Chest pain is one of the commonest presenting complaints in urgent/emergency care, with a lifelong prevalence of up to 25% in the adult population. Pleuritic chest pain is a subset of high investigation burden because of a diverse range of possible causes varying from simple musculoskeletal conditions to pulmonary embolism.Among otherwise fit and healthy adult patients presenting in our emergency department with sudden onset of unilateral pleuritic chest pain, within 1 month we identified a cohort of five patients with pin-point tenderness in one specific costo-sternal joint often with referred pain to the back. All cases had apparent and, previously undiagnosed mild/moderate scoliosis.To confirm and validate the observed association between scoliosis and pleuritic chest pain, a retrospective audit was designed and performed using the hospital’s electronic medical record system to reassess all consecutive adult chest pain patients.The Odds Ratio for having chest pain with scoliosis was 30.8 [95%CI 1.71–553.37], twenty times higher than suggested by prevalence data.In scoliosis the pathologic lateral curvature of the spine adversely affects the functional anatomy of both the spine and ribcage. In our hypothesis the chest wall asymmetry enables minor slip/subluxation of a rib either in the costo-sternal and/or costovertebral junction exerting direct pressure on the intercostal nerve causing pleuritic pain.Thorough physical examination of the anterior and posterior chest wall is key to identify underlying scoliosis in otherwise fit patients presenting with sudden onset of pleuritic pain. Incorporating assessment for scoliosis in the low-risk chest pain protocols/tools may help reducing the length of stay in the emergency department and, facilitate speedy but safe discharge with increased patient satisfaction. Chest pain is one of the commonest presenting complaints both in primary and urgent/emergency care, with a lifelong prevalence of up to 25%  with a vPatients presenting with pleuritic chest pain with marginally abnormal scores in the emergency department (ED) are often subjected to 12 lead ECG, bloodwork and, if they fall into higher probability/clinical suspicion, may undergo either contrast mediated multi-slice computed tomography or thrombo-prophylaxis . Even wiChest wall tenderness is not unusual in PE because of reactive pleurisy. Physicians therefore have repeatedly been cautioned not to dismiss the possibility of a PE because of reproducible, seemingly musculoskeletal chest pain .Among patients presenting with sudden onset of pleuritic chest pain, we seemed to have observed a low risk subset with distinct commonalities; all reported sudden, non-traumatic, unilateral localised pain with or without subjective shortness of breath.To determine the cause of in this cohort we decided that all consecutive low risk chest pain patients in the month of November 2020 would be assessed identically using a prospectively predefined structured history taking template and would be subjected to thorough physical examination. We hoped that establishing a series of homogenous cases might help us generating a viable clinical hypothesis. We also decided that if such a cohort can be set up, all similar cases of the past 6 months would be audited retrospectively to validate our cross-sectional findings., and vertically between the tip of the scapula and the spina iliaca posterior [Fig. During the above period in our small district emergency department (ED) with the yearly census of 30,000/year we recorded a case series of five adults and one nine-year old child presenting with low-risk chest pain. Low-risk was established at triage based on the Manchester Triage and TIMI score , 14. TheAll adult patients (5/5) reported sudden onset of very intense (stabbing or knife like) pain, which was localised only on one side of the chest. Four out of five complained of difficulty in breathing . Upon further questioning the breathing difficulty was reported to be due to pain with patients struggled to take deep breaths and therefore, subjectively feeling short of breath. All had normal pulse oximetry values (> 94%) clear chests and equal breath sounds. If the onset of pain was a day prior to the index visit, patients often mentioned difficulty in sleeping as they could not find a comfortable position in bed due to back or chest pain when lying flat (3/5). Two patients reported previous similar episodes of chest pains, one even underwent investigation for pulmonary embolism. Almost all patients used NSAIDs (4/5) with little or no effect and all denied prior knowledge of their spinal condition (5/5). Those investigated previously said that they had not been asked to remove clothing from the upper body during examination.Even though we have documented our cases in line with the recommendation of the Joanna Briggs Institute , still cIn the above 6 months period using the filter option of e-audit function of the EMR (Symphony), we identified 31 patients matching the inclusion criteria. Fifty-two percent were female with the median age 42.5 ± 5. The median length of stay in the ED was 2.01 ± 0.79 h. All had ECG (as per department protocol) and during the index presentation nearly half of them was subjected to blood samples  none of which revealed any significant abnormality. Five patients (16%) had chest X-ray (CXR) during the work up. Interestingly, in seventeen cases (55%) it was documented that the pain was made worse by certain movements and/or taking a deep breath. Seven patients (22.5%) reported to have felt pain on lying on their back or their side. None of the notes made reference to scoliosis or any other obvious deformity of the chest or back. Upon interviewing the doctors who saw the patients involved in the audit all denied having examined the patient’s bare chest and/or back for deformity during their examination. After obtaining a waiver from the hospitals’ Ethics Committee we also cross referenced the available radiographic images of each patient identified by the audit. Twenty-one patients had previous CXR, two had previous thoracic  spine plane films and four had no images at all. In ten patients (35.7%) there was obvious radiological evidence of scoliosis. This is nearly a twenty-fold increase in scoliosis prevalence comparing to normal adult population . The OddTo the best of our knowledge, scoliosis in association with MSK chest pain has not been researched in the remits of emergency medicine. Interestingly though, pleurisy is known to cause acute, transient scoliosis , 19. We We opine that recognizing the relationship between scoliosis and pleuritic chest pain of probably musculoskeletal origin could create a more effective treatment plan  in this subgroup increasing patient satisfaction and facilitating speedy, safe discharge. Such holistic treatment might also prevent further unplanned returns with the same presentation as evidence suggests that most unplanned returns related to chest pains are attributed to lack of communication and failure to improve . If our Our presumed model may also explain the unsatisfactory pharmacological treatment of patients discharged with the diagnosis of Tietze syndrome, or idiopathic costo-chondritis. We opine that sudden onset of low-risk pleuritic chest pain with apparent scoliosis, is likely to be an acute-on-chronic problem. The management therefore, should be different in the acute stage (when the time elapsed between onset and attendance does not exceed 6 h) than in cases with either longer elapsed time or of high recurrence (subacute or chronic). In acute cases, the rib can be relocated in a fashion similarly to the repositioning of the radial head (nursemaid elbow), a quick manipulation can realign the costal head. We have reviewed sport medicine, physiotherapy and chiropractic literature with keywords of “slipping rib”, “popped rib”, “subluxed rib”. It appears that in the condition is known as subluxed/dislodged rib (“popped out”) and can easily be reversed . The manOur study has numerous limitations. Case series is inherently biased by convenience sampling, which we have tried to correct by auditing all consecutive patients discharged with “costo-chondritis”. We are also aware that retrospective audits can be flawed by recollection bias and cases might be missed by having been discharged with an alternative diagnosis. These methodological flaws could potentially be corrected by prospective studies. Also, our series was based on small-scale single centre observations in a British Overseas Territory therefore, single centre bias might apply. Scoliosis prevalence may vary by geographical areas, so larger, multi-centre cohorts might be needed to increase external validity. Mild and moderate scoliosis is often a clinical diagnosis without a “gold standard” diagnostic tool and/or a validated clinical scoring system. In the absence of such tools, the diagnosis of scoliosis might be vulnerable to observer and learning curve bias hence; structured postgraduate education and further academic work-up might be necessary.In patients presenting with sudden onset of pleuritic chest pain with reproducible chest wall tenderness, we identified a series of cases with previously undiagnosed scoliosis. We hypothesize that due to the thoracic asymmetry and the subsequent chronic changes in the functional anatomy of the spine and the rib cage; a subluxation may occur in the costo-sternal, and to a lesser extent the costo-vertebral junction. The displacement of the rib may result in pain on inspiration during certain positions/movements or even undertaking the Valsalva-manoeuvre. Recognition of scoliosis in this group of chest pain patients may help tailoring treatment with medications and non-pharmacological modalities like manipulations or exercises. If our findings are confirmed by larger multicentre, prospective observations, these patients would less likely be to subjected to unnecessary investigations, would spend less time in the overcrowded emergency department. Also, a proper education is likely to reduce the rate of unplanned returns with the same problem.


The objective was to describe the physical and psychosocial features of patients attending a specialized consultation hour for temporomandibular disorders (TMD). This investigation focused on those patients who did not receive a diagnosis according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD).From 2004 to 2017, patients seeking care during a TMD-specialized consultation hour were consecutively recruited. Each patient completed a TMD-related questionnaire, psychosocial questionnaires , and the Oral Health Impact Profile-49. The clinical examination was performed according to the RDC/TMD.NoTMDdx). The most frequent reasons for seeking care were orofacial pain/TMJ pain or headaches revealing an OR of 1.89 (for TMDdx group). A relevant proportion of patients was categorized as positive for anxiety , depression , non-specific physical symptoms , or dysfunctional chronic pain . In both patient groups, the oral health-related quality of life was impaired , and the frequency of therapy measures prior to the consultation hour was high.The mean age of the 1020 patients was 43.3 years . According to the RDC/TMD decision trees, 351 patients were categorized without a TMD diagnosis (Patients seeking care from TMD specialists were usually referred with TMD-associated symptoms. Of those, a relevant proportion did not receive a diagnosis according to RDC/TMD decision trees.Psychosocial screening and the avoidance of overtreatment are recommended for patients with TMD-related symptoms. Patients suffering from non-dental pain or complaints in the orofacial area are a challenge in daily dental practice due to the complexity of the diagnostics. Within daily dental clinical routines, patients with orofacial pain are estimated to account for 19% of all patients . TMD hasPrevious studies have provided insight into TMD diagnoses according to RDC/TMD within patient clienteles. A systematic review by Manfredini et al. on axis I diagnoses concluded that the mean age of patients ranged from 30.2 to 39.4 years and the patient population included a high percentage of females . RegardiFurthermore, dental patient-reported outcomes (dPRO) revealed that impairment of oral health-related quality of life (OHRQoL) in TMD patients is 2- to 3-fold higher than that in the general population . The OHROverall, specialized units or consultation hours for orofacial pain or TMD at hospitals/universities are visited frequently by patients seeking care . The varThe objective of this study was to describe the physical and psychosocial features of patients who attended a TMD-specialized consultation hour in a German university setting even if no TMD diagnosis according to RDC/TMD axis I decision trees was made. The focus was on the main complaints, psychosocial characteristics, and OHRQoL.n = 37), as the RDC/TMD are only validated for adults . For the analysis of the data, children and adolescents under the age of 18 years were excluded . Furthermore, the German OHIP-49 was included. In addition, the main reason for attending the TMD-specialized consultation hour (only one answer possible) and the number of health care practitioners who had been visited due to the complaints were assessed in the questionnaires. Moreover, previous treatments related to the complaints were reported. For axis II assessment, the psychosocial questionnaires addressed the chronicity of pain within the last 6 months   as well During the consultation hour, all patients were examined according to the RDC/TMD. Over 13 years, the patients were examined by eight experienced dentists who were not calibrated. Moreover, no reliability values were assessed for the examiners. TMD diagnoses were computer-aided conducted with the help of digitalized RDC/TMD decision trees.d was calculated. Mann-Whitney U tests were used for comparisons of ordinal and continuous data since the latter were not normally distributed (Shapiro-Wilk tests: p < 0.001). Regarding categorical variables, chi-square tests were performed for statistical comparisons. Dummy variables were created to compare the main reasons for seeking care between the two patient groups and odds ratios (OR) were calculated including 95% confidence intervals (95% CI). The level of significance was set to p < 0.050.Statistical analyses were performed with SPSS . For descriptive statistics of continuous variables, means and standard deviation were calculated; frequencies were determined for ordinal and categorical variables. The 95% CI of the prevalence values were constructed with bootstrapping assuming 1000 samples and a simple sampling approach. For continuous data, Cohen’s NoTMDdx group), and 669 patients were given an RDC/TMD diagnosis . Of those, 55.5% (n = 371) received a single diagnosis and 44.5% (n = 298) received multiple diagnoses , and the patient population included 75.3% females. Eight dentists who were trained but had not received RDC/TMD calibration examined the patients. According to the RDC/TMD decision trees, 351 patients received no TMD diagnosis , and women predominated in the gender distribution and comprised an even higher percentage of the TMDdx than the NoTMDdx group . Within the NoTMDdx group, the main reasons for attending the specialized consultation hour were pain in the orofacial area/headache, limitations in jaw movements, and joint sounds. In the TMDdx group, the main reasons were “pain in the orofacial area/headache,” “joint sounds,” and a need for a “TMD examination” (Table p < 0.001). An OR of 1.89  was calculated for the category “pain in the orofacial area/TMJ including headache” indicating a higher chance to be categorized as TMDdx group. Moreover, an OR of 0.56  for “limitations of jaw movements,” an OR of 0.21  for “bruxism/wear,” and an OR of 0.33  for “tinnitus” were detected that suggest a lower chance to be categorized with an RDC/TMD diagnosis according to decision trees. Regarding other categories, all 95% CIs of the ORs included 1.00.Upon comparing both groups, the age pattern was similar (p ≥ 0.076) (Table NoTMDdx/TMDdx 53.8/62.9%) and previous physiotherapy (62.3/62.3%) were highly prevalent. In contrast, analgesics were chosen less often (21.5/28.2%). In general, patients had already consulted three health care practitioners (p = 0.171).Splint therapy, physiotherapy, and analgesics were used to a similar extent prior to the TMD-specialized consultation hour in both groups (6) Table . SplintsNoTMDdx/TMDdx 11.5/18.2%), anxiety (30.8/41.2%), depression (20.8/23.9%), and non-specific physical symptoms (31.4/44.1%). Statistically significant differences were observed for pain-related impairment and non-specific physical symptoms, which were more prevalent in the TMDdx group. The HADS-related outcomes for anxiety or depression were similar between the two groups  , although perceived oral health was broadly similar in both groups (p = 0.518).High OHIP sum scores were identified, yet sum scores were significantly increased for 1) Table . HoweverNoTMDdx group described pain-related impairments, and 20–30% had positive findings for anxiety, depression, or non-specific physical symptoms. Every tenth patient perceived pain-related impairments. Moreover, the oral health-related quality of life was impaired. Nonetheless, the scoring results for anxiety, non-specific symptoms, pain-related impairments, and OHRQoL revealed lower values in the NoTMDdx than in the TMDdx group.The results of the present study revealed that patients who did not receive any axis I diagnosis according to RDC/TMD decision trees were seeking care from TMD specialists with similar main complaints as those of patients who received a diagnosis. The main complaints were described as pain in the orofacial area, limitations in jaw movements, and joint sounds. According to psychosocial assessment, 10.2% of the TMDdx group. Myofascial pain and DD with reduction were highly pronounced. In contrast, arthralgia was less common in the recent patient population than in the population examined in the systematic review. The number of patients who did not meet the criteria for any RDC/TMD diagnosis (34.4%) was high in comparison to the results for an Italian patient population (16.4%) [The age pattern and proportion of women in both patient groups were comparable to the results of a systematic review on TMD patients . The latpulation .4% [16].NoTMDdx patients in the present study. These treatment options are financially covered by German statutory health care, while diagnosis is only covered by most private health insurances. However, the authors assume the percentage of TMD patients with private health insurance who attend the specialized consultation hour to be less than 10%. On the other hand, the demand for treatment might be a reason for referral to TMD specialists. Consequently, continuous education of colleagues and patients could decrease the variety and number of visited health care practitioners, since, for instance, pain-free TMJ clicking usually does not require any intervention.In Germany, specialization in the area of TMD is an extra qualification, and qualified dentists usually continue to work in prosthodontics, orthodontics, or maxillofacial medicine. Thus, it can be assumed that there are fewer possibilities to attend appointments with TMD specialists in Germany than in other countries. Moreover, recent surveys on non-dental orofacial pain/TMD diagnoses and treatment in Sweden and Germany revealed that general dentists desire an improvement in undergraduate/postcurricular TMD/orofacial pain education , 17, 18.TMDdx group according to RDC/TMD decision trees might be a reason for the high values of NoTMDdx patients, as the decision trees are only supposed to reveal the core of TMD diagnoses. Besides, painful TMD conditions are well represented in the decision trees, which are corroborated by the results of the present study revealing an OR of 1.89 for painful main complaints, whereas, e.g., limitations of jaw movements had an OR of 0.56. Thus, an expanded taxonomy of TMD diagnoses [NoTMDdx patients. As the collection of the presented data had already begun in 2004, the only available two-axis diagnostic system in the German language was the RDC/TMD, and only diagnoses established based on the RDC/TMD decision trees were gathered in the database. Since the end of 2018, the translation of the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) into German has been approved by the international INFoRM consortium [NoTMDdx patients since headache was one of the main complaints in the present study.The classification of the iagnoses  or othernsortium . The DC/NoTMDdx group, that were summarized as “others” in Table Moreover, some symptoms reported by the patients in the current study are considered controversial. In particular, the presence of tinnitus is reported by a vast number of TMD patients and might be regarded as a comorbidity, but evidence from previous investigations is low , 23. OthNoTMDdx patients had positive results for anxiety, depression, or non-specific physical symptoms. Every tenth patient perceived pain-related impairments. These values are striking and should indicate that dentists and specialists should keep psychosocial modulators in mind. Thus, it seems important to address possible psychosocial origins early and to clarify psychosocial modulators with a multidisciplinary approach, where applicable.Psychosocial characteristics may be a relevant factor for a high number of patients without any TMD diagnosis. A total of 20–30% of the During the 13-year period, a total of eight dentists examined the patients during a TMD-specialized consultation hour, but none of them was calibrated, which can be seen as a limitation of this study. However, a current investigation focusing on DC/TMD diagnosis revealed that self-instruction can be a reliable approach to teach examiners . AnotherThe data of the present study might help to adjust current research focusing on complaints that are not covered by the diagnostic algorithms, revise therapeutic interventions by dentists, and accompany ongoing modifications of the taxonomies of temporomandibular disorders or orofacial pain-related diagnostic criteria.


Medical treatment with antibiotic therapy remains the mainstay of treatment for pyogenic spondylodiscitis (PS). Nevertheless, orthopaedic treatment is also very important in relieving pain, preventing neurological damage, and avoiding development of spinal deformities  due to spinal instability. Rigid thoracolumbosacral orthosis (TLSO) bracing is often needed in patients with PS, and average duration of treatment of 3 to 4 months. However, TLSO bracing can be poorly tolerated and limit ability of the patient to go back to a normal life. In 2004 our group developed an alternative surgical treatment to TLSO bracing by percutaneous posterior screw-rod bridge instrumentation of the infected level. This treatment allows early and free mobilization of the patients and is associated with faster recovery, lower pain scores and improved quality of life as previously reported. Herein, we report the clinical outcome of the first 3 patients who have completed the 10 years follow-up mark after the procedure. A case report is also described and details of the procedure are provided.  S. aureus, coagulase-negative staphylococci). If left untreated, PS can have serious consequences including worsening pain, onset of neurological deficit, development of spinal deformities  due to disruption of structural integrity of the spine, local or haematogenous spread of the infection, multiple organ failure, and death [Spinal infections represent 3–5% of all cases of osteomyelitis, with incidence ranging from 0.5 to 5.8/100,000 inhabitants/year . The ternd death . Risk ofOrthopaedic management of PS is aimed at relieving pain, treating any actual or impending neurological damage, and preventing development of spinal deformity or neurological deficit due to compression on spinal cord/nerves . Rigid bThe aim of this case report and brief communication is to provide clinical, functional, and X-ray follow-up data of the first 3 patients who have completed the 10-years follow-up mark. We believe these data can be valuable to clinicians and orthopaedic surgeons alike in informing their treatment choices for PS.Following Institutional Review Board (IRB) approval, we contacted all consecutive patients who underwent posterior percutaneous screw-rod instrumentation for PS at our institution and completed the 10-year follow-up mark. Patients were retrieved from a longitudinal, singe-center, prospective database of spinal infections that was started at our institution in January 2008. All patients gave their written informed consent at the enrolment into the database.The diagnosis of PS was made on clinical , radiological , and microbiological  grounds. Indications for surgical treatment through percutaneous posterior screw-rod instrumentation were as follows: single-level (one-disc) lower thoracic (T9-T12) or lumbar PS, known infectious agent, no actual or impending neurologic compromise, no systemic compromise , and no gross spinal instability. Mechanical instability was defined as less than 25% change of segmental kyphosis at the infection level in standing and supine lateral view X-rays. Patients were given the option to choose between TLSO bracing or surgery, therefore no randomization process was used for treatment allocation.Surgical operation consisted of a percutaneous posterior instrumentation with a four to eight screw construct bridging the level of the infection. Screws were placed in the vertebral bodies adjacent to the infected level and rods were passed percutaneously after appropriate contouring. Patients were allowed free mobilization as pain tolerated immediately after surgery. Antibiotic therapy was prescribed as per consultation with infectious diseases specialists at our institution. During treatment C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and complete blood count were obtained at the time of diagnosis and at 4, 8, 12, and 24 weeks follow-up. Lateral spine standing X-rays were obtained before surgery, before hospital discharge and at each follow-up visit. Patients were also asked to fill in Visual Analog Scale (VAS), Short-Form 12 (SF-12), and EuroQol five dimension (EQ-5D) questionnaires at each follow-up visit. A healed infection was considered after a complete course of antibiotic therapy (minimum 6 weeks), negative blood inflammatory markers, absent clinical findings  12 months after the end of treatment .For the current analysis (10 years follow-up), clinical and functional outcome was assessed through VAS, SF-12, and EQ-5D questionnaires. Whole spine standing antero-posterior and lateral X-rays of the spine were obtained along with CT scan of the previously treated area of the spine.Data are expressed as mean with ranges unless stated otherwise; counts and percentages are used as appropriate. Data were analyzed using Microsoft Office Excel 2016 Professional .A total of 214 patients with confirmed pyogenic spondylodiscitis (PS) were included in our institutional database from January 2008 through December 2018. Among these, 32 patients received surgical treatment through percutaneous screw-rod instrumentation, 4 of them more than 10 years ago. All four patients were contacted for the current analysis. One patient suffering from severe heart failure died 2 years before the current study and was not included in the study. Demographics and baseline data of the three patients included in the current study are summarized in S. aureus MSSA was the causative agent in on patient, S. aureus MRSA + E. coli was the causative agent in the second patient, while S. hominis was isolated in the last patient. Antibiotic therapy is listed in The level of the infection was T11-T12 in two patients and T8-T9 in one patient. All three patients underwent percutaneous posterior screw-rod instrumentation. Mean operative time was 75 (55–115) minutes. There were no intraoperative complications; intraoperative blood loss was minimal (<50 mL). Complete healing was achieved in all patients; average healing time was 68.3 (55–75) days. Pre- and post-treatment VAS, SF-12 mental and physical component, and EQ-5D score changes are shown in Average pre-operative segmental kyphosis was 20.2° (15.9–22.4). Immediately after surgery segmental kyphosis was 17.0° (13.6–21.4), which was maintained at 15° (11.3–20.4) at 10 years follow-up . There wS. hominis pyogenic infection. The patient was started on intravenous teicoplanin and ceftriaxone therapy which was continued for 4 weeks and followed by other 4 weeks of iv therapy with teicoplanin and co-trimoxazole. At the end of iv antibiotic therapy the patient was prescribed oral therapy with co-trimoxazole and rifampicin for 4 more weeks. Before starting antibiotic therapy the patient was prescribed a rigid TLSO brace to relieve pain and prevent development of spinal deformity. The brace was poorly tolerated by the patient and for this reason operative treatment with percutaneous posterior screw-rod instrumentation was offered. Posterior fixation from T10 to L1 was performed uneventfully (In June 2009, a 68-year old man presented to you hospital with a 1 month history of worsening axial back pain at the thoracolumbar junction. Past medical history of the patient was positive for high blood pressure and benign prostatic hyperplasia. At first the patient was assessed by his general practictioner and was prescribed oral antibiotic therapy with ciprofloxacin for a suspect urinary tract infection. Therapy was unsuccessful and patient developed fever, night sweats and fatigue over the course of the following 15 days. The patient was admitted to our hospital with the suspect diagnosis of pyogenic spondylodiscitis. Spinal X-ray, CT and MRI scans were obtained A,B. Imagentfully C,E. The entfully D,F.This is the first study to report long-term outcomes of percutaneous posterior screw-rod instrumentation for thoracolumbar pyogenic spondylodiscitis. Our results confirm some of the observations reported in our previously published study . More spAntibiotic therapy remains the mainstay of treatment for pyogenic spondylodiscitis . NeverthIn 2009 we started offering our patients an alternative treatment to TLSO bracing. Our treatment consisted of percutaneous posterior screw-rod bridge instrumentation of the infected level [Interest in minimally invasive procedures has increased in recent years. Even in the field of spinal infection, several minimally invasive procedures have been developed and the field is rapidly expanding ,15,16,17Our study has some limitations. We acknowledge the fact that the number of patients presented in this report is limited and longer follow-up of other patients will be needed in order to consolidate our results. Furthermore, follow-up clinical outcome of patients treated with TLSO brace was not available at the time of this report. Nevertheless, in a previous publication on this technique a formal comparison with a conservative treatment group has been published, although with a shorter follow-up, demonstrating quicker recovery of the surgically treated group .In conclusion this brief report confirms and expands on our previously published results on a percutaneous posterior fixation technique for pyogenic spondylodiscitis. Our technique allows early mobilization of the patients, decreases pain and prevents development of long-term spinal deformities due to infection-driven spinal instability. No significant complications were noted in our first three patients who have completed the 10-year follow-up and overall satisfaction rate of the patients was high.


The treatment of chronic pelvic pain (CPP) with botulinum neurotoxin type A (BoNT/A) has increased lately, but more studies assessing its effect are needed. This study aimed to evaluate the evolution of patients after BoNT/A infiltration and identify potential responders to treatment. Twenty-four women with CPP associated with dyspareunia were treated with 90 units of BoNT/A injected into their pelvic floor muscle (PFM). Clinical status and PFM activity were monitored in a previous visit (PV) and 12 and 24 weeks after the infiltration  by validated clinical questionnaires and surface electromyography (sEMG). The influence of patients’ characteristics on the reduction in pain at W12 and W24 was also assessed. After treatment, pain scores and the impact of symptoms on quality of life dropped significantly, sexual function improved and sEMG signal amplitude decreased on both sides of the PFM with no adverse events. Headaches and bilateral pelvic pain were risk factors for a smaller pain improvement at W24, while lower back pain was a protective factor. Apart from reporting a significant clinical improvement of patients with CPP associated with dyspareunia after BoNT/A infiltration, this study shows that clinical characteristics should be analyzed in detail to identify potential responders to treatment. Chronic pelvic pain (CPP) is a complex pathology characterized by a pelvic pain lasting longer than six months and whose origin cannot be clearly identified . VariousIn female patients, dyspareunia is one of CPP’s most common manifestations of , affectiThe latest Cochrane review, published in 2014, reported that CPP is being increasingly treated by infiltrating botulinum neurotoxin type A (BoNT/A) in patients with CPP symptoms related to a PFM dysfunction . Once inThe purpose of this study was thus to assess the clinical improvement in CPP patients with dyspareunia associated with myofascial syndromes after treatment with BoNT/A, as well as changes in their pelvic floor myoelectrical activity after infiltration, and to study the influence of individual patients’ characteristics on their response to treatment.The study was carried out at the Hospital Universitari i Politècnic La Fe  within the framework of a prospective, minimally invasive, non-masked and non-randomised Phase III clinical trial entitled “Electromyographic Study for the Help and Guidance of Botulinum Neurotoxin A. Administration in the Treatment of Chronic Pelvic Floor Pain (SEMG)” . The study adhered to the Declaration of Helsinki and received the approval of the institutional ethics committee. Given the lack of a global BoNT/A’s effect size estimate in the treatment of CPP associated with a gynecological condition . InclusiA specialist collected the patient’s sociodemographic  and anthropometric (body mass index) characteristics, as well as obstetric , urogynaecological  and musculoskeletal medical history and comorbidities. The patients’ academic background was grouped into two categories (“basic” and “superior”) to enable its inclusion in the risk ratio (RR) analysis see . The fir®, Merz Pharmaceuticals GmbH, Frankfurt, Germany) diluted in 2 mL of lidocaine at 2% was injected with a 75 mm needle  into one spot of the pubococcygeus muscle under transvaginal digital guidance. The region was then massaged.BoNT/A was administered in one side of the PFM. In women with bilateral pain, BoNT/A was only injected in the most painful side to avoid adverse events such as constipation. A single dose of 90 units of incobotulinumtoxinA : 2 on each labia majora and 1 on each sciatic spine , as PFM myoelectrical activity was monitored before BoNT/A infiltration by sEMG. The skin of the vulva and perineum was gently exfoliated with an abrasive gel . Surface electromyographic (sEMG) recordings were performed with 6 Ag/AgCl adhesive electrodes . Two statistical tests were performed separately for each follow-up visit, in which a p value < 0.05 was considered to denote statistical significance:The distribution of numeric clinical variables  was characterized by means and standard deviations, as well as the scores of the clinical questionnaires of each visit  according to the Wilcoxon signed-rank test.Test 1: Significant differences in VAS, PFIQ, FSFI, RMS from baseline (PV) to follow-up (VAS relative change from PV to W12 (or W24) was calculated:Test 2: Significant influence of patients’ characteristics on their response to BoNT/A according to the RR analysis. To quantify the response to treatment, VAS was lower or higher than 50%, respectively. RR and 95% confidence intervals (CI) were thus computed as the ratio between the risk of a low response in the presence of a given characteristic and the risk of a low response in its absence. Numerical descriptors were dichotomized to perform the RR analysis: <35 vs. 35 years (age), <25 vs. ≥25 kg/m2 (body mass index), 0 vs. > 0 (No. pregnancies) and ≤2 vs. > (years since pain onset). Only characteristics with at least 5 observations per category were analysed.In each follow-up visit, the patients were classified as low or high responders to BoNT/A according to whether their ∆The test results are shown for each follow-up visit, using a (*) to highlight statistically significant differences.2, the mean No. of pregnancies was 1.92 ± 1.06 and the mean number of years since pain onset was 4.79 ± 4.90 years. As seen in Out of the 25 women initially recruited, 24 patients completed the 6-month evaluation, while 1 patient was lost to the follow-up. A summary of sociodemographic, anthropomorphic and clinical characteristics of the 24 patients is shown in total, PV = 18.92 ± 9.20, vs. FSFItotal, W12 = 22.36 ± 9.43, FSFItotal, W24 = 23.88 ± 8.85). Regarding the pain domain, FSFI rose from 1.88 ± 1.27 (PV) to 3.53 ± 2.09 (W12) and 3.88 ± 1.88 (W24). As for the other domains, FSFI also rose at follow-up with statistically significant differences in all cases except for lubrication.Regarding ∆VAS, 62.50% and 79.17% of the patients showed a value equal to or higher than 50% at W12 and W24, respectively. The study’s main outcome of the BoNT/A infiltration assessment was reduced pain; according to the VAS, it is the most frequently used technique to quantify pain in published studies on pain treatment as a valid measure of subjective pain evolution and clinical improvement . Like otAs the patient recruitment was focused on women whose main CPP presentation was deep dyspareunia, changes in their sexual function after BoNT/A infiltration were monitored according to the FSFI test. After treatment, almost all FSFI domain scores significantly increased, as well as the total, which can be interpreted as a clinical improvement. The remarkable increase observed in the FSFI pain domain shows that the patients’ dyspareunia symptoms decreased after treatment. The impact of urinary, faecal and vaginal symptoms on their functional, social and mental health was evaluated according to the PFIQ test and showed a significant reduction in their values in the follow-up. This change can also be interpreted as a clinical improvement since it implies a smaller impact of pelvic symptoms on the patients’ lives, showing that they not only experienced a drop in their pain scores, but also an improvement in their sexual function and quality of life after BoNT/A treatment.This is the first study monitoring changes in the PFM myoelectrical activity in the follow-up visits after BoNT/A administration to treat CPP associated with a deep dyspareunia by means of sEMG recordings. Signals were acquired with an sEMG recording system that has previously shown its potential to objectively evaluate the PFM . The sigAs far as we know, no study has assessed how the patients’ clinical characteristics may condition their clinical evolution after BoNT/A infiltration with the aim to identify potential responders to treatment either. In the present study, the influence of different clinical characteristics on the reduction in painful symptoms after BoNT/A treatment was evaluated. The assessment was mainly focused on painful comorbidities such as headaches, lower back pain and abdominal pain. The reason is that some of them have been associated with central sensitization, which has been shown to be a risk factor for a lower response to “local” treatments in pain syndromes, i.e., treatments focused on a defined organic cause . Other cThe headaches concomitant to CPP were a risk factor for a lower clinical improvement after treatment, which could have been related to the concept of central sensitization, unleashing an amplified pain perception in the central nervous system . Once inLower back pain concomitant to CPP was a protective factor against a small improvement at Week 24. The visceral and somatic afferent signals from various pelvic regions converge at the dorsal horns of the spinal cord , so thatRemarkable findings were made when patients with third-degree perineal tears were analysed. According to the literature, perineal tears during vaginal delivery are mainly first or second-degree, while incidence rates of third and fourth-degree (more severe) traumas are 3.3% and 1.1%, respectively . HoweverAccording to the literature, the most frequent adverse effects after BoNT/A infiltration are constipation, stress urinary incontinence, faecal incontinence and localized pain and/or bleeding from the injection site ,14. UnliIn this study, a significant improvement in painful symptoms, sexual function and quality of life, as well as a reduction in the PFM myoelectrical activity during contractions and relaxations, was observed in women with CPP associated with a deep dyspareunia after treatment with a single injection of BoNT/A into the PFM. Unlike previous studies in the field, no patient reported adverse events after treatment with BoNT/A. The reduction in painful symptoms after treatment was lower in patients with headaches concomitant to CPP, possibly associated with a central sensitization of these patients, and/or bilateral pelvic pain, and greater in patients with lower back pain concomitant to CPP, which could be associated with the perception of an overall musculoskeletal relief after treatment, given the convergence of noxious stimuli at the spinal cord. Therefore, the presence or absence of these characteristics should be considered to identify potential responders to treatment. A more thorough selection of potential beneficiaries of BoNT/A would avoid its administration to non-responders. This would prevent them and the physician from experiencing frustration due to an absence of a clinical improvement after treatment, as well as allowing a more efficient use of hospital resources. In future research, the influence of other unexplored clinical characteristics on the patient’s clinical evolution after BoNT/A infiltration should be assessed, as well as BoNT/A’s placebo effect by means of a control group. Furthermore, this analysis should be extended to other clinical conditions commonly associated with CPP, such as endometriosis, given the heterogeneous pathophysiology of the syndrome.


This was a phase IV study conducted on osteoporotic patients who received an Iranian teriparatide biosimilar with a dose of 20 μg daily. The primary outcome of this study was to monitor for adverse events (AEs). Effectiveness as the secondary outcome was measured using the EQ-5D quality-of-life questionnaire and back pain Visual Analogue Scale (VAS) score. Among 193 analyzed patients between September 2015 and March 2019, the most common AEs were hypercalcemia (4%), nausea, and pain (3%). No deaths, serious AEs, or other significant AEs occurred in this study. The mean EQ-5D scores decreased after the course of the treatment from 2.3 ± 0.66 at the baseline to 2 ± 0.66. The mean back pain VAS scores also decreased from 4.9 ± 3.6 at baseline to 1.8 ± 2.1 at the end of the study. Both changes were statistically significant (p < 0.001). Consistent with the findings of previous studies and the drug monograph, no new safety concern was observed with this biosimilar teriparatide, and the drug was effective based on the VAS score and EQ-5D in osteoporotic patients.The safety of teriparatide has been studied in various phase III and phase IV trials. However, a postmarketing study of the biosimilar of teriparatide, CinnoPar Osteoporosis is defined as decreased bone mineral density (BMD), which results in increased fracture risk and its subsequent complications . In the Osteoporosis, thus, imposes a significant financial burden on the patients, their caregivers, and healthcare systems and also decreases patients' quality of life and increases their morbidity and mortality . Pharmac® is an Iranian biosimilar teriparatide produced by CinnaGen biopharmaceutical company. This product was compared with the comparator Forteo® in terms of efficacy and safety in a previous phase III clinical trial [® in osteoporotic patients.There are a few teriparatide biosimilar products across the world , 8. As dal trial . In thisThe present trial was a phase IV, observational, cohort, single-arm, prospective study conducted in multiple centers across seven cities of Iran from September 2015 to March 2019 to evaluate the safety and effectiveness of Iranian biosimilar teriparatide in patients diagnosed with osteoporosis. Patients were followed up for 12 months after the start of the study. This trial was conducted in accordance with the Good Clinical Practice (GCP) and ethical principles. Patients were informed of their participation in a clinical trial.th month. Back pain was evaluated using a visual analogue scale (VAS) score at baseline, 3rd, 6th, 9th, and 12th months.The inclusion criterion was osteoporotic patients diagnosed with BMD, and there were no exclusion criteria for this study. Normal status was defined as T-score ≥−1.0, osteopenia as −2.5< T-score <−1.0, osteoporosis as T-score ≤−2.5, and severe osteoporosis as T-score ≤−3.5 or ≤−2.5 with a fragility fracture. The patient's characteristics were recorded by a physician in a booklet at the baseline visit. Four booklets were allocated to each patient, and each booklet covered three months of drug administration. At the first visit, the recorded characteristics comprised demographic data, habitual history, and past medical history, including allergic history, both renal and hepatic impairments, and other medical conditions. If available, the exact diagnosis of each patient's medical condition together with the diagnosis date, last BMD results, and pertinent laboratory data were recorded in this visit. Previous medications that each patient had received for osteoporosis treatment, previous fractures due to osteoporosis, and back pain experience due to spinal fracture were written as well. On the subsequent visits, physicians recorded each patient's course of the disease, adverse events (AEs), and patient's concomitant medications. EQ-5D questionnaires for health quality assessment in the booklets were filled at the baseline and 12®) 20 μg provided as a pen or vial. During the study, the dosage form changed from vial to pen for its convenience and decreased usage error. Patients were suggested to inject an Iranian biosimilar of teriparatide at night before sleep to prevent orthostatic hypotension. Calcium and vitamin D supplements were advised in all of the patients unless there was a precaution.The patients received daily subcutaneous injections of teriparatide  for categorical variables. For each AE, data were summarized using incidence according to system organ class and preferred term of AEs. In addition, causality assessment was performed, and its results were reported by frequency and percentage. A generalized estimating equation (GEE) model was used in order to analyze the patients' back pain VAS score. The trend of improvement with regard to the EQ-5D, from baseline to the last visit, was assessed by the paired A total of 193 patients were included and analyzed in this study. The majority of the patients were females with a mean ± SD age of 65 ± 11 years. Demographic data and baseline characteristics are presented in ® (4%).The incidence of AEs among the 193 included patients is listed in Ninety-five percent of the observed AEs were considered at least possibly related based on the causality assessment of the AEs. All observed AEs were of grade 1 or 2, and no deaths, serious AEs, or other significant AEs occurred in this postmarketing study.th month. At baseline, 151 patients (78%) had back pain, whereas 44 patients (61%) had back pain at the end of the study. The mean back pain VAS score of the patients at baseline and the end of the study was 4.9 ± 3.6 and 1.8 ± 2.1, respectively. The mean back pain VAS score significantly changed during the study (p < 0.001). The number of patients with back pain decreased during therapy. At baseline, 78% of the patients had back pain, and this number decreased to 61% at the 12p < 0.001). The corresponding scores were 2.3 ± 0.66 and 2 ± 0.66, respectively, with a mean (95% CI) difference being −0.3 (−0.43 to −0.17).The mean EQ-5D score before and after therapy significantly improved , 1996, patients who initiated 20 se event .μg group [μg teriparatide daily with risedronate for 18 months in postmenopausal women, 4% of patients in the teriparatide group had hypercalcemia [μg teriparatide daily for 18 months, the incidence of hypercalcemia was 4% [μg daily teriparatide for 24 months in 503 postmenopausal women with severe osteoporosis, and hypercalcemia frequency was reported to be 5% [In our study, the frequency of hypercalcemia, the most common AE, was 4%. The landmark phase III clinical trial of teriparatide on postmenopausal women with osteoporosis reported 11% for mild hypercalcemia incidence in the 20 μg group . The higμg group . Other scalcemia . In anota was 4% . Obermayμg teriparatide with risedronate in postmenopausal women at high risk for fracture for 24 months, nausea incidence was 5%, which was consistent with our results [We reported an incidence of 3% for nausea. In the phase IV study by Kendler et al. comparing the efficacy of 20  results . Similarμg teriparatide.We also found no cases of osteosarcoma. As mentioned, there were no deaths or serious AEs. However, there were two AEs that led to drug discontinuation; one was a case of headache, and the other was a case of injection site pain.p < 0.001). Other studies showed a significant improvement in this domain as well. In line with our findings, in Langdahl et al.'s study, the back pain VAS score had a significant change of 46% (p < 0.0001) after 24 months [The mean back pain VAS score of patients decreased by 64%, which was statistically significant and showed the efficacy of Iranian teriparatide biosimilar in decreasing pain (4 months . Similar4 months . Both afp < 0.001), suggesting an improvement in patients' quality of life during the study period. In comparison, the reported scores in the study of Ljunggren et al. conducted on 1581 patients for 18 months can be expressed as a 24% improvement [The EQ-5D score showed a significant decrease of 13%  subcutaneous injections daily based on physicians' routine clinical practice. The present study shows a favorable safety profile for CinnoPar® in osteoporotic patients.In this phase IV, observational, cohort study, a total of 193 osteoporotic patients were included and received 20


The objective was to examine the effectiveness of the updated approach.  With IRB approval, outpatients with cancer were enrolled from January to December 2018. Assessments were recorded at baseline and three consecutive visits , including Numerical Rating Scale (NRS), the Brief Pain Inventory (BPI), the Edmonton Symptom Assessment System (ESAS), side effects, and analgesic use. The primary outcome was a favorable response, defined as an NRS decrease more than 30% or NRS <4. Secondary outcomes included trends over time in BPI, ESAS, side effects, and analgesic use. Pain response predictors at FU3 were analyzed using logistic regression. p < 0.05). Median morphine equivalent daily dosage (MEDD) at BL was 20 mg/day, with a statistically significant, but clinically modest increase to 26.4 mg/day at FU3. Radiation therapy during pain care was a predictor of pain responders.  Among 150 patients, 72 (48%) completed follow-ups. Of these, 61% achieved a favorable response at FU3. Pain interference diminished at all visits relative to baseline ( The current Siriraj multidisciplinary approach provided effective relief of pain and stabilization of other cancer-related symptoms. Radiation therapy during pain care can be used to predict pain outcomes. Ongoing improvement domains were identified and considered in the context of cultural, economic, and geographic factors. Cancer is the second leading cause of death worldwide, with approximately 18.1 million new cases and 9.6 million deaths reported in 2018 , 4. RecePatients with cancer often present with multiple symptoms and functional decline. Evidence supports multidisciplinary approaches to address symptoms and suffering, including early palliative care referral –9.In 2016, cancer was the second leading cause of death in Thailand . In 2020Siriraj Hospital is the largest hospital in Thailand and the country's most active cancer treatment center. The Siriraj Pain Clinic has been providing treatment for patients with cancer and noncancer pain since 1989. Two retrospective studies evaluating cancer pain management in outpatients and inpatients conducted in 2014 found that approximately half of the patients with cancer pain seen at the Siriraj pain clinic achieved adequate pain control (30% pain reduction from baseline) , 13.To improve the quality of pain management, the authors and pain clinic team approved and introduced new clinic guidelines for cancer pain management.A prospective observational study is reported here assessing the impact of pain protocols, nurse-guided analgesic rescue program, selective referral for interventions, early referrals for psychological support and palliative care, and telephone follow-up in addition to standard WHO analgesic guidelines. The overall aim was to assess the effectiveness of this program on measures of pain, other symptoms, and quality of life and to identify persistent barriers to improved treatment.With approval from the Siriraj Institutional Review Board (no. Si 622/2017) and registry with ClinicalTrials.gov (NCT03474406), we conducted a prospective observational study of patients 18 years and older who received new consultation for cancer pain at the Siriraj Pain Clinic from January to December 2018. Written informed consent was obtained from all patients. We excluded patients who had difficulties with listening, reading, and writing Thai and those who were unable to interpret evaluation forms/questionnaires.All patients enrolled in the study received standard care by pain specialists in the clinic. The WHO analgesic guidelines, selective consideration of pain interventions, and nurse-directed analgesic rescue program were implemented. Additionally, patients received phone calls as reminders to attend follow-up visits. Patients were followed every 2–4 weeks based on physician judgment and pain severity.The primary outcome of this study was the percentage of patients defined as “pain responders” by either 30% reduction in pain intensity rating or pain intensity less than 4 at the third follow-up visit (FU3) –16. SecoData were collected at baseline and at three follow-up times . Patients' baseline demographic data  and clinical characteristics  were recorded. Pain severity, performance status, pain interference, other symptoms, side effects, pharmacological treatments and dosage, and patient satisfaction were recorded at every visit. We retrospectively reviewed palliative care medical records for additional data related to pain intensity, performance status, opioid consumption, date of first palliative care visit, and dates of death, if applicable. Data were collected by research assistants, nurses, and physicians and entered into Case Report Forms.We used patient-reported seven-day average pain scores  as a primary endpoint, with 0 designating “no pain” and 10 designating “worst possible pain” .Functional impairment was evaluated using the Karnofsky Performance Status (KPS)  , 19.We used the validated Brief Pain Inventory (BPI), translated to the Thai language, for measuring pain interference in the last 24 hours, including general activity, mood, walking ability, normal work, relations with other people, sleep, and enjoyment of life. Each category ranges from 0 to 10, where 0 indicates no interference and 10 maximum interference . PatientThe common symptoms at the time of assessment in cancer were evaluated using validated Edmonton Symptom Assessment System (ESAS), previously validated and translated to the Thai language, including pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being, and shortness of breath, at the time of assessment, with 0 being no symptoms reported and 10 being the worst possible symptom .Nausea and vomiting was evaluated using four-point scales . Stool-fMorphine equivalent daily dosage (MEDD)  was calcA three-point scale of patients' satisfaction was used to assess patients' attitudes toward the services of pain clinic as 0, designating satisfied; 1, designating neutral; and 2, designating dissatisfied with services.d = 0.7); therefore, the calculated sample size was 126  was 47.9 (IQR = 29.4–66.7), 49.3 (IQR = 30.7–76.2), 54.2 (IQR = 41.2–93.80), and 52.8 (IQR = 35.7–100) from BL to FU3. The percentage of patients receiving acetaminophen, anticonvulsants, antidepressants, and laxatives also increased significantly at all follow-up time points compared to baseline.There were 6 (4%) patients who underwent pain interventions through the Pain Clinic, including celiac plexus neurolysis, abdominal cutaneous nerve injection, erector spinae plane block, and bilateral pudendal nerve block.In addition, 29 (19.3%) patients received specialty evaluations from other departments. Sixteen patients were referred to the palliative care unit, four patients were referred to psychiatrists, and the other nine patients were referred to oncologists, general surgeons, hematologists, radiation oncologists, orthopedic surgeons, and internal medicine specialists. 33 patients (22%) received additional radiotherapy during pain care.Among the 16 patients referred to palliative care, four (25%) died before the first palliative care visit. Data from the 12 remaining patients' records showed the median of days from the last pain clinic visit to the first palliative care clinic visit was 6.5 days (IQR = 0.0–16.5), the median of days from first palliative care visit to death was 20.0 (IQR = 13.5–34.5), and the median of days from the last pain visit to death was 24.0 (IQR = 15.5–49.0). At the first palliative care visit, the median NRS pain score was 5.0 (IQR = 4.0–8.0), and the median Palliative Performance Status (PPS) was 30% (IQR = 20.0–40.0). The median opioid dosing prescribed at that visit, expressed as MEDD, was 41.0 (IQR = 30.0–66.0). Among the 12 patients referred to palliative care, 7 (58.3%) died at home and all 12 died without cardiopulmonary resuscitation (CPR).Including the 4 patients who died before the first palliative care visit, 28 patients died during the study period. From the available data on 14 patients, 9 died in hospital (64.3%). One patient received CPR.Among the 28 patients who died during pain care, 14 (50%) were diagnosed with GI cancer. The median of months from diagnosis to the first pain visit was 8.0 (IQR = 1.0–21.5); however, only seventeen patients had records regarding the death date. The median of months from diagnosis to death was 10.6 (IQR = 7.2–22.3) and the median of days from the last pain visit to death was 16.0 (IQR = 11.0–28.0).Qp=0.104).The percentage of moderate-to-severe side effect showed not more than fifteen percent from BL to FU3 . However, the percentage of moderate-to-severe constipation over time was 12.5% at BL, 15.3% at FU1, and 11.1% at FU2 and reached 23.6% at FU3 (Cochran's p=0.034) and to have received radiation therapy (p=0.002) compared to nonresponders. These factors did not remain significant in multivariable logistic regression models, as shown in In bivariate analyses, pain responders were more likely to be married  . PatientIn many countries, the COVID-19 pandemic has led to a dramatic acceleration in the effective use of telehealth services. It seems likely that in the future, there could be a greatly expanded role for telehealth in Thailand as a means for providing continuity of care and improving cancer pain management and palliative care services both in the larger cities and throughout the country.To improve cancer pain management in Thailand, future research may focus on understanding potential barriers associated with comparatively low opioid consumption, use of telehealth for providing ongoing care at a distance from tertiary centers, physicians', patients', and healthcare system perspectives, and consideration of cultural factors in a country undergoing rapid change. In view of the advanced state of disease and short survival of many of the patients in this series, efforts should focus on earlier pain and palliative care referral and better integration of pain and palliative care programs.This study is a single-site study in a university hospital and tertiary referral center in Bangkok. Patient characteristics and care patterns may not generalize to care throughout the country. Many patients were unable to return to Bangkok for follow-up and returned to local healthcare systems or traditional healers. This led to incomplete information for many patients on their progression of symptoms, responses to pain treatment, and patterns of end-of-life care.


Background and Objectives: Clinicians are required to manage a growing number of elderly patients with several medical comorbidities, and invasive surgical treatments are sometimes not advisable for these patients. The aim of this study was to evaluate the efficacy of minimally invasive intraspinal canal treatment, trans-sacral canal plasty (TSCP), for patients with and without failed back surgery syndrome (FBSS). Materials and Methods: A multicenter analysis was conducted. TSCP was performed in patients with chronic low back pain and leg pain due to lumbar spinal disorders. An adhesiolysis by TSCP was carried out, then a mixture of steroid and local anesthesia was injected. Visual Analog Scales (VAS) for low back pain and leg pain, and complications were evaluated. Results: A total of 271 patients with a minimum 6-month follow-up were enrolled. There were 80 patients who had a history of previous lumbar spinal surgery (F group), and 191 patients without previous lumbar spinal surgery (N group). There were no significant differences in sex and age between the two groups. VAS scores for low back pain (N group/F group) preoperatively, immediately postoperatively, and 1 month, 3 months and 6 months postoperatively, were 51/52 mm, 24/26 mm, 33/34 mm, 30/36 mm, and 30/36 mm, respectively. VAS scores for leg pain were 69/67 mm, 28/27 mm, 39/41 mm, 36/43 mm, and 32/40 mm, respectively. Both VAS scores for low back pain and leg pain were significantly decreased from baseline to final follow-up in both groups (p < 0.01). However, VAS scores for leg pain at 3 months and 6 months postoperatively were significantly higher in F group (p < 0.05). There were three catheter breakages (2/3 in F group), and one dural tear in F group. Conclusions: TSCP significantly reduced both VAS scores for low back and leg pain in patients with and without FBSS. However, co-existence of intractable epidural adhesion might be associated with less improvement in FBSS. The aging of the population will be a worldwide problem. According to the World Health Organization and the United Nations, when the proportion of persons aged 65 years or older exceeds 7% in a society, it is called an aging society. If it exceeds 14%, it is defined as an aged society; and if it exceeds 21%, it is defined as a super-aged society. Nowadays, the elderly population is about 28.4% in Japan, thus it is categorized as a super-aged society, and is the highest in the world [To date, spinal surgeries have been increasing and are associated with the development of various surgical techniques and recent spinal instrumentation. However, one of the problems is residual and/or recurrent symptoms after lumbar spinal surgery. North et al. first termed this condition “failed back surgery syndrome (FBSS)” . Chan etHere, we named our PEN procedure as trans-sacral canal plasty (TSCP) in the sub-study group of minimally invasive spinal treatment (MIST) society . TSCP would be applied to chronic and residual low back pain and/or leg pain due to various lumbar spinal disorders. The aim of this study was to evaluate the efficacy of TSCP between patients with and without FBSS.®, Biomedica Healthcare Ltd., Tokyo, Japan) was used as an epidural access catheter . The Racz catheter was more frequently used in N group (65/191 = 34.0%) than in F group (16/80 = 20.0%) (p < 0.05).A total of 271 patients with a minimum 6-month follow-up were enrolled. Diagnosis consisted of lumbar spinal stenosis (240), degenerative spondylolisthesis (27), lumbar disc disease (4), lumbar disc herniation (19), degenerative lumbar scoliosis or kyphosis (13), osteoporotic vertebral fracture (5), iatrogenic (3), and unknown reason (11), and 56 patients were diagnosed with several diseases. There were 191 patients without previous lumbar spinal surgery , and 80 patients who had a history of lumbar spinal surgery . The majority of the patients were in their 60s to 80s (228/271 = 84.1%). There were no significant differences in sex and age between N group and F group (p < 0.01 each). However, VAS scores for leg pain 3 months and 6 months postoperatively were significantly higher in F group (p < 0.05 each). Although VAS scores for low back pain 3 months and 6 months postoperatively tended to be higher in F group, they did not reach a significance. A more than 50% reduction of the VAS score for low back pain 3 months postoperatively was obtained in 71/191 patients (37.2%) in N group, and in 25/80 patients (31.3%) in F group. A more than 50% reduction of the VAS score for leg pain 3 months postoperatively was obtained in 89/191 patients (46.6%) in N group, and in 26/80 patients (32.5%) in F group. Although there was no significant difference between the two groups in low back pain, leg pain significantly remained in F group (p < 0.05).VAS scores for low back pain in N group preoperatively, immediately postoperatively, and 1 month, 3 months and 6 months postoperatively were 51.1 ± 28.0 mm, 23.7 ± 22.6 mm, 33.0 ± 26.6 mm, 29.7 ± 24.7 mm, and 29.5 ± 22.6 mm, and those in F group were 51.5 ± 28.2 mm, 26.3 ± 24.3 mm, 34.2 ± 24.6 mm, 36.2 ± 23.7 mm, and 35.7 ± 23.9 mm, respectively . VAS scop < 0.05). Decompression surgery was performed more frequently in N group (48/191 = 25.1%) than in F group (7/80 = 8.8%) (p < 0.01). Fusion surgery was performed equally in N group (21/191 = 11.0%) and in F group (11/80 = 13.8%).Overall, definitive surgery was performed in 69/271 patients (32.1%) until final follow-up due to residual low back/leg pain after TSCP, or neurological deterioration. Definitive surgery was performed more frequently in N group (69/191 = 36.1%) than in F group (18/80 = 22.5%) (There were 3 catheter breakages, and 2/3 cases were observed in F group, and one dural tear with transient neurological deficit occurred in F group. No major complications were observed during the follow-up period.Spinal surgeries have been increasing and are associated with the development of various surgical techniques and spinal instrumentation. However, one of the problems is residual or recurrent low back pain and/or leg pain after lumbar spinal surgery, which has been recognized as FBSS . RecurreISCT is the direct approach to the spinal canal, and PEN is a minimally invasive lysis procedure for chronic low back pain and/or leg pain due to lumbar spinal disorders . The myeTo date, there has been no comparative study investigating the efficacy of PEN between patients with and without FBSS. We named our lysis procedure TSCP and conducted a comparative study investigating the efficacy of TSCP between patients with and without FBSS in a multicenter analysis. Our results showed that TSCP significantly reduced low back pain and leg pain both in patients with and without FBSS. In this study, the majority of the patients were in their 60s to 80s. Before we could perform the TSCP procedure, we had to consider definitive surgery, even for the elderly patients, in case nonsurgical treatment failed. However, some of the elderly patients could not undergo general anesthesia due to their medical conditions. TSCP would be a less invasive approach for the elderly or immunocompromised patients under local anesthesia. However, leg pain significantly remained in FBSS patients 3 months and 6 months after TSCP. There might be a severe epidural adhesion in FBSS patients due to previous surgeries. The catheter was stuck, and contrast dye did not spread effectively at the site of adhesion b, and brOur study showed that definitive surgery was performed in 32.1% due to residual pain after TSCP, and definitive surgery and decompression were more frequently performed in N group. We suggested that patients with FBSS might be prone to refusing reoperation even if they have residual leg pain. Although TSCP significantly reduced low back pain and leg pain in both patients with and without FBSS, the TSCP procedure is still under development, and it is needed to achieve better clinical outcomes by improving the lysis procedure and developing equipment which can be available in the epidural space in the future.TSCP was considered a minimally invasive and safe procedure, and it significantly reduced both VAS scores for low back and leg pain in patients with and without FBSS. It can be a treatment option for elderly and immunocompromised patients, for whom multiple surgeries are inadvisable. However, the co-existence of intractable epidural adhesion might be associated with less improvement in leg pain for patients with FBSS. Dural tear and catheter breakage should be avoided in FBSS.


Despite an increasing number of available therapies, the treatment of neuropathic pain remains a major issue. Systematic reviews and meta-analyses indicate that only a minority of patients with neuropathic pain have an adequate response to pharmacological treatment and that most drugs have dose-limiting side effects. We conducted a systematic review and meta-analysis of randomised controlled trials published in the last five years. We searched for relevant papers within PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Clinical Trials database . Two authors independently selected studies for inclusion, data extraction, and bias assessment. We identified 39 randomised controlled trials and included 16 in the meta-analysis. Trial outcomes were generally modest even for first-line drugs such as tricyclic antidepressants, serotonin-noradrenaline reuptake inhibitors, and gabapentinoids. Many drugs acting on new pain targets are currently under development. Clinical data are currently available for sodium channel isoform-specific antagonists, anti-nerve growth factor molecules, and fatty acid amide hydrolase inhibitors. Despite an increasing number of available therapies, the treatment of neuropathic pain remains a major issue. Systematic reviews and meta-analyses indicate that only a minority of patients with neuropathic pain have an adequate response to pharmacological treatment and that most drugs have dose-limiting side effects , 2.In 2015, the Neuropathic Pain Special Interest Group (NeuPSIG) of the International Association for the Study of Pain (IASP) conducted a systematic review and meta-analysis that included 229 randomised double-blind trials testing oral and topical pharmacotherapy for neuropathic pain . This anIn the last few years, new medical treatments for neuropathic pain have been tested, including compounds acting on new pain targets .We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of all pharmacological treatments for neuropathic pain published in 2015 or later in order to analyse the efficacy and safety of drugs tested in the last five years and provide an update to the 2015 NeuPSIG meta-analysis.Systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statements. We searched for relevant papers within PubMed, EMBASE, and the Cochrane Database of Systematic Reviews and considered studies published in peer-reviewed journals between January 2015 and July 2020. Search terms were related to pharmacological treatment of neuropathic pain. The primary search was supplemented by a secondary search using the bibliographies of retrieved articles. RCTs involving at least 10 patients were considered, and the search was limited to English language publications. Studies published only as abstracts were excluded. We checked ClinicalTrial.gov in order to include studies currently in progress. The target population was patients of any age with neuropathic pain according to the IASP definition  and related to different aetiologies. Mixed pain  and conditions such as fibromyalgia and atypical facial pain were not included in the analysis.The review process was performed independently by two reviewers . The autI2 . . 10]. Inχ2 = 2.1; df = 1; P=0.15; I2 = 51.28)  . The combination of gabapentin and trazodone is currently being tested in painful diabetic neuropathy  .Two RCTs testing the effect of mirogabalin on central neuropathic pain and diabetic peripheral neuropathic pain are currently ongoing   .Four RCTs globally involving 215 patients tested the effect of opioids in different neuropathic pain conditions, including postherpetic neuralgia, diabetic peripheral neuropathy, and central pain related to multiple sclerosis  24–27].–27.24–27In the study by Gavin et al., the transdermal oxycodone patch was compared with placebo in patients with postherpetic neuralgia . The autμg/h was tested in comparison with placebo in patients with diabetic peripheral neuropathy .–32.28–32The effect of nabilone 2 mg combined with gabapentin was compared with placebo in patients with central neuropathic pain related to multiple sclerosis . Pain deχ2 = 1.7; df = 1; P=0.191; I2 = 41.41%)  .NCT03099005).The effect of acutely administered cannabidiol/THC is currently being tested in HIV-related neuropathic pain .Four RCTs globally involving 319 patients tested the effect of selective sodium channel blockers in different neuropathic pain conditions, including trigeminal neuralgia, postherpetic neuralgia, and painful polyneuropathy  33–36].–36.33–36A novel selective Nav1.7 sodium channel blocker (PF-05089771) was also tested in 135 patients with diabetic peripheral neuropathy . AlthougA novel topical sodium channel inhibitor (TV-45070) was compared with placebo in 70 patients with postherpetic neuralgia . Althougde Greef et al. tested the effect of lacosamide in 47 patients with Nav1.7-mutation-related small-fibre neuropathy . In 58.3χ2 = 3.7; df = 3; P=0.160; I2 = 45.46%)  (test for heterogeneity: NCT03777956).The effect of lacosamide on peripheral neuropathic pain with and without the irritable nociceptor phenotype is currently being tested  in 73 patients with neuropathic pain related to spinal cord injury . No diffTwo RCTs tested the effect of monoclonal antibodies in neuropathic pain treatment , 43. In μg/kg) reduced pain, but treatment differences were not significant. The most common side effects included arthralgia and headache.Subcutaneous and intravenous tanezumab was compared with placebo in patients with diabetic peripheral neuropathy and postherpetic neuralgia . Only diTopical diclofenac (1.5%) was compared with placebo in 28 patients with neuropathic pain . After 2NCT03094195) and painful diabetic neuropathy  were prematurely suspended due to preclinical toxicity data.Two randomised placebo-controlled trials testing the effect of EMA 401  in postherpetic neuralgia . Other drugs currently being tested in RCTs include N-desmethylclobazam in patients with peripheral neuropathic pain , clonidine, and pentoxifylline in different neuropathic pain conditions , ziconotide in patients with severe refractory neuropathic pain , and brivaracetam in spinal cord injury .The CGRP receptor antibody, erenumab, is currently being compared with placebo in patients with trigeminal neuralgia  for antidepressants (venlafaxine XR and imipramine), 8.40  for gabapentinoids , 4.64  for selective sodium channel blockers, 12.73  for lidocaine, and 2.96  for cannabinoids . AdmitteWe found poor trial outcomes even for first-line drugs such as antidepressants and pregabalin. These findings, consistent with those of the previous NeuPSIG metanalysis , may parUnexpectedly, in our meta-analysis, we found that antidepressants had a relatively high NNT, larger than that reported in the previous NeuPSIG meta-analysis. This finding, however, may merely reflect the inclusion of only two studies that tested the effect of venlafaxine XR and imipramine. We did not include any study on the efficacy of amitriptyline, the most widely used tricyclic antidepressant for neuropathic pain.For pregabalin, we found a slightly larger combined NNT than that reported in the previous NeuPSIG metanalysis. The effect size of pregabalin and its clinical usefulness are currently sources of debate , 47. RecOur meta-analysis showed a large NNT for topical lidocaine (about 12). This finding is in line with previous large meta-analyses , 46. HowWe found a large effect (NNT = 2.96) for cannabinoids. This finding is in contrast to the previous NeuPSIG recommendations, which provided a weak recommendation against the use of cannabinoids in patients with neuropathic pain . Our finIn this meta-analysis, we have now included also selective Nav1.7 sodium channel blockers. We found a larger effect of new selective Nav1.7 sodium channel blockers than that of currently used neuropathic pain medications, including first-line drugs. Nav1.7 plays a key role in pain perception  and has Another novel research field concerns the development of antibodies targeting the activity of human nerve growth factors. In a phase II trial in patients with postherpetic neuralgia and painful posttraumatic neuropathy , fulranuAmong the new emerging drugs, ASP8477, a selective fatty acid amide hydrolase inhibitor, is under development. This drug was recently tested in patients with peripheral neuropathic pain and showed a good safety profile, though no significant pain relief as compared with placebo was found .Our systematic review and meta-analysis, which included data from randomised controlled trials in patients with neuropathic pain, extend previous knowledge by demonstrating small effect sizes and/or large NNTs for all compounds used to treat neuropathic pain . The mod


Objectives: Penile surgery is commonly performed in pediatric surgical centers. There is no consensus regarding which analgesic method is most effective in controlling pain in these children.Methods: Consecutive children between 4 months and 16 years of age who underwent elective penile surgery were recruited. After inhaled induction of anesthesia, children were randomized to one of three methods of intraoperative analgesia: caudal block, IV fentanyl titrated to surgical response and spontaneous respiration, or dorsal penile nerve block (DPNB). All patients were given inhaled agents; fentanyl was added if either block was insufficient. Demographic data, analgesic use and pain scores were recorded by a blinded investigator in the PACU and ward. Pain scores, analgesic requirement, and recovery parameters of returning to normal activity level, eating, and voiding post-operatively for up to 4 days, were compared.Results: 116 children were recruited. Pain scores in the post anesthesia care unit were significantly lower in the DPNB and caudal block groups compared to the fentanyl group for the first 30 postoperative min. Pain scores and analgesic use were subsequently similar among the three groups for the rest of the study period. There was no statistical difference in time to eat, return to normal activity or in parental satisfaction scores among the groups. There was a trend toward earliest time to void in the DPNB group.Conclusions: Regional blocks most effectively controlled pain for 30 min after surgery. The choice of intra-operative analgesia protocol had no effect on later pain and recovery parameters. Penile surgery, including circumcision, revision of circumcision and repair of penile torsion, chordee or hypospadias, is commonly performed in pediatric surgical centers. Analgesic methods include caudal, penile, pudendal and ring blocks, opioid and non-opioid systemic analgesics, as well as application of topical agents. Despite the importance of pain control in these patients, there is no consensus regarding which analgesic method is most effective and safe in controlling perioperative pain in these children , 2. RegiWe studied children between 4 months and 16 years of age who underwent elective penile surgery under general inhaled anesthesia using three different methods of analgesia: caudal block, intravenous fentanyl or dorsal penile nerve block (DPNB). The primary aim of this prospective, randomized double blind study was to compare pain scores and need of supplemental analgesics in the immediate post-operative period. The secondary aim was to compare recovery parameters up to 4 days post-operatively, as well as overall parental satisfaction scores.This study was designed as a randomized, double blind, prospective clinical trial, with three arms, and was conducted in accordance with the CONSORT guidelines . After oChildren were kept fasting according to institutional guidelines. In the holding area they were premedicated with oral midazolam 0.5 mg/kg, not to exceed 15 mg.2, N2O and sevoflurane. Routine monitors  were used. A laryngeal mask airway (LMA) was then placed while the patient was breathing spontaneously and was sufficiently anesthetized; an intravenous (IV) line was then placed. All patients were given 10 cc/kg IV lactated ringers solution (LR) over the first h of surgery and maintenance fluid for the subsequent hours of surgery. If blood losses exceeded an estimate of 2 cc/kg, they were replaced with LR at a ratio of 3:1.Anesthesia was induced in all children with O2 in N2O and isoflurane at inspired fractions of 0.6–1% under spontaneous ventilation with pressure support 7–10 cmH2O. If apnea occurred, or end tidal pCO2 rose above 65 mmHg, or if O2 saturation dropped below 94%, controlled ventilation was started via the LMA. Intubation was performed if ventilation or oxygenation did not improve the latter. No muscle relaxants were given unless needed as an emergency treatment of laryngospasm. At the end of surgery, inhaled agents were discontinued, the LMA was removed, and the patient was allowed to awaken breathing 100% O2 via a face mask. The patients were brought to the PACU while breathing room air.Anesthesia was maintained with 40% OAfter induction, patients were randomized via slips of paper pulled from an envelope by the circulating OR nurse to one of three methods of analgesia: (1) caudal block using 0.6 cc/kg of 0.25% bupivacaine (group C); (2) IV fentanyl of 1 mcg/kg increments titrated to lack of movement or hemodynamic response to surgical stimuli, and targeted to a spontaneous respiratory rate of 12–24/min according to patient's age (group F); (3) dorsal penile nerve block injection of 0.25 cc/kg (not to exceed 8 cc) of 0.5% bupivacaine, using the landmark technique (group P). A block was considered a “failed block” if the patient responded (by movement or changes of hemodynamic parameters) to incision, despite 15 min having elapsed from time of block placement to skin incision . These children were diverted to receive general anesthesia with IV fentanyl as needed and their data were eliminated from that time onward; only their demographic data were included. The same anesthesiologist (ME) performed all intraoperative anesthetics but was not involved in the later data collection or analyses.A dedicated PACU nurse, blinded to the method of each child's analgesia, followed patients' recovery in the PACU. She/he recorded oxygen saturation on room air, heart rate, respiratory rate every 15 min, as well as any untoward events (including nausea/vomiting) and medications given. In addition, the blinded nurse assessed pain using two scores: (1) Objective scale: FLACC score , Activity, Crying and Consolability, each graded between 0 and 2 points, and (2) the subjective numerical rating scale (NRS) as assessed by the parents on a scale of 0 = no pain to 10 = the worst pain possible. The nurse also recorded the sedation status of the child on a four point sedation scale of 0–3, in which 0 = completely awake; 1 = responds to voice; 2 = responds to touch, 3 = does not respond to touch.Pain and sedation scores were recorded upon arrival to the PACU (time 0) and at 10, 20, 30 and 60 min later. If pain score by either scale was >3/10 and/or the parent requested medication for the child, 0.05 mg/kg of IV morphine was administered. Additional doses were available every 10 min, up to a total of 0.2 mg/kg. Ondansetron 0.15 mg/kg IV was available if there were signs of nausea or vomiting. The child was allowed to drink if fully awake, starting from 10 min after arrival to the PACU. Following existing directives, all children stayed in the PACU for a minimum of 60 min; they could stay longer if still sleepy or in pain.After discharge from the PACU, patients were admitted to the pediatric surgery ward. Pain and sedation scores were recorded upon arrival (time 0), and 2, 4 and 6 h after arrival by the ward nurse, the parent being consulted every time. If pain score by either scale was >3/10, 10 mg/kg ibuprofen syrup was given to the child; if this was insufficient to control pain after 30 min, 0.2 mg/kg oxycodone syrup was added. Those who refused or were unable to drink 4 h after arriving to the ward were re-attached to IV fluids of 5% Dextrose in 0.45% normal saline for maintenance, until they started to drink. The time to first analgesic, time to drink, eat and stand/walk (age dependent), as well as time to first void, were recorded by a blinded research assistant. All medications given, and any untoward effects, were recorded by the ward nurse.Those who did not have a urethral stent inserted during surgery, were discharged home the same day of surgery, provided they drank, were able to walk (age dependent), had adequate pain control on oral medications, and had voided spontaneously. Time to spontaneous voiding was recorded. Children who had a urethral stent inserted intraoperatively were discharged the next day, when meeting the same criteria except for voiding requirement.On post-operative day (POD) 4, the blinded research assistant (YK) called the parent (or guardian) for a short interview. Number of doses of analgesics, and the times of their administration, were recorded. Recovery parameters, consisting of when the child returned to his normal eating pattern and to his normal level of activity, and an overall parental satisfaction score (0–10) were also recorded.Data was collected by a blinded research assistant (YK) who followed each child once consent was obtained, throughout the perioperative period, including the telephone interview on POD 4. Data included demographics: age, weight, ASA status, surgical procedure, surgical time and total operating room time, as well as PACU and ward parameters as described. Patients were dropped out of the study if parents requested it at any time, if the procedure was canceled, or changed to one of those listed in the exclusion criteria after randomization was performed.post hoc analysis. Kruskal-Wallis nonparametric test was used when appropriate. A significance level of .05 was used. All analyses were carried out using the IBM® SPSS® 21 for Windows.Statistical analysis of the data was carried out for categorical variables with the χ2 and Fisher exact test where appropriate, for comparison of mean of scale variables ANOVA was used and Tukey test was used for Out of 150 children responding to inclusion criteria, due to last minute parental refusal, 116 children between the ages of 4 months and 15 years were recruited. 39 were blindly randomized to the caudal block group (group C), 40 to the fentanyl group (group F), 37 to the dorsal penile nerve block group (group P). Of the two block groups, six had failed blocks and were given fentanyl in the operating room; their pain and recovery data were excluded from analysis. Interviews on POD 4 were obtained in 68 patients  lower in the DPNB and caudal block groups compared to the fentanyl group during the first 20 min postoperatively, as detected by the FLACC score and for the first 30 min by the NRS score   was lowest in the caudal group (< 0.001) . The tim< 0.001) .p < 0.05) higher in the caudal group (Group 1) for the first 30 min in the PACU compared to the fentanyl or the DPNB group . Respiratory rates as well as oxygen saturation (while breathing room air), both on arrival and on discharge from the PACU, were not different among the three groups. There was no statistical difference in time to eat, void or return to normal activity among the groups  than in the caudal group (2.5%). We performed the DPNB using landmark technique rather than an ultrasound guided technique. Nevertheless, a more recent prospective study by Teunken comparing analgesic outcome using DPNB for circumcision via either the landmark or ultrasound technique found no difference in pain scores or in needs for analgesic supplementations intraoperatively or 24 h postoperatively . The fai% than inOur finding that patients with penile blocks had a trend toward earlier return of spontaneous micturition is supported by Metzelder et al. who found less impairment of micturition after hypospadias repair with a DPNB compared to a caudal block . Wang etThis study bears with it several limitations. These include the small number of patients, which is the probable cause for the near statistically significant results. Children from a broad age range were included in this study. It is plausible that blocks may have different effectiveness in different age groups, such as pre-pubertal vs. post-pubertal boys. The small number of participants is not sufficient for sub-analysis of age groups. In addition, the telephone interview (POD 4) was accomplished in approximately half of the cases because many parents did not answer the calls. Their eventual interview upon their postoperative visit (7–10 days after surgery) was discarded since real-time data could not be analyzed with delayed responses. Some of the studied children required urethral stents, while others did not; however, they were equally distributed among the groups, so that results appear not to be biased toward one subgroup. Finally, there were some children who, despite an apparently adequate block during surgery, came to the PACU and required analgesia within the first 0–30 min. Although all were premedicated with midazolam, some of these children might have been agitated or crying on arrival to the PACU because of emergence from the inhaled anesthetics. Due to their high FLACC and parental VAS score, they were therefore medicated with morphine. Analgesia is part of the initial treatment of emergence agitation in non-communicative children  and mighIn conclusion, post-operative pain was initially better controlled with regional anesthesia; however, once immediate analgesics were administered , pain scores, analgesia requirements and 4-day recovery, as expressed by time to start eating and the return to normal activity, as determined by parents, were not different among all penile surgery groups of children.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Tel-Aviv Medical Center ethics committee. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.ME concept, design, analysis of data, and drafting of manuscript. YB-Y concept, design, interpretation of data, and drafting of manuscript. YK acquisition and analysis of data. RS interpretation and analysis of data. EA interpretation and analysis of data. JB-C concept, interpretation of data, and revision of manuscript. AW design, interpretation of data, and revision of manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.