Background: Sacroiliac joint (SIJ) pain is a common source of low back pain. Previously reported management strategies for this pain include conservative treatment, SIJ injection, radiofrequency denervation ablation, and SIJ fusion. Herein, we describe the use of biportal endoscopic radiofrequency ablation (BERA) to treat patients with low back pain. Methods: We included 16 patients who underwent BERA from April 2018 to June 2020. We marked the S1, S2, and S3 foramina and the SIJ line under fluoroscopy. Skin entry points were positioned at 0.5 cm medial to the SIJ line and at the level of the S1 and S2 foramina. Under local anesthesia, we introduced a 30° arthroscope with a 4 mm diameter through the viewing portal; surgical instruments were inserted through another caudal working portal. We ablated the lateral branches of the S1–S3 foramina and L5 dorsal ramus, which were the sources of SIJ pain. Results: Clinically relevant improvements in both visual analog scale and Oswestry Disability Index scores were noted at 1-, 6-, and 12-month follow-up time points after surgery. The overall patient satisfaction score was 89.1%. Conclusions: BERA for SIJ pain treatment has the advantage of directly identifying and ablating the innervating nerve to the joint. Through this technique, an expanded working angle can be obtained compared with traditional single-port endoscopy. Our study demonstrated promising preliminary results. The sacroiliac joint (SIJ) is a common cause of low back pain, although it can be overlooked as a cause of such pain ,2. A hisTo treat SIJ pain, the anatomy of SIJ must be emphasized. The joint space, muscle around the SIJ, ligament supporting the SIJ, and the nerve innervating the SIJ make the SIJ complex. SIJ pain is believed to be caused by the lateral sacral branch that extends from the posterior sacral foramen and innervates the interosseous and dorsal sacroiliac ligaments as well as the joint. A previously reported strategy for SIJ pain management included conservative treatment with stabilization or medications, SIJ injection with local anesthesia or steroids, radiofrequency (RF) denervation ablation, and SIJ fusion . SeveralOur study protocol was reviewed and approved by the China Medical University Hospital (CMUH) Research Ethics Committee .We selected the medical records of 16 consecutive patients who had undergone BERA for treating SIJ-related low back pain between April 2018 and June 2020.We used the following inclusion criteria: having a chief concern of low back pain with signs and symptoms of SIJ involvement on physical examination, undergoing conservative care  that failed to alleviate the pain, and having persistent low back pain  lasting more than 12 weeks. In addition, we stipulated that the included patients had a 50% or higher improvement in pain from baseline according to visual analog scale (VAS) measurements conducted after diagnostic intra-articular and multisite lateral sacral branch blocks of the SIJ complex. Finally, we required the included patients to have undergone 12 months of follow-up.We also used the following exclusion criteria: having tumors of the SIJ, previously receiving surgery on the SIJ (such as SIJ fusion or posterior plating of the SIJ due to trauma), or having severe comorbid medical conditions.All patients underwent BERA treatment, and the clinical results were assessed preoperatively and at 1-, 6-, and 12-month time points postoperatively by using an outpatient clinic or phone call questionnaire. VAS and Oswestry Disability Index (ODI) scores were recorded preoperatively and at each follow-up time point. The VAS and ODI were the primary outcome assessments. In addition, a patient satisfaction survey was administered 6 months after surgery. All clinical assessments were performed by a single coresearcher.p ≤ 0.05. Statistical analyses were performed and graphs were designed using SPSS version 25 (IBM Corp. (ICC/POK), USA 2017).Due to smaller patient sample, we used nonparametric statistics. The Wilcoxon signed rank test was used to compare preoperative and postoperative VAS and ODI scores. Statistical significance was set to All patients were placed in the prone position on a radiolucent table. Patients remained awake during the surgery to maintain communication with the surgeon throughout the procedure.After sterile preparations and draping, an anteroposterior fluoroscopic view was obtained using a C-arm. A transducer was tilted cephalad at 10°–15° to optimally visualize the posterior aspect of the SIJ. We marked the S1–S3 foramina and the SIJ line under fluoroscopy a. Skin eWe injected 3 cc of local anesthetic with 1% lidocaine hydrochloride at each entry point and 5 cc of lidocaine to infiltrate into the space between S1 and S2 area. Subsequently, two 0.5 cm skin incisions were made at the entry points. A pair of Kelly forceps was used in each of the incisions, and a blunt supported the space between the erector spinae muscles (multifidus and longissimus muscles) and interosseous ligament overlying the posterior SIJ. After the insertion of the cannula, we introduced a 30° endoscope with a 4 mm diameter  through the viewing portal c. DuringWe ablated the area between the lateral border of the sacral foramen and the medial border of the SIJ. The lateral branches nerves usually penetrate from the sacral foramen and are accompanied by their nutrition vessels and surrounded by fatty tissue. Therefore, we identified the lateral branches of S1, S2, and S3 in the region lateral to the S1–S3 sacral foramina and ablated them a,b. SubsWe attempted to visually confirm the lateral branches exiting the sacral foramina and the branches coursing toward the SIJ to ensure accuracy during nerve lesioning . Throughp < 0.001). The patients’ blood loss was minimal . Second, the BERA technique involves less restriction of motion and a wider angle corridor compared with conventional single-port endoscopy . A surgeOur study has several limitations. First, this was a retrospective study with a limited number of cases, and we report only 12-month follow-up data. Some patients might experience pain recurrence in the long run. Second, we did not directly compare the clinical results and perioperative parameters of BERA with those of a single-port surgical technique or other methods. Therefore, we cannot make the conclusion that BERA is superior to other treatment in terms of pain control. In the future, we plan to conduct a meta-analysis to compare the different strategy in treating SIJ pain.In this paper, we demonstrate a new technique involving the use of BERA to treat SIJ pain. According to our experience, BERA for SIJ pain treatment has the advantage of directly identifying and ablating the innervating nerve to the joint. It does not require special endoscopic instruments and has a superior working angle to single-port endoscopy. Our patients experienced long-term pain relief and improved physical function with minimal complications.


Myofascial pain syndrome with trigger points is the most common cause of nonodontogenic pain. Although injection of the trigger points is the most effective pain reduction treatment, many patients exhibit recurrence after a short period. Therefore, the aim of the current study was to evaluate the clinical efficacy of magnesium sulfate injections in the treatment of the masseter muscle trigger points when compared to saline injections.This study randomly (1:1) assigned 180 patients to one of two treatment groups based on whether their trigger points were injected with 2 ml of saline or magnesium sulfate. Pain scores, maximum mouth opening (MMO), and quality of life were measured at the pre-injection and 1, 3, and 6 months post-injection.p < 0.001). However, the difference in MMO ceased to be statistically significant after 6 months of follow-up (p = 0.121). Additionally, the patient’s quality of life score was significantly higher in the magnesium sulfate group compared to the saline group (p < 0.001).The pain scores were significantly higher in the saline group during all follow-up assessments, whereas the MMO was significantly higher in the magnesium sulfate group up to 3 months of follow-up  5/2/2021. Myofascial pain syndrome with trigger points (TrPs) is the most common cause of nonodontogenic pain in the orofacial region , affectiMuscle pain and fatigue change muscle structure and function. It affects the jaw functions and force by decreasing the firing rate, conduction velocity, and excitability of motor units. In addition to the condylar degeneration which is a bone remodeling response to mechanical pressure , 5.Injection of materials such as local anesthetics, botulinum toxins, corticosteroids, and physiologic saline is an effective method of reducing local and referred pain associated with TrPs. The needling action of these injections and the substances used contribute to successful management of chronic and active trigger points by relaxing the muscle fibers and alleviating pain –8. HowevMagnesium sulfate (MgSO4) is commonly used for the treatment of musculoskeletal problems as it has muscle relaxant and vasodilator properties that can have an analgesic effect . These pThis study was conducted between February 2021 and December 2021 at the Oral and Maxillofacial Department, Faculty of Dentistry, Fayoum University. The study was approved by the Beni Suef Research Ethics Committee (code: FDBSUREC/11022021/SA) and the protocol was registered on ClinicalTrials.org (ID: NCT04742140) on 5th February 2021.Informed consent for sharing clinical data and images for scientific purposes was collected from all patients prior to commencement of the study, which was performed in accordance with the Declaration of Helsinki  and repoThe primary outcome measure was pain measured using a visual analog scale (VAS). A sample calculation STATA V16.0) performed using data from a previous study showed that a total of 150 patients would need to be included for a study power of 80% at an alpha of 0.05. However, this study included a total of 180 patients (90 in each group) to account for any possible dropouts [.0 perforThis prospective randomized (1:1) blinded clinical trial used an unstratified random block design  to ensure balance in the number of patients assigned to each group.This study included 180 patients diagnosed with orofacial pain and trigger points in the masseter muscle unilaterally or bilaterally for a period of at least 6 months. The inclusion criteria were as follows: (1) definite diagnosis of myofascial pain based on the DC/TMD criteria with a referral ; (2) preThe patients were randomly assigned to one of two groups based on the treatment methods used, as follows: Group I (MgSo4 treatment) and group II .The primary predictor variable was the treatment method used. The patients, surgeons, and assessors were blinded throughout the period of the study.After localization of the TrPs, the skin was disinfected with alcohol, the tight muscle band was grabbed between two fingers, and a 30-gage , Egypt) .Outcomes, including the pain score, maximum mouth opening (MMO), and quality of life, were measured preinjection and 1, 3, and 6 months after injection.Pain intensity was measured using a 10-point VAS, where a score of 0 indicated no pain and a score of 10 indicated maximum pain . The MMOp < 0.05, and all statistical analyses were performed using R, version 4.1.1 for Windows [Categorical data were presented as frequencies and percentages and were compared using Fisher’s exact test, whereas numerical data were reported as mean and standard deviation values. The Shapiro–Wilk test was used to assess normality, and parametric analyses included independent t-tests for intergroup comparisons and repeated measures analysis of variance and posthoc Bonferroni corrections for intragroup comparisons. Nonparametric analyses included Mann–Whitney U tests for intergroup comparisons and Friedman’s test followed by pairwise comparisons using multiple Wilcoxon signed rank tests with Bonferroni correction for intragroup comparisons. The significance level was set at  Windows .. However, the differences in MMO were no longer statistically significant after 6 months of follow-up . This could likely be attributed to the increased vasodilation provided by the former in several vascular beds, resulting in greater blood flow to the trigger point and removal of irritating substances that cause pain. Additionally, it also eliminates muscle tension and excessive tenderness by competing with calcium at the motor end plate and reducing acetyl choline discharge [The current study used the VAS scale to estimate pain intensity at each study interval, and significantly lower values were observed in patients receiving MgSo4 injections at all follow-up intervals when compared to patients receiving saline injections , although this statistical significance ceased to exist after 6 months (p = 0.121). Increased tension in the muscular band, inhibition of motor activity, muscle shortening, and occurrence of spasms often results in hypomobility, and the improvement in MMO observed in this study could be attributed to the muscle relaxation effect of MgSO4 which lowers acetylcholine release at the myoneural junction, blocking peripheral neuromuscular transmissions and inhibiting skeletal muscle contractions [The MMO was significantly higher in the MgSO4 group up to 3 months of follow-up . This could be attributed to a reduction in pain intensity and improvement of function in the former [Quality of life is an important parameter when evaluating the outcomes of various treatment measures for chronic pain. OHIP-14 is a specific tool used to assess oral function and measure oral health related quality of life. In the current study, all treatment groups exhibited improvement in the OHIP-14 score at the follow-up assessments, with the MgSo4 injection group exhibiting significantly better outcomes compared to the saline injection group (e former , 38–41.Compromised quality of life has been often reported for patients suffering from chronic pain which recovered with different treatment that improves the pain level . This isThe present study had several limitations. First, it did not compare the effects of MgSo4 injections to any other materials such as local anesthesia, botulinum toxin, or platelet rich plasma. Second, objective methods of assessment such as EMG could not be used due to limited resources.The findings of this study suggest that MgSo4 injections are an effective treatment modality for myofascial TrPs of the masseter muscle. It reduces the pain and improves the maximum mouth opening, in addition to the quality of life. However, further studies with an improved design that addresses the limitations of the current study are necessary.


We enrolled 540 subjects affected by cervicobrachial pain referred to the Ozone Therapy Ambulatory at the Mater Domini Hospital of Catanzaro  and to the Center of Pain in Taurianova . All the subjects (n = 540) completed the treatment and the follow-up visits. The subjects received a mean of 11 cervical intramuscular treatments with an O2–O3 mixture (5 mL) with an O3 concentration of 10 μg/mL bis a week. The improvement of pain was measured by a change in the mean of the Visual Analog Scale (VAS) score from baseline to the end of treatment and during follow-ups. Patient satisfaction was assessed at the end of treatment using the SF-36 Questionnaire. The development of adverse drug reactions was recorded. The mean (±standard deviation) VAS pain score at baseline, at the end of treatment, and during follow-ups showed a significant reduction in pain over time (p < 0.001). All the patients who were enrolled (n: 540) were pain-free after one year. According to the pain distribution, all subjects showed a significant reduction in pain over time in each group (p < 0.05). No significant differences were observed with respect to sex or age. No adverse events were observed during the study. In conclusion, we documented that the intramuscular injection of an O2–O3 mixture is an effective and safe treatment option for patients with cervicobrachial pain.This prospective, open-label clinical study was carried out to evaluate both the efficacy and safety of intramuscular paravertebral injections of an oxygen–ozone (O Pharmacd joints . Recentldiseases ,6. It haes [2–O3 .2–O3 decreases the production of reactive oxygen species (ROS) [Moreover, Oes (ROS) , and inces (ROS) ,10.2–O3 has analgesic and anti-inflammatory activities also related to the increased stimulation of the secretion of both serotonin and endogenous opioids [In particular, the improvement of tissue oxygenation increases the use of glucose in cellular metabolism, protein metabolism, and erythrocyte activity. Taken together, it is easy to understand that O opioids ,12.3 upregulates Nrf2, which reduces the intracellular signaling pathways of inflammation and increases antioxidant activity [Moreover, other authors have suggested that after continuous administration Oactivity ,14.2–O3 in the management of musculoskeletal or inflammatory pain has not been reported in the guidelines [However, to date, the use of Oidelines ,16.2–O3 mixture in patients referred to medical care with cervicobrachial pain.Therefore, in this study, we evaluated the efficacy and the safety of intramuscular paravertebral injections of an OWe conducted an open-label prospective clinical study between 1 February 2021, and 31 August 2022, on patients with cervicobrachial pain referred to the Ambulatory of Pain Medicine of Mater Domini Hospital in Catanzaro  and the Center of Pain Disease in Taurianova . The study, approved by the Ethics Committee, was carried out according to the Good Clinical Practice guidelines and under the ethical principles of the Declaration of Helsinki. Before the beginning of the study, all participants signed a written informed consent form.At admission (T0), each patient, after medical history, underwent a physical examination, e.g., detection of vital parameters, thoracic and cardiac evaluation, abdominal palpation, and evaluation of osteotendinous and osteo-muscular activity. Particular attention was paid to the cervical brachial area to evaluate motility and the presence of points of greater pain. Radiological, ultrasound, and laboratory examinations were also employed. Pain severity was evaluated using the NRS  score , while n2–O3 cervical intramuscular infiltrative therapy, adding on to their current drug therapies. The follow-ups were performed after 8 (T1) and 12 (T2) sessions of topical O2–O3 therapy. Each patient was monitored using telemedicine, and patients with a new instance of brachial pain were immediately admitted to the hospital. We added only the data after 1 year because, until this period, we did not record any impairments due to symptoms. The development of adverse drug reactions (ADRs) during the treatment with O2–O3 was evaluated in agreement with our previous studies [Once the diagnosis of cervicobrachial pain was made or confirmed, patients were evaluated for appropriate prescriptions considering the Body Mass Index, age, gender, and comorbidities. Only patients whose drug treatments were not effective were scheduled for a cycle of O studies ,22.2–O3 mixture with an O3 concentration of 10 mcg/mL in the cervicobrachial tract  [Subject to written informed consent, patients underwent cervical intramuscular injections of an Of 30 mL) .2–O3 in the tissues. The gas mixture was obtained using an ozone generator , Italy) connected to a pure O2 source.The injections were performed bilaterally to improve the oxygenation in the body region, bis a week for the first month and once a week for the second month. After the injections, the area was massaged with a topical compound to increase the activity of OWe enrolled patients aged >18 years with clinical symptoms of cervicobrachial pain. Patients previously treated with ozone or patients with blood diseases , pregnancy (a relative contraindication), uncontrolled hyperthyroidism, severe cardiovascular diseases, and heart failure were excluded.The primary clinical endpoint was the statistically significant reduction in pain at T1 (end of the study) compared with T0 (admission) in terms of changes in NRS.The secondary clinical endpoint was a significant change in the DN4 score and/or in the SF36 value for T2 vs. T1 vs. T0.Finally, the primary safety endpoint was considered to be the absence of ADRs or drug–drug interactions (DDIs) related to ozone administration. The persistence of symptoms in T2 vs. T1 and/or the development of ADRs that could lead to the discontinuation of treatment were defined as clinical failures.t-test was used to compare variables. For categorical parameters, the chi-square test was used. Changes from baseline to end of therapy were analyzed using ranked one-way analysis of variance (ANOVA) with a term for the treatment group. Both Kruskal–Wallis and sign tests were used for non-parametric variables. The Shapiro–Wilk test was used to evaluate the normality of distribution. To reduce the error related to false positives, our hypotheses were tested using Bonferroni-adjusted alpha levels of 0.025 per test. p-values < 0.05 were considered statistically significant. Statistical analysis was performed using SPSS 21.0 . To evaluate the effects of sex and age on both the efficacy and safety of the intramuscular administration of O2–O3, we performed a sub-analysis of the data.Data are presented as mean ± standard deviation (SD). At baseline, the independent sample 2-tailed p = 0.2) The most common comorbidities were obesity and blood hypertension (37.8%), followed by type 2 diabetes (24.4%), with differences relating to both sex  34–87 years old (mean age 61.2 ± 11.7 years) were enrolled and completed the study . In partboth sex  and age both sex .p = 0.939) without correlation with respect to age  or BMI ; in 110 patients (20.4%), we documented neuropathic pain (DN-4: 5.8 ± 3.9) (p = 0.107).At admission (T0), an NRS questionnaire documented a severe pain level of 7.7 ± 1.3  ; in 70 p8 ± 3.9) . All pat8 ± 3.9) . All the2–O3 administration induced a statistically significant (p < 0.01) improvement in quality of life, recorded using an SF-36 score (p < 0.01) in both the DN4 (T1: 4.04 ± 4.37) (p = 0.234543) without correlation with respect to age  or BMI . These effects were also maintained during the entire study until the follow-up (T2)   and NRS -up (T2) .2–O3 treatment significantly reduced (p < 0.01) the use of drugs considering both sex  (Patients subjected to the O ± 0.74)  and age  ± 0.74) . Finally, during the study, we did not record the development of serious adverse drug reactions able to stop the treatment or the use of other drugs.2–O3 therapy in patients with cervicobrachial pain. Cervical pain is commonly due to cervical spondylolysis or osteoarthritis, a chronic degenerative condition inducing changes in bones, intervertebral discs, and/or joints connected to the neck. In this study, we evaluated the efficacy and safety of topical O2–O3 therapy reduced pain and DN4, improving the quality of life in both sexes without differences considering age. We documented that O2–O3 therapy may be related to the mechanism of action of this compound. In fact, O2–O3 can elicit the upregulation of antioxidant enzymes such as superoxide dismutase (SOD), GSH-peroxidases (GSH-Px), GSH-reductase (GSH-Rd), and catalase (CAT), inducing an antioxidant response able to reduce the chronic oxidative stress [The clinical efficacy of Oe stress . 2–O3 decreases the NF-kB pathway and inhibits the cascade of proinflammatory cytokines involved in the chronic inflammatory process and in pain [Moreover, O in pain . 2–O3 therapy in cervicobrachial pain; Alexandre et al. [2–O3 preceded and followed by 5 intramuscular paravertebral injections in the treatment of 252 patients with cervical disc herniation, documenting a significant decrease in pain in 79.3% and sensory dysfunction in 78.1%. In 61.9% of patients, the authors showed the complete regression of motor deficits.Several studies highlight the efficacy of Oe et al.  assessed2–O3 and lidocaine treatments showed superior, although not statistically different, results compared with a dry needling group. In a case series, Martinelli et al. [2–O3 (O3 concentration of 16 mcg/mL once a week) in 168 patients affected by cervicobrachial pain, showing a significant pain reduction (p < 0.001) at follow-ups after 1, 2, 3, 4, and 5 years. Raeissadat et al.  documenti et al.  studied 2–O3 mixture therapy in 44 patients with cervical disc herniation and chronic neck pain. A 73.1% decrease in the average VAS score compared with the baseline values at the final follow-up was observed. In total, 88.6% of patients were satisfied, 9.1% were moderately satisfied, and 2.3% were poorly satisfied. Beyaz et al.  investig2–O3 induced a time-dependent decrease in pain with an improvement in quality of life, as recorded using the SF-36 scale. Moreover, this treatment significantly reduced the use of drugs in both sexes and all ages. This point is very relevant because, in elderly patients, the high number of drugs increases the risk of drug interaction with a decrease in quality of life [No data related to the effect of this treatment on drug use have been published. In the present study, we documented that all enrolled patients received a drug treatment to reduce pain. These treatments did not reduce the clinical symptoms. In contrast, intramuscular treatment with O of life ,30.2–O3 efficacy could be related to (i) an imprecise ozone generator; (ii) an imprecise gas volume; (iii) an undefined ozone concentration; or (iv) a nonoptimal dose for achieving a therapeutic effect. Low O2–O3, the concentration should be set to a specific range to ensure safety; after injections, patients might feel a little burning and/or a sensation of heaviness at the injection site that spontaneously decreases in a few minutes. Adverse effects might be related to an incorrect administration technique, including pain, hematoma, infections in the injection site, vagal crisis, and even death [Before the administration of Oen death . In our 2–O3, as an add-on to pharmacological treatments, can favor an improvement in the clinical conditions of patients.In agreement with the statistical analyses, we can argue that, in neck and brachial pain, the intramuscular administration of O2–O3 treatment, we documented a statistically significant reduction in the pain rating scales and a statistically significant improvement in quality of life. Subsequent studies are required to broaden the patient sample and to evaluate the efficacy of placebo-controlled oxygen–ozone infiltrative therapy alone. The present study has some limitations. The most important is the absence of a control group; it is impossible to use an intramuscular treatment with a placebo  or other drugs . In our study, we documented that before the treatment the patients reported the presence of pain and fatigue with a decrease in physical functioning that induced, particularly in women, a decrease in social functioning with the presence of anxiety and depression. After the O2–O3 injections represent an effective, safe, conservative approach in patients affected by cervical pain, particularly in patients with comorbidities and polytherapy.In conclusion, we reported that intramuscular–paravertebral O


Tonsillectomy is one of the most common surgical procedures performed by Otolaryngologists world-wide. There are various techniques for tonsillectomy, but none of the techniques has been accepted as the best one universally. Despite the efforts of all the surgeon and use of recent techniques, some post-tonsillectomy morbidity is unavoidable. The main objective of our study is to find out the mean duration for cessation of pain among the patients following tonsillectomy operation in a tertiary care hospital.st August 2020 to 31st July 2021. Convenient sampling technique was used. Ethical Approval was taken from Ethical Clearance Committee of hospital (Reference number: 2207202005). Proforma containing visual analog score was given to every patient for scoring the severity of postoperative pain. The scoring of pain was done from 1st postoperative day till 14th postoperative day. Descriptive statistical analysis was done.This is a descriptive cross-sectional study of 104 patients who underwent tonsillectomy in department of otolaryngology of Kathmandu Medical College from 1One hundred four patients had undergone tonsillectomy in our hospital. The mean duration for cessation of pain was 10 (9.75+1.97) days with mean duration of analgesia taken of 11 (10.84+2.15) days. The mean duration after tonsillectomy operation for cessation of pain on drinking was 8 (7.51±1.19) days and on eating solids 12 (11.59±2.56) days. Patients reported the first normal night of sleep at seven (6.90+1.41) days and return to normal daily activities 11 (11.18+2.53) days.From the study concluded that the mean duration for cessation of pain after tonsillectomy is slightly lower than other similar study. Reactionary hemorrhage is the most feared complication post-tonsillectomy, despite the efforts of all surgeons to low reactionary hemorrhage rates seem to be unavoidable. Incidence of haemorrhage is not related to grade and seniority of the surgeon.The main objective of our study is to find out the mean duration for cessation of pain among the patients following tonsillectomy operation in a tertiary care hospital.This is a descriptive cross-sectional study of 104 patients who underwent tonsillectomy in department of otolaryngology of Kathmandu Medical College over a period of 1 year duration from 1st August 2020 to 31st July 2021. Ethical Approval was taken from Ethical Clearance Committee of KMCTH(Reference number: 2207202005). Patients with history of recurrent tonsillitis, chronic tonsillitis, obstructive sleep apnoea syndrome (OSAS), second attack of quinsy were included in our study. The patients with bleeding disorders, hemoglobin level <10gm%, severe trismus, any chronic illness affecting recovery were excluded from the study. Convenient sampling technique was used.The sample size was calculated by using the formula,2 × σ2 / e2n = Z2 × (0.5)2 / (0.1)2  = (1.96)  = 96Where,n= required sample sizeZ = 1.96 at 95% Confidence Interval (CI)σ = standard deviation for mean duration of cessation of pain among the patients following tonsillectomy operation, 0.5e = margin of error, 10%Here, the calculated sample size is 96, taking nonresponse rate 8%, the sample size is 104. All the patients to be enrolled in our study were examined by consultant ENT surgeon. History regarding the indications of tonsillectomy and mouth opening were evaluated. Anterior rhinoscopy was done to find out deviated nasal septum (DNS) which would have obscured nasal intubation. All the patients undergoing tonsillectomy were positioned in Rose's position and anesthetized by using nasal Ring-Adair-Elwin (RAE) endotracheal tube. The patients' mouth was held open with Boyle-Davis gag for adequate exposure of the oropharynx. The patients were operated by two different techniques, Cold Dissection Technique (CDT) and Bipolar Electrocautery Technique (BET). The average time taken in both the procedures was 45 minutes.In Cold Dissection Technique, tonsil was grasped with tonsil holding forceps and the anterior tonsillar pillar was cut with No. 12 knife. Surgical plane between the tonsillar capsule and superior constrictor muscle was identified and was dissected from the superior pole towards the lower pole by a serrated tonsil dissector. Inferior pole pedicle was crushed and cut completely by using Eve's tonsillar snare. Following dissection, the tonsillar fossa was packed with a cotton swab for a few minutes and then, the other tonsil was similarly removed. Finally, the gauzes were removed and when necessary, bipolar electrocautery was used to secure hemostasis.In Bipolar Electrocautery Technique, bipolar electrocautery forceps, set at a power of 35-40 W was used. In this method, incision on the anterior tonsillar pillar was made from superior pole towards inferior pole using the tip of a bipolar forceps. Superior pole of the tonsil was dissected off from the tonsillar fossa in the surgical plane. During dissection, encountered vessels were cauterized and then separated from the tonsil. The inferior pedicle was cauterized and the tonsil was completely removed. Any further hemostasis of the tonsillar fossa was secured by coagulation with the bipolar forceps. After securing complete hemostasis of both the tonsillar fossa, the gauzes and throat pack were removed. After extubation, post-tonsillectomy position  was maintained in the postoperative ward for about 6 hours.The patients were treated with intravenous 3rd generation cephalosporins and supportive medications for at least 5 days in the hospital. Proforma containing visual analog score was given to every patient for scoring the severity of postoperative pain. The scoring of pain was done from 1st postoperative day till 14th postoperative day. The data for mean duration for cessation of pain on drinking, on eating of solids, first normal night of sleep, return to normal daily activities were collected and analyzed for two different techniques. Descriptive statistical analysis was done.One hundred four patients, age ranging from 15-50 years were enrolled in our study. The mean duration for cessation of pain was 10 (9.75±1.97) days after tonsillectomy. The mean duration of analgesia taken of 11 (10.84 ±2.15) days. The mean duration for cessation of pain on drinking was 8 (7.51±1.19) days and on eating solids 12 (11.59±2.56) days. Patients reported the first normal night of sleep at seven (6.90±1.41) days and return to normal daily activities 11 (11.18±2.53) days .Reactionary hemorrhage was seen in 3 (2.88%) patients, while secondary hemorrhage was seen in 2 (1.92%) patients. Postoperative fever was seen in 5 (4.80%) patients, 27 (25.96%) patients had referred otalgia and oedema of uvula was seen in 12 (11.53%) patients .Among the total patients, the tonsillectomy was done by cold dissection technique in 44 (42.30%) and 60 (57.69%) by bipolar electro cautery technique.The mean duration for cessation of pain was 9 (9.07±2.00) days with mean duration of analgesia taken of 11 (10.57±2.12) days in CDT .The mean duration for cessation of pain was 10 (10.25±1.81) days in BET group with mean duration of analgesia taken of 11 (11.03 ±2.17) days in BET group .9 He also described scraping the tonsils and cutting them out by a hook-like instrument.10 At the beginning of the twentieth century that Worthington11 described the modern technique of tonsillectomy by dissection. In 1909, a surgeon named Cohen adopted ligature of bleeding vessels to control per operative bleeding and thereafter, tonsillectomy became a common and safe procedure in hospitals around the world.10 In 1968, Remington-Hobbs, Haase and Noguera12 in 1969 described the use of diathermy for removal of tonsils.13 In 1982 Goycolea described electrodissection by using monopolar diathermy14 and Pang, 10 years later, reported the first tonsillectomy by bipolar electrocautery.2History of tonsillectomy dates back to 3000 years ago with the first report referring to Hindu medicine about 1000 years B.C. In 40 AD, a Roman surgeon, Cornelius Celsus performed this operation for the first time using his fingernails.Nowadays, tonsillectomy is performed with a variety of techniques such as: conventional cold dissection, mono and bipolar electrocauteries, cryosurgery, harmonic, coblation, radiofrequency and laser. All these techniques have advantages as well as drawbacks, as reported by the surgeons from time to time, hence none of them have been accepted as the single best technique universally. Over the last century many different techniques of tonsillectomy have been described, of which Cold Dissection-Snare method and Bipolar Electro dissection methods are commonly used. These methods have frequently been compared with each other by different investigators around the world, addressing especially the conventional cold dissection technique (CDT) versus the bipolar electrocautery technique (BET). In our study, we decided to assess the mean duration for cessation of postoperative pain after tonsillectomy during different day-today activities.15 More than 52% of the patients needed 1 to 3 rescue analgesic doses daily during the first week after tonsillectomy. The mean duration for cessation of pain on drinking was 8 days  and on eating solids 12 days . Patients reported the first normal night of sleep at seven days  and return to normal daily activities at 11 days . Cardozo AA and colleagues have noted positive relationship between the total amount of bipolar diathermy used and postoperative pain.16 Similarly, Atallah, et al.17 found an increase in pain and a related prolongation of oral intake time in the postoperative period done by using bipolar cautery tonsillectomy. Increase in postoperative pain in intensity and duration in bipolar diathermy cases; was also observed by Fiona, et al.18We found the mean duration for cessation of pain was 10 days  with mean duration of analgesia taken of 11 days  which is slightly lower than the previous study. 2 Stephen O'Leary, et al. in his study reported that the difference in the risk of bleeding after dissection and diathermy tonsillectomy did not reach statistical significance.8 Whereas Gendy S and colleagues have reported a higher incidence of secondary haemorrhage with bipolar dissection (2.3%) compared to cold dissection (1%) which is similar to our study.3 One explanation for higher post-tonsillectomy bleeding rates after diathermy techniques may be related to greater thermal damage as the result of excessively high power settings or excessively frequent or prolonged application of diathermy.19In our study, 3 (2.88%) patients had reactionary hemorrhage, for which conservative treatment was sufficient to control the bleeding. Two (1.92%) patients, had secondary hemorrhage on 2nd week for which 1 patient required operation theatre for bleeding control and the other patient was managed conservatively in the ward. Pang YT has reported incidence of postoperative hemorrhage as 1.7% with bipolar diathermy tonsillectomy compared to 3.4% with cold dissection.20 (28%), Niels Rasmussen21 (25.9%), Al-Yasiri (25%), Roos K, Lind L (32%) had similar results of referred otalgia as our study. Oedema of uvula was seen in 12 (11.53%) patients, this is normal and is due to the cauterization of the tonsil blood vessels that forces the uvula to swell up until the glands develop an alternative drainage pattern.Referred otalgia after tonsillectomy is one of the common postoperative morbidity. Twenty seven (25.96%) patients in our study complained of referred otalgia following tonsillectomy. Study done by Kurt Breson and Jeep Diepeveen22Postoperative fever is a common problem after tonsillectomy; 3 (2.88%) patients having a temperature higher than 37.5°C and 2 (1.92%) patients higher than 38°C in the first 24 hours post-tonsillectomy. Fever may occur due to trauma associated surgery that elicits the production of pyrogenic cytokines in the absence of infection. The production of host endogenous pyrogens, or pyrogenic cytokines is the final common pathway through which fever occurs from such diverse causes as infection and trauma in the absence of infection. Pyrogenic cytokines have various effects on stimulating or controlling the inflammatory response and fever. Cytokines act as an intracellular mediator and messenger controlling the host response to injury and infection.The mean duration for cessation of pain after tonsillectomy is slightly lower than other similar study. Despite the different techniques and efforts of all the surgeons, some postoperative morbidity is unavoidable. Reactionary hemorrhage is the most feared complication post-tonsillectomy because of the risk of airway obstruction, shock and ultimately death if inappropriately managed. Excessive pain associated with referred otalgia, postoperative fever, oedema of the uvula, infection in tonsillar fossa promoting secondary hemorrhage etc are the other complications mainly seen in our practice.


Vertebral augmentation techniques are widely used to treat osteoporotic vertebral compression fractures (OVCFs). Superior analgesic effects and shortened bed rest time means patients recover quickly, but prolonged unscheduled hospitalization can increase medical expenses and the risk of bed rest complications. The aim of this study was to investigate the reasons for prolonged hospitalization after vertebral augmentation surgery and to determine the relative risk factors.A single-center retrospective study was conducted to enroll patients with OVCFs and accepted vertebral augmentation surgery from January 2017 to December 2017. Clinical information was collected from the Hospital Information System (HIS). The criterion of delayed discharge was postoperative hospitalization more than 3 days. Telephone interviews and medical history evaluations were conducted to confirm the exact reason for retention. The risk factors were analyzed by multiple logistic regression.P > 0.1) and chronic comorbidities (P > 0.1) were not predictors in this model.Overall, 1,442 patients were included, and 191 (13.2%) stayed in the hospital for more than 3 days postoperatively. The reasons for delayed discharge were psychological factors (37.2%), residual pain (32.5%), cardiopulmonary complications (15.7%), nonspecific symptoms (8.4%), incision abnormalities (2.6%), thrombosis (2.1%), and postanesthesia reactions (1.6%). The multiple logistic model was significant; age , preoperative stay , operation type , and the number of surgical segments  showed statistical significance. In contrast, gender (Overall, 13.2% of OVCF patients who underwent vertebral augmentation surgery were not discharged within 3 days postoperatively, and several predictors were found. Preoperative communication and comprehensive evaluations are calling for more attention; physicians should adopt an appropriate medical process to enhance rehabilitation in geriatric orthopedics. Osteoporosis has become a global disease of the elderly that develops with age and is thought to be the underlying cause of osteoporosis fractures (OFs). Osteoporosis vertebral compression fractures (OVCFs) are an important component of OFs, as approximately 520,000 incidents occurred in the European Union in 2010 , 4. ReseThe application of vertebral augmentation technology calls for the concept of rapid rehabilitation in geriatric orthopedics, including the removal of preoperative fear, surgical confidence, postoperative rehabilitation training, and functional recovery. However, we observed that some patients could not be discharged within the scheduled time and even undergo successful surgery, which may be caused by various factors. A randomized controlled trial reporting that 23% of acute OVCFs retained chronic low back pain after PVP  caused cDatabase searching found no relevant study on prolonged hospitalization or delayed discharge after PKP/PVP surgery. Therefore, the purpose of this study was to investigate the causes and predictors of delayed postoperative discharge to provide an informative clinical reference for the rehabilitation of patients with OVCFs.We retrospectively reviewed patients who accepted PVP or PKP in our spine surgery department from January 1, 2017, to December 31, 2017, and all of the participants were in-patients. This study was performed in line with The Code of Ethics of the World Medical Association (Declaration of Helsinki) and was approved by the ethics committee of Honghui Hospital affiliated with Xi’an Jiaotong University.All patients had to meet the following inclusion criteria: (1) persistent back pain after slight exertion of energy or trauma and no evidence of relief; (2) clinical and imaging examinations, including x-ray, computed tomography, and magnetic resonance imaging presenting an OVCF related to the back pain; (3) osteoporosis diagnosis by dual-energy x-ray absorptiometry; and (4) complete information in the medical record system. The exclusion criteria are the following: (1) pathological fractures, including hemangioma and spinal metastasis; (2) chronic fractures, vertebrae osteonecrosis (like Kümmell disease), and intravertebral vacuum cleft in the vertebrae; (3) other coexisting traumas in addition to the spine ; and (4) severe comorbidities and other local or systematic disorders that may prolong the hospitalization.To obtain the most consistent results according to the clinical situation, we did not limit the number of surgical segments or the age of participants. Preoperative examinations including lower limb arteriovenous ultrasound, blood routine, liver and kidney function, electrolyte, coagulation index, and infectious diseases were routinely performed. Patients with unstable comorbidities were consulted with relevant departments, and surgical treatment was performed only after excluding contraindications. All patients were informed of the treatment strategies by the physician, including operating procedures and prognosis.PVP or PKP was chosen according to the specific fracture form and economic condition. PVP combined with the free-hand reduction was considered when the compression degrees of vertebrae anterior column were less than 30%; PKP and free-hand reduction were preferred in patients with greater than 30% compression. Patients who required a PVP due to poor economic conditions were informed about the risk and signed a consent form.All procedures were conducted with standard procedures by senior spinal surgeons. Antibiotics were used intravenously 1 h prior to the procedure. The free-hand reduction was performed in a prone position, and a moderate restoration under x-ray was acceptable. Most of the patients were treated under infiltration anesthesia with 1% lidocaine, while a few others were treated with general anesthesia (in consideration of strong fear of surgery). One or two trocars  were inserted into the pedicles of the object vertebrae under the surveillance of a C-arm x-ray . The needles were inserted at the 3 or 9-o’clock position of pedicles with a specific inclination to approach the anterior third of the vertebrae body on anteroposterior and lateral radiographs. The vertebrae were then expanded by a balloon in PKP procedures. Pasta-like polymethylmethacrylate  was injected until the cement approaching the posterior wall of the vertebrae or cement leakage was observed.Patients remained in bed after surgery, and x-ray examination was undertaken within 12 h to ensure the cement location was good. Patients were advised to walk moderately with a plastic thoracolumbosacral orthosis  routinely on the second day after surgery. A 3-month brace stabilization was generally recommended.To analyze the factors of delayed discharge after PKP/PVP, relevant clinical information covering gender, age, prehospital time, pre- and postoperative stays, preoperative bone mineral density (BMD), preoperative VAS, operation type, the number of surgical segments, and complete admitting/discharge diagnosis was obtained from the Hospital Information System (HIS). The third-day postoperatively VAS score was recorded to represent the pain relief at discharge. Diagnosis including cardiopulmonary diseases, hypertension, liver and kidney dysfunction, and diabetes was recorded as chronic comorbidities. Telephone interviews and medical history research were conducted to confirm the main reason for not being discharged on time.We used the following discharge criteria: (1) successful operation, no severe surgical complications such as cement embolism (in pulmonary arteries or cerebrovascular vessels) and intraspinal leakage , which usually leads to urgent interventional thrombectomy or spinal decompression surgery; (2) visual analog scale (VAS) score decreased to below 4 (at most slight pain) –13; and Subject to the requirements of local medicare policy and our hospital's clinical pathway, patients after vertebral augmentation surgery should be discharged within 3 days if they meet the above standard. Therefore, in this study, delayed discharge was considered to be postoperative hospitalization time over 3 days.t-test/non-parametric tests were performed for univariate analyses, and P values <0.1 were considered significant temporarily. The Box–Tidwell test was used to verify whether a linear relationship existed between continuous independent variables and logit conversion values of dependent variables. Then, binary logistic analysis was performed to identify the predictors and odds ratios for delayed discharge, and P values <0.05 were considered significant.All statistical analyses were performed with Statistical Packages for Social Sciences V21.0 for Windows . To describe the basic characteristics of the patients, quantitative variables were reported by means and standard deviations, while counts and percentages were recorded for qualitative variables. Chi-square tests and After filtering 1,877 patients who underwent PVP or PKP from January 1, 2017, to December 31, 2017, 1,442 patients  with 1,549 treated vertebrae (1–4) were included in our study . The meaAfter referring to the case history, we recorded chronic comorbidities including hypertension, diabetes mellitus, coronary heart disease, arrhythmia, cerebral infarction, and chronic obstructive pulmonary disease. Overall, 715 (49.6%) patients suffered one or more chronic comorbidities before hospitalization, and the rest of the patients simply had osteoporosis except for other local diseases, which were not recognized as comorbidities .We carried out phone interviews combined with medical history research in HIS, summarized the main reasons for the delay, and sorted these in P < 0.05), preoperative time (P < 0.001), preoperative VAS (P < 0.05), third-day postoperative VAS (P < 0.001), operation type (P < 0.05), and the number of surgical segments (P < 0.001) showed significance to delayed discharge, while prehospital time (P = 0.484), preoperative BMD (P = 0.396), and chronic comorbidities (P > 0.1) were not significant between the two groups. Gender (P = 0.056) approached statistical significance and was included in the multivariate analysis. A binary logistic analysis was performed to investigate the predictors of delayed discharge. Third-day postoperative VAS was excluded for direct relation to delayed discharge. The Box–Tidwell test showed a linear relationship between continuous independent variables and logit conversion values of dependent variables. Collinearity diagnostics showed negative results between the independent variables. Overall, the logistic model was significant . Age , preoperative time , preoperative VAS , operation type , and the number of surgical segments  showed statistical significance. Gender (P = 0.103) was not a predictor of delayed discharge of patients after PVP/PKP  patients stayed in the hospital longer than 3 days postoperatively, which was considered delayed discharge. All of the above patients got relevant treatments and reassessment and were finally discharged in a few days (range 4–25 days postoperatively). According to telephone interviews and medical history analyses, the reasons for delayed discharge related to incidence were psychological factors (37.2%), residual pain (32.5%), cardiopulmonary complications (15.7%), general discomfort (8.4%), incision abnormalities (2.6%), thrombosis (2.1%), and postanesthesia reactions (1.6%) . To furtAs we present in As previously mentioned, psychological factors were the most common reason for delayed discharge in this study, accounting for 37.2%. All of these patients had successful surgery and significant pain relief (VAS < 4) and met the discharge criteria. However, they rejected the discharge advice and asked for further conservative treatment in the hospital. Patients tend to like more comprehensive therapy when a fracture incident led to surgery, even if the pain got prominent relief. Mental disorders were excluded, and the feasibility of discharge was told to the patients and agents. Conservative treatment such as antiosteoporosis medication  and functional rehabilitation exercises was conducted. A retrospective study investigated the disposition of hospitalized patients after PVP. Approximately one-half of the patients (44%) living at home before surgery were discharged to rehabilitation facilities after surgery . Other aBack pain is the leading symptom of OVCFs, but it could also come from adjacent soft tissue injuries. Thus, it is rational that pain relief is a subjective measure of surgical efficacy. In this study, patients with other injuries (such as distant fractures) were excluded to reduce bias, but inconspicuous injuries adjacent to the vertebrae were hard to detect. Sixty-two patients in the study complained of medium-to-severe pain  after surgery, which was considered residual pain. Analgesic therapy was used after confirming no missing vertebral fractures, and all these patients got different levels of relief when finally discharged.From During the procedure, the leakage of bone cement around the vertebral body can also cause postoperative back pain . AlthougMoreover, nonunion of OVCF  will cause long-term pain that is difficult to relieve. Ischemic necrosis and exudation formed in the nonunion vertebral body, which are not conducive to adequate fixation of bone cement, made the efficiency uncertain . We haveAccording to the mechanism of vertebral augmentation surgery, the volume of bone cement filling is closely related to pain relief. Some studies have shown that sufficient cement filling helps stabilize the vertebral body and relieve pain , 27. HowIn general, many issues influence residual pain after surgery, and no consensus has been reached. It should be noted that a comprehensive and accurate diagnosis before surgery plays a crucial role. Assessment of curative effects should be emphasized when accompanying adjacent injury. Furthermore, significant degeneration in the elderly also reminds us to identify the pain source accurately.The mean age of the patients in this study was 71.95 ± 8.79 years, among which the delayed discharge population was 73.58 ± 8.28 . ElderlySixteen patients developed nonspecific symptoms of discomfort and complained of fever, headache, and stomachache, and general treatment was effective. Five patients reported incision pain but denied obvious deep structure pain while moving. We observed slight redness and swelling in the incisions, no fluid exudation, and neither fever nor abnormal laboratory results. As we know, vertebral augmentation has a rare incidence of infection, but it can still be a formidable and life-threatening complication. Surgery should be avoided for patients with infectious tendencies, and preventive antibiotic therapy should be conducted for those with low immune function in the perioperation period . Four thThere were several limitations in the present study. First, only a few indicators of medical information were collected in this study. Thus, part of the results in the regression analysis seemed to be nondistinct, such as preoperative stay; it has not been completely explained how the preoperative extension prolonged the length of postoperation. Second, details of cement leakage in all 1,442 patients were not reported, although leakage surrounding the vertebrae can also cause postoperative residual pain. Further research requires improved clinical data for more details.Overall, 13.2% of patients in this study who underwent vertebral augmentation surgery were not discharged within 3 days after surgery. The most common causes are psychological factors, residual pain, and cardiopulmonary complications. Multifactor analysis revealed that age, number of surgical segments, operation type, and preoperative stay were the main factors related to delayed discharge. Preoperative communication and comprehensive evaluations are calling for more attention, and physicians should adopt an appropriate medical process to enhance rehabilitation in geriatric orthopedics.


Patients were arbitrarily treated with four monthly injections of PRP or a single injection of 100 U of BoNT-A. All injections were followed by cystoscopic hydrodistention. The primary endpoint was the global response assessment (GRA), and secondary endpoints were changes in the O’Leary-Sant IC symptom score, visual analog score (VAS) of bladder pain, voiding diary, and uroflow measures from baseline to six months after the first injection day. Results: The baseline demographics revealed no significant difference between groups. The GRA at one, three, and six months was similar between groups. A significant improvement in IC symptom scores was noted in both groups. Although VAS was significantly improved in overall patients, no significant difference was noted between the PRP and BoNT-A groups at 6 months. Only half of the study cohort had a GRA ≥2 at six months. An increase in the post-void residual was noted one month after the BoNT-A injection, but there was no difference between groups at three and six months. More patients reported dysuria  and urinary tract infection  after BoNT-A injection than after the PRP injections. The time from the first injection to receiving alternative treatment was similar between groups. Conclusion: Both intravesical PRP and BoNT-A injections have similar efficacy in IC symptom improvement. However, only half of the study cohort had a GRA of ≥2 at the six-month follow-up BoNT-A injection carries a potential risk of UTI after treatment.Background: Intravesical injection of Botulinum toxin A (BoNT-A) and platelet-rich plasma (PRP) have been reported to alleviate bladder pain and decrease nocturia in patients with refractory interstitial cystitis/bladder pain syndrome (IC/BPS). Both treatments are novel and there has no comparison between them. This study compared the therapeutic effects and adverse events between IC/BPS patients receiving PRP or BoNT-A injections. Materials and Methods: This study retrospectively analyzed female patients with IC/BPS who were refractory to conventional treatment and received BoNT-A ( Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic bladder inflammatory disease characterized by bladder pain and frequency urgency. Current treatments using pain killer or anti-inflammatory medications cannot completely eradicate symptoms and increase bladder capacity . SeveralIntravesical botulinum toxin A (BoNT-A) and platelet-rich plasma (PRP) injections are novel treatments for IC/BPS refractory to conventional therapies. BoNT-A can reduce the release of acetylcholine and inflammation-related neuropeptides from nerve terminals . The BoNPatients with chronic IC/BPS usually cannot be successfully treated with conventional medical or intravesical treatments. Although previous clinical trials provided evidence that intravesical BoNT-A or PRP injections were effective ,12,13, tAmong the 56 female patients included in the study, 30 received four monthly PRP injections and 26 received a single BoNT-A injection. Patients’ baseline demographics, including symptom score, voiding diary data, uroflowmetry data, findings of cystoscopic hydrodistention, and duration of IC/BPS symptoms are listed in This study demonstrated that intravesical injections of either PRP or BoNT-A are safe and effective in IC/BPS symptoms improvement without significantly increasing the PVR. Bladder pain reduction was not significant between groups at 6 months. Patients who received PRP injections did not experience UTI or dysuria after treatment. However, only half of the study cohort had a GRA of ≥2 at the six-month follow-up, and the remaining patients sought additional bladder therapy to improve symptoms. Although the therapeutic efficacy for IC/BPS at 6 months was similar between PRP and BoNT-A, the patients who received the BoNT-A injection had a greater potential risk for UTI after treatment.The pathophysiology of IC/BPS is complicated and not completely understood. The recent IC Data Base study noted that loss of epithelial integrity is a predominant histopathologic finding in patients with IC/BPS. The epithelial damage may precede other histopathologic findings, such as suburothelial inflammation and sensory nervous activation in the bladder wall, leading to increases in the sensation of bladder fullness and pain in response to bladder inflammation ,15. The An intravesical injection of 100–200 U of BoNT-A followed by cystoscopic hydrodistention has been reported effective in decreasing bladder pain and nocturia in patients with IC/BPS . PatientAlthough the BoNT-A injection seems promising for treating symptoms of IC/PBS, long-term results have not revealed a successful outcome . The limAutologous PRP is growing in the treatment to augment wound healing, fasten the recovery speed of muscle and joint injuries, and enhance surgical repair recovery . PRP is PRP injecting into the bladder wall could initiate the wound healing process, induce a new inflammation, complete the wound healing, resolve previous inflammation, and promote the relief of neuropathic pain. The cytokines and growth factors released from PRP could induce a new inflammation, which might override the residual inflammation, and increase tissue regeneration . Our preAlthough this was not a head-to-head randomized trial, the results of this comparative case series study reveal that PRP and BoNT-A are equally effective in reducing IC symptoms. Based on the therapeutic mechanism of PRP and BoNT-A on IC/BPS, either treatment can reduce chronic inflammation and improve urothelial regeneration . TherefoBoth PRP and BoNT-A treatments are novel and currently off-labeled therapies for IC/BPS refractory to conventional therapy. The long-term efficacy has not been well investigated. Although fewer adverse events were reported following treatment with PRP than with BoNT-A, the therapeutic effect of PRP on chronic inflammation and for promoting recovery of defective urothelium was limited. As shown in this study, the GRA increased with the increasing number of PRP injections, suggesting the therapeutic efficacy needs an adequate PRP dose to achieve a therapeutic level. Therefore, repeated intravesical PRP injections every month are necessary to achieve a therapeutic efficacy similar to that of BoNT-A at six months. However, repeated monthly PRP injection treatment requires frequent anesthesia, which might place a tremendous burden on the patients. Four monthly injections might also increase the complications related with bladder injections, including hematuria and UTI. Although therapy with a single high-dose injection of PRP has been attempted, the efficacy on symptom improvement was inferior to that of four monthly low-dose PRP injections . In addiLimitations of this study are small case numbers, the lack of a control arm, and the non-randomization of the study design. The treatment option was based on patients’ choice after informing advantage and disadvantages of the treatment outcome and potential adverse events. Because all patients were chronic IC/BPS and had received many different conventional therapies, they might have had high expectations to BoNT-A or PRP injection. Further, all patients were not selected with a strict inclusion criterion as in the clinical trials but were diagnosed according to their present symptoms and past history. Therefore, the patients in this retrospective study are highly heterogeneous with varying severity of disease. Finally, although a GRA ≥2 was reported in around 50% of patients treated with BoNT-A or PRP and the ICSI and ICPI also showed improvement, the decrease in bladder pain VAS was limited. The higher VAS in the baseline of the BoNT-A group could have resulted in bias in the VAS reduction between PRP and BoNT-A group. Because this was a retrospective analysis, patients were informed of the advantages and disadvantages of treatment at baseline, and patients were allowed to choose treatment; therefore, more patients who had a higher bladder pain VAS might have chosen the BoNT-A injection. Although a significant reduction in bladder pain VAS was observed in the BoNT-A group, the difference of VAS changes with time between PRP and BoNT-A groups was not significant. Nevertheless, the results of this study may reflect the treatment outcome of BoNT-A and PRP injection in a real-life practice.In clinical trials for functional urology such as in IC/BPS, OAB, or LUTS, the subjective primary endpoint and objective secondary endpoints are usually not equally improved. Although the primary endpoint can reach a significant result, a placebo effect of up to 30% can usually be found in clinical trial. In this study we found the treatment success was limited in GRA improvement and the other objective variables such as voiding diary parameters, bladder volume increment, and bladder pain reduction were very mild. These results bring a message that, in real-life practice, treatment with a single small dose of BoNT-A or PRP might not be as successful as that in clinical trials. Nevertheless, the safety endpoints also revealed that both treatments were safe and tolerable. With repeated injections of BoNT-A or PRP, the treatment success might be improved. In the future, randomized controlled trials with different doses might be necessary and a search for prognostic factors could help urologists select IC/BPS patients for a good response to PRP or BoNT-A injections.The results of this comparative case series study revealed that intravesical injections of either PRP or BoNT-A were safe and effective for improving IC/BPS symptoms without significantly increasing the PVR, but the bladder pain reduction was limited. Only half of the study cohort had a GRA ≥2 at six months. Repeat treatment of PRP or BoNT-A would be necessary to achieve long-term success. The BoNT-A injection carries a potential risk of UTI after treatment compared with that of the PRP injection.n = 26) or four monthly PRP injections (n = 30) within the two previous years. The IC/BPS was diagnosed according to the characteristic symptoms and cystoscopic findings after hydrodistention under anesthesia [A total of 56 female patients with confirmed IC/BPS who had failed conventional treatments received either a single intravesical BoNT-A 100 U injection  an intravesical injection of 10 mL PRP (which was extracted from 50 mL of patient’s blood) at 20 sites every month for four months, or (2) one intravesical dose of BoNT-A 100 U at 20 injection sites. Both treatments were followed by cystoscopic hydrodistention in the operation room. The primary endpoint was the global response assessment (GRA) recorded at six months after the first treatment day. The GRA scale included 6 items: worsening of symptoms (less than 0%), no change (0%), mild improvement (less than 50%), moderate improvement (50–75%), marked improvement (more than 75%), and completely cured (100%) .All patients were asked to maintain a three-day voiding diary at baseline for recording the functional bladder capacity (FBC), urinary frequency, and nocturia. The IC symptoms were assessed by the O’Leary-Sant symptom score (OSS), including IC symptom index (ICSI) and IC problem index (ICPI) . The blaThe VUDS was performed at baseline and time-points after intravesical injections. The VUDS was performed with an infusion rate of 20 mL/min, and the procedures and terminology were according to the International Continence Society recommendations . After tg, 20 min, <20 °C) and fast spin  of the supernatant plasma containing platelets. The lower third of the tube comprised PRP, and the upper part was platelet poor plasma (PPP). The platelet pellets were added to the plasma to obtain the desired concentration of PRP. In this study, 6 mL of sterile PRP was obtained. We sent 1 mL of PRP for culture and platelet count. The remaining 5 mL of PRP was used for intravesical injection. A total of 20 suburothelial injections of the PRP solution were performed, with 0.25 mL of PRP at each site, using a 23-gauge needle and a rigid injection instrument . The injection was approximately 1 mm in depth into the suburothelium equally distributed at posterior and lateral bladder walls, Cystoscopic hydrodistention was performed immediately after PRP injection to activate the injected platelets and determine the maximal bladder capacity (MBC). The PRP injection procedure was repeated every month for four months. A total of 10 mL of sterile normal saline was used to dissolve the BoNT-A powder to a concentration of 5 U at each site. The BoNT-A solution was gently shaken and then slowly withdrawn and injected at 20 well-distributed sites at posterior and lateral bladder wall followed by cystoscopic hydrodistention as previously reported [PRP was prepared according to previously reported standard procedures . In briereported . After tThe three-day voiding diary data , ICSI, ICPI symptom score, and bladder pain VAS were recorded at baseline (first PRP and BoNT-A injection), and at one, three (fourth PRP injection), and six  months. At the one-, three-, and six-month (primary endpoint) follow-up, patients reported any improvement in IC symptoms and adverse events were recorded. An excellent treatment outcome was considered when patients reported a GRA of ≥2 or no bladder pain (VAS = 0). The outcome was considered improved if there was improvement in the GRA by = 1 or the pain VAS score reduced by two or more and there was at least a 25% decrease in urinary frequency and nocturia. Patients with excellent and improved results were considered as having a successful treatment. After the primary endpoint assessment, the patients were continuously followed up with medications, such as anti-inflammatory agents and pain killers only. If the patient’s IC symptoms exacerbated and they requested bladder therapy, the duration from the first injection day to the consecutive bladder therapy was recorded as the effective duration.p-value of less than 0.05 was considered statistically significant.The data of voiding diary, VUDS parameters, symptom score, and bladder pain VAS score at baseline, one, three, and six months after the first injection day were compared in each group. A successful result was assessed by a self-reported improvement in GRA and pain VAS score. The data were presented as the mean ± standard deviation. Comparisons between PRP and BoNT-A groups were analyzed by the Student’s t-test to compare numerical data, and the Chi-square test for categorical data. Cumulative success rate was also calculated using Kaplan–Meier survival curves to compare the success rates from the initial treatment day to receiving additional treatment between groups. All statistical analyses were performed using the statistical package SPSS for Windows . A


The use of long duration sonophoresis (LDS) for musculoskeletal injuries is a new and emerging treatment option for patients undergoing rehabilitation. The treatment is non-invasive, provides multi-hour mechanical stimulus expediating tissue regeneration and deep tissue heat along with local application of therapeutic compound for improved pain relief. The objective of this prospective case study was to evaluate real-world application of diclofenac LDS as an add-on intervention for patients non-responsive to physical therapy alone.clinicaltrails.govNCT05254470.Patient who failed to respond to at least 4 weeks of physical therapy were treated with the addition of 2.5% diclofenac LDS daily for 4 weeks. The numerical rating scale, global health improvement score, functional improvement, and treatment satisfaction index were measured to assess pain reduction and quality of life improvement from treatment. Patient outcome data was organized by injury type and patient age groups, and statistically analyzed with ANOVA to assess treatment differences within and between groups. The study was registered on The study included (n=135) musculoskeletal injury LDS treatments with no adverse events. Patients reported a mean pain reduction from baseline of 4.44 points (p<0.0001) and a 4.85point health improvement score after 4-week of daily sonophoresis treatment. There were no age-related differences in pain reduction, and 97.8% of patients in the study reported functional improvement with the addition of LDS treatment. Significant pain relief was observed in injuries related to tendinopathy, sprain, strain, contusion, bone fracture, and post-surgical recovery.The use of LDS significantly reduced pain and improved musculoskeletal function and quality of life for patients. Clinical findings suggest that LDS with 2.5% diclofenac is a viable therapeutic option for practitioners and should be further investigated. Musculoskeletal injuries can lead to limited physical mobility and disability, contributing significantly to the cost of healthcare and insurance expenditure, which is estimated to exceed $213 Billion each year in treatment and lost wages . AdditioRest, ice, compression, and elevation (RICE) alongside oral or topical non-steroidal anti-inflammatory drugs (NSAIDs) and physical therapy are typically the first treatments to reduce pain in musculoskeletal injuries. However, studies have shown that RICE may have limited benefit in the early phase of the injury (3-4 days). NSAIDs are applied in oral and topical forms. They regulate the activity of cyclooxygenase enzymes COX-1 and COX2 -9. HowevRehabilitation after a musculoskeletal injury is a complex process and can take a long time to heal fully ,17. ProlUltrasound therapy has been used clinically to accelerate soft tissue regeneration and fracture healing, reduce inflammation, and pain management ,20. UltrContinuous long-duration home-use ultrasound treatment is a non-invasive therapy delivering 18,720 joules per treatment for up to 4 hours per day. Long duration continuous ultrasound penetrates tissue activating cellular proliferation, migration, and regeneration. The prolonged continuous ultrasound signal generates deep heat, convection, and vasodilation, enhancing oxygenation and nutrient exchange in the damaged tissue . MicrobuPrior studies have evaluated long duration ultrasound on musculoskeletal injuries after failure of physical therapy. The objective of this study was to evaluate the application of long duration sonophoresis (LDS) of non-steroidal anti-inflammatory 2.5% diclofenac in a similar context after patients failed to respond to physical therapy alone.A self-controlled trial design was used to direct this study of home-use LDS on musculoskeletal injuries that failed conservative intervention. The 4-week LDS interventional phase of the study followed the failure of 4 weeks of conservative intervention including rest and physical therapy. For the primary outcome measure, change in pain on the numeric rating scale  after intervention, statistical power analysis for the sample size was based on a mean effect size calculation from peer reviewed research ,22,23. ANCT05254470) (One hundred thirty-five patients (n=135) participated in and completed the study  which fo5254470) .The inclusion criteria for the study were patients 18 years of age or older undergoing physical therapy for musculoskeletal injury including acute conditions  and chronic conditions , and failed to respond with pain reduction to physical therapy for a minimum of 4 weeks. Patients were excluded if they were not willing to follow the daily treatment protocol, had a known neuropathy, were type 1 or type 2 diabetic, had a cortisone injection into the treatment site in the last 6 months, had a malignancy in the treatment area, had an open wound or had other contraindicated conditions to long duration ultrasound and diclofenac sonophoresis.Demographics and baseline pain information of the patients were recorded prior to the start of LDS treatment. Participants were provided with diaries for reporting: 1) pain rated on an 11-point numeric rating scale , 2) overall health improvement on a 15-point global rate of change  scale and 3) general 8 question patient/provider satisfaction with LDS treatment implementation into physical therapy. All procedures, consent to participate, data collection and training were conducted by the healthcare staff and patient reported outcomes. Study data was deidentified, tabulated into Microsoft Excel Spreadsheet Software by research staff and analyzed by an independent biostatistician. The investigative team reviewed and synthesized the results of the study.® 2.0, ZetrOZ Systems, LLC., Trumbull, CT) with a high viscosity 2.5% diclofenac ultrasound coupling gel . The LDS device delivers continuous ultrasound at 3 MHz, 1.3 Watts total power, and 0.132 W/cm2 spatial average temporal intensity. Long duration ultrasound is FDA cleared class II medical device for 4hr in-home treatment. The LDS system has two ultrasound transducer heads, each connecting to diclofenac ultrasound gel patches  and applied over the musculoskeletal injury site. The LDS output setting is preset and thus cannot be altered by the patient. The user operates the device with an on/off button and treatment timer switch (1-4hrs).Daily LDS was delivered with a wearable home-use continuous ultrasound device  score at the beginning and end of the 4-week study. The NRS is a validated and consistent pain measurement for several musculoskeletal conditions, including shoulder tendinopathy, upper neck and shoulder injury, knee arthritis, lateral epicondylitis, and others ,28. In aThe secondary outcome measure of the study was GROC improvement after 4 weeks of intervention compared to physical therapy alone. The GROC scale measured the patient’s overall improvement or deterioration of musculoskeletal injury. Patients reported on the 15-point GROC scale. The GROC scale was labeled with −7 being “a very great deal worse,” 0” being “no change,” and +7 being “a very great deal better.” The GROC scale has high test-retest reliability in patients with musculoskeletal pain, and the GROC scales have good face validity.At the completion of the study, both providers and patients completed exit questions on LDS treatment. These included experiential questions about ultrasound use, sonophoresis training, applying, and continuing the use of LDS for musculoskeletal injury with physical therapy.Baseline demographic and outcome variable data were compared between three age groups using ANOVAs to assess baseline differences. Age groups were categorized as under 30, between 30 and 59, and over 60 years of age. Paired t-tests were used to assess NRS pain score change from baseline by sub categorical grouping. ANOVAs were used to assess NRS and GROC differences by age type. One-sample proportions were used to assess survey responses to satisfaction, function, compliance, and participant process questions. Statistical analyses were conducted using R software . Results are expressed as means ± standard deviations (SD), sample size, 95% confidence intervals, and p-values. The p-values of less than 0.05 were considered statistically significant.A total of n=135 completed the study with an average age of 37.6±19.52. This consisted of patients with musculoskeletal injuries occurring in workplace or home including collegiate, professional sports and military service-related injuries. No adverse events such as skin burn, skin irritation, or skin sensitization were reported from LDS during 3,780 individual treatment sessions. Participants included a variety of injury types categorized into 8 anatomical locations and 15 specific condition types. The most common anatomical injury sites were to the shoulder and knee (53% of participants in the study). Bone fracture healing, lower back pain, and hamstring injuries represented the less common conditions treated.Pre and post-treatment pain was evaluated after 4 weeks of LDS. The distribution of pain change score (NRS), and health improvement score (GROC) for n=135 participants is shown in Patients with shoulder injuries reported a 4.15-point  NRS reduction, and GROC was improved by 4.65 ± 1.78. The greatest improvement was reported in shoulder sprain and dislocation NRS 4.43 points  and GROC 5.00 ± 0.58 points  and GROC improvement of 5.39 ± 1.19 points. The highest 4.90 points  NRS pain reduction and GROC 5.59 ± 1.27 points improvement were observed in biceps and elbow tendinopathy.Pain was significantly reduced in lower back by 4.10 NRS points , hamstring 4.78 NRS points  and hip 4.91 NRS points  injuries , and GROC was improved by 4.46 ± 1.66 points. Patients with knee cartilage damage  reported the greatest reduction in NRS pain, 4.68 , and GROC improvement of 5.34 ± 1.20 points (The pre (baseline) and post (4 weeks) of pain and health improvement by injury type: tendinopathy, sprain-strain-contusion, bone fracture, post-surgical rehabilitation, and cartilaginous injury, including arthritis, are shown in Patients less than 30 years of age (mean age 21.37 ± 1.64) showed an overall pain reduction of 4.71 points on the NRS scale  and GROC health improvement score of 5.14 ± 1.35 points after 4 weeks of LDS intervention  with 2.5% diclofenac in treating musculoskeletal injuries, which were nonresponsive to first-line physical therapy. The wearable LDS device with 2.5% diclofenac was successfully administered for use in the home setting with no adverse events. In addition, the treatment showed high patient compliance and satisfaction. The LDS intervention enhanced healing and provided localized relief from pain and inflammation without systemic medication or invasive procedures. Patients responded well to at-home treatment, potentially limiting the visits to other health care facilities.Daily LDS treatment effectively reduced pain associated with soft and hard tissue musculoskeletal injuries. This novel LDS treatment approach combines the mechanotransductive properties of continuous ultrasound with targeted delivery of diclofenac to the injury site. The mechanotransductive properties of continuous ultrasound have been shown to increase cellular proliferation, migration, and regeneration ,30. PrevDiclofenac is one of the most common NSAIDs to alleviate pain, taken orally or applied as topical cream or gel -36. HoweLong duration sonophoresis with 2.5% diclofenac shows a significant reduction of musculoskeletal injury pain when combined with physical therapy. The treatment alleviated the pain in soft tissues, joints, and bone, but it was most prominent in the hip, lower back, and shoulder. This could be due to the large surface area compared to the knee and wrist, where the transducers’ placement is more challenging. In addition, the improvement in the GROC score shows an improvement in quality of life after 4 weeks of the treatment. Additionally, LDS of 2.5% diclofenac treatment may show stronger pain reduction effects compared to long duration ultrasound alone in treating upper should and neck, knee osteoarthritis, and tendinopathy ,32,40. TThe study shows the potential of LDS of 2.5% diclofenac as a potential treatment for patients with musculoskeletal injuries associated with pain when bi-weekly physical therapy is insufficient. LDS may be easily integrated into patient care to reduce the pain and accelerate the healing process. The study had a high treatment satisfaction rate showing ease of use of the at-home treatment option for patients. In addition, statistical analysis shows significant improvement in pain for multiple injury types and overall quality of life. Despite being a self-controlled real-world study with encouraging results, the study did not have a parallel control group for direct comparison with LDS treatment. Future studies could address this issue to utilized LDS prior to failure of conservative intervention.Daily long duration sonophoresis (LDS) of 2.5% diclofenac significantly reduces pain and increases the quality of life for patients undergoing physical therapy for musculoskeletal injury. The treatment has potential synergistic effects of reducing pain and accelerating the healing process considering the mechanotransductive and drug delivery ability of continuous long duration ultrasound. Our clinical findings suggest that daily home use LDS treatment is a viable add-on treatment to physical therapy for musculoskeletal injuries, including tendinopathy, muscle sprain and strain, bone fracture, and cartilaginous damage.


To validate the comprehensive complication index (CCI) for mini-percutaneous nephrolithotomy (mPCNL).Data from 287 patients who underwent mPCNL were analyzed. Complications after mPCNL were classified using both the CCI and the Clavien–Dindo classification (CDC). Descriptive statistics and linear/logistic regression analyses detailed the association between clinical predictors and mPCNL outcomes.r = 0.32; p < 0.01 vs. CDC: r = 0.26; p = 0.01). Patients with multiple complications had higher stone volume (p = 0.02), longer operative time and LOS . A higher rate of post-operative hospital readmission  and lower rate of stone free  were found in patients with multiple complications than in those with single complication. Linear regression analysis revealed that multiple complications were associated with longer LOS (p < 0.001) after accounting for BMI and stone volume. Similarly, having multiple complications was associated with fivefold higher risk of readmission (p = 0.02).After mPCNL, 83 (28.9%) patients had complications, of which 12 (4.2%) patients with multiple complications had a higher CCI score compared to the traditional CDC system accounting only for the highest grade. The CCI enabled a more accurate prediction of length of stay (LOS) than CDC (CCI: The CCI is a valuable metric for assessing post-operative complications after mPCNL. The cumulative CCI is a better predictor of LOS than the CDC for mPCNL. Minor complications not captured by the highest CDC score are relevant since patients with multiple complications have longer LOS and higher rate of readmission than those with single ones.The online version contains supplementary material available at 10.1007/s00345-022-04045-9. Percutaneous nephrolithotomy (PCNL) is the gold standard surgical technique for large renal stones in adult patients . VariousIn clinical practice, the Clavien–Dindo classification (CDC)  is the mTo this aim, the Comprehensive Complication Index (CCI) has been recently introduced in clinical practice to score the burden of post-operative adverse events . The CCIIn particular, we wanted to introduce the CCI in mPCNL, which is the most widely employed PCNL option by the urological community . TherefoWe performed a retrospective analysis of all consecutive patients who underwent mPCNL for renal stones at a single tertiary-referral academic center between January 2017 and December 2021. Mini-PCNL represented the technique of choice when PCNL was planned, except in case of complete or almost complete staghorn stones, for which standard PCNL (24 Ch) was indicated.Patient’s demographics were collected. Health significant comorbidities were scored with the Charlson comorbidity index (CHI), further segregated as 0 vs. ≥ 1 . Weight All procedures were performed by two experienced (> 150 PCNL performed) endourologists  in a standardized fashion as previously described , 25.Briefly, with the patient placed in the supine Valdivia position, under general anesthesia, a ureteral catheter was placed in the renal pelvis to inject contrast medium. Subsequently, the renal puncture was performed with combined fluoroscopic/ultrasonographic control and tract dilation was executed one-shot with a 16 Ch metallic dilator. A 16 Ch metallic sheath was placed and the 12 Ch Karl Storz “minimally invasive PCNL” (MIP) nephroscope was introduced . A 550 μNumber of the percutaneous tracts and operative time (OT) were recorded. The evaluated post-operative data included hemoglobin drop and length of hospital stay (LOS). According to internal protocol of our institution, uncomplicated procedures were managed as follows: on post-operative day one the bladder catheter was removed and the nephrostomy tube was closed; on post-operative day two a percutaneous pyelography was performed to assess ureteral canalization and the presence of residual stones. If ureteral canalization was confirmed, the nephrostomy tube was removed. Patients were discharged on post-operative day three.www.assesssurgery.com [Only events that occurred during the hospital stay or within 30 days of the initial procedure were considered. Post-operative complications were graded according to the PCNL-adjusted Clavien Score (CDC) . For thegery.com . Of notePatient counseling and follow-up were standardized among the cohort. All patients were instructed to return to the emergency department of the same hospital if they developed post-PCNL complications. Phone calls for the evaluation of possible complications were scheduled 15 and 30 days after surgery as per standard clinical protocol. Patients were evaluated within 3 months after surgery with CT scan to identify residual stones. The stone-free (SF) rate was defined as the absence of residual fragments. Patients with residual fragments were offered, according to stone dimension, observation or auxiliary procedures including second-look PCNL, extracorporeal shockwave lithotripsy, or retrograde intrarenal surgery.N = 15); scheduled staged procedures for large stone burden (N = 27); concomitant additional procedures other than PCNL (N = 15); endoscopic combined intrarenal surgery procedures (N = 2). A final cohort of 287 patients who underwent mPCNL for kidney stones was considered for statistical analysis.We excluded patients with congenital renal anomalies .Distribution of data was tested with the Shapiro–Wilk test. Data are presented as medians  or frequencies (proportions). Descriptive statistics were used to describe the whole cohort. Clinical parameters, intraoperative and post-operative characteristics were compared among patients with single vs. multiple post-operative complications with the Mann–Whitney test and Fisher Exact Test, as indicated.p < 0.05.Univariable and multivariable linear regression models were used to investigate potential predictors of hospitalization time. Similarly, logistic regression models tested the association between clinical variables and re-hospitalization event in the whole cohort. Statistical analyses were performed using SPSS v.26 . All tests were two sided, and statistical significance level was determined at 2, respectively. A CHI ≥ 1 was found in 105 (36.6%) participants. Above all, 191 (66.6%) patients had multiple stones, with a median stone volume of 2.2 (1.0–4.6) cm3. Multiple access tracts were used in 49 (17.1%) cases. Median operative time and LOS were 107 (80–140) min and 4 (3–6) days, respectively.Table Of 287, 83 (28.9%) patients had post-operative complications, of which 24 (8.4%), 45 15.7%), 10 (3.5%) and 4 (1.4%) were of highest CDC of I, II, IIIa and IIIb, respectively. Supplementary Table 1 reports the type and the severity of post-operative complications. Median CCI score was 20.9 (8.6–20.9) .Of 83 participants with post-operative adverse events, 12 (4.2%) patients had multiple complications resulting in a higher total CCI score compared to that calculated from the traditional CDC system accounting only for the highest grade [total CCI mean 24.8 (range 12.2–34.8) vs. non-cumulative CDC mean 19.8 (range 8.7–33.7), p = 0.02), longer operative time and LOS  than those with single adverse event. A higher rate of post-operative hospital readmission  and lower rate of stone free  were found in patients with multiple complications (Table Table p < 0.01) (Table p = 0.02), stone volume  and one  or multiple complications  were independent predictors of longer LOS, after accounting for CHI. Of clinical relevance, the average LOS for mPCNL with multiple complications was expected to be 5 days longer than that of surgeries with single adverse event (p < 0.001).Table 1) Table . Multivap = 0.02).Table This is the first study which introduces and validates the CCI in mPCNL cases for kidney stones. We found that the CCI was more accurate than the CDC in depicting the overall burden of post-operative complications and that the CCI enabled for a more precise prediction of LOS than the Clavien classification. Approximately 4.2% of patients showed a higher CCI value than that corresponding to their highest CDC grade, thus suggesting that the CCI is relevant in capturing minor complications which are underestimated by the Clavien–Dindo score. Of note, having multiple complications after mPCNL was associated with longer LOS and higher rates of hospital readmission.Quality control in urological surgery is crucial to ensure patient safety and improve patient care. Therefore, it is of utmost clinical importance that post-operative complications are reported systematically, objectively and reproducibly . To thisThe CCI has been first validated in major uro-oncological series. Vetterlein et al. analyzed a cohort of 506 patients treated with radical cystectomy for bladder cancer and showed that the proportion of cases with severe complications was higher using the CCI than the CDC (31% vs. 11%) . Of noter = 0.32; p < 0.01 vs. CDC: r = 0.26; p = 0.01). We showed that, along with patient’s BMI and stone volume, having multiple complications was independently associated with longer LOS. Of clinical importance, the average LOS for mPCNL with multiple complications was 5 days longer than that of surgeries with single adverse event. Therefore, in research setting and in clinical practice, the use of CCI, which takes into account multiple adverse events and not only the most severe, gain even more importance in terms of patient’s management and health-related costs [Nowadays, the miniaturization of the instruments has improved PCNL outcomes in terms of SFR and post-operative complications, widening the indications of PCNL to a greater range of stone volumes . In facted costs . We alsoThis study is innovative because it specifically validates the CCI in a series of mPCNL, which is the most preferred surgical technique for stone diseases by endourologists . TherefoOur study is not devoid of limitations. The retrospective nature of our investigation might lead to data loss in terms of complications; however, as for our internal protocol, patients were checked by phone calls 15 and 30 days post-operatively. Therefore, we can assume that our scoring of complication is rigorous. Also, this was a single center-based study, which raises the possibility of selection biases; thereof, larger studies across different centers and cohorts are needed to externally validate our findings. Lastly, the relatively low rate of complications in our cohort precluded the investigation of association between the CCI and more severe outcomes  in a multivariable fashion. For that reason, multicenter studies should further investigate the role of CCI in PCNL.In this study, we validated the CCI as a score for reporting post-operative complications after mPCNL. We found that the CCI was more accurate than the CDC in depicting the overall burden of post-operative complications and that the CCI enabled for a more precise prediction of LOS than the Clavien classification. Only 4.2% of patients had multiple complications leading to a higher CCI value than that corresponding to their highest CDC grade. Of note, having multiple complications after mPCNL was associated with longer LOS and higher rates of hospital readmission. Therefore, the CCI is relevant in clinical practice to capture the overall burden of complications, in terms of major and minor adverse events, which have a strong impact in patient’s management and health costs.Supplementary file1 (DOCX 13 KB)Below is the link to the electronic supplementary material.