Microvascular decompression (MVD) is frequently used for the treatment of trigeminal neuralgia (TN). We present a case of TN with multiple recurrences despite different interventions. A 50-year-old patient presented with a five-year history of left TN. He initially had an MVD with Teflon padding that eliminated his pain for a year. When pain recurred, he went on to stereotactic radiosurgery, which did not help. He then had two percutaneous retrogasserian glycerol injections, the first one relieved pain for a year and the second only six months. After the second recurrence, we repeated the magnetic resonance imaging (MRI) of the brain, and it showed kinking of the nerve with the padding in place. We decided to re-explore the nerve based on the MRI findings. Intraoperatively, we observed the Teflon padding had become adherent to the petrous bone which caused deformation of the nerve. We did adhesiolysis with debulking of the padding, following which the nerve appeared more relaxed. Postoperatively, the patient had immediate resolution of his pain. At eight-month follow-up, the patient remained pain-free. Multiple factors can be involved in recurrence of TN after MVD. In this case, the size of the padding, continued distortion from the offending artery in addition to scarring from radiosurgery may have contributed to the deformation of the nerve and the recurrence of symptoms. A new MRI can be beneficial when the neuralgia symptoms recur in delayed fashion after successful MVD. Also, the use of a more compact padding material, like Gore-Tex, may cause less deformation of the nerve. Trigeminal neuralgia (TN) is a paroxysmal, recurrent, lancinating, or electric shock-like pain . The paiA 50-year-old man presented with a five-year history of left V2 and V3 TN, and the pain was frequent with multiple episodes on daily basis, sharp in nature with an electric shock-like sensation. There were multiple triggers including skin touch and chewing. His pain score was 5 according to the Barrow Neurological Institute (BNI) pain intensity score. He initially had an MVD with Teflon felt padding that eliminated his pain (BNI grade 0) for a year. Then pain recurred spontaneously, and it was similar in quality and intensity (BNI grade 5) to his initial pain. He then was treated with SRS with an 80 Gray in a single fraction that targeted the transitional zone, but there was no improvement. He then had two percutaneous retrogasserian GIs, the first relieved pain for a year and the second for only six months. We repeated his MRI scan (Fast Imaging Employing Steady-state Acquisition [FIESTA] protocol), and it showed a dramatic posterior kinking of the nerve with the padding apparently still in place Figure . We considered repeat GI versus exploration, and following a discussion with the patient, decided that a re-exploration of the nerve was warranted based on the MRI findings showing the obvious nerve distortion possibly amenable to microsurgical correction. Intraoperatively, we observed that the Teflon padding was still in place between the nerve and the superior cerebellar artery (SCA) with both the nerve and the artery were severely to the pad. The caudal edge had become posteriorly displaced and scarred to the dura over petrous bone tethering and deforming the nerve Figure . We did Postoperatively, the patient reported immediate resolution of his pain with only mild residual numbness in the V2/V3 distribution unchanged from preop. Although most patients develop new or increased numbness after MVD, this was not evident in our case. This can be explained by the lack of significant manipulation of the nerve as the bulk of our microdissection was to release the adhesions between the Teflon pad and the petrous ridge, and debulking the pad itself. There was no hearing loss or facial weakness. At eight-month follow-up, the patient remained pain-free. MVD is frequently used in the treatment of typical TN after failure of initial medical management. It is the most successful option and is optimal for otherwise healthy patients. Longitudinal studies have shown that MVD provides an initial and long-term pain relief in more than 90% and 70% of patients, respectively. These results are higher than other treatment modalities. It also provides the highest long-term patient satisfaction -11. ApprThe available treatment options for recurrent TN include redo MVD, percutaneous glycerol or radiofrequency rhizotomy, SRS, and percutaneous balloon compression ,12,13.In this case, after discussing the available treatment options with the patient, it was decided that SRS would be the next step in the treatment of the recurrent symptoms. This decision was reached by weighing the perceived risks of redo MVD versus the high safety profile of SRS, and acknowledged the lack of treatment guidelines for recurrent TN. In this case, transmitted distortion by the SCA through the bulk of the Teflon padding, in addition to scarring from radiosurgery, may have resulted in the deformation of the nerve, and the multiple recurrences of symptoms despite multiple subsequent interventions.Our experience with this case indicates that a repeat MRI after the initial recurrence of symptoms is warranted as it can identify the position of the padding, and the offending artery. It will also show if deformation of the nerve has developed. In the case of nerve deformation or loss of the padding, a re-exploration is probably the best option. It may result in lower cumulative risk and cost than multiple less durable procedures to treat multiple recurrences of TN. Cheng et al. reported that redo MVD provided immediate pain relief in 80% of patients for a mean duration of two years, and partial pain relief in an additional 7% of patients. The complications were higher in redo MVD, hearing loss 5%, wound infection 2.5%, and cerebrospinal fluid leak 2.5% . Raygor Jafree et al. reported that repeat MVD yielded the highest proportion of long-term pain relief at five years (66.7%) in patients with recurrent TN after initial MVD . We suggRecurrence of TN after a successful initial MVD can be attributed to different factors such as padding, deformation of the nerve due to adhesions, and continuous irritation by the offending vessel. A re-exploration can result in pain relief in the majority of patients.


P < 0.0001) and 4.3 (P = 0.0017) at long-term follow-up. The quality of sleep improved in 50% of the patients, whereas the remainder indicated no difference. No complications were registered. The results show that AFT alone, even over a longer period of time and in patients refractory to multiple treatment modalities, can be useful to treat peripheral neuropathic pain without apparent cause. For definitive evidence, a larger prospective study is warranted.Neuropathic pain has a far-reaching effect on the daily lives of patients. Recently, autologous fat transfer (AFT) has demonstrated promising results in patients with painful scars or after neuroma excision. However, there is a subgroup of patients who do not show any apparent cause for the pain. We hypothesized that in these patients, AFT alone in the area around the affected nerve might lead to beneficial results. Patients with clearly demarcated neuropathic pain and who had exhausted all other treatment options were referred by a pain specialist. Fourteen patients who met the inclusion criteria received AFT in the area of the affected nerve. Pain scored on the visual analog scale, patient satisfaction, and quality of sleep were recorded before and after surgery. To investigate long-term effects, a second follow-up was planned at least 1 year later. Patient satisfaction was 93% after the first follow-up and 86% after more than 1 year. The mean VAS score was 7.4 before surgery and significantly decreased to 3.8 after autologous fat grafting ( The majority of the patients presented with a history of trauma or a surgical procedure in the area before the onset of the pain. Preoperative examination included Tinel’s sign and completion of the visual analog scale (VAS) as an assessment of pain intensity. Inclusion criteria were a clearly demarcated area of pain and positive Tinel’s sign in the absence of obvious scars or neuromas as validated by means of high-resolution ultrasonography.Surgery was performed under general anesthesia. The donor site  was infiltrated with saline (NaCl 0.9%) and 0.001 mg adrenaline/ml before adipose tissue was harvested through a 3-mm blunt Mercedes tip cannula, at low suction settings using a Cytori pure graft system . The lipoaspirate was then reinjected subcutaneously in the preoperatively marked area using a fanning technique.Baseline characteristics were recorded. Primary outcome measures were patient satisfaction (yes or no) and pain scores pre- and postoperatively on the VAS ranging from 0 “no pain at all,” to 10 “unbearable pain.” A long-term follow-up was planned after a minimum of 1 year after surgery to evaluate changes in pain experience. Quality of sleep and safety of the procedure were also evaluated.t test. A P value < 0.05 was considered to be statistically significant.Statistical comparison of the pre- and postoperative VAS scores was performed by paired Student’s P < 0.0001; range, 0–8; Fig. P = 0.0017; range, 0–10) at long-term follow-up (on average 28 mo). In 3 patients, the VAS increased between the first and second follow-up but was still below the preoperative value. The quality of sleep improved in 50% of the patients, whereas the remainder indicated no difference. No complications were registered.Fourteen individual patients were included. Their baseline characteristics can be found in Table 3 This effect was reached in 9/14 patients (64%), whereas 5/14 patients (36%) reported a pain reduction of at least 50%. The meaningful effect of the procedure was corroborated by the fact that previous “standard care” pain treatments had either no or short-lasting effects, whereas the effect of AFT lasted much longer.The study results revealed that the vast majority of patients (86%) were satisfied with the pain relief after more than 1 year follow-up and 50% of the patients reported improved quality of sleep. In the literature, a pain reduction of at least 30% is generally regarded as being clinically relevant.10 reported a reduction of 23.2% in the mean disabilities of the arm, shoulder, and hand scores and an improvement in the VAS score of 22%  after perineural fat grafting in 8 patients for the treatment of painful end neuromas of the upper limb. Fredman et al.14 noted a pain reduction in 6 of 7 patients with burn scars. Huang et al.16 reported a significant decrease in VAS score of 4.38 after 1 week, 5.38 after 4 weeks, and 5.62 after 24 weeks of treatment, and a likewise decrease in the Neuropathic Pain Symptom Inventory in 13 patients with painful scars. In patients with postmastectomy pain syndrome, several studies revealed that AFT significantly decreased the VAS score versus nonoperated controls, with a mean decrease of >3 points.18The significant decrease in pain reflects the results from studies wherein cause of the pain was known. Vaienti et al.16 found no recurrence of pain in patients responding to treatment, Vaienti et al.10 described a similar deterioration of the pain relief over time in some patients. We hypothesize that graft volume loss, in literature described to be between 40% and 80% in the first months postoperative, may be responsible for the recurrence of pain.21 If that is the case, treatments or methods, which improve graft volume retention, may also improve the long-term effects on pain.Interestingly, all 14 patients reported pain relief in the first weeks after surgery. However, 2 patients indicated recurrence of pain after 2 months with an increased VAS score compared with preoperative. Another patient reported at the long-term follow-up that the VAS had been rising slightly after a few months but was still at acceptable levels at the last follow-up. Although Huang et al.This study shows that AFT is a useful alternative in localized peripheral neuropathic pain with a high patient-reported satisfaction even after 1 year of follow-up. Nevertheless, prospective studies with larger study populations are required to provide definitive evidence.We would like to thank the Department of Anesthesiology of Maastricht University Medical Center and especially Dr. Balthasar and Dr. Sommer.


Adequate pain management has led to increased comfort in emergency patients, reducing morbidity and improving long term outcomes. Different pain management modalities have been applied in the emergency department among which systemic analgesia is commonly used by preceding a nerve block. Several factors have been associated with poor pain management in low resource setting areas. We aimed to determine pain management modalities and associated factors among emergency surgical patients. After obtaining ethical approval from Ethical Review Committee, 203 volunteer patients were enrolled. Institutional based cross-sectional prospective study was conducted from April to May 2018 in Gondar University Specialized Hospital Emergency Department. The severity of pain was measured through Numerical Rating Scale and statistical analysis was performed using SPSS statistical package version 23. Descriptive statistics cross-tab and binary logistics were performed to identify factors related to pain management in emergency department. A total of 203 patients, 138 (68%) males and 65 (32%) females with response rate of 94%, participated in this study. Among them, 66% patients received analgesia within two hours of ED presentation with a mean ± SD of 61.0 ± 34.1 minutes. 70.4 % of patients complained of moderate and severe pain after receiving analgesia. There was a significant difference between trauma and nontrauma patients in mean time of analgesia receiving and residual pain severity (p < 0.001). Age, trauma, physician pain assessment, and severity of pain were the predicting factors for analgesia delivery. The overall practice of pain management in Gondar University Specialized Hospital Emergency Department was not adequate. Therefore, it is vital to implement an objective pain assessment method and documentation of the pain severity to improve pain management practice. Pain is the main reason triggering patients to seek help in emergency department. International Association of Pain Study (IAPS) defines pain as an unpleasant sensory and emotional experience arising from actual or potential tissue damage. Pain affects all age groups without discriminating individuals based on gender or ethnicity .Analgesia plays an important role in speeding the patient's recovery, reducing morbidity as well as improving clinical outcomes. The Emergency Department (ED) should be able to provide different services including pain management. Several studies have reported that pain is not treated adequately in the ED even though suitable analgesic drugs and different techniques are available. Moreover, several studies have identified different reasons for poor pain management in ED including an attitude of suspicion, a culture of ignoring the problem, and an environment that is not suitable for change in practice –8.Lack of guidelines, regular training sessions, and measurement pain could play a role but these factors have not been widely studied . PatientThe prevalence of acute pain in the ED has been widely recognized and evidences support that 7 out of 10 patients come to ED because they are in pain . In the In Switzerland a survey among emergency physicians and anesthesiologists involved in ED pain management responded that morphine is the most frequently used opioid in the ED (41%), followed by nicomorphine and pethidine. Furthermore, propacetamol and ketorolac are the most frequently used intravenous nonopioids in the emergency room reported by 26% of respondents [A randomized controlled trial done by Mahshidfar and his colleagues in 2017 showed that 0.2mg/kg of ketamine has a significant reduction of acute pain when compared to that of 0.1mg/kg IV morphine ED .A study done in USA on geriatric hip fracture patients showed that patients who received fascia iliac compartment block (6% vs 60% ) in the ED had a shorter time to first analgesic use (93 minutes VS 103 minutes) and received fewer morphine equivalents in the first 24 hours . In addiGuidelines for the management of pain in the ED have been introduced by the British Association of Accident and Emergency Medicine. Patients with severe pain  should receive appropriate analgesia within 20 minutes of arrival or triage. Patients with moderate pain should be offered analgesia at triage . HoweverA prospective cohort study done in Nigeria showed that 58% were trauma patients and 42% were nontrauma cases presenting with pain in ED. The mean pain score for all patients on the VAS was 6.9. The trauma cases had significantly lower VAS scores than the nontraumatized patients (6.1 vs 8.1). Analgesia was not prescribed in 45.2% of the patients, 65% of whom were with severe pain. In addition, 81% who were given preoperative analgesia had moderate to severe residual pain .Agodirin and his colleagues performed a randomized controlled trial in Nigeria showing that preoperative use of tramadol does not affect the accuracy of the diagnosis of acute abdomen in ED . In addiThis study was designed to determine pain management modalities and associated factors among emergency surgical patients in Gondar University Specialized Hospital Emergency Department.After obtaining ethical approval from ethical review board of college of medicine and health science, an institutional based cross-sectional prospective study was conducted from April to May 2018 in Gonder University Specialized Hospital Emergency Department, located in Gondar town. Gondar is the capital of North-Gondar administrative zone in Amhara regional state, located 748 km northwest of Addis Ababa. The hospital is estimated to serve over 5 million people around the area.All adult emergency surgical patients aged greater than 18 years who were present at the ED during the study period were enrolled in this study. Surgical patients having chronic pain, Glasgow Coma Scale < 14, and documented cognitive disability, uncooperative patients, and patients who had multiple site injuries and hemodynamically unstable patients were excluded from the study.n= (Zα/2)2p(1-p)/ω2 where n is the minimum sample size, Z is the standardized normal distribution value at α/2, P is the incidence/proportion of pain, and d is the margin of error. A study done in Nigeria on preoperative analgesia in emergency surgical care showed that the incidence of pain is 85% (p=0.85) [Zα/2 at 95%  CI (1.96), the sample size was 196, by adding 10% for nonresponse rate, and 216 participants were involved in the study. Consecutive sampling technique was used in this study.The sample size was calculated using a single population proportion formula (p=0.85) , Zα/2 atSociodemographic variables, causes of ED admission, physician's pain assessment, and pain documentation and management modalities were collected by using chart review and a pretested structured questionnaire. The questionnaire was designed and modified appropriately and translated into local language (Amharic) to be understood by all participants and translated back to English again to ensure its consistency. Training was given for four data collectors and one supervisor. Pretest was done on 15 emergency surgical patients two weeks before the day of actual data collection. The data collectors were supervised daily, and the filled questionnaires were checked by the supervisor and the principal investigator. Pretested respondents were not included in the main study.Sociodemographic variables, severity of pain, associated factors, and management modalities of pain data were entered and analyzed using SPSS 23.00 version statistical software. The severity of pain and management of pain were expressed as descriptive statistics and binary logistic regression was used to adjust or control the possible confounding factors and to identify associated factors of pain in the ED. The cut point for statistical significance was P < 0.05.Ethical clearance was obtained from Ethical Review Committee of College of Medicine and Health Science University of Gondar. Written informed consent was obtained from each participant after clear explanation of what they would have to do to take part in the study. Anyone not willing to participate in the study was informed that they had full right not to participate or withdraw at any time. Confidentiality was guaranteed by keeping the secrecy of personal identification, keeping completed questionnaires and results in well secured area.A total of two hundred and sixteen emergency surgical patients were studied. Thirteen patients were excluded from analysis for incomplete data. Among the study participants 138 (68%) were males and 65 (32%) were females. Fifty-nine percent of the respondents were adults with range of 18-29 and the mean (±SD) age was 33.1±14.6 years .The main reason for ED presentation was trauma, 134 (66%), which resulted from domestic violence 48 (23.6%) followed by motor vehicle accident 44 (21.7%). Nontrauma ED presentation accounted for 34% of patients. Nontrauma patients came with appendicitis, large bowel obstruction, and small bowel obstruction which were relatively common causes of ED admission with 18(8.9%), 16(7.8%), and 12(5.9%) patients, respectively. Fracture and soft tissue injury were the two common injury types for trauma patients, 58 (28.6%) and 66 (32.5%), respectively .During presentation in ED 25 (12.3%) patients with trauma received analgesia; however, nontrauma cases did not receive analgesia within 30 minutes of presentation. After two hours of ED presentation, there was a highly significant difference in analgesia given between trauma and nontrauma with a p value < 0.001. Among nontrauma cases only 34 (49.3%) of patients received analgesic drugs but among trauma patients 100 (74.6%) of patients received analgesic drugs .The mean time to first analgesia was 60.98 + 34.05 minutes for all emergency surgical patients. The mean time of analgesia was also statistically significant between trauma and nontrauma patients with a p value < 0.001 .Pain severity during presentation at ED and two hours after presentation was 7.67±1.89 and 5.19 ±2.35, respectively, and there was a significant difference between trauma and nontrauma patients both at ED presentation and at two hours after ED presentation with a p value 0.016 and < 0.001, respectively, but there was no statically significant difference between males and females on pain severity .The severity of pain in ED was expressed according to WHO classification after NRS score obtained. At ED presentation 193 (95.1%) emergency surgical patients presented with severe and moderate pain. After two hours of ED presentation 32.5%, 37.9%, and 29.6% emergency surgical patients complained from severe, moderate, and mild pain, respectively .Tramadol was given to 81 (39.9%) of patients followed by diclofenac 40 (19.7%) at 2 hours after ED presentation. 69 (34%) of patients did not receive any analgesia in ED. Among those who did not receive analgesia 61 (88.4%) of patients reported analgesic medications were not prescribed. Overall 107 (57 %) patients reported that the analgesic was not adequate and needed additional analgesia .Factors associated with analgesia delivery in ED were age of the patient, cause of ED admission, physician pain assessment, and severity of pain. Patients aged 30-59 were 4 times more likely to receive analgesia compared to those greater than 60 years (p = 0.024). Trauma patients were also four times more likely to receive analgesia than nontrauma patients (p < 0.001). Pain assessed by physicians was an independent factor but only 41(20.2%) of patients were assessed. Patients assessed by a physician were three times more likely to receive analgesia than those not assessed (p=0.02). A patient presenting at ED with severe pain was 3.5 times more likely to receive analgesia compared to those with mild pain (p= 0.007). Even though patient analgesic request was not associated with analgesic administration in the ED, 128 (63.1%) of patients requested analgesia during ED stay and 75 (36.9%) patients did not request analgesia. The main reasons for not requesting analgesia were that patients, thought the physicians did what was important for them, hoped the pain would get better, had no idea about analgesia, thought asking was culturally unethical, and lastly had fear of drug complications 42(56%), 16(21.3%), 14(18.7%), 2(2.7%), and 1 (1.3%), respectively .This observational study was conducted to determine the practice of pain management modalities and associated factors among emergency surgical patients in ED. The mean severity of pain during ED presentation was 7.67 ± 1.89, which was a high mean of pain severity when compared to a study in Nigeria which was 6.9 ± 2.5 . With thResidual pain after two hours of ED presentation was 5.19 ± 2.35. Similarly, in Pakistan, a study showed that postanalgesic mean residual pain score of all patients was 5.0±1.8. This score was less in trauma patients (4.7±1.9) as compared to acute abdomen patients (5.7±0.9). In this study mean residual pain for nontrauma was higher which could be explained by a delay to administer analgesia to these patients, specially for acute abdomen because of fear of masking the signs for correct diagnosis . By clasIn this study only 12.3% of patients received analgesia within 30 minutes of ED presentation in contrast to the British Association of Accident and Emergency Medicine (BAEM) guidelines. These state that patients with severe pain should receive appropriate analgesia within 20 minutes of arrival and those with moderate pain should be offered analgesia at triage . Within The mean time to delivery of analgesia was 61 ± 34 minutes, three times longer than the British Association of Accident and Emergency Medicine acute pain guidelines. In a study in the UK the mean time of arrival to analgesia was 72 minutes for severe pain and 236 minutes for moderate pain . In contThe type of analgesia used in ED varies from hospital to hospital and from country to country. In this study 39.9% of patients received tramadol and 19.7% received diclofenac. The majority (95.1%) of patients complained of moderate and severe pain in the ED. Similarly a study from Jimma, Ethiopia, showed that tramadol was also the most prescribed analgesic for postoperative pain management . This maIn contrast to this study, a study by Todd and his colleagues showed that the majority of analgesics administered were opioids (59%). Morphine was the single most commonly administered analgesic (20%), followed by ibuprofen (17%) , 31.Berben and his colleagues showed that 33 (40%) of ED pain treatment consisted of local anesthesia, for suturing or repositioning of fractures. The other 51 (60%) received systemic pain medication, explained as they included patients for discharge including procedural analgesia . Nerve bThere are many different factors which result in undertreatment of pain in the ED . In thisAge greater than 60 was associated with oligoanalgesia. Adult patients within the age range of 30 to 60 received analgesia four times as often (95% CI 1.14-13.65) as those with an age greater than 60. In a study similar to this Jones and his colleagues showed that 66% of elderly patients received analgesia compared to 80% of their younger counterparts. They also had significant underdosing of pain medication and received less opioid analgesia . A meta-Physician pain assessment was the one predictor to getting analgesia at ED. In this study pain assessment was performed in only one-fifth (20.2 %) of patients and was significantly associated with analgesia delivery. A study by Silka and his colleagues showed that pain scoring in the ED improves analgesia administration for trauma patients .Severe pain was associated with analgesia delivery compared to mild pain with AOD ratio of 3.09 . In a similar study to this in Central Africa by Rampanjato and his colleagues pain severity was highly associated with the median time of analgesia administration by nurses . After aThis study focused on the clinical perspective of pain management modalities and did not look at knowledge and attitudes of emergency healthcare providers and patients which are confounding factors for poor pain management. The physician to patient ratio was not analyzed which has also been identified as a factor in previous studies for poor pain management in ED.The practice of pain management in the ED was inadequate. The type of analgesics administered did not match the severity of pain. The time to analgesia was delayed and one-third of emergency surgical patients did not receive analgesia within two hours of ED presentation. Even though the severity of pain decreased after two hours of ED presentation, the prevalence of pain after treatment was high. Moreover, lack of objective pain assessment, lack of documentation of the severity of pain, and time of analgesia at GUSH surgical ED were the independent risk factors for poor pain management.According to the result of this research we recommend that the healthcare staff should administer adequate analgesics to the nontrauma patient in equal measure to trauma patients. In addition, healthcare providers should assess and document severity of pain as a fifth vital sign so as to administer appropriate analgesic drugs including potent opioids and regional nerve blocks.Furthermore we recommend further study on knowledge and attitudes of emergency department health workers towards pain management.


Rocuronium bromide (RB) is known to cause vascular pain. Although there have been a few reports that diluted administration causes less vascular pain, there have been no studies investigating diluted administration and the onset time of muscle relaxation. Therefore, we examined the influence of diluted administration of RB on the onset time of muscle relaxation and vascular pain.39 patients were randomly assigned to three groups: RB stock solution 10 mg/ml (Group 1), two-fold dilution 5 mg/ml (Group 2), or three-fold dilution 3.3 mg/ml (Group 3). After the largest vein of the forearm was secured, anesthesia was induced by propofol and 0.6 mg/kg of RB was administered. The evaluation method devised by Shevchenko et al. was used to evaluate the degree of vascular pain. The time from RB administration until the maximum blocking of T1 by TOF stimulation was measured.p = 0.033).There was no significant difference in escape behaviors of vascular pain among the three groups, and the onset time of muscle relaxation was significantly slower in Group 3 than in Group 1 (Our results suggested that it is unnecessary to dilute RB before administration if a large vein in the forearm is used.UMIN000026737.UMINCTR Registration number Registered 29 Mar 2017. Rocuronium bromide (RB) is the most commonly used non-depolarizing neuromuscular blocking drug (NMBD) due to its shorter onset time and duration of action, and good operability as compared with other NMBDs. However, unconscious body response , which iThis study was approved by the Ethics Committee of the School of Dentistry, Aichi Gakuin University . Clinical trial registration was performed at UMIN-CTR before the start of the study . After providing an adequate explanation regarding the aims of the research to all subjects, we obtained written informed consent from all the patients.Overall, 45 ASA-PS 1–2 patients between 20 and 70 years of age who were scheduled to undergo general anesthesia at our hospital. Patients who did not give consent, who had neuromuscular diseases, or who had a BMI ≥25 were excluded from the study. Patients were randomly assigned to the following three groups: patients receiving RB the stock solution of 10 mg/ml (Group 1:13 patients), patients receiving the two-fold dilution of 5 mg/ml (Group 2:13 patients), or patients receiving the three-fold dilution of 3.3 mg/ml (Group 3: 13 patients) .For the patient background, sex, age, height, and weight were evaluated. We also investigated the onset time of muscle relaxation using TOF and the escape behaviors from the vascular pain. The degree of vascular pain was evaluated using the scale devised by Shevchenko et al. as follows: grade 1 = no response, grade 2 = movement at the wrist only, grade 3 = withdrawal involving the arm only (elbow or shoulder), grade 4 = generalized response or withdrawal in more than one extremity. Pain of grade 2 or above was considered to indicate vascular pain [The minimum sample size in total (30 patients) was calculated from a preliminary study based on the onset time of muscle relaxation .d = N/(1-R)2 where N is sample size calculated assuming no dropout and Nd that required with dropouts [The dropout rate in a preliminary study was 0.1. If an R dropout rate is expected, a simple but adequate adjustment is provided by Ndropouts . Therefop < 0.05 was considered to indicate significance.Statistical analysis was performed for age, height, weight, and the onset time of muscle relaxation using one-way ANOVA and multiple comparison by Tukey’s method. The chi-square test using the m × n division table was employed to investigate the impact of sex. In addition, escape behaviors from vascular pain were tested by the Kruskal-Willis test, and A CONSORT Diagram is shown in Fig. p = 0.033) (Table The patient backgrounds are shown in Table Grade 2 or higher escape behaviors from vascular pain were observed in 53% (7/13) in both Group 1 and Group 2, and in 46% (6/13) in Group 3  [2O and that of RB at 1 mg/ml of 306 mOsm/kg H2O. Taken together, the pH and osmotic pressure values of RB solution used are consistent with those reported in previous studies and are unlikely to affect vascular pain, which may be why there was no difference in escape behaviors from vascular pain noted in our study.It has been reported that vascular pain due to single administration of RB is observed in approximately 50 to 80% of patients , 13. AltIn our study, Group 2 and Group 3 did not exhibit differences in escape behaviors from vascular pain as compared with Group 1, which was inconsistent with previous studies , 7 demonWe investigated the influence of diluted administration of RB on the onset time of muscle relaxation and vascular pain. We found that when diluted RB was administered through a large vein, there was no significant difference in escape behaviors from vascular pain. However, it should be noted that the onset time of muscle relaxation is delayed by dilution.


Consider degenerative cervical myelopathy in patients over 50 with progressive neurological symptoms, such as pain and stiffness in the neck or limbs, imbalance, numbness, loss of dexterity, frequent falls, and/or incontinencePerform a full neurological assessment as early symptoms are subtle and non-specificA magnetic resonance imaging (MRI) scan is essential to detect degenerative changes in the cervical spine and cord compressionTime is Spine: Refer patients with suspected DCM promptly to a specialist for consideration of spinal surgery, as delayed diagnosis can lead to residual symptoms and functional disabilityA 54 year old man presents with neck stiffness for about a year. He complains of numbness in his fingers and difficulty buttoning up his shirt, which has not improved following surgery for carpal tunnel syndrome. Of late, he has experienced unsteadiness and has started to use a walking stick after sustaining falls. He sees a neurologist who identifies hyperreflexia in his arms and legs. An MRI scan shows multilevel cervical spondylosis and disc herniation causing cord compression. He is diagnosed with degenerative cervical myelopathy and referred to spinal surgery for operative decompression.spondylosis , earlier referred to as cervical spondylotic myelopathy, involves spinal cord dysfunction from compression in the neck.ndylosis .3Box 1The epidemiology of DCM is poorly understood, in part because of the difficulties in diagnosis.The prevalence of surgically treated DCM is estimated as 1.6 per 100 000 inhabitants.The incidence of DCM is expected to rise with an ageing population.Studies in healthy volunteers have shown that incidental cervical cord compression is commonly detected on MRI, and becomes more common with age.A proportion of individuals with asymptomatic cord compression will go on to develop DCM. The exact figure is unknown. The only prospective study to consider this (n=199) found that 8% of individuals with asymptomatic cord compression will develop DCM after one year and 22% in total over the observation period Many patients with DCM remain undiagnosed. A small study in 66 patients with hip fracture found 18% of patients who were previously undiagnosed to have clinical findings suggestive of DCMNon-specific and subtle early features that overlap with other neurological conditions can delay the diagnosis.Spinal cord compression results in progressive neurological decline and affects quality of life.Detecting early DCM can be challenging. A high index of suspicion, alongside a comprehensive neurological examination is advised. Box 2Neck pain/stiffnessUnilateral or bilateral limb/body painUpper limb weakness, numbness, or loss of dexterityLower limb stiffness, weakness, or sensory lossParaesthesia (tingling or pins and needles sensations)Autonomic symptoms such as bowel or bladder incontinence, erectile dysfunction, or difficulty passing urineImbalance/unsteadinessFallsMotor signso Pyramidal weakness o Limb hyperreflexiao Spasticity o Clonus, especially Achilles tendono Hoffman’s sign o Babinski’s sign (upgoing plantar)o Segmental weakness (corresponding to the level of compression)Sensory loss (limb and/or trunk)Lhermitte’s sign Gait disturbancePain is a common reason to seek treatment. Musculoskeletal pain might be present in the neck, while neuropathic pain can affect upper and lower limbs and occasionally the trunk. Patients often report neck stiffness, at times without pain. A textbook case would describe gait dysfunction and bilateral hand impairment. Frequently not all symptoms are present. For example, pain might be absent and symptoms can be unilateral and vary in severity, even on a daily basis.The more consistent feature of DCM is the evolution of symptoms. Most patients describe symptoms that have been ongoing for months and getting worse.Symptoms might precede objective examination findings.Request an MRI scan of the cervical spine to detect cord compression  in suspeThe pathway to diagnosis varies depending on local services. In the UK, for example, many primary care physicians do not have direct access to MRI imaging and referral to neurology might be warranted.Often cord compression is an incidental finding and at least initially does not cause symptoms.Guidelines from AOSpineThe AOSpine series showed that decompressive surgery can halt disease progression and enable meaningful, albeit limited, recovery across a range of measures including pain, function, and quality of life.It is not possible to predict the long term outcome of surgery. Maximal recovery occurs at around 6-12 months. Residual symptoms beyond this are likely to be permanent and should be managed appropriately. Functional deficits are common, and include falls and reduced mobility, incontinence, depression, sleep deficits, and struggles with self-care, and often the most troublesome symptom is pain. Discuss with your patient that complete resolution of pain is unlikely. Neuropathic analgesia and anti-spasticity medication can be offered to manage the pain. Early referral to specialist pain clinics is often helpful.Ask patients to report any worsening or new symptoms or signs as untreated levels of the cervical spine might further degenerate and cause spinal cord compression.What features would prompt you to suspect DCM in a patient?How would you explain a diagnosis of DCM to your patient?Are you aware of the appropriate local pathways for arranging an urgent MRI scan for patients with suspected DCM?After reading this article, are there any aspects of imaging or referral that you would approach differently?This article was reviewed and endorsed by individuals experiencing DCM who were part of a committee at Myelopathy.org. The committee was keen to emphasise the possible prevalence of DCM and its long term effects, even after surgery. More specifically, it was involved in shaping the paragraph “What is DCM?”www.myelopathy.org) is the first organisation dedicated to raising awareness, providing information, and supporting research for DCM. It provides a forum for individuals to communicate their experiences of DCM and offers peer to peer support to patients. Reports of delayed and/or misdiagnosis are common, which result from a lack of awareness among frontline medical specialties, particularly primary care. The committee proposed an educational initiative, which included this article.Myelopathy.org (


Objectives: This prospective cohort study explored whether two distinguished sensory parameters predicted acupuncture effects in chronic pain patients; namely high temporal summation of pain (TS) indicating spinal synaptic facilitation as well as a low vibration detection threshold (VDT) indicating a loss of Aβ-fiber function.Methods: Pinprick induced TS and VDT were assessed by standardized, validated methods at the most painful body site and a pain free control site in 100 chronic pain patients receiving six acupuncture sessions as part of an interdisciplinary multimodal pain treatment (IMPT). Immediate change in pain intensity after the first acupuncture session (first treatment on the first day of IMPT) was assessed by the verbal rating scale . After 4 weeks of treatment, patients indicated in a questionnaire whether acupuncture had relieved pain immediately and whether it had contributed to overall pain reduction and well-being after IMPT.Results: Logistic regression analysis revealed an association between high TS at the control site and a reduction in pain intensity of at least 30% (VRS) after the first acupuncture (OR [95%-CI] 4.3 [1.6–11.8]). Questionnaire ratings of immediate pain relief after acupuncture were associated with high TS at the control site  and at the pain site (OR [95%-CI] 3.2 [1.2–8.9] any pain relief). Appraisals of the contribution of acupuncture to overall pain reduction and well-being after IMPT were not associated with TS. The VDT was not associated with any outcome.Conclusion: This explorative study provides first-time evidence that high TS, especially at a pain free control site, but not VDT, might predict immediate analgesic response to acupuncture in chronic pain patients. Thus, highly centrally sensitized chronic pain patients might respond particularly well to acupuncture. In the management of chronic pain it is crucial to identify effective treatments in order to minimize the patient's risk of further chronification and to reduce health care costs  is a sensory sign observed in various chronic pain conditions . Acupuncture was applied as the first treatment modality on the first day; meaning that effects of other therapies were excluded. The percentage change in pain intensity after this first acupuncture treatment was evaluated by the verbal rating scale (VRS). In addition, the subjectively perceived immediate pain relief experienced through acupuncture and its contribution to the overall pain reduction as well as to the general well-being during the whole 4-week treatment period was assessed by a patient questionnaire.TS and VDT were evaluated at the most painful site (PS) and a pain free control site (CS) before the first acupuncture treatment and were analyzed as predictors for the acupuncture effect. TS and VDT were also assessed at the last day of IMPT and are not subject of this publication.Recruitment of study participants was performed among chronic pain patients undergoing a multimodal pain treatment program, the Munich Outpatient Program in Complementary and Alternative Medicine (MOCAM) at the Multidisciplinary Pain Center at the Department of Anesthesiology, University Hospital of the Ludwig-Maximilians University of Munich, Germany. The MOCAM follows the national criteria for IMPT, combining education, physical exercises, relaxation and cognitive behavioral therapy. MOCAM also integrates complementary methods of Traditional Chinese Medicine  and classical naturopathy (poultices and packs). It is carried out in an outpatient setting. Recruitment period of this study was from 2013, 3rd June to 2015, 23rd February. Data acquisition was completed on 2015, 20th March.Inclusion criteria were age between 18 and 75 years, chronic pain condition (>3 months), command of the German language and written informed consent. General exclusion criteria were malignant, neurodegenerative or chronic inflammatory diseases. Patients suffering from pain in the hands were also excluded, because the dorsum of the dominant hand served as a pain free control site. Patients who had received less than six acupuncture treatments in the course of the MOCAM were retrospectively excluded. Patients were informed about conduct and purpose of the study in oral and written form after the introductory seminar of 75 min on the first day of the multimodal pain treatment program. Inclusion was performed after the subsequent coffee break in case that written informed consent was obtained.DÄGfA). Treatments are usually performed in a group setting and point localization, needling depth as well as type and strength of needle stimulation are chosen individually. The individual treatment regimens integrate elements of TCM based acupuncture and western acupuncture techniques. Treatments rely on a differentiation of symptoms according to ba gang as well as on differential point selection according to zang-fu in case of internal diseases or according the theory of qi, blood and fluids. In addition, treatment included meridian orientated choice of points according to the site of pain as well as microsystem and trigger points. Five to ten needles are inserted per treatment. Needling depth is on average 0.5–1 cm and needle stimulation is performed by up and down movement as well as twisting of the needle. Acupuncturists attempt to elicit deqi, but this is not mandatory. Electrical or laser stimulation devices are available, but were not used in any of the patients included in this study. With the needles in place patients relax for 20–40 min.The schedule of the MOCAM stipulates that participating chronic pain patients receive eight acupuncture treatments during the 4-week multimodal pain program. Study documentation included the number of treatments that were actually received. For the course of this study acupuncture was scheduled on the first treatment day as the first intervention. Acupuncture in the MOCAM is exclusively performed by experienced medical acupuncturists with at least 200 h of acupuncture training . According to recommendations of the US Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT)  during the waiting time before the first acupuncture treatment on the first day of the multimodal pain treatment program. Both sensory signs were determined at the most painful body site (PS) and at the dorsum of the dominant hand, which served as a pain free control site (CS). In headache cases, the temple was classified as the pain site. Measurements were performed according to the protocol for quantitative sensory testing (QST) designed by the German Research Network on Neuropathic Pain (DFNS)  was used. Patients were asked to rate the pin-prick evoked pain intensity on the VRS (0–100). First, the researcher applied a single pin-prick stimulus followed by a series of 10 pin-prick stimuli applied with a frequency of 1 Hz within an area of 1 cm2. WUR assessments were repeated three times per measurement site at intervals of at least 15 s. The WUR was calculated by division of the arithmetic mean of the three VRS ratings of the 10 stimuli by the arithmetic mean of the three VRS ratings of the single stimuli. This is indicated by the denotation [VRS-ratio], since the wind-up ratio is a dimensionless quantity.As a measure for TS, the pin-prick evoked wind-up ratio (WUR) was applied. The WUR represents the quotient of the pain intensity evoked by 10 pin-prick stimuli and the pain intensity evoked by one single pin-prick stimulus. For all measurements a pin-prick of 256 mN  which allows the application of vibration stimuli of 64 Hz. The continuously decreasing vibration amplitude can be read from a gauged scale ranging from 0 to 8 with an accuracy of 0.5 points. Patients were asked to notify the examiner as soon as their sensation of vibration stopped, and the corresponding amplitude was recorded. The final VDT value also represents the arithmetic mean of three measurements.The VDT was evaluated by the Rydel-Seiffer tuning fork , previous surgery (yes/no) and use of analgesics . Pain duration in months, the most painful body site as well as the average and maximum pain intensity  were assessed during the first study visit on the first treatment day.Sample size estimation was performed on the basis of reference data for the WUR provided by the DFNS which suppose a log-normal data-distribution  as well as in R version 3.5.2  to represent responders and non-responders. As recommended for analyses of pain data  and ROC-analyses.Logistic regression was used to assess confounder adjusted associations between the dichotomous outcome parameters representing acupuncture effects (dependent variables) and the VDT as well as the WUR at the control site and at the pain site (independent variables). Based on the neurophysiological considerations introduced above, VDT and WUR data were categorized before application as independent variables in the logistic regression models. We pragmatically chose the 33%- percentile for the VDT and the 66%-percentile for the WUR as cut-off values in order to identify patients with the highest WUR and lowest VDT. These cut-off values were verified by visual inspection of scatter plots of predictors against percent change in pain intensity  as well as correctly specified cases (sensitivity & specificity) were used to describe the predictive value of the VDT and the WUR at the control site and at the pain site. Collinearity was assessed by the variation inflation factor (VIF). Effect modification was assessed by introduction of interaction terms in the final models. For additional graphical illustration , identified metric confounders were categorized with cut-off values identified by the receiver operating characteristic (ROC-) analysis.Assessed confounders included age, gender, pain duration, pain related surgery before participation in the multimodal pain treatment and intake of analgesics. First, the crude associations of acupuncture effects and patient characteristics were assessed in an exploratory analysis. Subgroups formed according to the different dichotomous outcome variables were compared for metric variables by Mann-Whitney-U test and for categorical variables by Fisher test. Subsequently, final logistic regression models were identified by automated covariate selection using the R-function Of 171 screened patients 116 met the inclusion criteria and gave written informed consent. Of these 16 were excluded from the analysis. A late detection of exclusion criteria accounted for exclusion in 12 cases. Three patients had received less than six acupuncture treatments during the multimodal treatment program for organizational reasons, and one patient discontinued the acupuncture treatment after experiencing a strong vegetative reaction during the first session. Four patients did not attend the follow-up visits for personal reasons .n = 42). Migraine or other headache syndromes (G43.- or G44.-) were present in 21, arthropathies (M00–25) in 18 and disorder of the trigeminal nerve (G50.-) in 12 patients. The most frequent mental and behavioral diagnoses were mood or affective disorder (F30–39) present in 34 patients. The most frequently reported area of the main pain problem was the lower back (25%) followed by the neck and cervical-spine area (22%), the shoulder-arm region (10%), the head (9%) and the area of the thoracic spine (8%).Patient characteristics of the 100 patients available for analysis are displayed in p < 0.001).Pain intensity as evaluated by the VRS (0–100) was significantly reduced after the first acupuncture treatment when compared to baseline (median (IQR) 30 (10–50) vs 45 (30–60), 30) and 25 (26.6%) of at least 50% (Resp50) after the first acupuncture treatment as evaluated by the VRS (0–100).Six patients had no pain on the first day of MOCAM and were therefore excluded from responder rate calculations. Of those suffering from pain on the first day of the multimodal pain treatment, 38 (40.4%) experienced a pain reduction of at least 30% (RespThirty seven patients (38.5%) reported that they had experienced an immediate pain relief through acupuncture in the questionnaire filled in after the end of the 4 weeks of treatment. Twenty-four patients (25%) affirmed that acupuncture had reduced their pain immediately by over 50%. Subjective rating of the contribution of acupuncture to the overall pain relief over the whole 4-week treatment period was positive in 52 cases (54.7%). Seventeen patients (17.9%) perceived acupuncture to be responsible for an overall pain relief of over 50%. Seventy-five patients (80.6%) experienced a beneficial effect of acupuncture on general well-being.TS was similar at the control site and at the pain site with a median WUR (IQR) of 1.9 (1.3–3.0) and 2.0 (1.5–3.1), respectively. Insensitivity to pin-prick stimuli (VRS rating of 1 stimulus with 0) leading to missing values of the WUR were observed in one patient at the control site and in two patients at the pain site. In two patients TS assessments at the pain site could not be performed due to strong hyperalgesia.Median VDT at the control site was 8.0 with an IQR of 7.0–8.0 indicating a ceiling effect . At the pain site median VDT was 5.4 (IQR 4.0–6.6).30) or 50% (Resp50), subjective perception of acupuncture effects as assessed by the questionnaire—immediate pain relief, immediate pain relief of over 50%, contribution to overall pain relief after 4 weeks of treatment, overall pain relief over 50% and contribution to overall well-being (p = 0.050). Patients who had reported an immediate pain relief of over 50% were even more demarked form the remaining patients in terms of a higher TS at the control site (median WUR (IQR) 2.5 (1.6–4.4) vs. 1.6 (1.3–2.9); p = 0.029). In addition, there was a trend toward higher TS at the pain site in patients with an immediate reduction in their pain intensity after the first acupuncture treatment of more than 50% (Resp50) as evaluated by the VRS (p = 0.085). Conversely, patients with and without acupuncture effects differed neither with regard to the VDT at the control site nor with regard to the VDT at the pain site (p > 0.05).Comparisons of TS and the VDT at the control site and at the pain site were performed between patient subgroups formed according to the different dichotomous outcome variables: reduction of the pain intensity as evaluated by the VRS after the first acupuncture treatment over 30%  as evaluated by the VRS than in patients not responding to the first treatment . The proportion of patients with high TS at the control site was also larger among those who subjectively rated the immediate pain relief through acupuncture as positive  or even over 50% . High TS at the pain site was merely associated with the report of an immediate pain relief through acupuncture of over 50% in the questionnaire . In addition, a ROC-analysis confirmed the WUR cut-off of 2.5 for all outcomes. Both a low VDT at the control site ( ≤ 7.7) and a low VDT at the pain site ( ≤ 4.3) were equally frequent in patients with and without acupuncture effects.Comparisons of frequencies of low VDT and high TS between patient subgroups with and without acupuncture effects  support p = 0.062). All 24 patients who had reported an immediate pain relief through acupuncture of over 50% in the questionnaire took analgesics, while 20.8% (15 out of 72) of patients who experienced less or no immediate pain relief after one of the acupuncture sessions were not on pain medication (p = 0.019). Patients of chronicity stage 2 and 3 as defined by the MPSS rated the contribution of acupuncture to their general wellbeing more frequently as positive than patients of chronicity stage 1 . Furthermore, older age was associated with immediate analgesic response to acupuncture. Patients with immediate, clinically relevant reductions in VRS pain scores were older than patients without such response (Resp30: mean (SD) 51.7 (9.4) vs. 46.4 (10.8) years, p = 0.005; Resp50: (52.8 (9.6) vs. 47.0 (10.6) years, p = 0.006). The subjective experience of an immediate pain relief through acupuncture of over 50% was also associated with older age (53.3 (8.4) vs. 46.3 (11.3) years; p = 0.010). A similar age trend was also observed between patient subgroups formed according to whether an immediate pain relief was experienced at all (50.8 (11.2). vs 46.3 (10.7) years; p = 0.063)  .p < 0.01 and H-L test > 0.07). There was no collinearity between explanatory variables (VIF <1.1). Explained variance according to Nagelkerkes R2 was between 18 and 25%. As identified by automated covariate selection, age was the only additional significant explanatory variable. Effect modification by any patient characteristic was not observed. Specificity of prediction (80–94%) was usually larger than sensitivity (13–55%).Logistic regression confirmed the positive association of high TS at the control site as well as at the pain site with an immediate reduction in pain after acupuncture and identified age as a relevant confounder  at the control site had a 4.0  times higher chance that their pain intensity was reduced by at least 30% after the first acupuncture treatment. With each year of age the chance to belong to the Resp30-subgroup increased by 8% . The model correctly classified 55% of responders and 80% of non-responders.Model 1 describes the association between a high TS at the control site and the outcome Resp50) and a high TS (WUR > 2.5). However, when subgrouping patients according to an age cut-off identified by a ROC-analysis (53 years), the cumulative response function (There was no significant association between a reduction in pain intensity after the first acupuncture treatment of over 50% (Respfunction  shows a p = 0.007) times higher odds in patients with a high TS (WUR > 2.5) at the control site. With every year of age the likelihood of such positive appraisal of the immediate analgesic effect of acupuncture increased by 6% . Specificity was slightly higher (86%) and sensitivity lower (36%) than in model 2.Model 2 indicates that the subjective experience of an immediate pain relief through acupuncture was reported with a 3.8  times more likely to report such strong immediate analgesic response. The influence of age was larger when compared to the other final models . With 78% the percentage of correctly classified cases was also high when compared to the other models. Specificity was 94%, while sensitivity was lower than in the other models (26%).The association between a subjective immediate pain relief of over 50% after one of the acupuncture sessions with a high TS at the control site is described by model 3. Patients with a WUR of over 2.5 at the control site were 5.5  times. The odds was further increased by 7%  with every year of age. As in model 3, specificity was as high as 94% while the sensitivity of 13% was the lowest among all models.According to model 4, a high TS (WUR > 2.5) at the pain site increased the chance to experience an immediate pain relief of over 50% after one of the acupuncture treatments by 3.2  and the vibration detection threshold (VDT) as predictors for acupuncture effects. The results support the hypothesis that high TS might predict response to acupuncture in chronic pain patients with regard to immediate effects. The presumed association of vibration detection with acupuncture effects was not ascertained.A WUR over 2.5 indicating elevated TS at a pain-free control site and at the most painful body site increased the likelihood to experience immediate analgesic effects through acupuncture by three to five times. This suggests that in chronic pain patients in whom spinal synaptic transmission is facilitated acupuncture may be particularly effective for immediate pain relief. This appears plausible considering that immediate analgesic acupuncture effects are mainly mediated by bottom-up and top-down mechanisms which reduce spinal transmission Zhao, . These iIncreased TS has been shown to be associated with the efficacy of drugs i.e., Ketamin  in fibromyalgia  indicating descending pain control. Acupuncture has been shown to activate descending pain control mechanisms, but it has not yet been investigated whether CPM predicts acupuncture effects, or whether a lack in CPM can be reestablished by continuous acupuncture treatment.Strong central sensitization reflected by high TS, in particular at pain free control sites, seems to predict the immediate analgesic response to acupuncture. Clinically spoken, acupuncture could be especially effective in highly sensitized chronic pain patients.Study conduct was in accordance with the Declaration of Helsinki formulated by the World Medical Association [updated version, Seoul  for an oral presentation of the results presented in this manuscript at the congress of the International Council for Acupuncture and Related Techniques (ICMART) in June 2017. PB and DI receive honorarium and travel costs from non-profit academic organizations, physician chambers and universities for teaching and lecturing. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Wearable long-duration low-intensity ultrasound is an emerging non-invasive and non-narcotic therapy for the daily treatment of musculoskeletal pain. The aim of this randomized, double-blind, placebo-controlled study was to examine whether long-duration low-intensity ultrasound was effective in treating pain and improving function in patients with knee osteoarthritis.n = 55) or placebo (n = 35) devices applied daily to the treated knee. Investigators and subjects were blinded to treatment groups. Ultrasound  was applied with a wearable device for 4 h daily for 6 weeks, delivering 18,720 J per treatment. The primary outcome was change in pain intensity  assessed prior to intervention (baseline) and after 6 weeks. Secondary outcomes of functional change were measured at baseline and after 6 weeks using the Western Ontario McMaster Osteoarthritis Questionnaire (n = 84), along with range of motion  and isometric muscle strength  tests on the injured knee in a small pilot subset (n = 17).Ninety patients with moderate to severe knee pain and radiographically confirmed knee osteoarthritis (Kellgren-Lawrence grade I/II) were randomized for treatment with active (p < 0.0001), compared with a 0.85 points reduction for placebo (p = 0.13). The functional score was also significantly improved by 505 points for the active group over the 311-point improvement for placebo group compared to baseline (p = 0.02). In the pilot subset evaluated, rotational strength increased from baseline to 6 weeks ; however, no other measures were significant.The study had a 93% retention rate, and there were no significant differences between the groups regarding demographic variables or baseline outcome measures. Patients treated with active therapy observed a significant mean NRS pain reduction over the 6-week study of 1.96 points for active (Long-duration low-intensity ultrasound significantly reduced pain and improved joint function in patients with moderate to severe osteoarthritis knee pain. The clinical findings suggest that ultrasound may be used as a conservative non-pharmaceutical and non-invasive treatment option for patients with knee osteoarthritis. Additional research is warranted on non-weight bearing joints of the musculoskeletal system as well as extended treatment time frames and follow-up.https://clinicaltrials.gov/ct2/show/results/NCT02083861NCT02083861, registered 11 March 2014,  Osteoarthritis (OA) is a serious and debilitating health problem affecting more than 27 million Americans and is a common work-related injury simulated by repetitive stresses . ArthritThe most frequent treatment for OA is prescription painkillers and anti-inflammatory medications . SeriousUltrasound treatment has been utilized in the medical setting with minimal safety risks for the symptomatic management of OA pain for many years; however, the clinical efficacy of office-based ultrasound remains controversial. In 2010, a Cochrane review determined that ultrasound may provide clinical value for knee OA patients by reducing pain and improving function and quality of life and that larger-scale clinical trials were justified . More re. Our study utilized sustained acoustic medicine (SAM), a United States Food and Drug Administration approved (2013) prescription use wearable multi-hour ultrasound device to investigate the efficacy of long duration ultrasound in treating osteoarthritic pain and disability. Validated measures of OA pain, stiffness, function, and strength were used to determine effectiveness.The aim of this randomized double-blinded placebo-controlled study was to determine whether a wearable home-use long-duration daily low-intensity ultrasound therapy is an effective treatment option for patients with knee osteoarthritis symptomsn = 55) or placebo (n = 35) SAM device. Patients subsequently self-applied the respective treatment 4 h per day for 6 weeks to the lateral and medial arthritic knee. Measurements of pain were recorded in a daily patient diary, while functional measurements were completed during clinic visits. The study was approved by the institutional review board of Schulman Associates, and all patients provided informed consent to participate. The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2000.This prospective randomized, double-blinded, placebo-controlled, study was conducted in the USA and registered with ClinicalTrials.gov identifier NCT02083861. Patients meeting inclusion criteria, and who successfully completed 2 weeks of baseline pain measures were randomized 3:2 for a 6-week treatment with active  grade I/II ) in one Exclusion criteria included having presence of severe knee OA (KL grade III); having had a knee replacement, surgical intervention, or hyaluronic acid injection in the affected knee in the previous 6 months; being a non-ambulatory patient; being unable to self-apply the device to their knee; having current treatment with corticosteroids; or having had osteoarthritis develop secondary to a metabolic disorder.n = 90). A small pilot cohort was assessed for clinic-administered range of motion and muscle strength at the end of the baseline period (n = 17). Then, patients were randomized using a computer-generated random number list into either the active group, in which they received an active wearable device, or the placebo group, in which they received a device that functioned and appeared like the active device but did not emit ultrasound energy (deactivated transducers provided by the manufacturer). Treatment arms were balanced by age, sex, and BMI. Treatment allocation was concealed from the clinic and research staff enrolling patients and performing data entry for analysis. Study patients, the investigator, research assistants, and study staff were blinded to the intervention.Pain scores were recorded three times each day in a paper diary during the 2-week baseline period (weeks 1–2). Upon completion of baseline data, patients were asked to meet with clinical site staff to review data entry into the diary. WOMAC scores were obtained at the end of the baseline period for all subjects continuing to the treatment protocol . Patients were permitted to continue use of pain medications as long as those medications were maintained at a stable dose throughout the trial. Co-interventions were not assessed in this study. Ultrasound was self-administered in the home-setting with a wearable US Food and Drug Administration (FDA) approved 2013) class II prescription medical device SAM® Sport . The device was self-administered 4 h per day, 7 days per week for 6 weeks. The device operates at 3 MHz in continuous wave mode and delivers 1.3 W output power divided evenly across two transducers. The average ultrasonic intensity from each transducer is 132 mW/cm3 class IThe primary outcome was weekly change in pain intensity relative to baseline through 6 weeks of therapy, as measured on the numeric rating scale (NRS) . The NRS pain scale has been validated for consistency and reliability to assess pain associated with a variety of conditions, including OA . Patientn = 17) of sequentially enrolled patients using computerized dual inclinometry range of motion and muscle tester equipment . To assess range of motion, one inclinometer was positioned on the quadricep muscle at mid femur and the other at mid-tibia. Patients were asked to lay flat on their back and lift their leg and flex at the knee to measure flexion. Patients were then asked to sit at the edge of the table and extend their leg to measure extension. To assess muscle strength, a manual muscle tester was used. Patients were asked to sit at the edge of the table with their knee at approximately 90 degrees. The manual muscle tester was positioned and held at anterior mid tibia while patients were asked to extend their leg to measure extension strength. To measure flexion strength, the muscle tester was held at anterior mid-tibia and the patient was asked to flex at the knee. Each range of motion and muscle strength test was repeated three times and the average was recorded.Secondary outcome measures assessed were change in WOMAC score for pain stiffness and function, range of motion, and muscle strength assessed at baseline and the end of the study. Range of motion and strength measurements were acquired by trained clinic staff on a small pilot cohort , week 3 (treatment randomization), week 5 (patient follow-up), week 7 (patient follow-up), and week 8 (study completion). During follow-up visits, the research staff reviewed the patient’s daily pain diary, addressed any questions the patient had about using the device or being involved in the study, and monitored for any adverse events  or reactions  from the device.t tests were used to analyze other demographic and outcome data. Data analysis was conducted in the R software environment for statistical computing . Data are expressed as means ± SDs (standard deviations). Statistical significance was achieved with p values less than 0.05.Chi-squared proportional assessment was used to assess gender demographics between groups, and n = 93), 90 were randomized into two ultrasound intervention groups (n = 55 active and n = 35 placebo). A total of n = 51 active and n = 33 placebo completed 6 weeks of therapy resulting in a 93% retention rate for the intervention.A total of 114 patients were screened; 93 patients enrolled, and 90 patients were randomized into active or placebo groups Fig. . Ten patThe patient demographics for treatment intervention are shown in Table p = 0.04) SAM device (Table p = 0.13).There was a significant reduction of pain from baseline to the end of 6 weeks of therapy favoring activate low-intensity ultrasound treatment. Pain was reduced by 1.96 points for active, which was significant compared to 0.85-points reduction for placebo  and 311 points for placebo (p = 0.0002) after 6 weeks of intervention (Table p = 0.02). For WOMAC pain, the change of 107 points in the active group was significantly greater than that in the placebo group of 60.8 points (p = 0.02). For WOMAC stiffness, the change in the active group of 45 points was again significantly greater than that in the placebo group of 17 points (p = 0.002). For WOMAC function, the change in the active group of 352 points was significantly greater than the 220 points of the placebo group (p = 0.03).The WOMAC score measuring pain, stiffness, and function was significantly improved for active SAM by 505 points .JTECH range of motion and strength measurements of the treated leg for active and placebo SAM are shown in Table p < 0.001). Additionally, pain, stiffness, and function (WOMAC) improved significantly for patients with KL grade I/II knee OA treated with active SAM over the placebo group .The wearable SAM device can be successfully administered for use in the home setting under the monitoring of a healthcare professional familiar with low-intensity ultrasound devices. This non-pharmacological therapy shows high patient compliance and significantly improves symptomatic management of patients with KL grade I/II knee OA. In this study, 84 of 90 patients completed the SAM intervention phase (93% retention). The six patients who did not complete the study was a result of damage to the device (3), skin irritation (2), and no follow-up (1). Active SAM significantly reduced knee pain on average by 1.96 points after the 6-week intervention period , reducing the need for intensive training of the patient. Furthermore, the wearable, patient-applied, multi-hour treatment does not interfere with the normal daily activity of the patient.There are several similarities and differences worth noting between the wearable SAM device and other low-intensity ultrasound devices. The frequency and power of operation are within the same clinically utilized range of low-intensity ultrasound: between 1 to 3 MHz and 0.1 to 1.3 W. However, the total energy delivered by SAM was 18,720 J per 4-h treatment in this study, which is 133 times greater than most low-intensity therapy sessions which deliver 140 J per 20-min treatment. Monitoring of SAM device use and adherence to the study protocol was accomplished through in-office visits every 2 weeks. Wearable SAM ultrasound was well tolerated by the patients. In approximately 3528 unique treatment sessions with the device, two skin irritations were reported (less than 0.1%), and no significant safety risks or adverse events found.The SAM device is not the only prescription (1 to 3 MHz) wearable low-intensity ultrasound therapy device available in the USA. Another device that provides 20 min of daily low-intensity ultrasound at 1.5 MHZ  was approved by the FDA in 1994. The use of wearable ultrasound may be considered as a non-pharmaceutical and non-invasive home-use treatment option for patients with moderate to severe osteoarthritis pain. The intervention could be particularly meaningful for arthritis patients who are not candidates or exploring non-invasive alternative options to prescription NSAIDs and narcotics, viscosupplements, or surgical procedures.Future research on daily applied long-duration ultrasound shows promise to treat not only symptomology of osteoarthritis but perhaps the disease progression itself following joint injury or age-related degradation , 19. TheLong-duration low-intensity ultrasound significantly reduced pain and improved joint function in patients with moderate to severe osteoarthritis knee pain. WOMAC scores were significantly reduced in the active ultrasound group including assessments for joint function. ROM and strength data collection limited the statistical power of findings here, and larger sample sizes may corroborate with WOMAC functional assessments. The clinical findings suggest that low-intensity ultrasound may be used as a conservative treatment option for patients with knee osteoarthritis. Additional osteoarthritis studies are necessary to determine the efficacy and compliance of long duration ultrasound use in other joints such as the spine.


There is a paucity of literature regarding the implementation of enhanced recovery after surgery (ERAS) protocols for open lumbar spine fusions. We implemented an ERAS program for 1–2-level lumbar spine fusion surgery and identified areas that might benefit from perioperative interventions to improve patient satisfaction and outcomes.This institutionally approved quality improvement (QI) ERAS program for lumbar spine fusion was designed for all neurosurgical patients 18 years and older scheduled for 1 or 2 level primary lumbar fusions. The ERAS bundle contained elements such as multimodal analgesia including preoperative oral acetaminophen and gabapentin, postoperative early mobilization and physical therapy, and a prophylactic multimodal antiemetic regimen to decrease postoperative nausea and vomiting. No fluid management or hemodynamic parameters were included. Pre-ERAS and post-ERAS data were compared with regard to potential confounders, compliance with the ERAS bundle, and postoperative outcomes.p = 0.025). Post-ERAS patients required fewer rescue antiemetic medications in the recovery room compared to pre-ERAS patients (40 to 24%). There was no significant difference in postoperative pain scores or hospital length of stay between the two groups.A total of 230 patients were included from October 2013 to May 2017. The pre-ERAS phase consisted of 123 patients, 11 patients during the transition period, and 96 serving as post-ERAS patients. The pre-ERAS and post-ERAS groups had comparable demographics and comorbidities. Compliance with preoperative and intraoperative medication interventions was relatively good (~ 80%). Compliance with postoperative elements such as early physical therapy, early mobilization, and early removal of the urinary catheter was poor with no significant improvement in post-ERAS patients. There was no significant change in the amount of short-acting opioids used, but there was a decrease in the use of long-acting opioids in the post-ERAS phase (14.6 to 5.2%, Implementing an ERAS bundle for 1–2-level lumbar fusion had minimal effect in decreasing length of stay, but a significant decrease in postoperative opioid and rescue antiemetic use. This ERAS bundle showed mixed results likely secondary to poor ERAS protocol compliance. Going forward, this QI project will look to improve post-operative ERAS implementation to improve patient outcomes. Back pain and spinal disorders are one of the most commonly encountered medical problems facing the healthcare system. Approximately two thirds of the population will suffer from low back pain (LBP) at some point in their lifetime, and it is estimated that the USA spends over $100 billion annually in direct and indirect costs related to LBP  and decrease perioperative morbidity. Kehlet first introduced the enhanced recovery model in 1997 as a multimodal, evidence-based plan to improve patient care in the perioperative period Kehlet . To dateThis ERAS QI protocol was implemented at Stony Brook University Hospital in Stony Brook, New York, after receiving institutional approval. The program included neurosurgical patients 18 years and older planned to undergo a 1 or 2 level lumbar spinal fusion. This QI project excluded patients who were pregnant, age < 18, or planned for a revision of a previous fusion.The departments of neuroanesthesia and neurosurgery at our institution worked together to review neurosurgery spinal fusion cases to identify interventions that would address unmet postoperative patient care goals. The protocol was divided into preoperative, intraoperative, and postoperative interventions. While some of the bundle elements were already common practice for lumbar fusion procedures at our institution and were included in the ERAS protocol, there was no standardized care bundle for all lumbar fusion patients. Table Among the gaps of the existing care protocol, patient communication was observed to be an important issue to address since some patients were receiving inconsistent recommendations concerning medications to be taken on the day of surgery, and expectations following surgery varied between patients. It was also found that patients with chronic pain were not identified prior to surgery, and there was a need for better pain management postoperatively for all patients. Earlier involvement of physical therapy and social work was another area for improvement to decrease delays in mobilization and discharge. To address these issues, our goals included: improving preoperative patient education, decreasing case cancelations, decreasing hospital LOS, decreasing PONV, decreasing postoperative pain, and decreasing postoperative opioid use.To improve patient communication, a standardized education packet was given to patients in the neurosurgical clinic prior to surgery. This included information about the surgery, expectations, support services, management of diabetes, and smoking cessation among other things. To decrease case cancelations, the neurosurgery office administrative staff had an increased role in communicating with the surgeon and operating room staff to ensure proper scheduling of cases and to notify care providers of the need to adhere to the ERAS protocol. At preoperative services, education was reinforced and patients underwent a laboratory workup, history and physical prior to surgery. As a means to decrease PONV, all patients were scheduled to receive dexamethasone 8 mg IV after induction of anesthesia, and for patients with more than 2 risk factors  were identified through the electronic medical record (EMR) and included patients who underwent 1–2-level lumbar fusion surgery between October 23, 2013, and September 9, 2015. A transition phase after the ERAS protocol was started lasted from September 10, 2015, to November 5, 2015. During this transition phase, staff and physicians were educated on the protocol and became familiar with its steps to improve compliance. Regular meetings of all ERAS team leads and members were held. The entire ERAS protocol was made available in the EMR to be used as a reference when needed, and reminders were integrated into the intraoperative anesthesia EMR. After the transition phase, post-ERAS patients underwent surgery between November 9, 2015, and May 3, 2017.All preoperative, intraoperative, and postoperative data were collected from the EMR for both the pre-ERAS and ERAS groups and entered into a database. We followed patients for up to 1 year from their surgical date. This report includes data collected from the preoperative period through patients’ first postoperative visit within 30 days of discharge from the hospital Table .Prespecified quality metrics included the number of case cancelations, the incidence of postoperative nausea and vomiting (PONV), opioid usage, postoperative pain, and length of stay. The protocol planned to use rescheduled cases as a measure to track case cancelations. Length of stay was determined based on a patient’s admission time and discharge time as recorded in the EMR for the encounter number that correlated to the surgical admission for lumbar fusion. PCA use and all other analgesic medications used were recorded for postoperative day 0 through postoperative day 3, at which time it was expected that a majority of patients would be discharged. Medication use at each postoperative visit was also recorded. Patient pain was measured based on an 11-point numerical pain rating scale (NPRS) in which patients rate their pain ranging from 0 (no pain) to 10 (worst imaginable pain). The NPRS has been shown to be effective at showing pain improvement in patients with low back pain when the NPRS shows a difference of greater than 2 points  performed all statistical analyses. Categorical variables were computed using the Monte Carlo simulations of exact Overall, 230 eligible surgical patients were included. There were 123 patients in the pre-ERAS group (23-month period), 11 patients in the transition phase (2-month period), and 96 patients in the post-ERAS group (18-month period). The pre-ERAS and post-ERAS group patients were not significantly different with regard to potential confounders such as demographics and comorbidities except for the rate of obstructive sleep apnea . Prior to ERAS, 93% of patients were already receiving a PCA so the slight increase to 94.8% was not surprising.Compliance with the ERAS bundle was mixed Table . On the p = 0.0125) decrease in the administration of rescue antiemetics in the recovery room for nausea (40% pre-ERAS versus 24% post-ERAS) . Postoperative pain scores were similar in both groups. The NPRS at the post-discharge follow-up visit was also not statistically different between the two groups.After the implementation of ERAS, we observed a statistically significant p = 0.012 decreaseOur results did show a small improvement in the incidence of PONV and a decrease in the use of long-acting opioid, but no differences in postoperative pain, short-term opioid use, and length of stay were found.Patient care often lags behind the most recent evidence-based practice recommendations. The ERAS movement was started to improve efficiency, reduce morbidity, improve patient experience, and decrease cost. Our spine ERAS QI protocol was implemented to improve post-operative patient care and surgical outcomes similar to what has been done with ERAS in other surgical specialties.There are few reports of ERAS in spine surgery, with most publications focusing on the implications and feasibility of implementing a spine ERAS program (Wainwright et al. By focusing on improved communication between the clinic staff, surgeons, anesthesiologists, and operating room scheduling staff, we hoped to decrease delays and case cancelations. We attempted to measure case cancelations by determining which lumbar fusions had been rescheduled, but we found that this was unreliable due to case cancelations that occurred for unrelated reasons such as illness and other patient factors. It should be mentioned that the neuroanesthesiologists and neurosurgeons remarked that after the ERAS implementation, patients were better prepared on the day of surgery, and there were fewer delays due to problems with surgical consents, waiting for labs, retrieving missing preoperative evaluations, and medication histories.Pain control was another focus of the ERAS protocol. Our ERAS protocol included oral non-opioid medications preoperatively to help reduce opioid needs postoperatively. The acute pain service was to be made aware of all high-risk pain patients, and they were to receive ketamine 30 mg IV with the induction of anesthesia. All patients were to receive a PCA postoperatively, and 1500 mg of methocarbamol in the PACU for early pain control. Gabapentin, celecoxib, and acetaminophen were also added to the postoperative pain regimen which is reflected in the increased number of patients on anti-convulsant medications in the postoperative period. A multimodal approach to pain treatment has been shown to decrease postoperative opioid use and decreased time to mobilization in spine surgery (Mathiesen et al. PONV is often a problem in patients following surgery. In addition to the regular antiemetic regimen that is given to most patients including intraoperative ondansetron, the ERAS protocol included dexamethasone 8 mg after induction and oral aprepitant for high-risk patients preoperatively. Despite a small increase of 4 to 27% compliance between the pre- and post-ERAS patients receiving dexamethasone intraoperatively and only 2 patients receiving aprepitant in the post ERAS group, there was still a significant decrease in the patients requiring a rescue antiemetic in the recovery room. With improved compliance, this may improve further in the future.Decreasing LOS helps to reduce costs and is an important outcome measure in many enhanced recovery protocols (Gustafsson et al. New ERAS protocols not only focus on specific perioperative interventions by surgeons and anesthesiologists, but they have expanded to focus on preoperative patient education, building more effective team care models, improving patient satisfaction, and improved discharge planning. Our ERAS protocol focused on some of these expanded ideas to improve patient education and interdepartmental teamwork. Preoperative patient education has become an important part of improving patient care perioperatively. Educating patients about expectations postoperatively can improve postoperative patient satisfaction and decrease patient morbidities and pain scores after lumbar surgery (Archer et al. Some of the limitations of this study include a single institution, and it was a non-randomized, non-blinded project with historical patients identified from a record search of the EMR. Compliance from nursing, surgical, and anesthesia teams in following the protocol was also suboptimal which is reflected in the intervention compliance. There are many barriers to implementing ERAS protocols such as ineffective communication among team members, patient non-compliance, staff turnover with the need for continued education, and physician and staff non-compliance. This is not unique to this ERAS project and has been shown in other studies as well (Kahokehr et al. Despite the limitations, we were able to successfully implement the spine ERAS protocol at our institution with improvement in some aspects of patient outcomes. The care of the lumbar fusion patients intraoperatively has become more standardized, and perioperative teams have become more familiar with the protocol and compliance has continued to improve. This early data showing decreases in PONV and long-acting opioid use is also promising as we continue to move forward with this project. This study also demonstrates the areas where implementations are most challenging for ERAS QI projects. Future studies can focus on these areas for further compliance improvement.In our study, the ERAS protocol was associated with a decrease in the incidence of postoperative nausea, a shorter duration of opioid use and a decrease in long-acting opioid use. It also improved communication among the perioperative team and improvement in patient education preoperatively. However, it did not result in clinically significant reductions in LOS, decreased postoperative pain scores, or decreased short-acting opioid use. Moving forward, we have implemented steps and education to improve adherence to the protocol, in particular improving the timeliness of postoperative physical therapy and social work assessment of patients.