Numbing the area of oral mucosa with cold application prior to administration of regional anesthesia has been widely used by various dentists in alleviating pain caused by needle prick. Cryoanesthesia using Endo-ice as topical anesthesia has been studied as a replacement to prevail the fallibility of topical anaesthetics. This study aimed to evaluate and compare effectiveness of ethyl chloride spray with 5% lidocaine gel in alleviating buccal anesthesia injection pain.  Total of 90 outpatients were randomly divided into 3 groups as follows: Group 1 – cryotherapy with ethyl chloride at the anesthetic site preceding before administration of local anesthesia; Group 2 – topical application of 5% LIDOCAINE GEL preceding before administration of local anesthesia; and group 3 – control that did not receive any topical agent preceding before administration of local anesthesia. Visual analogue scale (VAS) was used to document pain immediately after injection prick. P=0.001). For group 1, about 15 (50%) patients suffered from mild pain, followed by 14 (46.67%) patients suffering from moderate pain. However, majority of the 21 (70%) patients in group 2 suffered from moderate pain. All the patients in group 3 suffered from severe pain.About comparison of pain scores, significant difference was found between group 1 (ethyl chloride) and group 2  patients ( Importance of alleviating fear of needle injection phobia amongst patients is of paramount importance. Ethyl chloride was found to be more effective than topical lidocaine in alleviating needle injection pain before administration of local anesthetic injection. Local anesthesia is one of the most essential parts of almost all of dental procedures to ensure a painless experience for the patients and reduce their anxieties. Although different local anesthetic agents are available, lidocaine is one of the most commonly used drugs in the field of dentistry to provide painless dental treatment. Dental patients often ask for the application of topical agents that would make their initial prick of injection painless irrespective of age and gender. Needle phobia can continue to disturb the patients during every dental visit of the patients if it is not properly managed by the dentists. Such fears if not addressed properly, can lead to avoidance behaviour by the patients toward the dental treatment. Dentists in their everyday practice come across patients with needle phobias, for which various techniques are used to cater to their needs. Whenever patients experience a painful dental procedure, that creates a vicious cycle of avoidance behaviour towards dental treatments which makes effective anesthesia a vital component of almost every dental procedure.Fear of needle or needle phobia  is a well-known fear that disturbs many patients, especially during their first visit to the dentists. However, such fear of needles is not just limited to dentistry, but also can be an anxious experience for patients receiving any kind of medical care such as vaccinations and taking blood samples. Lidocaine comes in various concentrations and varieties for topical anesthesia and their respective effectiveness is well documented. Concentrations and varieties such as 2%, 4%, 5% solutions, 2% or 5% gel, and 10% spray are available for use. Various methods have been used preceding local anesthesia for numbing the site of needle insertion to make the procedure painless for the patient. With the advancement of various pharmacological methods for alleviating needle prick pain, there have been many studies on non-pharmacological methods as well.Lidocaine is one of the most commonly used anesthetic solutions in dentistry. Lidocaine is widely used primarily because of its low toxicity and potent anesthetic effects. Ethyl chloride is widely used among dentists in their everyday practice and is one of the standard methods to evaluate the baseline of pulp sensibility test. Ethyl chloride is widely used in the field of medicine as a pre-injection anesthetic and antiseptic properties for various medical procedures such as venipuncture and immunization. However, the use of ethyl chloride has not been consistent in dentistry.A few studies report that cryotherapy or pre-cooling the area to receive local anesthetic has benefits over using topical local anesthetic agents are pain reduction, rapid onset, and patient compliance. However, very few studies have compared and evaluated the use of cryotherapy with other anesthetic modalities. Various pre-cooling agents have been used in multiple studies for the area to be anesthetized prior to the application of oral local anesthetic and have shown promising results. To the best of our literature search, no study has been conducted to evaluate the effectiveness of pre-cooling the buccal mucosa with ethyl chloride compared to 5% topical lidocaine gel during buccal infiltration. Hence, we conducted this trial. In this study, we aimed to compare and evaluate the effectiveness of pre-cooling with ethyl chloride versus topical anesthesia on pain perception during buccal infiltration in adult patients receiving a local anesthetic injection.α/2 + Zβ)2 × {(p1 (1 − p1)) + (p2 (1 − p2))}]/ (p1 – p2)2]).This randomized controlled trial was carried out between March and May 2022, in the Department of Oral & Maxillofacial Surgery, Sir Syed College of Medical Sciences for Girls, Pakistan. The ethical approval for this study was granted by the Ethical Review Committee of Sir Syed College of Medical Sciences for Girls, Pakistan. This study was carried out in accordance with the Declaration of Helsinki. This clinical trial was conducted according to the CONSORT guidelines and has been registered on the ClinicalTrials.gov site on 01/04/2022 with the number NCT05306470. The participants for this study were recruited by sampling strategy grouping via envelop method and participants were selected via non-probability convenience sampling method. The sample size for this study was calculated using OpenEpi software. Keeping the significance level at 5%, with power at 80%, and difference at 25%, the sample size was calculated to be 24 patients per group. (n = [(Z as presented in TM) on the targeted area was injected at slow speed for one minute using buccal nerve infiltrate anesthesia. After the administration of the injection patients were asked to rate their pain score according to visual analogue scale (VAS), as presented in In this study, participants were randomly allocated to one of the three groups as follows: Group 1 − ethyl chloride; Group 2 − topical lidocaine; and group 3 − control. The principal investigator carried out the procedure of the clinical trial and subsequently assessed the pain scores of the patients. After adequate isolation and drying of the targeted area, one of the allocated techniques was performed. For Group 1 Cryotherapy with Ethyl chloride was used, where using a digital thermometer, the temperature of ethyl chloride was noted to range from -2°C to 0°C,TM) was performed with a cotton ball on the oral mucosa for 30 seconds and local anesthetic injection was administered after 5 minutes and pain score was documented using VAS after administration. In the control group, no local application for numbing the site was performed, only saline was used as placebo and the pain was evaluated using a visual analogue scale after administration of a local anesthetic. The procedure was followed by an buccal nerve infiltration injection by the principal investigator.For group 2 application of 0.2ml of lidocaine 5% gel  was used. The mean and standard deviation was calculated for the demographic variables. One-way ANOVA and post hoc analysis was used to compare the mean pain score amongst the groups. Multiple linear regression analysis was used to compare the effect of age and gender on the pain scores. A In this randomized controlled trial, a total of 90 patients participated, as presented in the CONSORT flow diagram . The mea For group 1, the treatment required by the patients were as follows: 20 (66.67%) root canal treatment, 10 (33.33%) extraction of teeth. For group 2, the treatment required by the patients were as follows: 24 (80%) root canal treatment, 6 (20%) extraction of teeth, and For group 3, the treatment required by the patients were as follows: 21 (70%) root canal treatment, 7 (23.33) extraction of teeth, and 2 (6.67%) deep caries removal. Root canal treatment was performed on patients suffering from irreversible pulpitis, unsalvageable teeth were extraction, teeth with reversible pulpitis underwent filling treatment.The mean scores of patients belonging to each group was as follows: Group 1: 3.10 ± 1.605, group 2: 4.2 ± 1.42, and group 3: 8.8 ± 0.99. Regarding the pain scores of patients in group 1 who were given ethyl chloride, about 15 (50%) patients suffered from mild pain, followed by 14 (46.67%) patients suffering from moderate pain, and lastly only 1 (3.33%) patient did not suffer from pain upon administration of local anesthesia, as presented in P = 0.001). Using post hoc analysis, a significant relation was noted between groups 1 and 3 (P ≤ 0.001) and groups 2 and 3 . However, no statistically significant difference was noted between age and pain scores (P = 0.913). as presented in The comparison of age and gender with the pain scores of the patients was analyzed using multiple linear regression. Regarding the comparison of gender with pain scores, a statistically significant difference was noted  patients suffered from mild pain, followed by 14 (46.67%) patients suffering from moderate pain. Similar findings have been reported in a study by Chilakamuri et al, where when patients were given a pre-cooling agent for before local anesthesia, they reported a significant reduction in their pain scores as compared to topical anesthesia. However, one study does suggest that ethyl chloride increased the level of patient’s pain perception as compared to sampling procedure transabdominal chronic villus sampling. Hence, the application of pre-cooling in patients might vary from procedure to procedure. Moreover, one study has also used a fast-acting refrigerant which was found to provide similar pain relief as compared to topical anesthetic gel. A further benefit associated with using ice is associated with decreasing the discomfort of the patients upon being administered needle injections.Different studies have evaluated and found different methods to alleviate needle prick pain of the patients when buccal anaesthesia is administered, where topical anesthesia is one of the commonly used modalities. Moreover, one study also concluded that pre-cooling was slightly better in pain relief of the patients as compared to using topical lidocaine. However, one study suggests that the use of topical lidocaine resulted in alleviating the pain of patients prior to local anesthesia administration. Since the level of pain perception varies from individual to individual, there might be a difference in pain scores despite any pain alleviating modality being used for the patients.Secondly, in our study, we used topical lidocaine in patients before administration of local anesthesia to assess their pain scores. We, in our study, found that the majority of the patients suffered from moderate pain when local anesthesia was administered to them. Such results correspond with a study by Nusstein and Beck, where about 30% of the patients suffered from moderate to severe pain upon being given local anesthesia. Furthermore, in our study, there was no significant relation of pain scores with age. However, literature does suggest that young adults and paediatric patients tend to suffer from greater levels of pain.Besides, ethyl chloride and topical lidocaine, when the patients were not provided with any pain alleviating modality as in group 3, all of the patients in our study reported suffering from severe injection pain. Moreover, in our study, females experienced greater severity of pain upon injection administration as compared to males. Similar results have been reported in different studies that do conclude females suffer from greater levels of pain. Moreover, the technique of administration of local anesthesia has also been known to affect the perception of pain by the patients. The use of small needles of local anesthesia along with warming the solution of local anesthetic has shown to decrease the injection pain of the patients. Future clinical studies should focus on evaluating and comparing the use of ethyl chloride with pain alleviating modalities in order to further determine its effectiveness. There is always room for improvement to improve the field of painless dentistry.Different pain alleviating modalities have been used in literature other than ethyl chloride and topical lidocaine. Such modalities include benzocaine gel, and clove-papaya based gel with encouraging success in alleviating the pain of the patients noted. In our study, it was concluded that both ethyl chloride and topical lidocaine successfully decreases the pain scores of the patients, with ethyl chloride having greater effectiveness as compared to topical lidocaine. Despite the strengths of this study such as adequately measuring pain scores of the patients and techniques used to alleviate injection pain of the patients, we were met with some limitations. Firstly, we had a small sample size of patients. Lastly, unequal distribution of males and females in all of the groups might have affected the perception of pain scores amongst the participants. Effective management of injection pain prior to local anesthesia administration is of paramount importance, especially to patients who suffer from needle phobia. Cryotherapy with the help of ethyl chloride significantly alleviates pain perceived by patients receiving an injection of local anesthesia. Therefore, ethyl chloride can be used as a pain alleviating modality for patients. The authors would like to thank all the participants who participated in this study. The authors declare there are no conflict of interest. The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. All the participants in this study agreed to the use of their data by providing verbal and written informed consent. All the experiment protocols and consent were approved by the Ethics committee of Sir Syed College of Medical Sciences for Girls /2022/071). All the clinical investigations were conducted in accordance with the guidelines of the Declaration of Helsinki. This study did not receive any funding.


Background"Throwing shoulder" hinders athletes' shoulder functions, causing pain, weakness, and performance reduction due to anatomical, physiological, and biomechanical factors. Anatomical issues include superior labral anterior-posterior (SLAP) injuries, rotator cuff injuries, and glenohumeral instability.MethodsThis study compared arthroscopic labral repairs in patients under 40 years old with shoulder injuries between 2015 and 2017. Sixty eligible patients were divided into three groups: conservative treatment, arthroscopic repair, and tenodesis. Measures included pain, functional scores, and the range of motion pre-/post-operation.ResultsAt the last follow-up, pain relief and functional improvement were most significant with tenodesis , followed by repair , and least in conservative treatment . While all treatments significantly reduced pain and improved function (p<0.001), tenodesis demonstrated the highest effectiveness, suggesting it as a potentially preferred method. Significant improvements in pain relief and function were observed across all methods; however, surgical options suggested improved outcomes.ConclusionOur study compares conservative treatment, arthroscopic labral repair, and biceps tenodesis (BT) for SLAP lesions, highlighting significant pain relief and functional improvement across all. Conservative treatment suits patients with milder symptoms, while arthroscopic repair addresses larger tears. As the effectiveness of arthroscopic treatment is not inferior to conservative one, BT excels in cases of substantial bicep involvement. The term "throwing shoulder" refers to a set of functional limitations that prevent the proper function of the shoulder in athletes who perform throwing gestures, such as baseball, handball, volleyball, javelin throwing, or hitting the ball over the head, such as tennis players during the serve. This condition, which can occur with shoulder pain, weakness, muscle fatigue, stiffness, and inability to throw or make a correct throw, can have several coexisting causal factors. These factors may be of anatomical, physiological, and/or biomechanical origin . The mosThe diagnosis of SLAP lesions can be challenging as the sensitivity and specificity of both the physical exam and advanced imaging are questionable . ManagemAmong the biomechanical factors is an altered mechanics of the launch or deficits in the kinetic chain . The kinTypical injuries described in the throwing shoulder rarely occur in isolation; thus, an overlap of symptoms and clinical findings is common. The rationale for treatment is based on the pathophysiologic biomechanics and should involve stretching, scapular stabilization, and core and lower body strengthening, as well as correction of throwing mechanics, integrating the entire kinetic chain. When nonoperative treatment is unsuccessful, surgical options should be tailored for the specific changes within the pathologic cascade that are causing a dysfunctional throwing shoulder .While conservative treatments such as rest, physical therapy, and non-steroidal anti-inflammatory drugs (NSAIDs) have historically been employed and offer benefits, surgical interventions have gained attention for their potential to address the underlying structural abnormalities of the labrum more directly. Arthroscopic labral repair directly addresses the damaged labrum to restore joint stability. On the other hand, BT not only deals with the SLAP lesion but also any associated biceps pathology, which might be the cause of pain or discomfort for some patients. Given these distinct mechanisms of action, the clinical reasoning suggests that these treatments could result in different outcomes in terms of pain relief, shoulder function, and patient satisfaction. The clinical basis for the hypothesis lies in the intrinsic differences in how each treatment addresses SLAP lesions and the potential implications of these differences for patient outcomes.The complexity of the throwing shoulder is the result of an interplay of the different elements described in the cascade, as well as other factors such as pectoralis minor tightness and scapular dyskinesis. However, it is still unclear which event is the tipping point that breaks the balance between these adaptations and triggers the shift from an asymptomatic shoulder to a painful disabled joint that can jeopardize the career of a throwing athlete. Consequences are rotator cuff impingement and tear, labral injury, and scapular dyskinesis, which are seen both clinically and radiographically .A thorough understanding of the pathologic cascade is paramount for professionals who care for throwing athletes. The successful treatment of this condition depends on the correct identification of the point in the cascade that is disturbed. The typical injuries described in the throwing shoulder rarely occur in isolation; thus, an overlap of symptoms and clinical findings is common .The rationale for treatment is based on pathophysiologic biomechanics and should involve stretching, scapular stabilization, and core and lower-body strengthening, as well as correction of throwing mechanics, integrating the entire kinetic chain. When nonoperative treatment is unsuccessful, surgical options should be tailored for the specific changes within the pathologic cascade that are causing a dysfunctional throwing shoulder .According to our hypothesis, patients with SLAP lesions will exhibit significant differences in pain relief and functional outcomes based on the treatment approach they receive: conservative treatment, arthroscopic labral repair, or BT. This hypothesis is rooted in clinical observations and prior research that indicates varying outcomes of SLAP lesion treatments -9. The pA comparative study involving patients who underwent arthroscopic labral repairs in a tertiary hospital between November 2015 and November 2017 was conducted. Patients who met the following criteria were included in this study: (1) age under 40 years old, (2) follow-up for at least two years, (3) no history of shoulder pathology, (4) patients with a confirmed diagnosis of SLAP lesion, (5) patients who underwent a comprehensive evaluation of the throwing shoulder, including physical examination, imaging studies (such as MRI or CT scan), and diagnostic arthroscopy, confirming the presence of a labral tear. The following are the exclusion criteria: patients with (1) a history of previous shoulder surgery on the affected side; (2) significant shoulder instability or multidirectional instability; (3) concomitant systemic or musculoskeletal disorders that may significantly impact the outcomes of the study (such as rheumatoid arthritis or connective tissue disorders); (4) contraindications to general anesthesia or surgical intervention; (5) incomplete medical records or missing follow-up data; and (6) an associated rotator cuff injury, posterior labral injury, bony, humeral avulsion of the glenohumeral ligament or previous stabilization procedures to the shoulder.A total of 60 patients satisfied the inclusion and exclusion criteria. They were divided into three groups based on the arthroscopic findings and operative procedures performed: group A conservative treatment, group B consisted of 20 patients who underwent arthroscopic repair, and group C consisted of patients who underwent BT. All patients in groups B and C underwent surgery performed in the beach chair position under general anesthesia. The mean age of all patients was 27.5 years (range: 19-35 years). There was no significant difference in age between the groups (p=0.65). The mean follow-up time was 13.8 months (range: 12-16 months). All three treatment groups  have the same mean age of 27.5 years, indicating that the patient groups are well-matched in terms of age. The follow-up time for all three groups is consistent at an average of 19.4 months, with a range of 18-23 months. This suggests that the duration of follow-up is similar across the treatment groups.The outcomes measured in the study were the visual analog scale (VAS) for pain, shoulder functional scores using constant shoulder score, UCLA shoulder score, and Oxford instability score, as well as the examiner-determined range of motion (ROM) in both forward flexion and abduction.Both preoperative and postoperative data at three, six, and 12 months and two years were collected and analyzed. Failure was defined as a redislocation or a subluxation episode during the two-year period. In the case of conservative management, we similarly followed this group of patients at three, six, and 12 months and two years.The VAS score measures pain levels. The American Shoulder and Elbow Surgeons (ASES) scores and single assessment numeric evaluation (SANE) scores were used for assessing shoulder function. The Rowe scores and Constant-Murley scores were used for assessing functional outcomes in shoulder treatments. The hospital ethics committee audited and approved the study protocol. The study was carried out in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.The mean age of patients was 27.5 years (range: 19-35 years). There was no significant difference in age between the groups (p=0.65). The mean follow-up time was 13.8 months (range: 12-16 months). The VAS scores for pain decreased significantly in all groups at all follow-up time points (p<0.001). The ASES scores and SANE scores increased significantly in all groups at all follow-up time points (p<0.001). Table Table VAS scores for pain: In all treatment groups, the VAS scores for pain decreased significantly at all follow-up time points  with p-values less than 0.001.ASES scores and SANE scores: Similar to the VAS scores for pain, both ASES scores and SANE scores increased significantly at all follow-up time points in each treatment group (p<0.001) Table .Table The mean Constant-Murley score at three months was 82.6±9.3 in Group A, 91.2±7.5 in Group B, and 93.7±6.9 in Group C. At six months, the mean Constant-Murley score was 89.4±7.8 in Group A, 94.8±6.4 in Group B, and 96.1±6.2 in Group C. At one year, the mean Constant-Murley score was 93.5±6.2 in Group A, 96.3±4.8 in Group B, and 97.2±5.4 in Group C. At two years, the mean Constant-Murley score was 94.5±6.0 in Group A, 97.1±4.3 in Group B, and 97.6±2.6 4 in Group C. Table Although conservative treatment demonstrated effectiveness, the superior scores from arthroscopic repair and BT indicate that they might be more beneficial for patients seeking the best functional outcomes. In the appropriately indicated patient who has failed conservative management, tenodesis remains a safe and effective treatment option for patients with SLAP. However, the choice of treatment should consider factors such as the severity of the lesion, patient preferences, potential surgical risks, and other individual factors.A one-way ANOVA test was used, followed by Tukey's HSD post-hoc test for multiple comparisons. This provides transparency regarding the statistical methods used in our analysis.The analysis of our results indicates that, while all three treatments were successful in providing significant pain relief and functional improvement, there are gradations in their outcomes. Conservative treatment, for instance, serves as a dependable initial strategy for those with milder symptoms or for those who are apprehensive about undergoing surgery. However, our data suggest that its efficacy might wane in the long run, necessitating further longitudinal studies . ArthrosIn this comparative study, we evaluated the outcomes of different treatment approaches for patients with SLAP lesions. The three treatment groups included conservative treatment, arthroscopic repair, and BT. Our analysis focused on VAS scores for pain and Rowe scores and Constant-Murley scores to assess pain relief, functional improvement, and patient satisfaction. The results of our study demonstrated significant improvements in pain relief and functional outcomes in all treatment groups at all follow-up time points. The VAS scores for pain decreased significantly in each group, indicating the effectiveness of each treatment approach in alleviating pain. Additionally, the ASES and SANE scores increased significantly in all groups, indicating improved shoulder function and patient satisfaction . The difAt each time point , the arthroscopic repair group (Group B) consistently had higher Rowe scores compared to the conservative group (Group A), and the BT group (Group C) had even higher scores than the repair group. These findings suggest that both arthroscopic repair and BT yield superior outcomes compared to conservative treatment in terms of pain relief and functional improvement. Tenodesis appears to provide the highest level of pain relief and functional improvement throughout the follow-up period, followed by repair Table . The difConservative treatment can provide both pain relief and functional improvement for patients with SLAP lesions. Conservative treatment offers them a viable initial approach to alleviate pain and improve function without the invasiveness of a surgical procedure. Conservative treatment is a frequently employed initial approach for numerous musculoskeletal conditions, including SLAP lesions. Here are expanded reasons as to why conservative treatment might be selected for patients with SLAP lesions: patients with smaller, less severe lesions might respond well to conservative management without necessitating surgical intervention.Each patient presents a unique set of circumstances, including their age, overall health, activity level, and pain tolerance, which can significantly influence the efficacy of a chosen treatment. These nuances demand a thorough evaluation to tailor the most suitable therapeutic strategy. The Rowe scores and Constant-Murley scores were used to evaluate functional outcomes in our study. The results showed consistent improvement in both scores across all treatment groups and follow-up time points. Notably, the arthroscopic repair and BT groups consistently demonstrated higher scores compared to the conservative treatment group, indicating better functional outcomes. However, the differences between the groups were not statistically significant. These findings suggest that, while conservative treatment may be a viable option for some patients, surgical interventions such as arthroscopic repair and BT can lead to improved functional outcomes. The decision to proceed with surgery should consider the individual patient's needs, preferences, and the severity of the SLAP lesion -15.Furthermore, the results of our study align with previous research examining treatment options for SLAP lesions. Conservative treatment, including rest, physical therapy, and non-steroidal anti-inflammatory drugs (NSAIDs), has been shown to provide pain relief and functional improvement in some patients, However, surgical interventions have gained popularity due to their potential to address the underlying structural abnormalities and provide more significant and long-lasting benefits .Arthroscopic labral repair is a commonly performed procedure for SLAP lesions and has shown promising outcomes in terms of pain relief and functional improvement. Our study corroborates these findings, demonstrating a progressive increase in pain relief and functional improvement over time in the repair group. The repair group exhibited consistently higher Rowe scores and Constant-Murley scores compared to the conservative treatment group, indicating better shoulder function. These results support the effectiveness of arthroscopic repair in addressing SLAP lesions and restoring shoulder stability ,17. BT, Arthroscopic labral repair is a commonly performed procedure for SLAP lesions and has shown promising outcomes in terms of pain relief and functional improvement. BT, another surgical option, involves the detachment and reattachment of the long head of the biceps tendon to an alternative location. This procedure aims to alleviate symptoms associated with biceps pathology and SLAP lesions . Our stuIn more recent articles, the benefits and outcomes of these treatment options have been further elucidated. A study by Parnes et al. highlights that, while arthroscopic labral repair provides substantial relief in the short term, some patients might experience recurrent symptoms after a few years, emphasizing the importance of long-term follow-up . On the Comparatively, our results bolster the findings of these newer articles, showcasing consistent improvements in the BT group across all measured outcomes. Nevertheless, it is essential to note that individualized treatment decisions should be made, taking into account the patient's specific needs, the severity of the lesion, and associated pathologies. Furthermore, a review by Thayaparan et al.  underscoThis highlights the need for doctors to focus not only on the surgery but also on the post-operative recovery strategy. It is critical to understand that the dynamic field of SLAP lesion treatments is continually evolving. Constant review and comparison with newer studies will ensure that patients receive the best possible care based on the most recent evidence -23. The It is important to note that the study had some limitations. First, the sample size was relatively small, with a total of 60 patients divided into three treatment groups. A larger sample size would provide more statistical power and enhance the generalizability of the findings, the study had a relatively short follow-up period of two years. Long-term outcomes beyond two years should be considered to assess the durability of the treatment effects. Furthermore, the absence of a control group receiving no treatment, or a placebo limits the ability to directly compare the treatment groups. Future studies should address these limitations by employing larger sample sizes, prospective designs, and randomization to enhance the validity of the results.Our paper shows the importance of tailoring treatments to individual patients and emphasizes the importance of a personalized medical approach, echoing the global shift towards more individual-centric healthcare. The surgical strategy seems to lead to a better outcome and better pain control in long-term follow-up. Our study not only provides conclusive insights but also illuminates areas for future investigation, underscoring the need for a deeper delve into the long-term efficacy of conservative treatments and the potential advantages of combining treatments.


Musculoskeletal shoulder pain (MSP) is a common orthopedic condition frequently treated by orthopedic surgeons and physical therapists in an interdisciplinary manner. Dry needling with electrical stimulation (DNES) is an increasingly popular intervention used for the conservative treatment of MSP during physical therapy. To date, no systematic review and meta-analysis have examined the impact of DNES on outcomes in patients with MSP. This study aims to explore the effectiveness and safety of DNES in patients with MSP to improve patient outcomes. A systematic review and meta-analysis were conducted using PubMed, MEDLINE, CINAHL, and Web of Science from database inception to March 10, 2023. Inclusion criteria were studies with DNES as an intervention, recorded patient outcomes, and randomized controlled trials (RCTs) only. DNES with or without conventional physical therapy (CPT) was compared to CPT alone, which included interventions such as exercise, manual therapy, dry needling without electrical stimulation, and/or interferential current. A total of five RCTs were analyzed from 144 articles retrieved on the initial search. Included patients (n=342) had an average age of 48.75 ± 5.92 years, an average follow-up time of 3.40 ± 1.42 months, and 184 patients receiving DNES with or without CPT. Patients treated with DNES with or without CPT (n=163) had a frequency-weighted mean decrease in pain of 4.8 ± 1.4 points, whereas patients treated with CPT alone (n=158) had a frequency-weighted mean decrease in pain of 3.3 ± 2.2 points. For meta-analysis of pain outcomes , DNES with or without CPT improved pain by 1.40/10 points as compared to CPT alone with no significant difference between groups : 4.352; 95% CI: -2.343, 11.048). Patients treated with DNES with or without CPT (n=118) had a frequency-weighted mean decrease in disability of 34.7 ± 9.1 points. In contrast, patients treated with CPT alone (n=115) had a frequency-weighted decrease in disability of 20.1 ± 5.0 points. For meta-analysis of disability outcomes , DNES with or without CPT did not have a significant improvement in disability as compared to CPT alone . No serious adverse effects were reported for patients treated with DNES with or without CPT or CPT alone. DNES with or without CPT may significantly improve pain and disability in patients with MSP. However, DNES with or without CPT does not provide statistically significant improvements in pain or disability compared to CPT alone. Furthermore, DNES appears to be a safe intervention for MSP. Musculoskeletal shoulder pain (MSP) is a common condition frequently treated in a conservative manner by orthopedic surgeons and physical therapists via an interdisciplinary team approach -3. MSP iMethodsInformation Sources and Search StrategyA systematic review and meta-analysis were conducted in this study by using PubMed, MEDLINE, CINAHL, and Web of Science from the database inception to March 10, 2023. The full search algorithm used in each database was ("dry needling" OR "acupuncture") AND  AND . This study is in accordance with the most recent Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . This syInclusion and Exclusion CriteriaInclusion criteria for this study were studies with DNES as an intervention, diagnosis of musculoskeletal shoulder pain, recorded patient outcomes, full-text articles, articles in English, and RCTs only. Exclusion criteria for this study were no interventions with DNES in the study, pain in the shoulder region unrelated to musculoskeletal shoulder pain , lower level of evidence studies, systematic reviews, meta-analyses, books, non-full text articles, and non-English articles.Study DefinitionsFor the purposes of this study, DNES is defined as any form of dry needling or acupuncture that uses needle insertion into muscles and surrounding soft tissue along with the use of electrical stimulation provided by electrical current conducted through the needle. For this study, CPT is defined as numerous interventions, such as manual therapy, exercise, IFC, and other physical therapy interventions. For reported minimal clinically important difference (MCID), this study used 1.4/10 points for pain and 8 points for disability ,17,18.Selection ProcessArticle screening began with the use of the Rayyan software, which has been used elsewhere in the literature for systematic reviews and meta-analyses . First, Data ExtractionTwo authors performed data extraction for this study. Data collected included first author, year of publication, type of study (RCTs), information on DNES or control group, average patient age, number of included patients, pain outcomes via a 0-10 scale, disability outcomes via the Shoulder Pain and Disability Index (SPADI), adverse events and/or complications, and follow-up time.Bias and Quality AssessmentThis study's bias and quality assessment was completed via the Physiotherapy Evidence Database (PEDro) scale . The PEDSynthesis MethodsA random-effects continuous model meta-analysis using Cohen's d was performed for pain  and disability (SPADI). The random-effects model was used due to the heterogeneity of the interventions of the included articles and precedent in the literature with similar meta-analyses for physical therapy interventions ,21. UnstReporting Bias AssessmentThis study did not assess for the existence of publication bias via funnel plot asymmetry due to the small sample size of five included articles ,23.Certainty AssessmentThis study utilized the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence . The cerResultsStudy SelectionA total of five RCTs were analyzed after meeting inclusion criteria from a total of 144 articles retrieved on the initial search ,4-6,8. FRisk of Bias in Included StudiesBased on the PEDro scale for bias and quality, there was one included article with fair quality (20%), and four included articles with good quality (80%). None of the included articles had poor or excellent quality as determined by the PEDro scale. Table Study Characteristics and Patient DemographicsIncluded patients n=342) had an average age of 48.75 ± 5.92 years with an average follow-up time of 3.40 ± 1.42 months and 184 patients receiving DNES with or without CPT. Table  had an aImpact of Dry Needling with Electrical Stimulation on Pain OutcomesPatients treated with DNES with or without CPT n=163) had a frequency-weighted mean decrease in pain of 4.8 ± 1.4 points, whereas patients treated with CPT alone (n=158) had a frequency-weighted mean decrease in pain of 3.3 ± 2.2 points. For meta-analysis of pain outcomes from four included articles , DNES with or without CPT (n=163) improved pain by 1.40/10 points via UMD as compared to CPT alone (n=158) with no significant difference between groups  had a frequency-weighted mean decrease in disability of 34.7 ± 9.1 points. In contrast, patients treated with CPT alone n=115) had a frequency-weighted decrease in disability of 20.1 ± 5.0 points. For the meta-analysis of disability outcomes from three included articles , DNES with or without CPT (n=118) had no significant improvement in disability as compared to CPT alone (n=115)  being a common cause of MSP symptoms ,6. MTPs DNES with or without CPT may provide clinically significant improvements in pain and disability in patients with MSP. However, DNES with or without CPT does not provide statistically significant improvements in pain or disability compared to CPT alone based on a meta-analysis of five fair-to-good quality RCTs. Furthermore, DNES appears to be a safe intervention for MSP and could be a viable alternative to other interventions used in CPT. This study represents the first systematic review and meta-analysis of the effectiveness and safety of DNES for patients with shoulder pain. More research is needed on this topic as the relatively small sample size and heterogeneity of the included articles impact study interpretation and application.


Patients suffering from connective tissue disorders like Ehlers–Danlos syndrome hypermobility type/joint hypermobility syndrome (EDS-HT/JHS) may be affected by craniocervical instability (CCI). These patients experience myalgic encephalomyelitis, chronic fatigue, depression, extreme occipital-cervical pain, and severe widespread pain that is difficult to relieve with opioids. This complex and painful condition can be explained by the development of chronic neuroinflammation, opioid-induced hyperalgesia, and central sensitization. Given the challenges in treating such severe physical pain, we evaluated all the analgesic methods previously used in the perioperative setting, and updated information was presented. It covers important physiopathological aspects for the perioperative care of patients with EDS-HT/JHS and CCI undergoing occipital-cervical/thoracic fixation/fusion. Moreover, a change of paradigm from the current opioid-based management of anesthesia/analgesia in these patients to the perioperative opioid minimization strategies used by the authors was analyzed and proposed as follow-up considerations from our previous case series. These strategies are based on total-intravenous opioid-free anesthesia, multimodal analgesia, and a postoperative combination of anti-hyperalgesic coadjuvants  with an opioid-sparing effect. Chronic neuroinflammation, neuronal damage and central sensitization are common pathways that cause severe widespread pain in patients with Ehlers–Danlos syndrome hypermobility type/joint hypermobility syndrome (EDS-HT/JHS) and craniocervical instability.The use of opioid-free anesthesia with propofol, ketamine, lidocaine, and dexmedetomidine is feasible in patients with EDS-HT/JHS who are to undergo occipital/cervical fixation, and the support of a service specialized in postoperative acute pain is essential for the viability of this management.Opioid-free anesthesia plus perioperative opioid-minimization management may reduce the postoperative pain in patients with EDS-HT/JHS that undergo occipital/cervical/thoracic fixation..Postoperative infusions of anti-hyperalgesic coadjuvants  along with multimodal analgesia provide a significant opioid-sparing effect. However, more studies are needed to justify their use for more than 72 h in this type of patientThe perioperative opioid-minimization approach is a reasonable option for patients with EDS-HT/JHS suffering from gastrointestinal dysfunction, opioid-induced hyperalgesia, central sensitization and severe widespread pain.In the context of the perioperative opioid-minimization approach, methadone is the most suitable opioid for use as a rescue analgesic for severe pain owing to its anti-NMDA effect and its effect of reducing the reuptake of serotonin and norepinephrine. Some patients with Ehlers–Danlos syndrome-hypermobility type/joint hypermobility syndrome (EDS-HT/JHS) may suffer from Craniocervical Instability (CCI). CCI can result in continuous microtraumas and inflammation on craniocervical joint surfaces. It causes repetitive peripheral sensitization, which eventually leads to the phenomenon of central sensitization (CS) and hyperalgesia , 2. ThesThe current perioperative anesthesia and pain management protocols followed with patients with EDS-HT/JHS and CCI who were programmed for occipital-cervical fixation/fusion (OCF) call for opioid-based approaches. Using opioid-based protocols seems to be a contradiction, considering the proposed nociceptive mechanisms and the high percentage of patients with an intolerance to opioids.Owing to the complex clinical features of these patients and the difficulty encountered in managing their physical pain, updated information is included in this paper which covers important physiopathological considerations for the perioperative care of patients with EDS-HT/JHS and CCI that undergo OCF. Moreover, a change of paradigm from the current opioid-based management of anesthesia/analgesia in these patients to the perioperative opioid-minimization strategies used by the authors was analyzed and proposed as follow-up considerations from our previous case series. These strategies are based on total-intravenous opioid-free anesthesia (OFA-TIVA), multimodal analgesia, and a postoperative combination of anti-hyperalgesic coadjuvants  with an opioid-sparing effect.Due to the complex variety of symptoms, clinical signs, and additional syndromes that coexist in patients with EDS-HT/JHS and CCI who are going to undergo OCF, it is important that the perioperative team understand the proposed physiopathology that may explain the cause of all symptomatic features. Likewise, it is particularly important that anesthesiologists know that these patients frequently take a wide variety of chronic medications, some of which might provoke drug interactions with anesthetic medications and postoperative treatment for pain management Table .Table 1CPatients with connective tissue diseases may suffer from craniocervical instability (CCI). These diseases include systemic lupus, rheumatoid arthritis, and genetic disorders such as Ehlers–Danlos syndrome-hypermobility type/joint hypermobility syndrome (EDS-HT/JHS), Marfan syndrome, Loeys–Dietz syndrome, Stickler syndrome, Cleidocranial dysostosis, Morquio syndrome, osteogenesis imperfecta, and Down’s syndrome. This broad group of genetic diseases characterized by generalized joint hypermobility can bring on laxity of the spinal ligaments that provoke severe symptoms due to CCI , 6.Both CCI and EDS-HT/JHS can lead to the adaptation and compensation of movement patterns. Consequently, they cause overloading in other areas along with additional constant microtraumas to other joints, ligaments, and tendons of the movement apparatus, all of which are characterized by generalized soft tissue laxity. These conditions produce widespread chronic pain, which is triggered by complex noxious mechanisms like CS –11. AnotCMS may explain some of the neurological and ancillary symptoms in patients with CCI and EDS-HT/JHS, particularly when a Chiari malformation is present. An unstable cervical spine may cause functional brainstem compression, which may be influenced by neck movements and axonal damage due to deformative stress . CervicaOn the other hand, the presence of migraines, temporo-mandibular joint (TMJ) dysfunction syndrome and myofascial neck pain in patients with JHS are factors that make the diagnosis of craniocervical pain produced by CCI difficult , 18 whicUndoubtedly, some overlap exists among all hereditary diseases of the connective tissue when considering the multi-systemic nature of generalized joint hypermobility. Interestingly, the clinical characteristics of most patients who have undergone OCF by our surgical team present with EDS-HT/JHS accompanied by CCI, chronic fatigue, severe occipital-cervical pain, severe widespread pain with a poor response to opioids, functional gastrointestinal disturbances, MCAS and autonomic symptoms like POTS .On the other hand, genetic conditions in the encoding of α-tryptase presented in some patients with EDS-HT/JHS may be involved in the coexistence of symptoms that affect the skin, gastrointestinal tract, and circulatory and musculoskeletal systems , 20.may partially explain the coexistence of these multi-systemic symptoms that affect the skin, gastrointestinal tract, cardiovascular and musculoskeletal systems. This might also be related to the coexistence of MCAS, POTS, gastrointestinal disorders and EDS-HT/JHS. This coexistence is not a constant phenomenon (less than 15%) and it can occur with different levels of severity [Studies suggest that there is a common genetic condition related to excessive germline duplications and triplications in the allelic TPSAB1 gene encoding α-tryptase that provokes an increase in serum basal tryptase levels from mast cell activity (tryptase ≥ 8.0 ng/ml). It is a common autosomal dominant inheritance that severity , 20. We There are some opioids that are considered to have a high risk of histamine release, such as morphine, pethidine (meperidine) and codeine. These opioids should be avoided, particularly in patients with MCAS and POTS. On the other hand, there is evidence that tramadol, oxycodone, fentanyl, sufentanil and methadone have a low risk of histamine release. These opioids may be an alternative for occasional use, such as rescue analgesia . In factRelative to joint laxness, the symptoms of patients overlapped in the EDS-HT and JHS groups. Experts have recently considered these two disorders as indistinguishable at the clinical level , 22, 23.In patients with EDS-HT/JHS who develop CCI, both severe craniocervical pain and widespread pain have multifactorial causes . Pain isMoreover, many patients with CCI, JHS, chronic fatigue, and severe chronic pain receive distinct types of opioids, which further complicate pain due to opioid-induced hyperalgesia (OIH) , 24, 25.As noted in other publications, it is possible that the diagnosis of withdrawal-associated hyperalgesia (WAH) was erroneously included in our data as part of the prevalence of OIH, which may be biased. Therefore, it is advisable not to extrapolate our data to the general and the entire EDS-HT/JHS population under chronic opioid medication . An advaTaking into consideration the probable mechanisms of chronic severe pain that affect some our patients with EDS-HT/JHS and CCI, and their frequent association with gastrointestinal dysfunction, the use of opioids was stopped in total intravenous anesthesia (TIVA) during OCF.The differences were clearly visible. Therefore, we believe that the opioid-based protocol for anesthesia and pain management may be an improper way to manage EDS-HT/JHS patients with CCI and severe chronic pain who are going to have OCF.Intraoperative opioid-based analgesia (remifentanil or sufentanil infusions) has been replaced with infusions of lidocaine, ketamine, magnesium, and dexmedetomidine. They are coadjuvants with known analgesic and antihyperalgesic properties. This anesthetic protocol is directed toward enhancing postoperative pain control, decreasing postoperative opioid rescues, and reducing preoperative opioid doses in patients who have been prescribed these medications over a prolonged period. The infusions of lidocaine, ketamine, and dexmedetomidine were continued at lower doses up to 72 h postoperatively as part of a multimodal analgesia plan Tables , 5. ReceIn certain cases of EDS-HT/JHS patients underwent OCF, these infusions were used for more than 72 h without any complication (5 days). These cases suffered from severe widespread pain with significant neuropathic symptoms, and the use of opioids was completely contraindicated for severe intestinal disorders and MCAS. These cases represented less than 2% of our case series. It is important to mention that postoperative infusion of lidocaine, ketamine and dexmedetomidine for more than 72 h is not yet supported by the literature. In our cases, the prolongation of these infusions was justified by compassionate use.An exhaustive search for evidence related to opioid-free anesthesia and perioperative opioid-minimization management in patients with EDS-HT/JHS undergoing OCF has been carried out. Upon completion of this research, two independent reviewers (C.R-P and C.RC) screened the titles and abstracts using the Cochrane Library, Ovid Medline, PubMed Central, and Google Scholar databases according to PRISMA guidelines. Any arising differences were settled by a discussion with a third and fourth party (A.CB and A.SS). Only publications written in English since 2010 to 2022 with the following terms were applied to the search strategy: (((((hypermobile syndrome) OR (EDS-HT)) AND (Opioid-Free Anesthesia)) AND (opioid-free anaesthesia)) AND (perioperative opioid minimizing approach)) AND ) AND ) AND (OCF)) OR . Randomized clinical trials, case series, case reports, narrative review and editorials were equally included to complete the current information available on OFA plus perioperative opioid-minimization management in patients with EDS-HT/JHS undergoing OCF.Patients diagnosed with EDS-HT/JHS and CCI.Patients with EDS-HT/JHS and CCI undergoing OCF with opioid free-total intravenous anesthesia.Patients with an opioid intolerance due to gastrointestinal disorders, nauseas and vomiting, and/or OIH, and/or MCAS triggers.Patients under OFA-TIVA and postoperative use of lidocaine, ketamine, and dexmedetomidine infusions.The inclusion criteria were as follows:Patients with CCI without EDS-HT/JHS.Patients with EDS-HT/JHS and CCI who underwent any other surgery than OCF or OCF plus thoracic fixation.Patients with EDS-HT/JHS and CCI who underwent OCF under opioid-based anesthesia/analgesia, with or without medication for multimodal analgesia.The exclusion criteria were as follows:The database search identified 328 records. After removing duplicate records, 324 articles were screened for relevance of titles and abstracts. Four relevant articles were reviewed for eligibility, resulting in a full-text review. Two articles were excluded. One of them is a systematic review focused solely on the surgical treatment of craneocervical instability in patients with EDS-HT/JHS. The other article deals with the use of OFA plus opioid-minimization management in various clinical settings other than OCF, including EDS-HT/JHS , 35. Fi.Fig. 1FlTwo remaining articles were included in the final qualitative analysis, a case series study of 42 patients, and a narrative review , 37. The2O in their groups and the patients do not suffer from EDS-HT/JHS or any other collagen disorder.Information related to the use of opioid-free anesthesia plus postoperative infusions of lidocaine, ketamine, and dexmedetomidine as part of opioid-minimization management in patients with EDS-HT/JHS for any type of surgery is lacking. Only one previously published study by the authors of this paper can be found, registered in ClinicalTrials.gov Identifier: NCT04437589 by Ramirez-Paesano et al. , entitleA recently published review referred to OFA techniques followed by opioid-free analgesia such as OFAA, whose name and acronym could be synonymous with our OFA-plus protocol .p < 0.001). VAS at hospital-discharge was lower in the “OFA-plus” group (p < 0.001).For many years, our team has managed patients with EDS-HT/JHS who underwent OCF with TIVA using opioids like fentanyl, sufentanyl, or remifentanil as intraoperative analgesics. In the past, postoperative pain management was based on morphine, hydromorphone, nonsteroidal anti-inflammatory drugs, and benzodiazepines. The postoperative period used to be a challenging time with poor outcomes in terms of pain management, gastrointestinal side effects, and patient satisfaction. Based upon a better comprehension of nociceptive physiopathology, a decision was taken to change the paradigm around the use of opioids as mandatory analgesics in the perioperative period. The new paradigm for opioid minimization management includes infusions of lidocaine, ketamine, and dexmedetomidine as coadjuvant painkillers with significant anti-hyperalgesic and opioid sparing effects. Reducing the use of opioids by managing these patients with the “OFA-plus” protocol has resulted in a reduction in Visual Analogue Scale (VAS) in terms of postoperative time (p < 0.001). Among patients in the OFA-plus group, 78% (95% CI) required no methadone rescue, 8.7% required 10–15 mg/day, and 4.3% of patients required more than 15 mg/day.The methadone requirement was lower in the OFA-plus group (p < 0.001). In the OFA-plus group, 60.9% of patients had decreased opioid requirements at hospital discharge compared with the preoperative values. However, in the OP group, 26.3% of patients maintained the same opioid requirement, 63.2% increased, and no patients showed a decrease. A 77% reduction in anxiolytic requirements was observed [.In contrast, 95% (95% CI) of the OP group (group with opioid-based management) required methadone rescue at high doses. Thirty-six percent required 10–15 mg/day and 42.8% required more than 15 mg/day of methadone rescue. The OFA-plus group showed decreased ileus, nausea, and vomiting , an important part of the OFA-plus protocol, was provided following the protocol described in our recently published article . Since tAlso, the preventive use of haloperidol to reduce the incidence of ketamine-induced hallucinations have been included in patients who suffer from severe anxiety and important psychological disorders. The literature suggests that low-dose ketamine has a low potential for hallucinations. However, in our case series, the incidence of hallucinations was 17.4% despite all the patients received midazolam at 0.1 mg/kg intraoperatively. In addition, many of them were chronically medicated with benzodiazepines and antidepressants to treat severe anxiety, mood disorders, panic attacks, and depression.This incidence of hallucinations was considered to be very high, and this fact motivated us to search for the mechanisms of ketamine-induced hallucinations. We do not have a definitive explanation for this result. We hypothesized that potential causes such as genetic, psychologic or neuropsychiatric susceptibilities may be the explaination, but it is only a speculative reasoning. In any case, we needed an optional medication to reduce the ketamine-induced hallucinations. A recent meta-analysis and systematic review suggested that the phycomimetic effects of ketamine may involve the dopaminergic system, and a mechanism of neuronal firing by dopamine release was proposed . Acute aTable To decrease the requirement of opioids during postoperative period, we believe that it is helpful to keep the postoperative infusions of lidocaine, ketamine, and dexmedetomidine at lower doses. The goal is to attenuate the inflammatory response resulting from surgical trauma and its effect on pain, CS, and gastrointestinal function , 49, 50.Many of these patients present involuntary cervical and thoracic muscle contractures and spasticity leading to exacerbation of postoperative pain. Tizanidine or baclofen are used when muscle contractures and spasticity are identified as an additional component of pain. Tizanidine is a muscle relaxant with alpha-2-agonist analgesic mechanism with anti-nociceptive effect in neuropathic pain through inhibition of pro-inflammatory cytokines production via suppression of Toll-like receptor 4/Nuclear Factor-ƙB (TLR4/NF- ƙB) activation as well as postoperative opioid-sparing effect , 52.Baclofen, a gamma-aminobutyric acid type B receptor agonist, blocks the release of excitatory neurotransmitter in neurons and glial cells (glutamate and aspartate) by interfering with voltage-gate calcium channels. Baclofen decreases muscle tone and prevents reflex muscle contraction and spasticity .An improvement in those patients with “uncontrolled pain” by using oral baclofen (25 mg e/8 h) has been noticed. This fact led us to consider cervical-dorsal muscular spasticity or muscle contracture as an additional component of pain crisis. , 55.Methadone, an opioid with anti-NMDA effect, is used as a painkiller rescue to treat postoperative breakthrough pain . So far,Later, the administration of oral ketamine may be continued in patients with widespread pain that is difficult to control. This is also the case if there is a preoperative history of treatment with opioids, OIH, an important neuropathic component, or a propensity to receive high opioid rescue doses.Many articles on the advantages of OFA have been published. However, studies of OFA in patients that have undergone spinal surgery have revealed controversial findings relative to postoperative outcomes –59. The . On the contrary, the nociceptive flexion reflex threshold (NFRT) may be more fitting to monitor nociception in patients under opioid-free total intravenous anesthesia (OFA-TIVA) without neuromuscular blockers (NMB). NFRT, a method based on electromyography (EMG) and bispectral index (BIS), is able to predict movement as a response to surgical pain under propofol monoanesthesia. When using OFA-TIVA, NFRT might be useful in predicting movement due to surgical pain [A balanced combination of lidocaine, dexmedetomidine, ketamine and MgSO4 has antinociceptive and anti-hyperalgesic effects. However, there are still doubts about the analgesic efficacy of its use in OFA when compared to opioids. Doubts have also arisen as to the most appropriate combination of these coadjuvants to replace opioids. The absence of dependable nociceptive monitors has been an obstacle to changing the paradigm in spine surgery . Monitorcal pain .This article deals with the topic of a propofol-based OFA in a group of specific patients (EDS-HT/JHS) with widespread pain and SC that have undergone major spinal surgery to treat CCI. Intraoperative analgesia is delivered by means of a balanced combination of lidocaine, ketamine, MgSO4 and dexmedetomidine. These "opioid substitutes" have anti-hyperalgesic and anti-inflammatory properties as well as multiple mechanisms of analgesic action. In addition, anesthesia is provided without neuromuscular blockers (NMB) because our surgical team requires continuous evaluation with neurophysiologic monitoring that includes motor evoked potentials (MEPs) and electromyography (EMG). Somatosensory evoked potentials (SSEPs) are also monitored. In our practice, EMG recordings have confirmed the absence of movements related to the surgical stimulus in any patient. The dosage of lidocaine, ketamine, MgSO4 and dexmedetomidine used in our OFA-plus protocol  has been significantly reduced and methadone rescue has been reduced. Moreover, the postoperative comfort of the patients, gastrointestinal side effects and the need for anxiolytics drugs decreased ..Therefore, we believe that we are on the right pathway to providing better management of these patientsSome resistance to the LA effect has been noted in regional anesthesia techniques for dental, orthopedic, and obstetric procedures. However, there is no evidence that peripheral nerve blocks or spinal/epidural anesthesia are ineffective. On the contrary, regional anesthesia may be the better choice for some orthopedic and obstetric procedures in patients with EDS-HT/JHS. On the other hand, there are some case reports of resistance to certain LA with local infiltration –71. ResiAt the moment, our OFA-plus protocol does not currently include regional techniques with local anesthetic for postoperative analgesia. However, we believe that in the future the use of some techniques such as ultrasound-guided interfascial blocks would be possible and beneficial to further reduce methadone rescue. Further study will be necessary to test this hypothesis.So far, any sign of resistance or the absence of an analgesic effect from intravenous lidocaine has not been observed. This may be because the mechanisms of intravenous lidocaine analgesia are mediated by a strong systemic anti-inflammatory effect and multiple antinociceptive pathways other than Na+ channel blockade-mediated analgesia at therapeutic plasma concentrations , 66, 74.The coexistence of widespread chronic pain, CS, opioid intolerance, OIH, gastrointestinal disturbances, and the potential presence of MCAS has been the reason for the use of OFA-plus in these patients , 24, 25.If necessary, we use methadone to relieve severe breakthrough pain in the postoperative period. However, including the use of non-opioid options that affect different nociceptive pathways  remains important to reduce the use of postoperative opioids –78. BecaMoreover, at present, no analgesic can completely replace opioids during the postoperative period as rescue to control severe breakthrough pain.We are in complete agreement with some authors that OFA should not be taken as a popular (“fashionable”) trend to be followed in any type of surgery under general anesthesia . We firmRegarding pain management in patient with OIH and CS, we believe that methadone is the most suitable rescue opioid to treat severe pain owing to its anti-MNDA effect. Methadone decreases OIH and attenuates central sensitization. It also reduces the reuptake of serotonin and norepinephrine. Furthermore, the use of methadone with ketamine (both anti-NMDA) shows a synergy that enhances the opioid-sparing effect .Patients that have undergone major surgical procedures frequently require postoperative opioids to relieve breakthrough pain control. The OFA-plus protocol used in our hospital includes methadone only as a rescue agent for severe postoperative pain that is difficult to control with non-opioid analgesics .Recent literature has recommended the use of methadone (0.15–0.2 mg/kg bolus) at the beginning of anesthetic induction in complex spinal surgery . MethadoA recent meta-analysis confirmed the benefits of methadone use at the onset of anesthesia in extensive and painful surgeries , 84.If methadone is needed as a postoperative rescue, nausea and vomiting may be a problem. At some point, fosaprepitant may be an option for the management of intractable nausea and vomiting. Currently, our protocol does not include the use of methadone in the intraoperative period, which is consistent with the OFA concept. If a single dose of methadone is administered at the beginning of our OFA protocol, the anesthetic technique should be called modified OFA-plus, or simply not called OFA.Patients with EDS-HT/JHS and CCI experience severe chronic widespread pain and hyperalgesia, which are strongly related to the central sensitization phenomenon. The use of the “OFA-plus” protocol is feasible and safe to use in patients who are to undergo OCF with EDS-HT/JHS associated with severe pain, POTS, MCAS, and gastrointestinal dysfunction.The infusions of lidocaine, ketamine, and dexmedetomidine in combination with propofol for TIVA without NMB seem to provide adequate analgesia. The neuromonitoring  records suggest that this management is appropriate.Postoperative pain management in patients who are to undergo OCF is difficult and complex. The use of lidocaine, ketamine, and dexmedetomidine infusions during the postoperative period may be helpful in improving pain management while reducing the total amount of opioids used during the hospital stay.To date, it has been difficult to eliminate the use of opioid rescues to control severe postoperative breakthrough pain in its entirety. It is important to continue studying non-opioid therapeutic options to reduce gastrointestinal side effects, OIH, and opioid tolerance and dependence.Does OFA offer short-term benefits in the postoperative period?: In response to this it should be said that there are no randomized studies to give a definitive answer. However, at present we could say that OFA plus perioperative opioid-minimization approach reduce the total amount of opioid and the gastrointestinal side-effects in this patients. (2) Does “OFA-plus” offer long-term benefits regarding the pain?: To this question it is important to state that there are no studies that support it. (3) In these types of patients undergoing OCF, Could the use of a single dose of methadone be recommended at the beginning of the anesthetic induction? This could be possible. However, there are no studies using “the modified-OFA” in this context.Finally, the last questions we should answer are: (1)


The study showed that there were three obvious pain trajectories after anorectal surgery, including an unreported low-moderate-low type. More than 60% of patients maintained moderate to severe pain within 7 days after the operation. These postoperative pain trajectories were predominantly defined by surgery factors and patient factors.The evolution of pain after anorectal surgery has not been well characterized. The main objective of this study is to evaluate patterns in acute postoperative pain in patients undergoing short-stay anorectal surgery. A total of 217 patients were included in the study, which used group-based trajectory modeling to estimate postoperative pain and then examined the relationships between sociodemographic or surgical factors and pain trajectories. Three distinct postoperative pain trajectories were determined: hemorrhoidectomy , higher anxiety , and a higher preoperative pain behavior score . In multivariate analysis, they were associated with an increased likelihood of being on the high pain trajectory. The pain trajectory group was related to postoperative analgesic use ( Hemorrhoids and anorectal abscess fistulas are the two most common types of benign perianal disease with a high incidence rate ,2,3. It Muscle groups located around the anus have a specific autonomous ability to relax and tighten. Many sensory and motor nerves are distributed and dominate these muscles ,15, mainThe main goal of the study was to characterize, through a group-based trajectory analysis, unique groups of postoperative pain trajectories for postoperative days 1–10 following surgery for benign perianal disease. The second goal was to investigate how sociodemographic and clinical factors affected the pain trajectory in patients who had surgery for with benign perianal diseases.This trial is a prospective cohort study using samples from benign perianal surgery. The purpose is to study the relationship between population-based trajectory modeling and postoperative pain trajectory. The study protocol  was approved by the institutional review board’s China registered clinical trial ethics review committee. All patients provided written informed consent for their clinical data to be used for research purposes; they are usually recruited and registered more than 24 h before the operation to avoid unnecessary time pressure. This manuscript adheres to the STROBE  guidelines.The study included patients undergoing elective surgery for benign perianal diseases, including hemorrhoids, anal fistulas, perianal abscesses, anal fissures, and rectal prolapse. The inclusion criteria were as follows: surgical indications and surgical treatment; age > 18 years; estimated hospitalization time >48 h; the expected survival time was >6 months; American Society of Anesthesiologists (ASA) Classes I–II. Individuals with other important organ diseases, those who had previously undergone anorectal surgery, experienced postoperative bleeding, infection, or other complications, and were readmitted, individuals with neurological or mental disorders, and those with communication difficulties were excluded. All subjects underwent surgery at Shuguang Hospital, affiliated with the Shanghai University of Traditional Chinese Medicine, between 22 February and 18 May 2021. Patients who fulfilled these criteria were usually screened and recruited by a trained study coordinator one to two days before surgery. In addition, all eligible patients were screened by appropriate clinical staff on all weekdays and at all hours to minimize the risk of selection bias. A flow diagram illustrating the sample selection process is presented in A total of 244 patients underwent hemorrhoidectomy or anal fistula resection in the Shuguang Hospital during the study period from February to May, 2021. Of these patients, 217 were enrolled.The patients were given an oxygen mask inhalation (2 L/min) and intravenous infusions before the operation to maintain stable vital signs. Blood pressure, pulse oxygen saturation, and electrocardiography findings were monitored during the operation. All patients accepted the standardized surgical program of deepening rehabilitation, and the specific process was propofol (2 mg/kg) and sufentanil (0.2 μg/kg) for intravenous anesthesia induction. After the patient fell asleep, a bilateral pudendal nerve block was performed with ropivacaine 0.2%  and epinephrine (10 μg/mL). Intraoperative maintenance was performed with propofol (1.0–2.0 mg/(kg·h)). Vital signs were closely monitored during the operation, and symptomatic treatment was administered based on the response of the respiratory and circulatory systems. The main postoperative analgesics are oral paracetamol and external suppository. Compound paracetamol tablets  are taken twice per day, with one tablet (450 mg) for each dose. If pain was severe, it was used once more (not exceeding four tablets). External suppository is the Mayinglong Hemorrhoids Suppository . The main ingredients are artificial musk and artificial bezoar, which have the effect of clearing heat and relieving pain. Take one capsule (330 mg) twice a day.Sociodemographic variables, including age, sex, height, and weight, were obtained from the electronic health records using the values listed at the time of surgery. The preoperative pain behavior score    and preoA short pain scale was used daily for 10 days after the operation. Postoperative pain was assessed using a visual analogue scale (VAS). Subjects described the average intensity of pain per day after surgery (0 represented “no pain” and 10 represented “the highest degree of pain you can imagine”) and the frequency of taking analgesics. A trained research coordinator collected postoperative transient pain scale scores in the ward. After discharge, subjects were contacted via telephone to complete the evaluation for an additional 10 days.The main outcome measure was the VAS score from days 1 to 10 after the operation. Secondary outcome measures included sociodemographic data , preoperative anxiety, and pain behaviors), surgery-related factors (the surgeon and the type of surgery), and the impact of postoperative analgesic drug consumption on the postoperative pain trajectory.Statistical analysis was performed using SPSS version 26.0 . Continuous measurements are summarized as mean ± SD and classified as proportions. The normality of the main measures of mean pain was graphically examined using histograms stratified according to postoperative day.In the preliminary analysis, patient groups or subgroups with similar postoperative pain progressions  were identified, and group-based trajectory modeling was implemented in the Stata software using maximum likelihood estimation. All subjects were classified as members of a trajectory group, and the posterior probability of becoming a member was the highest . Group-bp < 0.25) [p < 0.05 were considered to be statistically significant [In the secondary outcome analysis, the relationship between several preoperative factors and trajectory groups was examined. Categorical preoperative factors were analyzed using the chi-squared test or Fisher’s exact test, and continuous preoperative factors were analyzed using one-way analysis of variance . The parameter test used quantile-quantile diagrams to evaluate the normal hypothesis; if it was violated, the nonparametric Kruskal-Wallis test would be used. Levene’s test was used to evaluate the equal variance hypothesis. If the hypothesis was violated, the Welch correction was used. The pain locus was used as the basis for classification, and the factors were analyzed using multiple logistic regression. Variable selection was based on univariate criteria ( < 0.25) . Collinenificant .A total of 244 patients were recruited, of whom three underwent other types of surgery and 10 were lost to follow-ups. A total of 231 individuals were registered, of whom 12 had incomplete data at the time of analysis and two had no available postoperative data. As such, data from 217 participants was included in the final analysis .2. Among the samples, 58.1% underwent a procedure for prolapse and hemorrhoids (PPH), 40.5% received a fistulectomy, 0.9% received seton therapy, and 0.5% received a fistulotomy. The mean preoperative anxiety and pain behavior scores were 1.3 ± 0.9 and 2.2 ± 1.0, respectively.A total of 217 patients were included in the present study. Patient demographic information and the types of surgery are summarized in A total of 217 patients were used for the group-based trajectory analysis. In the entire sample, the mean daily pain score was moderate on postoperative day 1 (5.1 ± 3.1) and decreased significantly by postoperative day 10 (1.8 ± 1.0) . Table 2Fifty-seven percent of patients were in the high-low group, 23.3% were in the low group, and 19.7% were in the low to moderate-low group.The characteristics of patients in the trajectory group are summarized in 2. The proportion of patients receiving PPH and fistulectomy is almost equal; one patient received seton therapy. Nearly half of the surgeons were chief physicians with rich clinical experience. The preoperative anxiety and pain behavior scores were 0.7 ± 0.5 and 1.9 ± 1.1, respectively. The total consumption of postoperative nonsteroidal analgesics was 2.2 ± 0.5 g.Low: The initial pain in patients with this trajectory was mild until it exhibited a downward trend. The average age of the patients was 41.8 ± 11.7 years, and the male to female ratio was approximately 6:4. The mean BMI was 25.1 ± 3.7 kg/mLow-moderate-low: The initial pain in this pain trajectory group was mild but gradually aggravated until it began to decrease after reaching the peak six to seven days after the operation. The mean age of the patients in this group was 39.1 ± 11.1 years, and the male to female ratio was approximately 7:3. The proportion of patients who underwent hemorrhoidectomy and fistulectomy was approximately 4:5 (19:24). The mean preoperative anxiety and pain behavior scores were 1.0 ± 0.6 and 1.9 ± 1.0, respectively. The mean total consumption of postoperative nonsteroidal analgesics was 2.7 ± 0.5 g.2. The proportion of patients who underwent hemorrhoidectomy and fistulectomy was approximately 2:1 (82:39), and one patient received seton therapy and one received a fistulotomy. Nearly 60% of the patients underwent surgery performed by an attending physician. The mean preoperative anxiety and pain behavior scores were 1.7 ± 0.9 and 2.4 ± 1.0, respectively. The mean total consumption of postoperative nonsteroidal analgesics was 3.2 ± 0.8 g.High-low: The initial pain of patients in this pain trajectory group was very serious but became increasingly lighter with each day. The mean BMI was 24.1 ± 3.9 kg/mVariables included in multiple logistic regression analyses were: BMI, types of surgery, preoperative anxiety score, preoperative VAS pain score, and postoperative analgesics. The low group was used as the reference group for multiple logistic regression analyses. According to group-based trajectory analyses, three pain trajectories identified patients with low, high-low, and low-to-moderate pain over time in the first 10 days after surgery for perianal benign disease. Patients who underwent hemorrhoidectomy were more common in the high-low group. Moreover, this group experienced more preoperative anxiety, exhibited pain behaviors, and had a greater demand for postoperative analgesia.Anorectal surgery could be carried out under general anesthesia, spinal anesthesia, nerve block, local anesthesia, or combined anesthesia. A meta-analysis found that the combination of local anesthesia and intravenous sedation can significantly reduce the pain score at 6 and 24 h after surgery . TherefoThe pain trajectories of our high-low and low groups were similar to those of other comprehensive surgery types  reported previously ,25,26. GOur results also demonstrated that postoperative pain in benign perianal surgery was severe and was not effectively resolved. In our included population, more than one-half (57%) were in the high-low group. The pain score on the first day after the operation was severe (>7 points); it was stable and persisted from days 1 to 9 and decreased to mild on day 10. The low-moderate-low group accounted for nearly 20% (19.7%), and the pain increased to moderate pain (4 to 6 points) on postoperative day 3 and decreased to mild on day 9. These two types of pain accounted for nearly 80% (76.7%) of the patients, while the low group (23.3%) experienced mild pain. In summary, 62.7% of patients reported stable and sustained moderate-to-high pain over the first seven days after surgery. Moreover, although the high-low group used more analgesics, this did not effectively decrease the postoperative pain score. Recently, a prospective cohort study also indicated high postoperative pain scores despite a multimodal analgesia approach, including local anesthetic infiltration and multiple oral analgesics , which were applied in ambulatory anorectal surgery . Thus, aOur study demonstrated that pain trajectories are related to surgical and patient factors. The number of patients who underwent hemorrhoidectomy was higher in the high-low group, consistent with our clinical experience. This may be related to the location of the occurrence. Hemorrhoids generally occur in the most sensitive areas of the rectum and anal canal, whereas anal fistulas mostly occur in the anal soft tissue outside the operation area ,27,28. OAccording to our data, more attention should be devoted to patients in the low-moderate-low group in the first three days following surgery, when pain is aggravated. As such, preemptive analgesia and analgesic drugs (or treatments) should be administered to reduce pain. Furthermore, patients were educated by being informed that, excluding surgical complications or infection, aggravation of pain is a normal phenomenon and should not cause significant concern.Our study had several limitations, the first of which was its single-centered design, which may limit the generalizability of our findings since there are significant differences in operative methods and the administration of analgesics across various hospitals. In addition, the sample size limited our ability to make stronger inferences about relevant factors influencing pain trajectories, including multivariate analysis and evaluation of longitudinal changes in pain protocols. This study only included patients undergoing benign perianal surgery under general anesthesia and nerve block. For other anesthesia methods, the postoperative pain trajectories need further study.Overall, our results revealed that there were three types of postoperative pain trajectories for benign perianal diseases after the administration of general anesthesia and a nerve block. Initially, some patients exhibited special pain trajectories, such as low-moderate-low, and 62.7% of patients reported stable and sustained moderate-to-high pain over the first seven days after surgery. These postoperative pain trajectories are predominantly defined by surgery and patient factors.


This report presents a case of a 70-year-old woman who developed anterior cutaneous nerve entrapment syndrome (ACNES) three years ago and had an anterior cutaneous neurectomy in the left Th10 region. Postoperatively, the pain had improved entirely, but 10 weeks later, she developed a recurrence in the vicinity of the wound. The anterior intercostal nerve branch (Th10), located between the transversus abdominis and internal oblique muscles, was dissected laparoscopically six months after the initial surgery. There was no re-recurrence of pain for four months postoperatively. The postoperative recurrence of ACNES was refractory to various treatments, including surgical neurectomy, and is often difficult to treat. In cases in which transversus abdominis plane block is effective, laparoscopic neurectomy through an intraperitoneal approach may be effective, and minimally invasive laparoscopic treatment may be an effective surgical option for patients with recurrent and refractory ACNES who have a low pain threshold and are prone to prolonged complaints due to wound pain. Anterior cutaneous nerve entrapment syndrome (ACNES) is a chronic abdominal wall pain caused by entrapped intercostal nerve as it passes through the anterior sheath of the abdominal rectus muscle . AnterioA 70-year-old Japanese woman had been experiencing needle-like tingling pain in the left lower abdomen for the past three years. Her occupation was an office worker. She had no underlying disease and no history of hospitalization or surgery. She also had no evidence of trauma, medication, or other factors that could be risk factors for ACNES. At first, she could tolerate the pain in her lower left abdomen, but gradually she began to experience excruciating pain. Her pain fluctuated diurnally and worsened when she worked long hours at her desk. It was difficult for her to work until regular hours during busy periods. Prescribed analgesic agents had little effect, and she had to rest and wait for the pain to pass. She gradually became unable to go jogging and became increasingly depressed. She visited a local hospital and underwent upper and lower intestinal endoscopy and computed tomography, but no abnormality was found. She visited our hospital's department of general medicine and was diagnosed with ACNES at her first visit based on physical findings, including Carnett's sign and the effect of trigger point injections. Although her pain disappeared after a trigger point injection, the pain flared up three days after local blocks. Systemic drug administration, such as nonsteroidal anti-inflammatory drugs, antiepileptics, antidepressants, and weak opioids, was ineffective. Under local anesthesia, an anterior cutaneous neurectomy was performed on the left Th10. Pain intensity was evaluated using the Numeric Rating Scale (NRS). Upon initial assessment at her first visit to our department, the patient's NRS score was recorded as nine. Postoperatively, a significant decrease in the NRS score to zero was observed, indicating the absence of pain remained resolved at eight weeks of outpatient follow-up. Given the NRS score of zero postoperatively, administering analgesics was deemed unnecessary during the postoperative period. At 10 weeks postoperatively, pain flared up in line with the wound. The NRS score had escalated to eight at the recurrence time. No discernible triggers for these pain flare-ups could be identified. Local trigger points on the anterior or posterior sheath of the abdominal rectus muscle were ineffective. After confirming temporary pain relief with the transversus abdominis plane (TAP) block in the left Th10 region, the anterior intercostal nerve branch (Th10), located between the transversus abdominis and internal oblique muscles, was dissected laparoscopically six months after the initial surgery. The ACNES pain disappeared the day after the operation, and the wound pain was almost entirely resolved within a week. Four months postoperatively, there was no recurrence of pain.Surgical procedureUltrasound-guided pulse stimulation was attempted to induce target pain in the transverse abdominal muscle on the median side of the tender point. This nerve was determined to be responsible and was blocked by marking 1 ml of 2% xylocaine mixed with indocyanine green (ICG) around this nerve. The NRS score was observed to decrease to zero or one within five minutes following the implementation of the block. General anesthesia was introduced after confirming that the TAP block had eliminated the pain. The 5 mm trocars for an endoscope were inserted through the umbilicus. Two 5 mm ports were placed on the contralateral abdominal wall of the upper and lower abdomen, respectively, to begin the procedure. The intra-abdominal insufflation pressure was meticulously regulated at 8 mmHg to minimize potential irritation to the abdominal wall. An ICG was observed through the peritoneum. A 3-cm incision was made perpendicular to the peritoneal nerve pathway. The transversus abdominis muscle was split along the muscle fibers to reach the dorsal surface of the internal oblique abdominal muscle. The nerve running between the transversus abdominis and internal oblique muscle was identified using a dye as a marker (Figure In this report, we describe a case in which a strategy of securely conducting a more central nerve transection via laparoscopy proved effective for treating ACNES recurrence, even when the responsible nerve had initially been transected. For cases of refractory recurrent ACNES post-surgery, where treatment options are limited, it is theoretically plausible that identifying, marking, and then transecting the nerve more centrally than the initial neurectomy site via laparoscopy could be effective. While there are reports of nerve transections performed at the level of the posterior sheath in recurrent cases , instancAnterior neurectomy for ACNES appears successful in approximately 70% of operated patients . HoweverIn cases where the patient initially received a relatively extensive nerve resection up to the partial abdominal rectus muscle and posterior sheath, including the anterior sheath, and there was little effect from the preoperative posterior block, there may be little surgical efficacy with neurectomy only up to the posterior sheath.A local block is a temporary and chemical nerve blockade. It seems reasonable to perform a neurectomy at the position where the local block is most effective. For patients with an effective TAP block, a neurectomy at the more central part of the intercostal nerves above the transverse abdominal muscle may be effective .Upon reflection, an initial laparoscopic central nerve transection could have obviated the need for subsequent surgery. However, the etiology of ACNES is fundamentally attributed to the nerve foramen, which is constricted by the anterior sheath . Even ifFurthermore, in patients with ACNES, the pain threshold is often decreased. Therefore, the pain from the surgical incision may be more potent than that of patients with equivalent incisions without ACNES ,6. Even In addition, even if lateral cutaneous nerve entrapment syndrome is present as a postoperative condition, neurectomy on the transverse abdominal muscle may be effective, making it a versatile surgical technique for various indications.We anticipate that the treatment will be considerably challenging for re-recurrence cases. There is no reported effective treatment in case of recurrence following multiple surgeries. Post-laparoscopic treatment involves reverting to the fundamental treatment of ACNES, initially involving conservative treatment with systemic oral medications, followed by nerve blocks or pulse ablation therapy. If the efficacy of the more central nerve blocks can be confirmed, we may consider severance at the higher-level nerves. However, theoretically, for recurrence after having undergone nerve severance surgery twice - which should ideally have been curative - there is a high probability that a third surgery merely severing the nerves would not lead to remission. If surgical excision becomes the only viable option, it would be necessary to thoroughly investigate the source of the pain and tailor our approach to each case. For example, we may consider a terminal excision for neuroma at the nerve endings, whereas scar excision may be appropriate for pain due to scar tissue.The present study's limitations lie in the reliance on the subjective evaluation of a single patient, which undermines the robustness and generalizability of the results. Therefore, there is a compelling need for a larger study to address these deficiencies. Notwithstanding these limitations, the reported success of complete posterior nerve transection in recurrent cases offers theoretical justification for pre-blocking the nerve , identifWe experienced a case of postoperative recurrence of ACNES in a patient who had benefited from laparoscopic neurectomy over the transverse abdominal muscle as a minimally invasive surgery. A less invasive laparoscopic procedure is reasonable for patients with a lowered pain threshold. When pain is localized, and local blocks of the target nerve are effective, laparoscopic neurectomy to the level of the transversus abdominis muscle may be a new treatment option for patients with refractory recurrence after nerve transection.