Many patients with chronic pancreatitis (CP) undergo a step-up approach with interventional procedures as first-line treatment and resection reserved for later stages. The aim of this study was to identify predictive factors for a significant clinical improvement (SCI) after surgical treatment.All patients operated for CP between September 2012 and June 2017 at our center was retrospectively reviewed. A prospective patient survey was conducted to measure patients postoperative outcome. The primary endpoint SCI was defined as stable health status, positive weight development and complete pain relief without routine pain medication. Additionally, risk factors for relaparotomy were analyzed.P = .02; OR .88; 95%CI .80–98). An endocrine insufficiency was a negative prognostic factor for SCI . In total, 96.2% of the patients had a complete or major postoperative relief with a mean pain intensity reduction from 8.1 to 1.9 on the visual analogue scale.A total of 89 patients with a median follow-up of 38 months were included. In most cases, a duodenum-preserving pancreatic head resection (n = 48) or pancreatoduodenectomy (n = 28) was performed. SCI was achieved in 65.3% (n = 47) of the patients after the final medium follow-up of 15.0 months (IQR: 7.0–35.0 months), respectively. Patients with a longer mean delay (7.7 vs 4 years) between diagnosis and surgical resection were less likely to achieve SCI (The results support that surgical resection for CP should be considered at early stages. Resection can effectively reduce postoperative pain intensity and improve long-term success. The type of surgical intervention should be tailored individually for each patient based on disease state. Moreover, a PD should be considered if pancreatic cancer cannot be ruled out with certainty. Otherwise, the possibility of parenchyma-sparing resections for preservation of maximum functional pancreatic tissue should be evaluated. In clinical routine, endoscopic interventions are frequently carried out as first-line treatment and surgery is avoided until all other medical and endoscopic treatments have failed repeatedly. Allowing pancreatic pain to persist may lead to years of uncontrollable symptoms and opioid abuse. Many patients suffer from the sequelae of alcohol abuse  and accumulate significant comorbidities along with disease progression  with concomitant increased perioperative risk for surgical intervention. Thus, the timing of operation is an important determinant of long-term clinical outcome in CP.,9 It contributes to a long-lasting effect on pain control and improved quality of life (QoL). The most crucial challenge in the management of CP is the early selection of patients who require an operation in order to avoid treatment failure or disease-related complications with concomitant increased perioperative risk.Chronic pancreatitis (CP) is a progressive inflammatory disease leading to an irreversible change of the pancreatic parenchyma in fibrotic tissue. Patients suffering from CP have a fivefold higher lifetime mortality and a reduced life expectancy of approximately 8 years less compared to the general population.Thus, the aim of the present retrospective study was to identify factors that can assist treatment allocation. The analysis focused on factors that affected postoperative pain relief, health status, weight development and complications after surgical treatment of CP.22.1This retrospective monocentric study was approved by the local institutional review board of the Technische Universität Dresden (decision number: 459112017). All patients with CP scheduled for elective pancreatic resection between September 2012 and June 2017 in the Department for Visceral, Thoracic and Vascular Surgery at the University Hospital Carl Gustav Carus Dresden were identified from a pancreatic database. Patients with confirmed pancreatic cancer in the postoperative histology were excluded. The rare presentation of CP limited to the pancreatic tail or remnant after pancreatic head resection was treated by distal pancreatectomy (DP). In cases involving the whole pancreas or recurrent CP, a total pancreatectomy (TP) with or without islet cell auto transplantation (IAT) was performed.The type of surgery was tailored to the pathology, symptoms and history. In cases where the CP was mainly limited to the pancreatic head, a DPPHR was attempted. In patients with severe duodenal stenosis or suspected malignancy and the portal vein was accessible, a PD was indicated. The standard approach for the DPPHR was performed according to the Bern modification.2.2The data were collected and entered in the database created from medical records, surgeons office notes and laboratory parameters. Preoperative clinical characteristics, which could potentially influence the outcome of surgical treatment, were recorded for each patient. These preoperative parameters included patient demographics, body mass index (BMI), etiology of CP, nicotine abuse, laboratory tests , previous endoscopic interventions, previous surgery and delay from diagnosis of CP until surgical resection.The preoperative morphology of the pancreatic gland was classified based on the available imaging studies. This presurgical diagnostic workup included computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreaticography (ERCP), endoscopic ultrasound and transabdominal ultrasound studies. The imaging modalities were used to assess portal vein thrombosis, portal hypertension, the diameter of the pancreatic main duct and common bile duct, inflammatory pancreatic head enlargement, parenchymal calcification and pseudocystic lesions. formation of postoperative pseudocysts (POPF) and new-onset endocrine insufficiency were also considered. The need for relaparotomy due to major postoperative complications (CDC>3a) was defined as secondary outcome parameter. Separate uni- and multivariate analyses were compiled to address for risk factors regarding the need for relaparotomy.Postoperative events, including morbidity (recorded according to the Clavien Dindo classification of complications [CDC]),2.3 In addition, the questionnaire was extended by 4 questions to assess the average pain intensity pre- and postoperatively as well as the ability to reintegrate back into working life and participate in leisure activities after surgery .Patients included in the retrospective study were interviewed by telephone or seen in the outpatient clinic. The study endpoint “significant clinical improvement” (SCI) was defined as stable health status, positive weight development and complete pain relief without routine pain medication . The quality of life was further assessed by using the 3-level version of the EQ-5D questionnaire. The EQ-5D-3L descriptive system comprises the following five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression.2.4t-test and ANOVA for normally distributed data and the Wilcoxon or Kruskal–Wallis test for not normally distributed continuous data. Adjustment for multiple testing was not performed. Multivariate analyses were realized using a stepwise backward logistic regression model, adjusting for age, gender, and BMI. Factors from univariate analyses  with 95% confidence intervals (95%CI).A statistical analysis was performed using the SPSS software package  and the graphical representation was realized with GraphPad Prism v7 . Due to the retrospective nature of the study, the sample size was not chosen on the basis of power calculations. Data were presented as median values and interquartile range (IQR), unless otherwise indicated. Categorical variables were compared using the Chi-Squared test. After testing for normal distribution, continuous variables were compared using Student 33.1In total, 89 patients with a median age of 52 years  were analyzed Table . The eti3.2Most of the patients underwent a DPPHR or pancreatic head resection. A distal or total pancreatectomy (TP) was performed in 13 cases Table . The typPreoperatively, 26 (29.2%) patients had diabetes: 18 patients (20.2%) were insulin dependent, 5 (5.6%) were on oral antidiabetics and 3 (3.4%) were following an antidiabetic diet. Postoperatively, new-onset endocrine insufficiency requiring insulin therapy (Type 3c) was seen in 14 patients (15.7%). The overall POPF rate was 21.3% , Grade B: 8 [9.0%] and Grade C: 4 [4.4%]). A postoperative complication requiring relaparotomy occurred in 13 patients (14.6%) within 90 days after the index operation. The reasons for relaparotomy were: POPF or anastomotic leak (n = 8), hemorrhage (n = 2), pancreatic head necrosis (n = 2), and burst abdomen (n = 1) , a SCI was achieved in 65.3% (n = 47) of patients after the median follow-up period of 15.0 months .A complete response on the QoL assessment was obtained from 52 (58.4%) patients during follow-up . According to the EQ-5D QoL questionnaire, the majority of patients reported the best outcome in relation to the surgical therapy for all 5 dimensions of the questionnaire: with regard to mobility, self-care and usual activities, 78.9% did not have any problems with ambulating, 88.5% did not have any problems with washing or dressing themselves, and 75.0% did not have any problems doing their usual daily activities. In terms of pain/discomfort, 53.9% had complete pain relief, 42.3% reported moderate pain or discomfort and only 3.8% still reported severe pain. For anxiety/depression, 96.2% were not anxious or depressed after surgery. The median current (postoperative) health status at time of last follow up was reported at a median of 72.5% .P < .01) . Importantly, they had a significantly shorter delay between CP diagnosis and surgical treatment (P = .04): 4.0 ± 4.8 years  vs 7.7 ± 6.9 years (n = 21 patients). They also had a lower incidence of postoperative new-onset diabetes (P < .01). In multivariate analysis, new-onset diabetes  and a longer interval between onset of CP and operation  were inversely correlated with SCI in the long-term . We observed that patients with SCI were of older age  and length of hospital stay  as significant factors for postoperative relaparotomy. The latter can be explained by the complicated postoperative course.When analyzing risk factors for postoperative morbidity (CDC>3a), univariate analysis identified operating time  and recurrent AP to early and end-stage CP, as outlined in a recent international consensus draft on a mechanistic definition of CP. DPPHR eradicates the pain syndrome in most patients (>85%) and eliminates local complications of CP. The significant pain relief after surgery was also shown in the present analysis. However, surgical resection competes with less invasive endoscopic options. Many centers follow a step-up approach to managing CP, starting with pain medication and escalating from multiple endoscopic interventions  to surgery at the end of the treatment pathway. Consequently, many patients are referred to a surgeon only after years of symptomatic minimally invasive procedures and a chronic pain memory has been established. Years of opioid abuse and repeated interventions often just treat the symptoms without eliminating the root of the problem. Furthermore, surgical resection is thought to remove the chronic inflammation trigger in the pancreatic head and effectively reduce pain in patients. Delayed surgical treatment can even prevent patients from achieving SCI. In line with this, the present study demonstrated that patients with shorter disease duration until surgery are more likely to achieve SCI. This important finding is supported by clinical trials and was recently included in consensus guidelines.,18 Recently, the ESCAPE study results support that early resection within the first months of opioid use, provides better pain relief with fewer interventions than the current step-up approach.Since the disease course is often unpredictable, the optimal treatment remains a clinical challenge. In addition, an understanding of the key players in pancreatic inflammation is crucial for improved management. In general, the inflammatory process in the pancreatic head is considered to be the pacemaker of CP. Today, a DPPHR modified according to Beger or Bern, a PD, or pancreatic duct drainage procedures with coring out of the pancreatic head (Frey procedure) are accepted surgical options for treating CP and do not show any differences in quality of life within 24 months after surgery. We failed to show direct connection between endoscopic interventions and higher risk of reoperation. But we could demonstrate a correlation between patients who underwent relaparotomy and those not to achieve SCI. From a surgical perspective, this can be explained by the more complex anatomical situation requiring high-risk surgery after less invasive procedures.According to Kempeneers et al early surgery compared to a long history of multiple endoscopic interventions is associated with a reduced risk of failure concerning pain relief, pancreatic insufficiency and re-intervention rates. However, there has been discussion about how inadequate primary surgery for CP significantly influences the rate of redo surgeries. In addition, partial resection of the pancreatic parenchyma with drainage of the choledochal and pancreatic duct seems to be superior to drainage procedures alone with regard to the need for redo surgery.,22 According to the latest results of the ChroPac trial, a PD is at least an equal alternative if a substantial subtotal pancreatic head resection cannot be accomplished during a DPPHR. In this field, a standardization of procedures and perioperative treatment is critical. This might enable high-volume centers to significantly reduce mortality and morbidity rates in order to maximize patient safety. Our results show that the risks and mortality rate for these operations are tolerable. In general, however, these procedures still pose a substantial risk, especially with regard to surgical complications. This is something that needs to be discussed individually with the patient. The fact that relaparotomy is associated with lower chance in achieving SCI status in our cohort supports the concept of centralizing treatment for patients with CP in high-volume centers. Higher procedure volume even plays a larger role than increased experience in reducing inpatient death rates. The high costs for health care systems and the burden placed on society due to insufficient treatment, hospital readmissions and long-lasting unemployment have to be considered as well.While redo surgery for CP is demanding, it can be performed with acceptable morbidity in high-volume centers.The present study has some limitations, which need to be considered. First, the study design was retrospective and not randomized, which results in a bias regarding the treatment approach, type of resection and monitoring/follow-up of the patients. Patient and treatment selection therefore had a potential influence on the studys outcome. Second, QoL was not routinely assessed preoperatively and, consequently, a direct comparison of pre- and postoperative QoL scores was not performed. Third, we analyzed a limited patient cohort size and observed a 22.5% dropout rate during the follow-up, which probably influenced the outcome data as well. However, the few available randomized controlled trials (RCT) show analogous results. Nevertheless, more RCTs are needed in order to demonstrate the superiority of early surgery compared to the standard step-up approach. Based on the findings of this study , we believe there is a need for strong interdisciplinary management of CP patients and discussion within gastrointestinal boards at specialized centers. The recently published Chronic Pancreatitis Pain Relief Score by Bachmann et al. might be an additional promising tool to identify those patients who benefit most from surgical procedures.In summary, the present retrospective analysis underlines that the choice to use a routine step-up approach until surgical resection should be critically assessed and surgical therapy of CP should be considered earlier  after diagnosis of symptomatic CP. Multiple interventions over years prior to surgical resection  can probably delay the course of disease, increase the risk of postoperative complications and negatively influence the long-term outcome. On the other hand, adequately performed surgical procedures can effectively reduce pain intensity during long-term follow-up.All authors revised the manuscript critically, approved the final version and agreed to be accountable for all aspects of the work.Antonie Willner: patient acquisition, data collection, drafting of the manuscript.Andreas Bogner: data analysis, data interpretation, drafting of the manuscript.Benjamin Müssle: data analysis, design and concept of the study.Christian Teske: data interpretation, design and concept of the study.Sebastian Hempel: data interpretation, design and concept of the study.Christoph Kahlert: data interpretation, design and concept of the study.Marius Distler: data interpretation, design and concept of the study.Jürgen Weitz: data interpretation, design and concept of the study.Thilo Welsch: data interpretation, design and concept of the study, drafting of the manuscript.


Pacing, avoidance, and overdoing are considered the three main behavioral strategies, also labeled activity patterns. Their relationship with functioning of patients with chronic pain is debated. The purpose of this study was to measure the influence of activity patterns on lifting tasks commonly used in daily life.  We performed a monocentric observational study and included patients performing Functional Capacity Evaluation (FCE). Avoidance, pacing, and persistence were assessed with using the Patterns of Activity Measures–Pain (POAM-P). Maximal safe performance was measured for floor-to-waist, waist-to-overhead, horizontal lift, and carrying with dominant-hand tests according to the FCE guidelines. Descriptive statistics, associations of POAM-P subscales with various sociodemographic variables, and correlations are presented. Standard multiple linear regression models were applied to measure the associations between FCE tests and POAM-P subscales, adjusting for the following potential confounders: age, gender, body mass index (BMI), pain severity, trauma severity, localization of injury, and education. p=0.001), waist-to-overhead , horizontal lift , and dominant-handed lifting . Pacing was found to have a negative influence on the carrying dominant-hand test , and avoidance was not found to have an influence on the 4 FCE tests.  Persistence was significantly positively associated with performance on the 4 FCE tests: floor-to-waist (coefficient = 0.20;  This study shows that task-persistence pattern is positively associated with physical performance in FCE, whereas pacing can have a negative influence on some tests. The relationship between these patterns and the functioning of patients with chronic pain remains subject to significant controversy [The influence of behavior on the development and perpetuation of chronic pain has been the subject of debate for many years , 2. Ther context : avoidanne study . The conne study . To be itroversy –9. One otroversy , 11. Fortroversy , 12. Imptroversy . Consequtroversy . Functiotroversy . It is btroversy . It has troversy –18. Selftroversy , 19–21. troversy , 21. To troversy . In anottroversy . There itroversy .The aim of our study was to investigate the influence of activity patterns on patients with chronic musculoskeletal pain during FCE by using the POAM-P questionnaire and to answer the following question. What are the associations between the 3 activity patterns and the FCE lifting performances in patients with chronic musculoskeletal pain? Based on previous research addressing observational measurements , our hypWe conducted an observational study at the Clinique Romande de Réadaptation, a rehabilitation center in the French-speaking part of Switzerland.Any patient of working age (18–65 years old) who had an FCE from October 2013 to April 2018 was eligible. As previously described , exclusiAll participants read and signed an informed consent form to allow access and the use of their clinical data for the present study. The protocol was approved by the ethical committee of the local medical association , and the study was performed in accordance with the ethical standards listed in the 2008 Declaration of Helsinki.Patients' sociodemographic data and variables of interest were chosen for their possible confounding influence on the FCE performances . They weThe Hospital Anxiety and Depression Scale (HADS)  was usedFor pain assessment, we used 2 subscales of the Brief Pain Inventory (BPI) questionnaire. The severity subscale measured pain at its “worst,” “least,” “average,” and “now” state with 4 numeric scales and was scored as the mean , with a high score indicating high severity –31. The Perceived functional ability was measured by the Hand Function Sort (HFS) and the Spinal Function Sort (SFS), which are pictorial questionnaires assessing the perceived capacity to achieve physical activities related to daily and work activities, including material handling, postural tolerance, and ambulation . The HFSAvoidance, pacing, and overdoing/persistence were assessed at entry using POAM-P, developed by Cane  and valiThe FCE helps determine the individual's safe functional capacity, a very important perspective for people with chronic pain who may be subject to fear of reinjury. Four of the FCE tests with high reliability were conducted during the rehabilitation program, according to Workwell–Isernhagen FCE standards , 40: theTo minimize the measurement bias, questionnaires and clinical and demographic data were collected during the 2 days following admission, patients being planned for two 30-minuteperiods devoted to questionnaires. The use of a digital pen allowed data capture and transfer from paper to the data files. FCEs were performed 3 to 4 weeks after admission and were done under the supervision of certified physical therapists, familiar with the tests through regular training and clear instructions.Descriptive statistics were expressed as mean and standard deviation for continuous variables, whereas median and interquartile range were used if the distribution was skewed after visual inspection of data. Categorical variables were expressed as count and percentage.t-test for binary variables. Eta-squared coefficient was expressed to determine and compare each categorical effect. Following Cohen [We compared the POAM-P scores according to sociodemographic variables with analysis of variance or Student's ng Cohen , eta-squWe looked for Pearson's or Spearman's correlations between the POAM-P scores and other variables, following the distribution of variables. Evans's  strengthTo study the association between activity patterns and the FCE tests, we used continuous scores of each of the three subscales of the POAM-P , 37, 38.A total of 304 patients were included. Patients were predominantly middle-aged men , nearly half were not French native speakers, and 42% had a low level of education. The median duration between trauma and rehabilitation was 15 months . Injury locations were 44.2% upper limb, 42.2% lower limb, 11.5% spine injury, and multiple sites for the rest. Most injuries occurred at work (54.3%) and were classified as minor or moderate according to the Abbreviated Injury Score. The mean pain severity assessed by BPI was 4.03 ± 1.76, and the mean pain interference with daily activity was 4.1 ± 1.97. The HADS score was just below 7 ± 4.05 points for depressive symptoms and 9 ± 3.98 points for anxiety symptoms. When looking at perceived ability to perform working tasks assessed with the SFS/HFS, most patients felt they could perform light work. Higher avoidance scores were found in nonnative French-speaking patients, whereas lower overdoing/persistence scores were found in patients with lower limb trauma. Effect sizes were small-to-medium (Eta-squared)  Table 2Table 2.r = 0.5), whereas only weak correlations were found for pacing and overdoing subscales with other variables , meaning that for each supplementary point at the overdoing/persistence score , an increase of 0.20 kg is expected for the maximal lifted weight. In other words, a difference of 2 kg at the maximal lifted weight is expected between patients having a difference of 10 points on the overdoing/persistence score. When looking at the standardized coefficient, 3.28 kg represents the increase expected for the maximal floor-to-waist lift for a gain of 2 standard deviations (16.42 points) at the overdoing/persistence score. We found no influence of avoidance and pacing patterns.Results of the multivariable model analysis are presented in p=0.004), meaning that for each supplementary point at the score, there will be an increase of 0.13 kg. When looking at the standardized coefficient, an increase of 2.08 kg is expected every 16.42 points. We found no influence of avoidance and pacing patterns.For the waist-to-overhead lift, similar associations were found. A high overdoing/persistence score was associated with higher performances , meaning that for each supplementary point on the 40-point scale, an increase of 0.31 kg is expected. When looking at the standardized coefficient, an increase of 5.15 kg is expected every 16.42 points (2 SD) for the maximal horizontal lift.For the horizontal lift, a higher overdoing/persistence score was also associated with higher performance  as opposed to pacing, which was negatively associated . A difference of 1 point on each questionnaire, respectively, represents an increase of 0.19 kg or a loss of 0.14 kg on the maximal carrying test. We found no influence of avoidance.For the dominant-handed carrying test, overdoing/persistence was again positively associated with performance  ranged from 2.1 kg for the maximal waist-to-overhead lift to 5.1 kg for the maximal horizontal lift. These gains counterbalance the expected loss of performance associated with age, as the expected change for age ranged from a 1.9 kg loss for the carrying with dominant-hand test to 3.4 kg for the floor-to-waist lift, for every increase of 22 years (2 SD). If we compare the effect with gender, it also partially compensates for the influence of female gender on physical performances during FCE.The influence of the overdoing/persistence pattern is debated in the literature, which is mainly based on subjective measures: Cane et al. found a positive association with disability in a population of patients with chronic pain recruited from a pain clinic, with a median pain duration of 7 years, and a high proportion of fibromyalgia, in contrast to our population , whereasWe found no significant association of pacing with the 3 FCE lifting tests. Other studies using the POAM-P and addressing subjective measures of functioning showed contradictory results: Cane et al. found lower perceived disability for patients with a high level of pacing , whereasWe found no association between the avoidance pattern and any of the 4 FCE tests. These results may seem surprising at first glance, as this pattern is associated with poor functioning in the literature , 47, 55.Our results highlight the importance of using observational measures in studies addressing the influence of behavioral patterns in patients with chronic pain. Such measures seem important, as subjective tools cannot just replace them and may lead to inaccurate or incomplete conclusions . These oThere is a positive association of overdoing/persistence pattern with objective physical activity measurements. Even if we cannot draw causal interpretation, our results suggest a behavioral strategy based on task-contingent persistence instructions may be more effective than modulation strategies often proposed in the rehabilitation of chronic pain . WithoutThis is the first study addressing measures of activity patterns in the context of patients with chronic musculoskeletal pain after trauma. The use of FCE as an observational measure is another strength because of its reliability and ability to determine a maximum safe effort for the patient. However, this study also has some limitations. First, the sample mainly consisted of men addressed for specialized rehabilitation. The setting in itself may influence activity patterns and indeed may limit the generalization of our results. This type of study should therefore be repeated in samples that include a greater number of women. This would be all the more interesting as the overdoing/persistence pattern has been positively associated with the female gender . A seconOur results suggest that the overdoing/persistence pattern as defined in the POAM-P is positively associated with the following functional tasks: carrying a load from the ground to the waist, carrying a load from the waist to the head, lifting a load horizontally, and moving a load with the dominant hand, all of which are common tasks in daily and professional life. Further studies will be needed to determine whether there is a causal relationship between this pattern and physical performance.


Standard protocols or algorithms are considered essential to ensure adequate analgesia. Germany has widely adopted postoperative protocols for pain management including oral opioids for rescue medication, but the effectiveness of such protocols has only been evaluated longitudinally in a before and after setting. The aim of this cohort analysis was to compare the effectiveness of an oral opioid rescue medication algorithm for postoperative management of pain to the gold standard of patient-controlled intravenous analgesia (PCIA).This study compared cohorts of patients of two prospective observational studies undergoing elective total hip replacement. After surgery patients received piritramide to achieve a pain score of ≤3 on the numeric rating scale (NRS 0–10). A protocol was started consisting of oral long-acting oxycodone and ibuprofen . Cohort 1  additionally received an oral opioid rescue medication (hydromorphone) when reporting pain >3 on the NRS. Cohort 2  was provided with an opioid by PCIA (piritramide) for opioid rescue medication. Primary endpoints were pain intensity at rest, during movement, and maximum pain intensity within the first 24 h postoperative. Secondary endpoints were opioid consumption, functional outcome and patient satisfaction with pain management.p = 0.023; maximum pain intensity: 7 (5–9) vs. 5 (3–8), p = 0.008. There were no differences in pain intensity at rest or between women and men in either group. The mean opioid consumption in all patients  was 126.6 ± 51.8 mg oral ME (median 120 (87.47–154.25) mg ME). Total opioid consumption was lower in C1 than C2  due to differences in rescue opioids . Basic analgesia opioid use was comparable . There were no differences in respect to the addition of non-opioids and reported quality of mobilization, sleep, frequency of nausea and vomiting, or general satisfaction with pain management.Pain during movement and maximum pain intensity were higher in C1 compared to C2: pain on movement median 1st–3rd quartile: 6 (3.75–8) vs. 5 (3–7), In this study PCIA provided a better reduction of pain intensity, when compared to a standardized protocol with oral opioid rescue medication. This effect was associated with increased opioid consumption. There were no differences in frequencies of opioid side effects. This study was a retrospective analysis of two cohorts of a major project. As with all retrospective studies, our analysis has several limitations to consider. Data can only represent the observation of clinical practice. It cannot reflect the quality of a statement of a randomized controlled trial. Observational studies do not permit conclusions on causal relationships. Caregivers have focused on improvement in postoperative pain management for several years; however, for some areas quality of pain management remains inadequate , 22. PreThe aim of this analysis was to compare the effectiveness of a standardized algorithm to control the process of application of rescue medication based on oral short-acting opioids to the administration of short-acting opioids via patient-controlled intravenous analgesia (PCIA).In this analysis of two cohorts of previously conducted prospective, observational trials we compared the effectiveness of a standardized algorithm based on an oral short-acting opioid postoperative pain management in comparison with PCIA. Both arms primarily aimed to investigate the influence of different pain-related characteristics in patients with osteoarthritis of the hip scheduled for total hip replacement on postoperative pain intensity, analgesic consumption and functional outcome , 16. ProData were collected consecutively from July to October 2012  and from April to July 2013  at a single center . The established clinical standards of the hospital were executed for postoperative pain management  and werePrimary endpoints were pain intensity at rest, pain intensity during movement and maximum pain intensity within the first 24 postoperative hours. Secondary endpoints were opioid consumption in morphine equivalents within the first 24 h, functional outcomes , and patient satisfaction with pain management. All patients were admitted to the hospital and consented to participate in the study on the day before surgery. In both arms, we collected data from hospital admission to the first postoperative day.Patients were included consecutively if they were at least 18 years old, able to understand the study information and the questionnaires and provided written informed consent. Furthermore, the indications for total hip replacement had to be primary osteoarthritis of the hip. No stratification for age or gender was applied. In order to minimize variations in pain intensity in the early postoperative phase due to different anesthetic techniques, all participants receiving spinal or regional anesthesia were excluded. Furthermore, we excluded patients diagnosed with dementia or any other major neurologic condition, active drug abuse, or preoperative opioid consumption of >30 mg of morphine equivalents. We did not include patients participating in other studies simultaneously. To ensure more homogeneous groups, patients with acute hip pain due to femoral head necrosis were not included. The C2 cohort underwent electroencephalogram (EEG) recording on the day prior to surgery. Therefore, patients with a significant neurologic disease, such as stroke or epilepsy were excluded in C2.On the evening prior to surgery and the following morning all patients received 20–30 mg dipotassium chlorazepate. General anesthesia was performed according to clinical standards and induced by a remifentanil (1–1.5 µg/kg for 3 min) and propofol bolus (1–2 mg/kg). Orotracheal intubation was facilitated by 0.5 mg/kg atracurium. Anesthesia was maintained with sevoflurane 0.7–1.0 MAC or propofol 3.5–4.5 mg/kg and h, along with remifentanil (0.15–0.25 µg/kg and min). According to hospital standard, depth of anesthesia was monitored by bispectral index . During the final stages of the operation, i.e. implantation of the femoral shaft, 0.1 mg/kg piritramide and 15 mg/kg metamizole  were administered intravenously. All patients were extubated and transferred to the postanesthesia care unit (PACU).Upon PACU arrival, pain was treated with repeated doses of 3.75 mg piritramide IV to reach a pain score of ≤3 on the numeric rating scale NRS 0–10) in all patients. While still in the PACU, all patients (C1 and C2) received 10 or 20 mg long-acting oxycodone orally  and 600 mg ibuprofen orally for basic analgesia. Once on the regular nursing ward, patients received oral oxycodone twice daily and ibuprofen 600 mg three times a day, following the standardized protocol  when NRS was >3. Pain intensity was reassessed 60 min after administration of an analgesic. If pain intensity remained >3 on the NRS, a second hydromorphone dose was offered. If pain persisted after further 60 min, a third dose of hydromorphone was administered, and the physician was consulted. Oxycodone dose was increased by 10 mg twice daily when 3 doses of hydromorphone were given within 24 h. Whenever the patients’ pain intensity scored <3 over the past 24 h, each dose of long-acting oxycodone was reduced by 10 mg  for 24 h instead of the oral hydromorphone. The PCIA was initiated in the PACU as soon as patients were able to operate the system. All patients were instructed about their respective postoperative analgesia protocol including pain assessment using NRS. “C1” patients were informed of the availability of supplemental doses of analgesics if required, while “C2” patients were instructed in the use of the PCIA system.The patients’ preoperative pain history was assessed by a standardized protocol based on the German pain questionnaire  .Postoperative pain was assessed 24 h after surgery by the quality improvement in postoperative pain therapy (QUIPS) questionnaire, a validated German outcome assessment tool, including questions about pain intensity during movement, maximum pain intensity and pain intensity at rest over the previous 24 h (NRS: 0 = no pain to 10 = worst pain) . In addiDue to interindividual variability the preoperative opioid consumption between the two cohorts was compared in two steps: 1) opioid intake “yes”/“no” and 2) “no”/“only as required”/“regular daily dosage <30 mg morphine equivalent”).To compare the postoperative analgesic consumption, opioid doses were expressed as oral morphine equivalent . For the current analysis, the postoperative opioid consumption was calculated for the time from surgery including the first postoperative day, which includes opioids received in the PACU.U-test). The distributions of frequencies of dichotomous attributes in groups were described using the Pearson χ2-test.Percentages were rounded to the nearest whole number. Categorical variables are presented either as percentages in groups or as median with first and third quartiles. Continuous attributes are described using the mean and standard deviation. Correlations between pain scores , opioid consumption and patient satisfaction were calculated with Kendall-Tau‑b. Group comparisons with categorical and continuous characteristics were analyzed using non-parametric tests . A further 8 were excluded due to planned spinal anesthesia and 3 patients due to preoperative opioid consumption with daily doses >30 mg ME. After inclusion and recording of baseline parameters 18 patients had to be excluded because the surgery was cancelled, postoperative delirium occurred, or they had acute (<6 months) hip pain due to femoral head necrosis.Of the 175 patients screened, 24 patients declined to participate; 1 was less than 18 years old; 1 was excluded because he was already enrolled in another study; and 1 was excluded because both hips were replaced in one session. One patient could not be included because he was a prisoner and informed consent could not be obtained. 13 patients were excluded due to planned spinal anesthesia, 4 patients due to preoperative opioid use with daily doses >30 mg ME, and 1 due to drug abuse. A further 17 patients were not included due to relevant neurologic conditions in their medical history. Another 18 patients were excluded after signing the informed consent because the surgery was cancelled or postponed. One patient was excluded because a postoperative transitional syndrome occurred, and 5 patients did not finish the PCIA therapy according to the study protocol for 24 h and/or pain intensity was not assessed after 24 h.n = 126; C2 n = 88). Even though the two groups did not differ with respect to age and body mass index (BMI), the proportion of men was higher in C1 than in C2. Due to this difference in distribution, the results for postoperative pain intensity and analgesic consumption were also presented separately for gender.A total of 214 patients were included in this analysis  reported lower maximum pain intensity and lower pain during movement. There were no differences in pain intensity at rest . There was no significant difference in the amount of long-acting opioids .The mean opioid consumption in all patients  was 126.6 ± 51.8 mg oral ME (median 120 [87.47–154.25] mg ME) over the first 24 h. Overall opioid consumption was higher in patients with PCIA  while there was no difference between women and men treated with an oral opioid rescue medication algorithm  total amount of opioids delivered via PCIA was not statistically different between women and men .2 = 0.656). If contraindicated most patients received 4 × 1 g metamizole/dipyrone; only 8 patients alternatively received 4 × 1 g paracetamol.There were no significant differences between the cohorts regarding the use of additional non-opioids, 79% in C1 and 81% in C2 received an antiphlogistic non-opioid , C2: 13 (12–14), n.s., Z = −1.279). We found no gender-specific distinctions in overall satisfaction . Variation in pain intensity and opioid consumption did also not affect the patients’ wishes to receive more pain medication (Table p = 0.001), as well as weakly correlated with overall opioid consumption within 48 h . We also found a mild negative correlation between pain intensity and patients’ satisfaction . There was no significant correlation between the pain intensities and the amount of long-acting opioid medication.Not surprisingly, pain intensity was correlated with rescue opioid consumption  after surgery .These results were similar in the cohort-specific analysis, except for an absence of correlation between pain intensity and opioid consumption in the PCIA cohort  or side effects (incidence of nausea and vomiting). This is supported by other studies reaching similar conclusions . In thesImplementation of standardized protocols has improved pain management for various surgical procedures and clinical settings as shown in studies using preintervention/postintervention measurements , 32, 35.Immediate availability of a potent, fast-acting substance on demand Control of effectiveness after a predefined period following administration of rescue medicationPossibility of repeating this rescue medication after a predefined periodBasic analgesia, including a non-opioid and an opioid Further instructions if pain relief remains insufficient, despite rescue medicationA recent analysis of the factual contents of standardized postoperative pain protocols showed that many of these concepts did not even include provision of a rescue medication . Some coGender differences in pain perception and tolerance have been a focus of research for a considerable time. . While sAnalyzing men and women separately in our study revealed that women treated with PCIA received and/or required fewer opioids than men. This finding may be explained by different psychological characteristics, or pharmacokinetic differences. Also, men without PCIA were less likely to actively demand an oral analgesic in case of relevant pain compared to women ; howeverData for both cohorts were collected on patients undergoing a surgical procedure with a high grade of standardization in a single recruiting hospital. All patients received the same baseline analgesics. The only difference between the cohorts was the method of providing rescue medication. Since the group with PCIA used this in addition to the same baseline medication, valid insights about the effectiveness of the oral rescue medication algorithm could be gained. Another strength of our study is the assessment of functional outcomes in addition to pain intensity and analgesic consumption. Assessment of functional outcomes in pain management should be a standard in both trials for postoperative pain management and monitoring of clinical practice. Outcome measures like QUIPS and/or Pain OUT (improvement in postoperative PAIN OUTcome) offer this possibility , 38.p-values has been questioned recently for retrospective observational studies [This retrospective study was a prespecified subgroup analysis of two prospective observational trials. Data collection was not blinded. The current results thus have relevant potential for bias or lack of control for confounding variables. As with all non-randomized trials, our results should not be interpreted as a causal relationship, but rather an association. The size of the two cohorts clearly differed, which could potentially affect the results. The differences in cohort size are a result of limited time windows for consecutive and prospective patient recruiting. Since this study was a subgroup analysis of previously recorded data, the number of patients included was determined by the time period of recruitment, and no additional effect or sample size was performed. In addition, the applicability and validity of traditional  studies , 33; how studies , 17.Furthermore, the study arms were not primarily designed and conducted to assess the effectiveness of an analgesic protocol. On the other hand, there were no other conceptual differences in the management of these patients than the difference in rescue analgesia . Throughout the study, multiple surgeons cared for patients in both cohorts. Thus, from a clinical viewpoint, the analysis reflects and supports the feasibility of a standardized protocol with oral opioid rescue medication.A further limitation is the assessment of opioid consumption. Only the total amount was assessed in the C group, without separation into basic analgesia (with long-acting opioids) and rescue administration (with short-acting opioids). Thus, no differentiated conclusions on patient behavior in the first cohort are possible. Furthermore, the pharmacokinetics of intravenous and oral opioids is substantially different, which might have influenced the effectiveness of the opioid medication irrespective of the dosing and the opioid used. Several publications have questioned the validity of conversions of opioid equivalents by highlighting relevant interindividual variations; however, this is a widely accepted approach to compare opioid regimens, which were highly standardized in this study despite the use of different opioids , 37. In While the standard clinical analgesia algorithm at the study-hospital combined different opioids for intravenous therapy, as well as oral rescue medication and basic analgesia, advantages for limiting the number of active substances used  have been described.The use of PCIA as rescue medication is superior to a standardized concept with an oral opioid rescue medication algorithm for reducing pain intensity; however, greater pain relief in patients with PCIA goes along with increased opioid consumption. In terms of functional aspects and pain intensity at rest, we found no differences. This clinical study was a retrospective analysis of previously collected prospective data. It therefore has inherent limitations and potential bias. There was no prospective calculation of effect or sample size, the two study arms were not primarily designed and conducted to assess the effectiveness of analgesic protocols, differences in cohort size occurred due to limited time windows of consecutive recruiting, and a control for confounding variables is lacking. Even though data were collected on patients undergoing one specific surgical procedure with a high grade of standardization in a single recruiting hospital and with the same overall management in both cohorts , study results only represent a clinical observation and not the quality and validity of a randomized controlled trial. Observational studies do not permit conclusions on causal relationships.


PurposeTechnetium Tc-99m sulfur colloid (99mTc-SC) breast lymphoscintigraphy is commonly performed to identify the sentinel lymph node (SLN) in patients diagnosed with breast carcinoma undergoing lumpectomy. The purpose of this report is to describe how the use of 2% topical lidocaine jelly immediately after the completion of needle localization and prior to scintigraphy may substantially reduce pain associated with the injection of 99mTc-SC.Materials and methodsThis was a quality improvement project. Patients were asked to score the severity of pain associated with the periareolar 99mTc-SC injections for sentinel node lymphoscintigraphy. In order to decrease the discomfort, topical lidocaine was applied to the periareolar skin after the completion of the needle localization, but prior to transferring the patient from the mammography room to the nuclear medicine department for the 99mTc-SC injections. At the time of 99mTc-SC injection, patients were asked to score the pain of injection from 0 (none) to 10 (worst).ResultsThe average pain score of the women who did not receive topical lidocaine jelly was 8 (range: 5-9). In the 10 women who received topical lidocaine jelly after needle localization, the average pain score was 2.5 (range: 1-5). Interestingly, the pain score for women who discussed the possible use of lidocaine jelly with the radiologists but still did not receive topical lidocaine jelly was also low at 6.5. For patients who received the lidocaine jelly only five minutes prior to injection, the average pain score was 6.ConclusionThe application of lidocaine jelly after the conclusion of needle localization, with a 15-40-minute delay prior to periareolar injections with 99mTc-SC for sentinel node lymphoscintigraphy, appears to substantially reduce the pain associated with the injection of 99mTc-SC. Lymphoscintigraphy is a common procedure used in oncology to identify and produce a “map” of the lymphatic system in order to identify the most likely first node of lymphatic drainage, the sentinel lymph node (SLN). The SLN is important as it is considered to be the first node to contain metastasis, and the biopsy of the node may assist in cancer staging . The proUnfortunately, severe pain is often reported by patients during the injection of the radiopharmaceutical, and several methods have been proposed to decrease or eliminate this pain, albeit with inconsistent results . MethodsIn this quality improvement project , we asked patients undergoing lymphoscintigraphy to score the severity of pain associated with each periareolar 99mTc-SC injections for sentinel node lymphoscintigraphy on a scale of 0-10  using the NIH Toolbox® pain-intensity measures . We furtAfter routinely recording the pain score in patients, we decided to do a pilot review of administering the leftover topical lidocaine jelly used during needle localization to the periareolar skin. This was done after the completion of the needle localization, but prior to transferring the patient from the mammography room to the nuclear medicine department for the 99mTc-SC injections. The time from administration of the topical lidocaine jelly to the injection of 99mTc-SC varied from 15 to 40 minutes. No other modifications were made to the procedure from the needle localization till surgery. If physicians added bicarbonate and/or lidocaine to the 99mTc-SC solution, this continued as before (which was the case with the vast majority). However, some physicians decided to continue with their usual methods, without the use of the topical lidocaine jelly. Another group used topical lidocaine jelly immediately prior to the injection of 99mTc-SC only. In one group of patients who received topical lidocaine jelly after needle localization, there was no migration of the radiopharmaceutical visible, and the SLN was identified during surgery with an intraoperative injection of dye.Thus, the patients fell into five groups: (A) patients whose pain score was measured prior to the discussion about using topical lidocaine jelly; (B) patients who received topical lidocaine jelly immediately after needle localization with approximately 15-40-minute delay prior to the injection of 99mTc-SC; (C) patients who did not receive any topical lidocaine jelly prior to the injection of 99mTc-SC even though they had a discussion about using topical lidocaine; (D) patients who received topical lidocaine jelly immediately after needle localization with approximately 15-40-minute delay prior to the injection of 99mTc-SC, but in whom there was no migration of the radiopharmaceutical to a sentinel node; and (E) patients who received topical lidocaine jelly in the nuclear medicine department a few minutes prior to the injection of 99mTc-SC.As this was only a pilot review of the pain scores kept in the department to determine if a formal study of topical lidocaine jelly should be carried out (and not a prospective study), we did not collect any demographic information. However, all patients were being evaluated for breast carcinoma. While there probably was no significant difference among patients in terms of age, race, underlying co-existing pathologies, or individual susceptibility to pain, we are not certain about it.The pain score in the 10 patients whose pain score was measured prior to the discussion about using topical lidocaine jelly, group (A), was 8 (range: 5-9), with many describing the pain as one of the worst ever. The pain score in the 10 patients who received topical lidocaine jelly immediately after needle localization with approximately 15-40-minute delay (caused by transferring the patient from the mammography suite to the nuclear medicine suite) prior to the injection of 99mTc-SC, group (B), was 2.5 (range: 1-5). The pain score for five women who did not receive any topical lidocaine jelly prior to the injection of 99mTc-SC even though they had a discussion about using topical lidocaine, group (C), was 6.5 (range: 4-8). The pain score for four women who received topical lidocaine jelly immediately after needle localization with approximately 15-40-minute delay prior to the injection of 99mTc-SC, but in whom there was no migration of the radiopharmaceutical to a sentinel node, group (D), was 8 (range: 6-9). The pain score for two patients who received topical lidocaine jelly in the nuclear medicine department a few minutes prior to the injection of 99mTc-SC was 6 (range: 4-8)  compared to the pain score revealed by patients prior to this pilot . Still, the pain score for group B was lower than that of group C (2.5 vs. 6.5, Table We conducted a review of the pilot trial administration of periareolar topical lidocaine to patients immediately after the completion of needle localization but prior to periareolar intradermal lymphoscintigraphy with 99mTc-SC. We found that patients experienced a substantial reduction in pain, and the effect appeared to be greater than if topical lidocaine was administered immediately prior to the injection. As such, we decided not to carry out a formal prospective blind study, and we now routinely administer topical lidocaine after needle localization to all patients who are scheduled to undergo periareolar intradermal injection of 99mTc-SC lymphoscintigraphy.


Percutaneous cervical cordotomy (PCC) is an interventional ablative procedure in the armamentarium for cancer pain treatment, but there is limited evidence to support its use. This study aimed to assess the effectiveness and safety of PCC.Analysis was undertaken of the first national (UK) prospective data repository of adult patients with cancer undergoing PCC for pain treatment. The relationship between pain and other outcomes before and after PCC was examined using appropriate statistical methods.Data on 159 patients’ PCCs (performed from 1 January 2012 to 6 June 2017 in three centres) were assessed: median (IQR) age was 66 (58–71) years, 47 (30%) were female. Mesothelioma was the most common primary malignancy (57%). The median (IQR) time from cancer diagnosis to PCC assessment was 13.3 (6.2–23.2) months; PCC to follow-up was 9 (8–25) days; and survival after PCC was 1.3 (0.6–2.8) months. The mean (SD) for ‘average pain’ using a numerical rating scale was 6 (2) before PCC and 2 (2) at follow-up, and for ‘worst pain’ 9 (1) and 3 (3), respectively. The median (IQR) reduction in strong opioid dose at follow-up was 50% (34–50). With the exception of ‘activity’, all health-related quality of life scores (5-level version of EuroQol-5 Dimension) either improved or were stable after PCC. Six patients (4%) had PCC-related adverse events.PCC is an effective treatment for cancer pain; however, findings in this study suggest PCC referrals tended to be late in patients’ disease trajectories. Further study into earlier treatment and seeking international consensus on PCC outcomes will further enhance opportunities to improve patient care. Pain control reduces suffering and improves quality of life. The WHO analgesic ladder serves as a foundation for the treatment of cancer-related pain.PCC is a procedure carried out in a conscious patient and uses radiofrequency ablation to create a heat lesion in the lateral spinothalamic tract in the upper cervical spinal cord, interrupting ascending pain signals.Cordotomy is indicated for unilateral cancer pain in patients with a life expectancy of less than 1 year who are not responding to other interventions.Despite PCC being an important part of the armamentarium for the treatment of cancer pain, there is limited evidence to support its use. A systematic review by our group, focused on the effectiveness of PCC in mesothelioma-related pain,Although the research done suggests that PCC might be safe and effective, more work is needed to inform clinical practice and support its continued provision.Following a UK-wide survey and subsequent Delphi processThe registry was launched in January 2012, which prospectively collects key preprocedure and follow-up data on all patients who have PCC for cancer pain. To our knowledge, this is the first national data repository for PCC in the world.Data from this PCC repository register were assessed between 1 January 2012 and 6 June 2017. The register collected data from three interventional pain centres offering cordotomy procedures  serving a geographically defined population of 60 million. A further centre in Oldham was not included within this analysis due to limited resources to input data and its subsequent closure in 2015.All patients in the register met the following criteria: pathological or radiological diagnosis of cancer; pain secondary to their cancer (≥4/10 (worst pain in the previous 24 hours) on a 0–10 numerical rating scale (NRS)); PCC indicated following PCC practitioner assessment; and over 18 years of age. Additionally, the PCC practitioner used their clinical judgement to ensure each patient had underwent a reasonable trial of opioids and adjuvant medication.The PCC was performed as an inpatient, under fluoroscopic guidance (X-ray) and performed by one of five pain medicine consultants trained in this techniqueTypically, patients required sedation for the procedure using either fentanyl alone, or in combination with sedatives . Patients were placed in the supine position with their head and neck stabilised in an external fixator (head support). An image intensifier and contrast  were used to identify C1 and C2 vertebrae and the dentate ligament on the side contralateral to the pain. A radiofrequency electrode was passed into the anterolateral spinal cord and the spinothalamic tract then localised through sensory stimulation. Incremental heat lesions were created in the lateral spinothalamic tract while assessment was made of ipsilateral motor function to ensure preservation of the adjacent corticospinal tract. The contralateral analgesia was then checked by pinprick and the power of the ipsilateral arm and leg was also checked between each lesion. If required the procedure was repeated. The total PCC procedure time was usually under 60 min, most lasting 30–45 min. The policy in all study centres was that strong opioid analgesics were reduced by up to 50% of total daily dose either immediately before or after procedure.The following were assessed before and after PCC: pain (average and worst) using a 0–10 NRS; health-related quality of life using the 5-level version of EuroQol-5 Dimension (EQ-5D-5L) Primarily, a descriptive analysis was undertaken. The primary purpose of the repository was data collection so formal hypothesis testing and sample size calculation were not appropriate. However, exploratory analyses were undertaken using appropriate non-parametric tests. Data checking (to ensure consistency with care records) was conducted. Only those patients who had data collected as part of the repository were assessed. All statistical analyses were performed using SPSS V.21.0. Where appropriate, means and SDs, or medians and IQR are reported throughout. A p value <0.05 was regarded as statistically significant.From 1 January 2012 to 6 June 2017, one hundred and fifty-nine patients had a PCC performed and were analysed as part of the present study. Patient demographics and baseline pain characteristics are shown in The median (IQR) age of patients was 66 (58–71) years. All but two patients (n=157) were on strong opioid analgesia . The median (IQR) strong opioid dose (MEDD) at baseline was 200 mg (100–400). The median (IQR) time from diagnosis of cancer to assessment for consideration of PCC was 13.3 (6.2–23.2) months. One hundred and twenty-nine patients (81%) had their cordotomy done within 48 hours of assessment by their PCC practitioner. The median (IQR) time to follow-up was 9 (8–25) days and within this time period 137 (87%) patients were alive. The median (IQR) duration of survival from procedure was 1.3 (0.6–2.8) months.Six patients (4%) had adverse events relating to their PCC including urinary retention (2) opioid toxicity (1) impaired balance (1) dyspnoea (1) and pain at the PCC site (1).The findings from our data repository suggest PCC is an effective treatment for patients with cancer-related pain and helps facilitate a significant reduction in opioid medication. The findings support previous observations that cordotomy has an ongoing role in the management of unilateral pain due to malignancy such as mesothelioma and lung cancer.It was also observed that patients tended to receive the procedure late in their disease trajectory (averaging just over a month before their death) and so potentially did not receive prolonged benefit from this intervention. Although this may relate to pain control issues not being significantly severe to merit a PCC, the services as a whole advocate early review to optimise procedure timing. It was noteworthy that 20 patients died after PCC and before the initial follow-up. This observation likely represents real-life clinical practice where factors such as overestimation of prognosis, uncertain disease trajectory and referrals being made too late are occurring. We also hypothesise that the lack of familiarity and limited access to PCC services may have compounded the aforementioned factors. Given the limited survival of these patients, getting the timing right for PCC is crucially important.A previous review article summarised six case series, totalling 677 patients with cancer, who were treated with unilateral cordotomy since 1990.Within this study, the most common source of PCC referral came from specialist palliative care teams. This may reflect the complex nature of the pain, and hence the need for specialist input. Alternatively, it may reflect a lack of awareness about the availability of the procedure. Within the UK, it is important to recognise that the number of centres offering PCC has reduced in recent years. One of the centres, in Warwick, closed in 2015 due to practitioner retirement; a further centre in Oldham, not included within this analysis due to limited resources to input data, also closed in 2015. Currently, there are only three centres  which offer the procedure, with less than 10 practitioners nationally who are trained to perform the procedure. This impacts patients, who may already have significant morbidity from their illness, who then have to travel substantial distances to be considered for a PCC. Internationally, this decline is also recognised with cordotomy being considered a ‘dying art’ within North America and the practice of PCC being infrequently used.This is the first national PCC data repository and one of the largest within the last 20 years.The study has several weaknesses. First, the numbers are modest as over a 5-year time period, 159 procedures were conducted. Second, the study is observational in nature, so lacks a comparison or control group to be able to draw more definitive conclusions about the implications for clinical practice. For example, the majority of patients had pain in the thoracic region and pain appeared to respond well to PCC. The lack of a sufficiently sized comparator group  meant that comparison in efficacy dependent on location was not possible, but this would be of interest in future work. Third, although pain was assessed, other outcomes  would also be of interest. Additionally, pain characterisation was limited; specifically whether pain was predominantly nociceptive or neuropathic was not consistently recorded. As previous work in this area would suggest that some pain types may respond better to PCC, garnering this in future work would be of importance. Finally, the degree of missing data limits the level of information provided such as specific details about the pain quality, more robust data on non-opioid analgesics and the provision of non-pharmacological strategies to manage the pain. More robust and systematic collection of data in these areas would be beneficial.Further recognition about the role of PCC within the patients’ trajectory would seem pertinent. With patients dying a mean of 1.3 months following PCC, potentially patients were not always deriving full benefit from the procedure. Additionally, some patients died following their initial assessment suggesting that there may have been an overestimation of prognosis. Hence, one of the key issues relates to the definition of clear triggers for considering PCC in a timely manner. Generally, PCC tends to be considered for those with unilateral pain , who are experiencing inadequate pain control, have dose-limiting adverse effects or a combination of both of these factors.Although centres were able to offer the procedure quickly (81% had PCC within 48 hours of assessment by a PCC practitioner) and respond well to patients’ needs, earlier referral for PCC could have provided better quality of life for a longer time period. Previous consensus work agreed that PCC should be considered when the patient is requiring strong opioids and/or symptoms persist or escalate following systematic oncology interventions.The present findings support the role of PCC yet the limitations highlight the need for future work which should include a comparator group, detailed characterisation of those referred including non-opioid and non-pharmacological strategies, geographical site and adverse events.Additionally, accepting that there may be a limited number of centres offering PCC, assessing innovative methods for ‘remote consultations’ would be a key line of exploration. Finally, seeking wider international consensus on routinely recording specific patient-related outcome measures for PCC would enhance numbers and therefore the robustness of recommendations.The present findings support the role of PCC as an effective and safe treatment for cancer-related pain. We propose that patients who have pain which may be adequately treated by PCC should be considered for this at the earliest opportunity, rather than progressing through multiple types of analgesia which may be suboptimal but also have side effects related to these. Patients were often referred late in their disease and potentially the full benefit of this procedure was not realised; it is not clear if this observation was specific just to the UK or reflects wider practice. Further work is needed to fully elucidate this and to assess potential wider benefits of PCC.As this paper reports the results of an observational study using routinely collected health data, we used the Strengthening the Reporting of Observational Studies in Epidemiology extension RECORD  checklist.


Thoracic surgeons have been incorporating enhanced recovery after surgery (ERAS) protocols into their practices, not only to reduce narcotic usage but also to improve complication rates and decrease lengths of stay. Here, we describe the utility of a regional block technique that can be used for patients undergoing urgent or elective thoracic surgical procedures or suffering from rib fractures.We report our initial one-year experience with these erector spinae plane (ESP) blocks.ESP blocks were placed in 42 patients. The procedure was performed by a trained team of anesthesiologists and certified nurse practitioners. It included placement of a catheter on the ipsilateral chest, followed by a 20 ml of 0.2% ropivacaine bolus and continuous infusion. Patients were then followed by the regional team, as long as the catheter was in place. While it had some technical challenges, the block was effective in 83.3% of patients with no reported mortality or major complications. However, given the confounding factors of the study (such as simultaneous implementation of ERAS protocol) and heterogeneity of the patient population, a control group was difficult to ascertain and meaningful opioid consumption analysis was difficult to perform.Regional blocks, such as the ESP block, complement fundamental ERAS principles and serve as an adjunct to the available armamentarium for non-narcotic ways to control pain in thoracic surgical and chest trauma patients. Continued collaboration between the thoracic surgeons and anesthesiologists is needed for its success. Injury to the chest wall, whether from operative intervention or trauma, has the potential to cause significant pain. Adequate analgesia while recovering from chest surgery or trauma is essential to providing patient comfort and preventing complications, such as pneumonia or respiratory failure. Opioids, administered enterally or parenterally, have been the traditional mainstays of analgesic regimens for thoracic pain, though are associated with a number of undesirable side effects and the potential for both tolerance and addiction. In an era when a national “opioid crisis” has reached epidemic proportions in the United States, non-narcotic adjuncts to pain management have assumed increasing importance.Thoracic surgeons, like practitioners in other disciplines, have been incorporating enhanced recovery after surgery (ERAS) protocols into their practices. Regional blocks offer advantages for postoperative pain control compared to other strategies, complementing fundamental ERAS methods and reducing the utilization of opioid medications. The erector spinae plane (ESP) block, first described by anesthesiologist Mauricio Forero in 2016, is a multidermatomal sensory block that provides regional anesthesia to the ipsilateral chest wall [The ESP block is an effective approach for analgesia in thoracic surgical and chest trauma patients, providing excellent pain relief while reducing narcotic requirements. Data on efficacy of pain control with ESP blockade is rapidly maturing with randomized controlled trials –5. WhileThe patients in this study all were treated at an 850-bed academic teaching hospital  in the District of Columbia. Beginning in January 2018, the thoracic surgeons, trauma surgeons, and dedicated thoracic anesthesiologists collaborated to perform ESP blocks on patients undergoing minimally invasive and open thoracic surgical procedures, as well as on non-surgical patients recovering from blunt thoracic trauma resulting in rib fractures. The blocks were performed by members of the regional block team comprised of anesthesiologists and certified nurse practitioners. A retrospective analysis of all patients undergoing ESP blocks between January 1 and December 31, 2018 was undertaken after institutional review board (IRB) approval was obtained.As seen in Fig. Between January 1 and December 31, 2018, ESP blocks were performed in 42 patients undergoing thoracic surgical procedures or with rib fractures secondary to acute trauma. Patient demographics are detailed in Table While most patients experienced excellent pain relief, 7 of 42 (16.7%) did not benefit from their blocks. As seen in Table p < 0.005).After excluding these 7 patients with ineffective blocks, we analyzed opioid consumption  on the remaining 35 patients. On average the patients consumed 131.4 mg of morphine, with a median of 50.6 mg. Three patients required no opioids at all. This is in comparison to retrospective control patients with similar procedures who have not undergone any block in the same time-frame, where on average their consumption was as high as 1200 mg per our pharmacy statistics  blocks, are commonly applied for abdominal or pelvic surgeries and have multiple uses within the field of orthopedic surgery. Utilization of regional blocks has been associated with a reduction in postoperative narcotic requirements and associated adverse effects, such as ileus, constipation, delirium, or urinary retention that can lead to prolonged lengths of stay (LOS) in the hospital. In addition to the financial benefits associated with shorter LOS, regional anesthesia blocks lead to a quicker recovery and faster return to baseline levels of activity compared to completely enteral or parenteral narcotic pain management strategies –14. The Although other regional anesthesia blocks exist for use following thoracic surgical procedures, the novel ESP block provides unique advantages over previously described modalities. While thoracic surgeons can perform intercostal rib blocks intraoperatively by injection of a local anesthetic such as liposomal bupivacaine , these blocks are not completely reliable and have low reproducibility. In a phase III clinical trial, liposomal bupivacaine did not achieve its primary endpoint of a reduction in cumulative pain scores at 72 h . SeveralThe ESP block technique is felt to be safer than that of both epidural and paravertebral blocks, as injection and catheter placement rarely are associated with adverse events such as epidural hematoma, headaches, urinary retention, or hypotension that can result from medication administration to the neuroaxis. Additionally, since ESP is considered a muscle or fascial planar block, it may be a safer alternative for patients with coagulation defects who otherwise might not be candidates for neuraxial blockade. And finally, the ESP block does not pose the risk of direct neurologic injury and, consequently, can be placed while the patient is anesthetized. Of note, we observed no serious complications in our series. Finally, recent prospective studies evaluating the efficacy of epidural catheters have reported a failure rate as high as 23–25% , 18.The ESP block is part of a multimodal analgesia regimen that has the potential to impact postoperative pain as well as opioid requirements following thoracic surgical procedures. As more institutions adopt ERAS protocols into their surgical practices –21, neurOur study has several limitations. We did not perform a robust analysis of patients’ pain scores or comparisons to patients undergoing epidural, intercostal or no nerve blocks. Of the 42 patients enrolled in this study, some were inpatients, referred with urgent conditions such as pleural effusions resulting from CHF or ESRD, and about 57% underwent elective procedures. To compare patients undergoing VATS or RATS to patients undergoing a thoracotomy is somewhat disingenuous. As we were introducing the ESP block into our management strategy, we were simultaneously instituting an ERAS protocol for elective thoracic surgical procedures that included a 3-day preoperative course of analgesic medications  followed by a similar postoperative regimen. The relative impact of each of these components on postoperative pain relief could not be assessed. As a follow-up to the current study, we plan to investigate patients undergoing elective surgery who received an ESP block, and compare their postoperative outcomes to those receiving no block, in a case-control matched analysis where the type of surgery, surgical approach , and the use of an ERAS protocol will be controlled between the two groups.Finally, consistent with the performance of other types of blocks, there appears to be a learning curve for ESP blockade. Three patients in our series did not achieve adequate analgesia after ESP catheter placement was unsuccessful. In all 3 of these cases, the anesthesiologist attempting the blockade was inexperienced with the technique. While we suspect proper placement might have been achieved with more operator experience, anatomic abnormalities prohibiting successful placement could not be excluded.In an era when opioid addiction and its attendant problems have reached epidemic proportions, non-narcotic methods to control acute and chronic pain resulting from thoracic trauma or operations on the chest have assumed increasing importance. While thoracic surgeons and anesthesiologists have utilized a number of techniques for relief of thoracic pain, the ESP block is safe, effective, and reliable, providing several advantages compared to other approaches. Accordingly, ESP blockade can be considered in any patient undergoing elective, urgent or emergent thoracic surgical intervention or suffering from thoracic trauma and adds to the available armamentarium of analgesic techniques.


The extraction of third molars is one of the most common procedures in oral and maxillofacial surgery clinic. Surgical extraction involves the manipulation of both soft and hard tissues, so the patient usually experiences pain, swelling, and trismus in the immediate post-operative period. Several studies have been conducted using different types of surgical flaps to provide access with the least possible damage of soft tissues. Designing and implementing an optimum flap, which provides easier technique, better visibility, minimal post-operative complications, and best healing, is an aspired goal of every oral surgeon. This study aimed to compare lingual-based four-cornered flap with conventional triangular flap, and to evaluate its effect on post-operative pain after surgical extraction of impacted lower third molars. Seventeen patients (age ranged from 19 to 26 years) with bilateral, symmetrical impacted lower third molars (n=34) were included in the study. This was a randomized clinical trial with a split-mouth design. The impacted molars were assigned randomly, by coin flipping, to two groups: Case side with lingual-based four-cornered flap (Group A), and control side with conventional triangular flap (Group B). Away from the incision, the prognosis, surgical intervention, and postoperative procedures were exactly the same for the two groups. Postsurgical pain was assessed for 5 days using visual analogue scale (VAS) and by recording patients need for analgesics on a daily basis. Patients were also evaluated via a self-reporting questionnaire, i.e. Postoperative Symptoms Severity (PoSSe) scale, administered on the seventh postoperative day.P<0.05). Total analgesic intake in Group B was significantly higher (P<0.05). PoSSe scores were lower in Group A, however, this difference was insignificant (P>0.05). Pain scores recorded in Group A were found to be significantly lower as compared to pain scores in Group B in the 5 postoperative days ( According to the data of the current study and within its limits, it appeared that lingual-based four-cornered flap design was superior to the conventional triangular flap regarding the postsurgical discomfort and pain. Key words:Impaction, third molar surgery, flap design, pain, PoSSe scale, split-mouth, RCT. The extraction of impacted third molars is one of the most common procedures in dental clinic. This is because of the relative high prevalence of impaction. About 90% of people have third molars . More thIndications of third molars extraction include caries , periapical pathology, recurrent pericoronitis, infection (i.e. abscess or osteomyelitis), internal and/or external root resorption (of third molar or adjacent tooth), fracture of mandibular angle, trauma and fracture of tooth, extraction for dental autotransplantation, orthodontic reasons, and periodontal disease -6. AlthoSurgical extraction of mandibular third molars involves mucoperiosteal flap reflection with or without bone removal. The postoperative complications that may occur following the extraction of impacted third molar include pain, edema, trismus, decreased masticatory function, dry socket and neurological complications ,10. PainMany researchers used different types of surgical flaps trying to provide access with the least possible soft tissue damage -14. InciThis study aimed to compare lingual-based four-cornered flap with triangular flap of modified Ward’s incision in regard to the post-operative pain of impacted lower third molar surgical extractions.- AbbreviationsVAS= Visual Analogue Scale, PoSSe=Postoperative Symptoms Severity, min= minutes, rpm= round per minute, RCT= Randomized Clinical Trial.The patients were enrolled in this split-mouth randomized clinical controlled trial and treated according to the prospective study protocol. The study protocol was reviewed and approved by Research Ethics Committee of Damascus University (Registration No. 2083). Seventeen patients, who attended oral and maxillofacial surgery department in Damascus University for surgical extractions in the period from December 2018 to May 2019, were included in this study. All patients provided informed consent. Inclusion criteria were as follows: 1) healthy patients with asymptomatic, bilateral, symmetrical impacted mandibular third molars; 2) impacted molars must be mesioangular and easy to extract, i.e. not too deep, too close to second molar, close to mandibular canal, nor having ankylosed, widely divergent, or bulbous roots; 3) good oral hygiene; 4) age range between 19 and 26 years; 5) absence of any medical condition that may contraindicate surgery, such as uncontrolled or poorly-treated diabetes, history of radiotherapy and/or chemotherapy, blood disorders, and immunosuppression.Preoperative evaluations of surgical potential complexity were done with aid of Pernambuco index . ImpacteThe lingual-based four-cornered flap was designed and marked on the mucosa using special pencil so that the flap base was drawn from the mid-point of distal surface of lower second molar to a point 1.5-2.5 cm posteriorly. A vertical incision was started from this posterior point 2-2.5 cm buccally toward the depth of buccal vestibule. Then, the incision is extended anteriorly 1.5-2 cm parallel to the flap base. Another vertical incision toward the disto-buccal angle of the second molar crown is made, and extended with a sulcular incision to the distal surface mid-point. Both flap base and apex had two corners each. This made the flap a four-cornered flap. A full-thickness mucoperiosteal flap was reflected afterward to expose the impacted lower third molar. 4-0 silk suture was used to retract the flap from the lingual side to ensure best possible access and field of view . Requisite bone removal was performed using carbide round bur on low-speed straight handpiece  with copious cooling by saline. Flip of a coin in order to achieve simple randomization was utilized twice; once to distribute patient’s impacted molars on both sides into two groups, and one more time to choose which side to begin with. A convalescent period of at least 20 days between the two surgical extractions (right and left sides) for each patient was given to ensure that symptoms of the first surgery totally disappeared, and to minimize effect of pain memory. With the aid of timekeepers, two durations were recorded in minutes; the total surgery duration from the beginning of incision to the last stitch sutured; and time particularly taken for bone removal.After surgery, all patients received fixed instructions regarding local homeostasis, cleansing, food and medical prescription. Postoperative medication included painkiller and mouthwash, and did not include any antibiotic. Patients were asked to rinse with 0.12% chlorhexidine solution twice daily for 10 days, starting the next day after surgery. The only allowed analgesic was oral Tablets of paracetamol 500 mg. Patients were instructed to take one Tablet as necessary, with a maximum of 6 Tablets a day. It was not allowed to add any other analgesic or medication to the prescription. Taking into account the ease of extraction predetermined in the inclusion criteria and the followed aseptic surgical procedures, there was no need for antibiotics. In addition, antibiotics and anti-inflamatory drugs could have been a variable, thus might have affected the results. So only a drug with less potent anti-inflammatory actions, i.e. paracetamol, was chosen for fair assessment. Patient analgesic need was assessed by asking the patient to write down the number of painkiller Tablets taken each day postoperatively for 5 days. A segmented 11-item numeric version of visual analogue scale (VAS) was used in this study. Patients were requested to select a number (0-10 integers) that best reflected the intensity of their pain on a horizontal bar. The scale was combined with descriptive 6-levels segments; 0= no pain, 1-3= mild pain, 4-5= moderate pain, 6-7= painful, 8-9= very painful, 10= unbearable pain. Patients were asked to report pain intensity at the worst time of the day, for 5 days post-surgery. Clinical follow-up and removal of sutures were done after one week. On that day, a comprehensive Postoperative Symptoms Severity (PoSSe) questionnaire was given to each participant. It consisted of questions that are commonly used in assessment of patients who have had third molar surgeries. These questions are related to seven subgroups that include patient’s capability to enjoy food, speak properly, sensation, appearance, pain, sickness, and interference with everyday activities .P values of less than 0.05 were considered significant.G*Power software V3.1  was used to perform calculations regarding sample size. It is noteworthy that split-mouth design requires smaller sample size than other RCT designs . The effP=0.233). Neither crown nor roots sectioning was necessary in any of cases. No complications were associated with the 34 surgeries, other than that few stitches were observed to be torn only in Group B. Duration of surgical extraction in Group B was significantly shorter than in Group A (P<0.001). However, the mean bone removal duration in Group B was slightly longer with no significant difference between the two groups (P=0.748).A total of 34 impacted mandibular third molars (n=34) in 17 patients  were included in the study and subsequently extracted. The progress of subjects in phases of this RCT is shown Fig. . No signP<0.05; P<0.05; P>0.05; P=0.008; All 34 surgeries were followed up and included in the statistical analysis with no missing data .Post-operative pain of impacted lower third molar surgery is developed due to localized inflammation in the surgical area. Surgical extraction, conjugated tissue injury and cellular destruction provoke releasing and production of several biochemical mediators, e.g. histamine, bradykinin and prostaglandins, which are involved in pain process . Althouget al . This was due to more time needed for suturing in Group A than in Group B. The Closed sockets in Group B were often broken down after few days and healed by secondary intention. Conflicting opinions regarding the primary and secondary wound healing have been expressed in literature . Since PoSSe scale is subjective, authors suggest that further research including objective parameters is needed to confirm that lingual-based four-cornered flap design has no effect on postoperative trismus and oedema. This result is in line with Glera-Suárez et al. who conducted a meta-analysis and found no clear differences in patient morbidity between different designs of surgical flap (P=0.008).Scores of full PoSSe scale showed that differences between the two study groups concerning the patient-reported severity of symptoms, e.g. trismus, swelling... etc, in total were insignificant (cal flap . HoweverAlthough surgical procedures’ durations were significantly elongated with the implementation of lingual-based four-cornered flap, it seemed to be preferable over the modified Ward’s buccal-based triangular flap with regard to pain after surgical extraction of impacted mandibular third molars.