an impact that goes beyond the physical plane and, over the years, it ends up deteriorating the emotional, working and social life of people who suffer it.Since we are working with patients who suffer a chronic pathology that cannot be cured, the objective of the group is to create a safe space in which these patients can feel understood, facilitating emotional expression and promoting an active attitude. Accepting pain and its limitations allows the person to regain their ordinary life.A multicomponent group therapy with a cognitive-behavioural orientation was carried out. The group was formed by 12 patients, all of them women with chronic pain. Eleven sessions were established on a weekly basis of one and a half hours of duration.In each session a specific aspect was worked on, favouring the learning of techniques, tools and strategies of coping. A global approach was made, including behavioural, cognitive and emotional elements. At the end of the process, the patients reported benefits in their ability to manage anxiety and depression symptomatology, and they reflected a lower impact of pain in their daily life.Given the complexity of the symptomatology in chronic pain, it is important to approach the treatment from a multidimensional perspective that envisages every component of pain in order to being able to give a response to the physical and psychosocial impact that it implies, favouring a better confrontation and adaptation.No significant relationships.


Their preoperative pain was recorded on Wong-Baker’s FACES pain rating scale. After chemo-mechanical canal preparation, intracanal medications were applied to the groups , Group 2 (2% chlorhexidine), Group 3 (tri-antibiotic paste), Group 4 (no medication (Control group)). Patients were instructed to record pain on the Wong-Baker FACES pain rating scale at 4, 48, 72 and 96 hrs, postoperatively. Pain scores were analyzed using a one-way ANOVA test and Tukey’s post hoc test and, if significant, Dunn’s test was used for pair-wise comparisons. The significance level was set at a p-value ≤ 0.05. Results: Tukey’s post hoc test revealed significantly lower pain scores in Group 3 compared with other groups at all follow up intervals. Dunnett’s test showed significantly lower pain in Group 3 compared with the Control group at 48, 72 and 96 hrs, postoperatively. Conclusions: Triple-antibiotic paste showed effective pain control as an intracanal medication on necrotic teeth with symptomatic apical periodontitis.Background: One of the main reasons for post endodontic pain is the polymicrobial intracanal flora that may survive the initial disinfection. A single antimicrobial agent might not provide adequate disinfection, and an antimicrobial combination such as triple antibiotic paste was tested to achieve this goal. Aim: The study aimed to assess the efficacy of three intra-canal medicaments on post root canal preparation pain. Materials and Methods: Eighty patients with single-rooted necrotic teeth and symptomatic apical periodontitis were randomly assigned to four treatment groups ( Pain of endodontic origin is an undesirable event for both the patient and clinician. It has been estimated that 80% of patients who have pre-operative tooth ache continue to feel pain after endodontic treatment. Post-treatment pain is generally mild, and settles down within 72 hrs with analgesics such as NSAIDS or Acetaminophen . HoweverEnterococcus faecalis, Candida albicans and anaerobic bacteria. Additionally, 0.1% to 2% CHX preparations are deemed toxicologically safe and effective for reducing pain during endodontic treatment  Durit-tests were applied, with a 95% confidence interval and 90% power. The minimum sample size needed was calculated as 80 (or 20 patients per group). The total sample was increased to 100 to make up for the anticipated drop-out of participants. Overall, 100 patients with age ranging between 16 and 50 years were enrolled in the study according to the following criteria.The sample size was calculated by utilizing PASS software version11 . Two independent sample A single-rooted teeth (anterior and posterior);Teeth with symptomatic apical periodontitis; andTeeth with necrotic pulp that gave a negative response to vitality testing.Patients were enrolled in the following cases:Patients were excluded from the study in the following cases Non-restorable teeth;Presence of endo-perio lesions;Teeth associated with an acute or chronic apical abscess;Teeth with chronic periodontitis;Teeth with anatomical difficulties, such as open apices;Teeth with calcified canals;Teeth with severe dilacerations;Teeth with internal/external root resorption;Teeth with occlusal interferences;Patients who were allergic to medications that were used in the study;Patients who were taking medicines that could influence pain perception;Patients that had serious medical illness;Patients with systemic disorders; andPatients with immunocompromised diseases such as AIDS or HBV.www.random.org (accessed on 2 February 2018)) by an independent operator [The participants were randomly assigned to four groups according to a simple random number table available online . After confirming the eligibility, the offending tooth was anesthetized with 1.8 mL of 2% lidocaine, with 1:100,000 epinephrine  using the local infiltration (mandibular anterior/maxillary teeth) and inferior alveolar block (mandibular premolars). Rubber dam isolation was performed for each patient to prevent teeth contamination by saliva. The dental caries was removed followed by complete deroofing of pulp chamber. The size of the access cavities was not standardized and was dependent upon the size of the carious lesion. A diagnosis of pulp necrosis was confirmed at this step, and only those teeth showing no bleeding upon access preparation and a visibly necrotic, dark pulp tissue were included (ICD 10 Code K 04.1). The pre-endodontic tooth build-up was carried out with glass ionomer cement to ensure the proper isolation and inter-appointment sealing of the access cavity for cases in which access preparation extended to more than one surface. The glide path was prepared with stainless steel hand K-files, #06, #08, and #10 . The working length was obtained by an electronic Apex locator  and verified by periapical radiograph. The root canal preparation was carried out to #20 (0.02 taper) with a hand K-file . The Ni-Ti Rotary assorted files  were then used to prepare the root canals using the crown down technique. Copious irrigation with 3% NaOCl was carried out. The canals were flooded with 17% EDTA solution  for 3 min, post root canal preparation, to remove the inorganic component of the smear layer. 5 mL saline solution was used as the final rinse, and the canals were dried with sterile paper points . Intra-canal medicaments, using a Lentulo spiral, were placed according to the groups assigned to the patients in the random number table.Group 1 received CH (20%) as intra-canal medicament; Group 2 received CHX (2%) gel; Group 3 received TAP ; Group 4 received no dressing (Control group).Excess medicaments coronal to the cementoenamel junction were removed with a moist cotton pellet, followed by placement of a sterile dry cotton pellet in the pulp chamber. Subsequently, the cavities were sealed with glass ionomer cement of minimum 3 mm thickness. The teeth were ground out of occlusion to prevent pain from occlusal forces. No medications were prescribed to the patients. Before dismissal, patients were instructed to record their pain intensity score on Wong-Baker’s FACES pain rating scale at 4, 48, 72, 96 hrs. Data were entered into an excel sheet and was later exported to SPSS. All analysis was carried out using SPSS version 24 . The normal distribution of data was checked by creating histograms, and after confirmation, parametric tests were used. A one-way ANOVA test and Tukey’s post hoc test were utilized to perform multiple comparisons of pain scores between different groups at different time intervals. The level of significance was set at less than 0.05. Lastly, all the experimental groups were compared with the control group using Dunnett’s test.2, Group 2 as Chlorhexidine, Group 3 as Tri-antibiotic paste and Group 4 as the Control group. A total of 100 patients were initially evaluated for eligibility. Twelve patients were excluded from the study as they did not meet the inclusion criteria. However, eight of the patients refused to participate in the study. Hence, a total of eighty patients were included in the study . The patThe mean age of the patients was 30 ± 2.34 years, and no statistically significant differences in baseline characteristics (age and gender) were observed between the groups . Table 2The Tukey’s HSD test for multiple comparisons revealed that at 4 hrs there was a significant difference in pain scores of Group 3 and Group 2, and at 48 hrs and 72 hrs there was a significant difference in the pain score of Group 3 when compared with other groups. Lastly, at 96 hrs, there was significant difference in the pain scores of Group 3 in comparison with the Group 2 and Group 4. The Dunnett’s test showed a significant difference in the pain score of Control group (Group 4) and Tri-antibiotic group (Group 3) at 48 hrs, 72 hrs and 96 hrs . Figure The Bartlett’s test was utilized to check the homogeneity of variance. It was found from the results that variance was homogenous for the preoperative, 48 hrs and 72 hrs pain scores. Conversely, non-homogenous variance was noted for the other time periods., i.e., 4 hrs and 96 hrs. Moreover, no adverse effects were reported by the patients in relation to medicaments that were used in this study.This study monitored the effects of different root canal medicaments in necrotic teeth with symptomatic apical periodontitis. Before the placement of the medicaments in the pulp canal, the smear layer was removed using an EDTA rinse to allow maximum penetration of the medicament in the dentinal tubules and the accessory canals. This allowed thorough disinfection of the canal space by effectively eliminating all the niches where bacteria may reside ,11. OnlyTAP is a combination of three different antibiotics, ciprofloxacin, metronidazole, and minocycline. Ciprofloxacin is a broad-spectrum antimicrobial agent which has bactericidal action against both Gram-negative and Gram-positive bacteria. Metronidazole is effective primarily against obligate anaerobic bacteria, while minocycline is a broad-spectrum tetracycline that mainly has a bacteriostatic action on bacteria through inhibition of bacterial protein synthesis. The synergistic effect of these three antibiotics in eliminating bacteria and achieving better post-operative pain control is in concurrence with the results of a previous study by Omaia et al. . HoweverIn the current study, CH has the second lowest pain scores of all the groups. CH is the most widely used intra-canal medicament and has good antimicrobial activity. Due to the alkaline environment created in the apical area, CH also neutralizes periapical inflammation . HoweverE. faecalis [Candida albicans [CHX is a broad-spectrum antimicrobial effective against Gram-positive and Gram-negative bacteria . CHX is faecalis  and Candalbicans . Howeveralbicans ,28. Singalbicans . This dePresence of minocycline has been reported to cause discoloration of teeth when used as an intra-canal medicament. This may be avoided by using dentine bonding agent in the pulp chamber to prevent minocycline uptake by coronal dentine. Another method may be alternating minocycline with cefaclor to make modified TAP, which has been reported to have good antimicrobial activity . The feaThe current study has certain limitations. Firstly, in the present study, cotton pellets were used as endodontic spacers and to wipe off excess medicaments from the access cavity walls. This step might leave residual cotton fibres on the access cavity walls, and can interrupt the seal of the temporary restoration as well as acting as a potential substrate for surviving bacteria . SecondlTriple-antibiotic paste showed effective pain control as an intra-canal medicament. Under the conditions of the present study, it is recommended to use TAP in necrotic teeth as an intra-canal medicament to achieve effective post-operative pain control. However, caution must be exercised in use of TAP as a first-choice treatment due to the potential of introducing antibiotic resistance, at least until a bacteria-specific antibiotic delivery system is developed. Further investigation is also required to find out the exact mechanism through which TAP affects the host inflammatory response, and find out what the impact of TAP in controlling postoperative pain in cases of irreversible pulpitis would be.