To assess incidence and characteristics of post-laparoendoscopic single-site donor nephrectomy (LESS DN) testicular pain.  A prospective comparative study of all male donors post-left LESS DN (group A) vs. postopen nephrectomies (group B) was performed at our center. Patients' demographics, perioperative data, and postoperative consultation reports were reviewed. Testicular pain, swelling, numbness, urinary symptoms, and sexual dysfunction were evaluated. Patients with a history of scrotal pathology or surgical procedure were excluded. Pain and tenderness were scored on a standard 10-point scale.  From September 2017 to December 2020, 85 and 35 male patients of groups A and B met the evaluation criteria. Ipsilateral testicular pain developed in 11 patients (15.3%) and 2 patients (9.5%) in groups A and B, respectively. In most instances, the pain was mild to moderate in severity, started after 6 ± 2.1 and 4 ± 1.1 days postoperatively in groups A and B, respectively. Six patients in group A were evaluated with transscrotal ultrasonography that showed no abnormalities. All patients in both groups responded well to medical treatment.  Post-LESS DN ipsilateral testicular pain is usually mild and self-limited. Preoperative patient education and discussion of the possibility of development of testicular pain and its management should be an integral component of laparoscopic donor nephrectomy informed consent. Laparoscopic donor nephrectomy (LDN) is currently considered a well-established kidney procurement technique. The main reasons for that are the rate of open nephrectomy (ODN) major complications ranging from 1% to 5%, a higher rate of minor complications from 13% to 30%, and a mortality rate of 0.03% , 6, 7, wGjertson CK et al. described the post-LDN testicular pain as mild, self-limited, and often emerged with direct questioning; this finding seemed consistent and recurrent . There aA single-center prospective comparative study was conducted, including male patients who underwent left LESS DN (group A) and ODN (group B) performed between Sept 2017 and Oct 2020 at Armed Forces Hospital Southern Region, Khamis Mushayt, to assess postoperative orchialgia. All patients consented to participate in the study. Patients' demographics and perioperative data were collected. The local institutional ethical committee approved the study. Patients with a history of scrotal pathology, testicular pain, or surgical procedure were excluded.A full detailed description of our LESS DN and ODN operative techniques was mentioned in our previous article . The ODNTM Maryland jaw device from Medtronic) and the ureter  was conducted above their junction with the iliac vessels. Between days 3 and 5, patients were discharged with the same analgesic medication.In ODN, the gonadal vein was ligated distally at the junction with the renal vein. Additionally, the proximal division of the gonadal arteries , testicular swelling, numbness, urinary symptoms, and sexual dysfunction. As recommended by the National Institute of Health (NIH), the standard 10-point numeric rating scale assesses postoperative pain. Zero indicates a complete absence of pain, and ten is severe. Complete relief of pain was considered when the score reached zero.t-tests, respectively. The statistical significance level was set at p ≤ 0.05, and all p values presented were two-sided. Continuous data were described as means and standard deviations, whereas categorical data were presented as proportions and percentages.Data were entered into an SPSS 27.0 spreadsheet . To compare categorical and continuous variables, we utilized chi-squared and Student's During the study period, a total of 85 male patients post-LESS DN (group A) and 21 post-ODN (group B) met the study inclusion criteria. Patients' characteristics and perioperative data are given in P value ≤0.250), respectively. In most instances, the pain was immediate onset, started after 6 ± 2.1 and 4 ± 1.1 days postoperatively in groups A and B, respectively. The pain was mild to moderate in severity in 82%, and 100% of patients with the mean visual analogue scale score was 4.7 ± 2.1 and 2.1 ± 1.2 in groups A and B. Moreover, the pain subsided after 3 ± 1.1 and 1 ± 0.6 months in groups A and B. Six patients  were evaluated with transscrotal ultrasonography that showed no abnormalities. 73% and 100% of patients responded to paracetamol in groups A and B, respectively. Ipsilateral scrotal swelling was found in groups A and B in 3 patients (4.2%) and 1 patient (4.7%), respectively. Fortunately, all swellings subsided completely with conservative management. In group A, ipsilateral scrotal and thigh numbness, pain during intercourse, and the number of medical consultations for testicular symptoms are observed in 4, 3, and 6 patients. Ipsilateral testicular pain developed in 11 patients (15.3%) and 2 patients (9.5%) in groups A and B  should be referred to chronic pain management specialists to assess neuropathic pain and provide appropriate treatment .To prevent postoperative testicular pain after laparoscopic hand-assisted nephrectomy, several researchers proposed preserving the gonadal vein and ligating it at the confluence of the renal vein , 15. SurIt is necessary to provide preoperative patient education and complete informed consent to define the risk of postoperative testicular events. Furthermore, patients should be adequately counseled postoperatively to manage mild pain with nonopioid analgesic (if required) and consult if they suffer unusual pain, such as sudden, severe, or long-lasting pain, or if analgesic failed .The main limitation of this study is the small imbalanced sample size of patients. Moreover, detection bias and overestimation of complaints rate could not be excluded. However, we recruited all patients who met the study inclusion criteria.Post-LESS DN ipsilateral testicular pain was generally mild and self-limited. However, patients should be informed about orchialgia risk during the predonation medical discussion.


TTR) gene mutation with a late-onset phenotype.Pain is a common symptom of hereditary transthyretin amyloidosis (ATTRv), however, its occurrence in late-onset ATTRv has not been investigated thoroughly. Our aim was to describe the pain experience and its impact on quality of life (QoL) in symptomatic patients and presymptomatic carriers harboring a transthyretin  were collected.Study participants (aged ≥18 years) were consecutively recruited from four Italian centers. Clinical disability was assessed using the Familial Amyloid Polyneuropathy (FAP) stage and Neuropathy Impairment Score (NIS). The Norfolk questionnaire evaluated QoL and the Compound Autonomic Dysfunction Test assessed autonomic involvement. Neuropathic pain was screened using the Douleur Neuropathique 4 (DN4) questionnaire, and pain intensity and its impact on daily activity were assessed using the Brief Pain Inventory severity and interference subscores. Data on the type of TTR mutations (mean age ± SD 63.6 ± 13.5 years) were recruited, including 78 symptomatic patients (68.1 ± 10.9 years) and 24 presymptomatic carriers (49 ± 10.3 years). Pain was reported by 75.5% of all subjects, but was more frequent in symptomatic patients than in presymptomatic carriers . Pain exhibited neuropathic features (DN4≥4) in 69.2% of symptomatic patients and in 8.3% of presymptomatic carriers. Subjects with neuropathic pain were older (p = 0.015) had worse FAP stage (p < 0.001), higher NIS scores (p < 0.001), greater autonomic involvement (p = 0.003), and a lower QoL (p < 0.001) than those without neuropathic pain. Neuropathic pain was associated with higher pain severity (p < 0.001) and had a significant negative impact on daily activities (p < 0.001) Neuropathic pain was not associated with gender, mutation type, TTR therapy, or BMI.Overall, 102 subjects with Approximately 70% of late-onset ATTRv patients complained of neuropathic pain (DN4≥4) that worsened as peripheral neuropathy progressed and increasingly interfered with daily activities and QoL. Notably, 8% of presymptomatic carriers complained of neuropathic pain. These results suggest that assessment of neuropathic pain may be useful to monitor disease progression and identify early manifestations of ATTRv. The mutated TTR tetramer dissociates in misfolded monomers that accumulate in tissues such as the heart and peripheral nervous system (PNS), leading, respectively, to cardiomyopathy and progressive axonal peripheral neuropathy  is a progressive multisystem disorder caused by mutations in the uropathy . PNS invuropathy . Accordiuropathy : the earuropathy , has a puropathy .Several symptoms are reported by patients. The most frequent symptoms are pain, numbness, fatigue, and weakness  that subPain, including electric shock, tingling, pins and needles, burning, and itching sensations , is wideTTR gene mutation associated with the late-onset ATTRv phenotype.Consequently, the aim of this study was to describe the neuropathic pain experience, its frequency, and impact on QoL in symptomatic patients and presymptomatic carriers harboring a This multicenter study was conducted in four Italian centers with experience in the diagnosis and management of ATTRv . The study was approved by the local institutional ethics committee in each center.TTR mutations. Carriers, who had normal nerve conduction, were identified as carrying a TTR gene mutation in the setting of genetic familial counseling (Study participants (aged ≥18 years) were consecutively recruited and included both symptomatic patients and presymptomatic carriers with known pathogenic unseling .Subjects were excluded from study if they had concomitant disease  in which pain could represent a relevant feature.Age at enrolment, gender, mutation type, ATTRv therapy, pain killers, body mass index (BMI), and the presence of cardiomyopathy were recorded.Symptomatic patients and presymptomatic carriers underwent an extensive neurological evaluation, and several scales were applied to assess disease stage  , neuropaThe presence of pain and its distribution  was recorded. The Douleur Neuropathique 4 (DN4) questionnaire was used to establish if pain had neuropathic features (DN4 ≥4) . The BriT-test was used to compare continuous variables between subjects with neuropathic pain (DN4 ≥4) and those without neuropathic pain (DN4 < 4). Pearson's chi-square test was used to compare categorical variables between these groups. When significant differences were detected (p < 0.05), post-hoc analyses of categorical variables through adjusted standardized residuals with Bonferroni-corrected p-values (p ≤ 0.006) were calculated in order to identify which cells of the contingency table contributed most to the significant effect  for numerical variables and percentage for categorical data. After verifying the Gaussian distribution of variables through the Kolmogorov–Smirnov test, the Student's t effect . AnalyseTTR mutations (mean age ± SD 63.6 ± 13.5 years) were recruited, including 78 symptomatic patients (68.1 ± 10.9 years) and 24 presymptomatic carriers (49 ± 10.3 years). Most symptomatic patients had a disease severity of FAP 1 (sensory neuropathy) or FAP 2 . Demographic and clinical findings are summarized in In total, 102 subjects with Pain was reported by 75.5% of all subjects, but was more frequent in symptomatic patients than in presymptomatic carriers . The distribution of pain was predominantly generalized or distal in symptomatic patients, whereas presymptomatic carriers reported distal pain or pain in the lower or upper limbs. Neuropathic pain (DN4 ≥4) was reported by 69.2% of symptomatic patients and 8.3% of presymptomatic carriers. These patients reported more frequently electric shock (66.7%) and less frequently burning (54.3%) and painful cold (52.6%) sensation. The pain was typically associated with tingling and numbness (91.2%) and less frequently with pins and needles (63.2%) and itching (31.6%) sensation. Reduced touch and pinprick sensation was present in the 82.5 and 68.4% respectively, whereas the allodynia phenomenon was reported only in the 49.1% of patients suffering from neuropathic pain.p = 0.015) and had more severe disease  and neuropathic impairment  than subjects without neuropathic pain (DN4 < 4). The presence of neuropathic pain was associated with significantly greater autonomic involvement  and lower QoL  compared with no neuropathic pain  (p < 0.001) and had a significant negative impact on daily activities  (Significantly more subjects with neuropathic pain had cardiomyopathy than those without neuropathic pain (= 0.005) . The pre< 0.001) .Neuropathic pain was not associated with gender, mutation type, TTR therapy, or BMI .Neuropathic pain was treated in 82.4% of subjects, most frequently with anti-seizure drugs (63.8%) like pregabalin or gabapentin. Seven subjects were treated with NSAIDs, 3 with opioids, 1 with antidepressants, 1 with local steroidal injection, and 4 with combination therapy. Patients reported a satisfactory pain relief (>50% on the item BPI_8) in less than half of cases (45.9%), whereas 40.5% of patients referred persistent pain despite the therapy (< 30% on the item BPI_8).Pain is a common symptom in ATTRv  and impaTTR-mutated subjects encompassing both symptomatic patients and presymptomatic carriers. We showed here that ~70% of symptomatic patients experienced neuropathic pain (DN4 ≥4) with a length-dependent distribution. The pain was mainly characterized by electric shock associated with tingling, numbness and reduced touch sensation. All these features are consistent with a prominent involvement of larger myelinated A-β fibers , had a lower QoL (Norfolk questionnaire), had significant autonomic involvement (CADT), and were more likely to have cardiomyopathy. Accordingly, we propose that neuropathic pain in ATTRv worsens as disease progresses and increasingly impacts patients' QoL.This suggests that a thorough assessment of pain is important to define an optimal treatment regimen. In addition, careful pain investigation may offer relevant information to clinicians for monitoring disease worsening or to assess multisystem involvement .N = 2) of presymptomatic carriers reported neuropathic pain. Both subjects were young women (aged 33 and 40 years at enrolment) and carriers of the Glu89Gln variant. Neither reported dysautonomic (CADT=16) or neuropathic (NIS= 0) symptoms, whereas both complained of a mild impact in QoL (Norfolk = 33 and 10).Interestingly, we found that 8%  had not received any symptomatic treatment for neuropathic pain. Moreover, patients receiving painkillers did not achieve significant pain relief in about 40% of the cases. In the late-onset ATTRv phenotype, pain and its treatment could be overlooked if clinicians are more focused on motor disability.TTR gene mutation. The DN4 questionnaire is a reliable screening tool to identify, with high specificity, the presence of neuropathic pain (TTR gene mutation.In conclusion, clinicians should not neglect the pain experience when evaluating ATTRv patients or presymptomatic relatives who carry a hic pain . As painThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Local Ethical Board University of Naples Federico II of Naples. The patients/participants provided their written informed consent to participate in this study.ST contributed to the acquisition, analysis and interpretation of data for the work, drafted, and revised the work. ML, GA, AM, and MN contributed to the acquisition, interpretation of data for the work, and revised the work. DS, AD, LL, MR, AR, FF, and LG contributed to the acquisition of data for the work and revised the work. CM contributed to the conception and design of the work and revised the work. FM contributed to the conception and design of the work, interpretation of data for the work, and drafted and revised the work. All authors gave final approval for the final version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.


Response to prior caudal block is a positive predictor of successful adhesiolysis.Adhesiolysis is minimally invasive and commonly used for pain associated with adhesion after lumbar spine surgery. Caudal epidural block may be used for radiating pain due to failed back surgery syndrome. We evaluated the predictive value of response to caudal block performed prior to adhesiolysis in failed back surgery syndrome. Between January 1, 2013 and June 30, 2020, 150 patients with failed back surgery syndrome were treated with adhesiolysis using a steerable catheter at the pain clinic of a tertiary hospital after failed conservative treatment . Patient demographics, pain duration, and lumbar magnetic resonance imaging findings were examined. Response to previous caudal block was determined as a binary result (yes or no). Patients were followed up 3 months after adhesiolysis. Successful outcome was defined as a ≥2-point reduction in the numeric rating scale scores for radicular pain 3 months after adhesiolysis, evident in 81/150 (46%) patients. Multivariable logistic regression analysis revealed that caudal block response was an independent predictor of successful adhesiolysis (odds ratio = 4.403;  Failed back surgery syndrome (FBSS) refers to a situation in which the surgical outcome is suboptimal compared with the expectation of the patient and the clinician before the surgery, because the back or radiating pain persists even after the spine surgery The pathophysiology of FBSS is complex Though the contribution of fibrosis in the origin of pain has been debated, caudal epidural injection and adhesiolysis are the most commonly applied interventions among the non-surgical methods for treating chronic pain in FBSS According to the ASIPP guidelines https://cris.nih.go.kr/cris/index.jsp, KC20RISI0917). The need for obtaining patient consent was waived owing to the retrospective nature of the study and the assessment of only the formal electronic medical records of the patients. We reviewed the medical records of patients diagnosed with FBSS and who had undergone adhesiolysis using a steerable catheter from January 1, 2013 to June 30, 2020, at the pain clinic of a tertiary hospital.This retrospective study was approved by the institutional review board of the Seoul St. Mary's Hospital, KC20RISI0665 and was conducted in accordance with the ethical principles of the Declaration of Helsinki. This study has been registered on CRIS  patients aged at least 20 years; (2) patients diagnosed with FBSS based on magnetic resonance imaging (MRI) who reported concordant leg and/or back pain; (3) patients with a leg pain duration >3 months; and (4) patients with leg pain severity of ≥4 on an 11-point numerical rating scale (NRS) after receiving conservative treatment, including oral medication and physical therapy. The following were excluded: (1) patients with other possible causes of symptoms ; (2) patients with malignancy or bleeding tendency; and (3) patients who were lost to follow-up before the third month of the procedure. Finally, 150 patient charts were selected and reviewed.Caudal epidural block was performed in a sterile environment at an outpatient clinic. Ultrasonography was used, and the participants were instructed to lie in the prone position. After sterile preparation, lidocaine was locally infiltrated around the sacral hiatus. Thereafter, the epidural space was accessed with a 22G Tuohy needle, and the exact needle tip position was confirmed by ultrasonography. Then, a mixture of 20 mL of 0.2% lidocaine, 5 mg dexamethasone, and 1500 IU hyaluronidase  was injected through the needle. After the procedure, neurological examination of the patient was performed to confirm the absence of any complication, and the patient was shifted to the recovery room. The patient was recalled for an outpatient visit 2 weeks or a month later, and the doctor inquired whether the caudal block showed any effect, even for a short duration. The patient's answer was obtained from the medical record as a binary result (was the pain reduced compared to the pre-treatment pain? Yes/No). If the effect of reduction in pain scores by more than half using the caudal block could be maintained for more than 3 months, the patient's pain was determined to be effectively controlled by repeating the caudal block. When the analgesic effect for caudal block was insufficient, adhesiolysis was considered as the next step when the pain scores were reduced by less than half or the duration of pain reduction was shorter than 3 months. We divided the cohort group with insufficient response to the caudal block into two groups according to the response degree and duration. If the pain reduction was less than half or more than half but the duration was less than 3 months, patients were considered as 'Yes'. In contrast, patients who did not show any other pain reduction were classified as 'No'. Even in patients who had undergone caudal block several times previously, 'the response to the previous caudal block' was determined based on the response to the caudal block performed closest to the time of the adhesiolysis.Adhesiolysis was performed under fluoroscopic guidance in a sterile operating room with constant monitoring of blood pressure, pulse rate, and oxygen saturation. The patient was instructed to lie in the prone position, and a pillow was placed under the abdomen to minimize the possibility of lumbar lordosis. The fluoroscope was adjusted over the lumbosacral area such that the caudal approach could be used in both the anteroposterior and lateral views. Local infiltration of 1% lidocaine was performed after accurately determining the needle insertion site around the sacral hiatus. A small incision was made at the needle insertion site, and an introducer was inserted into the epidural space through the sacral hiatus using a 15G Tuohy needle. Approximately 3 mL of contrast medium was injected and an epidurogram was obtained to confirm the correct location of the needle in the epidural space. A steerable catheter was inserted through the introducer after the removal of the Tuohy needle under fluoroscopic guidance. One of three types of steerable navigation catheters  was used, and the catheter was selected according to the operator's preference. The target level of adhesiolysis was determined in advance by considering the location of the filling defect, patient's symptomatic dermatome, and lumbar MRI findings. When the catheter tip reached the target level, 3 mL of contrast medium was injected to identify the filling defects by examining the flow of the contrast medium into the nerve roots. Adhesiolysis was performed by pushing, pulling, and rotating the catheter near the target area. During this step, the patient may experience pain in the same location as he/she may have experienced preoperatively. After mechanical manipulation, 3 mL of diluted contrast medium was injected to confirm whether satisfactory filling was obtained epidurally and at the targeted nerve root. Then, a mixture of 10 mL of 1% lidocaine, 5 mg dexamethasone, and 1500 IU hyaluronidase  was divided and injected separately into each target. In the event of suspected complications, such as dura mater puncture, the procedure was stopped immediately. Thereafter, neurological examination was performed, and the patient was discharged from the hospital only after repeated normal test results.We obtained clinical data pertaining to age, sex, body mass index, duration of symptoms in the past month, intensity of radiating leg pain as quantified using the NRS, per oral opioid use, and past medical history. Radiographic and MRI findings were reviewed to evaluate the severity of lumbar spinal stenosis, presence of spondylolisthesis, and past surgery history . The severity of stenosis was graded according to the standard classification The NRS was used to compare the intensity of leg pain between pre-treatment and 3 months after treatment. The NRS represents no pain as 0 and the worst pain imaginable as 10. Patients were categorized according to their response to adhesiolysis after 3 months as follows: (1) Patients in whom the NRS score decreased by 2 points as compared to the pretreatment score were defined as responders; (2) patients who required increasing dosages of opioids in the follow-up period of 3 months were defined as non-responders; (3) patients who received lumbar radiofrequency ablation or were treated using spinal cord stimulators after neuroplasty were defined as non-responders; and (4) patients referred to the department of surgery were also defined as non-responders. According to these definitions of response, patients were categorized into responders and non-responders, 3 months after the procedure.p values less than 0.05 were considered statistically significant. The paired t test was used to compare the NRS pain scores between pre- and post-procedures. Binary logistic regression techniques were used to quantify the relationship between successful outcomes and patients' clinical and demographic characteristics. To determine the independent positive prognostic factors of the procedure, multivariable logistic regression analysis was performed for statistically significant variables determined via univariable analysis using the enter method. All data were analyzed using SPSS version 24.0 .Patient characteristics (continuous variables) were compared between the groups using the Student t-test or Mann-Whitney U test. Categorical demographic data were analyzed using the Pearson chi-square test or Fisher's exact test. We reviewed the medical records of 150 patients who had undergone adhesiolysis from January 1, 2013, to June 30, 2020. The basic demographic data of the 150 patients and the clinical data for non-responders and responders 3 months after adhesiolysis are shown in Table p = 0.039) and response to previous caudal block (p = 0.026) were associated with successful outcome of adhesiolysis. Milder was the degree of foraminal stenosis, greater was the pain reduction evident 3 months after the procedure if a response to previous caudal block was evident. In patients with mild foraminal stenosis, the success rate of adhesiolysis at 3 months was 56.4%: 40.6% in those with moderate foraminal stenosis and 28.6% in those with severe. The grade of central stenosis showed no significant relationship with the effect of the procedure (p = 0.428).Table Baseline NRS pain scores were not significantly different between the responder and non-responder groups (p = 0.778).Table No complications were observed during the caudal block. However, 13 cases of suspected dura puncture were evident during adhesiolysis. Three patients complained of temporary discomfort immediately after the procedure but showed improvement within 2 days. No patient required any further treatment. There was no case of severe neurologic complications such as motor weakness.The results of our study showed that if NRS pain score for radiating pain was reduced by caudal block performed prior to adhesiolysis even for a short-term period, a successful outcome to adhesiolysis after 3 months is more likely. This is meaningful as this is the first report to show an association between the responses to adhesiolysis and caudal block.The results of this study suggest the possibility of a common mechanism of action for caudal block and adhesiolysis. FBSS can have multiple etiologies. We hypothesized that in patients who had received caudal injection without any response, facet or sacroiliac joint dysfunction could be the main cause of the pain; hence, subsequent adhesiolysis would not have any effect. Although it is clear that caudal block and percutaneous adhesiolysis are different procedures, there are some similarities. The caudal block targets multiple spine levels at the same time to permit the diluted local anesthetic to reach the target site, and adhesiolysis removes the deleterious effects of scar formation, followed by target delivery of a diluted local anesthetic. Additionally, lidocaine prevents sensitization of the sympathetic arc, has anti-inflammatory effects, and blocks the axonal transport of nerve fibers FBSS with prominent radicular symptoms was the subject of our study. Axial low back pain in FBSS is partially non-neuropathic pain, whereas radicular symptoms associated with FBSS could be neuropathic p = 0.052), probably owing to the retrospective design of the study.Additionally, grade of foraminal stenosis might also be independently associated with successful response 3 months after adhesiolysis. The variable showed a marginal significance (There are several limitations to our study. First, the follow-up period is short. Therefore, the power of the study may be low. Second, the retrospective study design is associated with greater researcher bias than the prospective design. Third, we did not include a placebo group. However, even if normal saline is injected instead of lidocaine, mechanical adhesiolysis is inevitable. Therefore, a sham group could not be formed owing to the characteristics of the study. Fourth, ultrasonography was used during caudal injection. In the clinic where the study was conducted, caudal injection is commonly performed, but owing to time constraints, it is not performed fluoroscopically. Therefore, we had to perform ultrasound-guided caudal injection. According to the 2021 ASIPP guideline FBSS is a complex pathophysiological entity that requires a multidisciplinary approach


Background: In contrast to other breast surgeries, modified radical mastectomy (MRM) with axillary lymph node clearance involves intense tissue dissection, with postoperative seroma formation and pain being the major complaints affecting patients. Among these, 40% of females experience acute postoperative pain, and between 25 to 60% develop persistent chronic postsurgical pain. The rationale of this study was that minimally invasive procedures can result in immediate pain relief in patients undergoing mastectomy, which has been proven to satisfy their needs and lead to early discharge in the local population.Objective: This study determined to find out the efficacy of instilling bupivacaine on wounds by means of surgical drains in controlling pain after MRM.Methodology: This was a randomized control study trial that was carried out in Surgical Unit 1, Ward 3, Jinnah Postgraduate Medical Centre, Karachi, from November 2020 to April 2021. All patients tested negative for coronavirus disease 2019 (COVID-19) by PCR test before randomly allocating them into two groups. Thirty women in Group B received 40 ml of 0.25% injection bupivacaine, and 30 in Group C received no drug. Duration of analgesia was recorded as time in hours when the patient was received after surgery in the post-anesthesia care unit until the patient felt ache and discomfort of > three scores according to the visual analog pain score chart (VAS).Results: The average age was 52.48±4.76 years. The mean period of time during which analgesia was observed was significantly higher in Group B as compared to Group C .Conclusion: There is improvement in postoperative analgesia after instilling bupivacaine through surgical drains on wound beds in MRM patients. Around the world, breast cancer is now acknowledged as the most prevalent cancer among females. The estimated incidence of breast cancer was 20% which has risen drastically since 2008, while mortality has escalated by 14%. One in every four females dies due to breast cancer . In variAmong these, 40% of the females experienced acute postoperative pain, and between 25 to 60% developed persistent chronic postsurgical pain . Tissue The rationale of this study was that minimally invasive procedures can result in immediate pain relief in patients undergoing mastectomy, which has been proven to satisfy their needs and early discharge in the local population. This will eliminate pain with the least side effects and at a minimal cost. The entire household chores of our community depend on females. If they have no discomfort after the operation, they will have a rapid recovery and return early to domestic responsibilities. This study will also help the medical community by reducing the number of admissions due to pain after mastectomy, early discharge, and reduction in the use of narcotics for pain relief such as morphine and fentanyl and their adverse effect on patients. The aim of this study is to determine the efficacy of bupivacaine instillation through surgical drains on a wound bed in controlling postoperative pain after MRM by comparing the mean duration of analgesia.After informed consent, 60 female patients aged between 45 to 60 years with the American Society of Anesthesiologists (ASA) physical status classification system I or II (Appendix II), undergoing unilateral MRM with axillary lymph node dissection were involved in this study. This was a randomized controlled trial (RCT) study with a probability random sampling technique. This study was conducted in Surgical Unit 1, Ward 3, Jinnah Postgraduate Medical Centre, Karachi, from November 2020 to April 2021. After approval was received from the Ethical Review Board (NO.F.2-81/2020-GENL/44820/JPMC) dated July 22, 2020, data collection commenced.All patients were tested for coronavirus disease 2019 (COVID-19) via nasal swab, and only those with negative PCR results in the last 48 hours were included. Pregnant females, any allergy to the local anesthetic drug, patients with weight less than 30 kilograms, those with known diabetes and having uncontrolled sugar levels with a fasting blood glucose level of more than equal to 110mg/dl, known hypertensive with a systolic blood pressure of more than equal to 140 mmHg, those with having ejection fraction of less than equal to 40% with ischemic heart disease and forced expiratory volume 1 to be less than equal to 70% of the normal in patients with pulmonary disease as per history and clinical record were excluded. History of long-term usage of the oral pain killers for more than one month, those with blood loss of more than one blood volume within 24 hours around 70ml/kg, and excess continuous blood collection into the drains were not included in the study.Patients were planned for MRM after detailed history, clinical examination, ultrasound or mammographic findings, and biopsy. Those patients who had carcinoma on histopathology and fulfilled the inclusion criteria underwent MRM. They were preoperatively randomized into two designated groups by lottery method. Group B (bupivacaine receiving patients) received 40 ml of injection bupivacaine 0.25%, 20 ml through each axillary and chest wall drain, and Group C (control) had no instillation.Patients were taught before the operation about the visual analog scale  to assess their postoperative pain. All routine investigations were taken strictly before surgery. Once in the operating room, IV was secured with an 18-gauge cannula sited under aseptic measures in the non-dominant hand, and 500 ml of Ringer's lactate preload was done. All standard monitoring, i.e., ECG, non-invasive blood pressure (NIBP), and arterial blood gas (ABG), was obtained throughout. Standard general anesthesia was induced with injection propofol with a dosage of 2mg/kg, and the opioid (injection fentanyl with a dosage of 2μg/kg) was administered. On completion of the surgical procedure, two drains were placed. One drain was placed in the axillary region, and the other one in the chest wall over the pectoral muscle was placed before closing the incision.Group B patients were the study group who received bupivacaine. The drains were kept nonfunctional by clamping them for a short 10 min time and released afterward to allow the bupivacaine to run from positive pressure into the negative pressure redivac drain. Neuromuscular blocking agents neostigmine and glycopyrrolate were used to reverse the anesthesia. Post-extubation patients have transferred to the recovery room for post anesthesia vital monitoring and pain control management. Duration of analgesia was calculated in hours starting when the patient was received in the recovery room till the patient felt the pain of score >3 according to the Visual Analogue Pain Score chart (VAS). Pain score at 0 hours was noted after extubation and subsequently every fourth hour by a trained resident for 24 hours. Similarly, Group C patients' span of analgesia was recorded without the instillation of a drug through the VAS scoring chart. All the data was noted and recorded in the attached proforma, along with the demographic details of the patient. All the general anesthesia was given by the same consultant. All MRMs were performed by the same surgeon and team to eliminate biases, and all confounding variables were controlled through exclusion criteria.SPSS version 25  was used to analyze and compute the collected data. A sample size of 60 was calculated with 96% power of the test on a 95% confidence interval while taking the expected mean duration of postoperative pain relief in patients undergoing MRM to be 14.6±9.6 h vs 4.3±5.2 hours in the bupivacaine and control group respectively . NumericA total of 60 women who underwent MRM were randomly assigned into two groups. In Group B 30 women received 40 ml of 0.25% injection bupivacaine, 20 ml through each axillary and chest wall drain, and 30 women in Group C received no instillation. The average age distribution was 52.48±4.76 years Figure . ASA-I wIn particular, in this study, the test suggests that there is a marked difference in the duration of analgesia within Group B and Group C with a p-value below 0.005 Figure . MRM is a procedure that involves extensive dissection of the chest wall, removing entire breast tissue with the overlying skin and nipple along with axillary clearance. It comes as no surprise that such extensive tissue dissection leads to both intraoperative and postoperative pain of similar magnitude . The paiAs per the WHO analgesic ladder guidelines for pain management , multiplMultiple studies conducted around the globe have shown the increased requirement of opioids for pain control post mastectomy, especially in those patients who underwent bilateral mastectomy and then early breast reconstructive procedures, when compared with other breast surgeries -15. AlthIn a prospective RCT, the resulting instillation of 0.25% injection bupivacaine via surgical drains inpatient undergoing MRM showed better analgesia in the postoperative period compared to the control group with no intervention done. We found that the mean time period of pain relief was much higher in Group B when compared to Group C (10.93±1.84 hours vs 5.03±1.35), supporting the hypothesis that there is a difference in the meantime period of analgesia in patients undergoing MRM with wound treated with bupivacaine. Our results are supported by Chhatrapati et al., with the duration of analgesia found to be much longer in their bupivacaine group with a p-value of <0.0001 [Alhussini et al. found that there was a marked decrease in VAS in the first 24 hours postoperatively in the bupivacaine group. Subsequently, the use of the analgesic drug was also reduced . LikewisAnother study by Wang et al. used a similar technique of infiltrating ropivacaine 4, long-acting local anesthesia with comparable anesthetic effect to bupivacaine but better safety profile , in the Patel et al. resulted from the indifference of the ropivacaine group and control of total tramadol consumption (P < 0.0001) with the duration of analgesia (P < 0.0001) . They stStudy limitationsThe occurrence of seroma and hematoma formation in the surgical wound, postoperative hemodynamic monitoring, infection in the wound, and patient body mass index were some of our limitations. We only compared with control and not any other local anesthetic drug. The duration of analgesia could be further prolonged if the continuous analgesic drug were infused through surgical drains. In this regard, new studies should be conducted using infusion catheters with different local anesthetics agents. There was no record of chronic pain on follow-up after discharge, and further work can be done to look for possible long-term effects of wound instillation with local anesthesia.Instillation of the wound with injection bupivacaine via surgical drains after MRM with axillary lymph node dissection offers better postoperative pain relief and decreases the need for oral and intravenous pain killer requirements. Moreover, patients perform well after surgery and recover rapidly postoperatively without the need for costly drugs. Thus, this technique should be used routinely in MRM surgeries.


Its recurrence causes hemophilic arthropathy, characterized by chronic joint pain. Watching movement recorded from a first-person perspective and immersively can be effective in the management of chronic pain. The objective of this study was to evaluate the effectiveness of an immersive virtual reality intervention in improving the pain intensity, joint condition, muscle strength and range of motion in patients with hemophilic knee arthropathy. (2) Methods: Thirteen patients with hemophilic knee arthropathy were recruited. The patients wore virtual reality glasses and watched a flexion–extension movement of the knee on an immersive 180° video, recorded from a first-person perspective over a 28-day period. The primary variable was the pain intensity . The secondary variables were the joint status , quadriceps and hamstring strength (dynamometry), and range of motion (goniometry). (3) Results: After the intervention period, statistically significant differences were observed in the intensity of the joint pain , joint condition  and quadriceps strength . We found that 38.46% and 23.07% of the patients exhibited an improvement in their quadriceps muscle strength and joint condition above the minimum detectable change for both variables . (4) Conclusions: One hundred and eighty degree immersive VR motion visualization can improve the intensity of joint pain in patients with hemophilic knee arthropathy. An intervention using immersive virtual reality can be an effective complementary approach to improve the joint condition and quadriceps strength in these patients. Hemophilia is a rare disease linked to the X chromosome. It affects 1:10,000 live births. From the pathophysiological point of view, it is characterized by the absence or deficiency of any of the clotting factors. In hemophilia A, clotting factor VIII is missing, while in hemophilia B, the deficiency is related to factor IX .The recurrence of bleeding events in the same joint causes progressive joint degeneration from an early age ; this isThe gold standard in the treatment of hemophilia for the prevention of hemarthrosis and hemophilic arthropathy is the prophylactic administration of blood clotting concentrates  or, moreFrom a neurobiological point of view, pain is a warning system that serves to protect us from potential damage . This syThe therapeutic approach, in connection with pain modulation from the cerebral response and not from peripheral information, has developed a hands-off model in the treatment of pain and, especially, chronic pain . TherapiSimilarly, the greater the immersion and the reality perceived by the brain, the greater the effect. Therefore, immersive virtual reality (VR) from a first-person perspective can help the patient to feel part of the immersive experience, being a valid option in the approach to patients with pain ,18.The aim of this study was to evaluate the effectiveness of an immersive virtual reality intervention in improving the intensity of joint pain, the joint condition, muscle strength, and the range of motion in adult patients with hemophilic knee arthropathy.A prospective, multicenter pilot study was developed in adult patients with hemophilic knee arthropathy. The aim of this pilot study was to evaluate the changes after an immersive virtual reality intervention.Patients with hemophilia were recruited in September 2021 from the Hemophilia Associations of Galicia and Malaga and the Spanish Federation of Hemophilia. The study took place between September 2021 and January 2022.The inclusion criteria of the study were (i) subjects being over 18 years of age; (ii) with a diagnosis of hemophilia A or B; (iii) with a severe hemophilia phenotype (<1% of FVIII/FIX); (iv) with a medical diagnosis of hemophilic knee arthropathy  ; (v) patwww.clinicaltrials.gov; ID: NCT04549402).The main researcher informed the patients about the potential risks and benefits of the study. Subsequently, the patients received an information sheet listing all the characteristics of the study. All subjects signed the informed consent document before being included in the study. The study was conducted in accordance with the Declaration of Helsinki. The study was approved by the Clinical Research Ethics Committee of the Virgen de la Arrixaca University Hospital (ID: 2020-2-9-HCUVA). Prior to the recruitment of patients, the research project was registered  and clinical variables  of the patients recruited in the study were collected.Two evaluations were performed: pretreatment (T0) and at the end of the intervention (T1). The primary variable was the intensity of the knee joint pain. The knee joint condition, quadriceps and hamstring muscle strength, and range of motion were the secondary variables. All assessments were performed by the same physiotherapist, with years of experience in the evaluation and treatment of patients with hemophilia, blinded to the study’s objectives.The intensity of the perceived pain was evaluated using the visual analog scale . This scThe joint condition was evaluated using the Hemophilia Joint Health Score . This scMuscle strength was measured with a pressure dynamometer  . PressurKnee ROM was assessed with an analog goniometer . This inBefore starting the study, a pilot study was carried out to calculate the evaluator’s intraobserver reliability. Reliability in assessing the joint condition, muscle strength, and range of motion was assessed. Six patients with hemophilia, not included in the study, were evaluated on two consecutive days. An excellent intraobserver reliability was obtained in the variables joint status (CHF = 0.982), and the muscle strength in the quadriceps (CHF = 0.903) and hamstrings (CHF = 0.978), and was good for the range of motion in flexion (CHF = 0.790) and extension (CHF = 0.876) movements.® with access from the He-Mirror App®, designed for this study by the research group. After installing the mobile application on the patients’ cell phones, the mobile terminal was coupled to the virtual reality glasses. All patients were given the same model VR glasses, so they all underwent the same intervention with the same program and the same VR system. The patients had to be seated in a chair, with their feet relaxed and only resting on their heels. The intervention was performed for 28 consecutive days at home. The patients performed one daily session. Each session was 15 min long, uninterrupted, without any breaks. During each session, patients had to only watch the movement of both knees on the video, without imagining the movement or performing it. As the procedure was performed in a seated no-load and no-movement position, the patients were informed that even in the event of joint bleeding, they could continue with the intervention. The main study researcher regularly followed up on patients via telephone, clarifying possible doubts about the intervention or solving issues that may arise, encouraging the patients to persevere and adhere to the treatment. The intervention consisted of immersively visualizing the knee flexion–extension movement. For this purpose, a 180-degree immersive video in a first-person perspective was used. This video was viewed on the patient’s smartphone, regardless of the operating system. In order to view the video immersively, the smartphone was coupled to virtual reality glasses  [The sample size was calculated using the statistical package G*Power  before recruiting the patients. Assuming a large effect size (d = 0.80), with an alpha level (type I error) of 0.05 and a statistical power of 80% (1 − β = 0.80), a sample size of 12 patients was estimated. Accounting for potential dropouts during the experimental phase, a total of 13 patients with hemophilia and knee arthropathy were recruited.The statistical analysis was performed with the software SPPS, version 21.0 for Windows . The descriptive statistics (median and interquartile range) of the patients were calculated at the baseline. The changes between the pre- and post-treatment evaluations were calculated with the non-parametric Wilcoxon test. The minimum detectable change (MDC) was calculated with the standard error of measurement (SEM). The SEM was calculated with the formula: SEM = SDpre ∗ √1-intraclass correlation coefficient (ICC) . Based o2. The majority of patients had a diagnosis of hemophilia A (92.3%). All patients presented a severe hemophilia phenotype (<1% FVIII/FIX) and received prophylactic treatment. None of the patients developed knee hemarthrosis during the experimental phase as a result of the intervention. There were no adverse effects resulting from the intervention of this study. The median age of the patients was 37 (IR: 14.5) years with a median body mass index of 26.76 (IR: 6.74) kg/mp < 0.001), joint condition , and quadriceps strength . 95% CI = 2.53; 17.47; p = 0.012). When comparing the changes after the intervention period, statistically significant differences were observed in the variables for the intensity of the joint pain  calculated for quadriceps muscle strength . Changes in the joint condition  were greater than the minimum detectable change (1.79) in 23.07% of the patients included in the study. The aim of this study was to evaluate the changes in the pain intensity, joint condition, range of motion, and muscle strength in patients with hemophilic knee arthropathy after an immersive virtual reality intervention. After the intervention, we found improvements in the perceived pain intensity, joint condition, and quadriceps muscle strength. During the immersive virtual reality intervention, no patient included in the study developed knee hemarthrosis.Jin et al.  noted a Adult patients with hemophilia, such as those recruited in this study, have a wide experience of pain from their early childhood as a result of recurring hemarthrosis and arthropathy. It has been described that a change in pain intensity must represent at least two points on the visual analog scale to be clinically relevant . AccordiVillafañe et al.  observedLee et al.  reportedAccording to the findings of this study, we are optimistic about the suitability of this intervention in the therapeutic approach to patients with hemophilia. Its easy implementation, low cost, and daily home use promotes the democratization of this protocol, making it more accessible.This pilot study has certain limitations that must be considered. On the one hand, the small sample size limits the generalization of results, although there are a series of changes that must be considered. Multicenter randomized clinical studies with an adequate sample size could confirm the results reported in this study. Another limitation is that in this study, the intake of analgesic drugs was not measured and this may affect the intensity of the pain perceived by these patients. In the same way, changes in the functionality of these patients as a result of the intervention have not been evaluated. The evaluation of variables such as functionality, modifications in muscle contraction, and psychosocial variables would provide more information about this intervention and its usefulness in the approach to patients with hemophilic knee arthropathy.One hundred and eighty degree immersive VR motion visualization can improve the intensity of joint pain in patients with hemophilic knee arthropathy. Conducting daily immersive motion visualization sessions for 4 weeks can improve the joint condition and quadriceps muscle strength in patients with knee arthropathy. Randomized clinical trials with a larger sample size are needed to confirm the changes observed in this pilot study.


Bertolotti’s syndrome is one of the differential causes of low back pain, especially within young people. The etiopathogenesis of the typical paramedian low back pain, associated with Bertolotti’s syndrome remains controversial, and there is no worldwide acceptance of treatment.This article presents the authors experience with surgical treatment of symptomatic patients with Bertolotti’s syndrome.Retrospective study of a selected series of patients with symptomatic Bertolotti’s syndrome submitted to surgical treatment.This study included 16 patients, being 8 submitted to the new modified mini-open tubular microsurgical transverse processectomy, Among those patients, intraoperative fluoroscopy was used in 6 surgeries to locate the base of the enlarged transverse process (6/8); intraoperative neuromonitoring was used in 6 patients (6/8), 3D intraoperative advanced spinal image (O-arm) with neuronavigation was used to localize the base of the pseudojoint to be removed and to check the final bone resection for the last 5 cases (5/8).The average paramedian lower back pain before surgery on the visual analogue scale for pain in the 8 patients was 6.6 (range: 5–8) and reduced to 1.5 (range: 0–3) at the latest follow-up after surgery, while the average pain score of the radicular pain on the right or left side before the surgery was 1.3 (range: 0–6) and reduced to 0.6 (range: 0–7) after the surgery.The mini-open tubular microsurgical transverse processectomy seems to be potentially safe and effective for the surgical treatment of selected symptomatic patients with Bertolotti’s syndrome. Lumbosacral transitional vertebra (LSTV) is the most common congenital spinal vertebra anomaly at the lumbosacral junctional area, it can be associated with low back pain, but the majority of LSTV cases are asymptomatic.Low back pain (LBP) is a widespread complaint, it is a leading cause of activity limitation and absenteeism from work.The coexistence of the anomalous at lumbosacral junction and LBP was first described by Mario Bertolotti, Italian neurologist and radiologist, in 1917.–10.The reported prevalence of Bertolotti’s syndrome (BS) ranges from 5 to 30%, this wide range can be explained by using different image studies done for symptomatic patient with low back pain.,–14 or abnormal position of large blood vessels.,–17. Erken et al claim that the presence of a cervical rib might be a clue to the existence of sacralizatioof L5 or vice versa, while Nakajima et al proposed that there is a strong association between lumbar ribs and lumbarisation.LSTV and BS can be associated with other anatomical variations, like displacement of lumbosacral plexus position and subsequent change in nerve distribution, This article presents the authors experience with surgical treatment of symptomatic patients with BS.The etiopathogenesis of the typical paramedian LBP, associated with Bertolotti’s syndrome remains controversial, and there is no worldwide acceptance of treatment.Retrospective study of a selected series of patients (16 patients) with symptomatic BS submitted to surgical treatment. All included patients were initially submitted to a detailed clinical and imaging assessment  for the proper identification of the enlarged transverse process (TP) and the potential painful pseudoarticulation between the TP and sacrum, and to stablish the Castellvi radiographic classification system.Upon the diagnosis of BS, patients were submitted to conservative treatment for at least 6 months, including the use of analgesics and physical therapy, patients with chronic and significant paramedian low back pain, with or without radicular pain, and considering surgical treatment, the pseudojoint injection test was suggested. We injected only into the potential painful pseudoarticulation joint, in which the temporary improvement of the pain was considered essential for surgical indication, in which the temporary improvement of the pain was considered essential for surgical indication. All cases who underwent surgery to treat Bertolotti’s syndrome were included in this study, with or without another simultaneous lumbar surgery to treat associated disc disease, like microdiscectomy, decompression or fusion. The surgeries were performed by the same senior neurosurgeon author, during the period of 2017 until 2022.To confirm the diagnosis, the patients had injection into the malformed pseudojoint between the TP and sacrum, under fluoroscopy, using local anesthesia, 2 to 5 mL of lidocaine (2%), being pseudo joint localized with contrast injection, followed by injection of 10 mL of bupivacaine (0.5%) with 40 mg of Methylprednisolone in the pseudojoint. A temporary localized pain relief was considered a successful diagnostic test block. This was used as a mandatory test for indication for the surgery. As part of the team’s treatment algorithm, the injection was performed only at the pseudo-articulation, no other spinal injection was done 1 month apart from the diagnostic test block.Patient in prone position, on the Wilson frame attached to the spinal table, under general endotracheal anesthesia, prophylactic antibiotic, intraoperative neuromonitoring, full protection of the body, face-eyes, anti DVT (deep venous thrombosis) mechanical and warming devices were also used. Using fluoroscopy, the level of base of the malformed transverse process pseudo articulation was marked approximately 4 cm long paravertebral incision, ipsilateral to the malformed joint, around 4 cm from the midline Fig. . StandarL4, L5 or LSTV), posterior superior iliac spine (PSIS), or taped-fixed to the skin. The 3D intraoperative images with neuronavigation were useful to localize the base of the TP to be respected, and to check later if the bone resection was enough to completely disconnect the malformed TP from the potentially painful pseudojoint, keeping a bone cleft or a gap of at least 5 to 10 mm between the medial part of the TP (close to the pedicle) and the lateral disconnected part of the enlarged TP-pseudojoint, to avoid late bone reunion.Real-time 3D intraoperative images system combined with the neuronavigation was used in the most recent samples of the series (since August 2020), fixing the reference frame to the lumbar spinous process (+4 cm) was performed ipsilateral to the malformed joint, directly over the region of the pseudoarticulation, +4 cm from the midline . Tubular retractors aiming to the involved TP were assembled, which confirmed that the retractors were docked on the base of the malformed TP by fluoroscopy or O-arm with neuronavigation, and then the retractors were fixed to the operating room table  for the superficial part of the bone removal, and ultrasound bone scalpel  for the deeper part, to lessen the risk of nerve or vascular injury.The soft tissue was cleaned on the surface of the enlarged TP, exposing the base of the malformed TP to be partially resected. At this stage, the surgical loupe was replaced by a surgical microscope for the proper bone removal and disconnection of the enlarged TP-pseudojoint from the lumbar segment of the spine. It was used high speed drill  Fig. . Completnd postoperative day, taking oral analgesics, following general advices for wounds and postoperative spine care provided by the hospital team. The usual regular follow-up is on the 5th postoperative day to change the wound dressing later, at 1, 3, 6, and 12 months postoperatively.Washing inside the space with saline, bone wax is applied to the edges of the bone gap for haemostasis and to reduce the chance of delayed bone reunion. Vancomycin powder can be left intrawound (500 mg), closured by layers, and topical skin adhesive is applied on the skin, followed by the wound dressing. Patient can ambulate at the same day, whenever fully awake, and is usually discharged at the 2 16 cases  were classified as type II, 13 cases as II A, being 8 with the pseudoarticulation on the right side, 5 left on the side, and 3 cases as II B  , low back pain, with or without radicular symptoms, not responding to the conservative treatment. According to the Castellvi radiographic classification,n) Table .Among those 16 patients, 12 females and 4 males, with the average age of the patients at the date of surgery of 39.125 years (range 24–55 y.o.). The average follow-up after the surgery was 17 months (range: 3–36 months). Eight patients had isolated Bertolotti’s syndrome (which was the focus of this article), and the other 8 had another associated lumbar disorder requiring surgical intervention (Tables O-arm) with neuronavigation was used to localize the base of the pseudojoint to be removed and to check the final bone resection for the last 5 cases (5/8).A total of 11 mini-open tubular microsurgical transverse processectomy (MO-TMTP) were performed for 8 patients (8/16) with isolated BS, which was the focus of this article, as the patients had only BS, avoiding confounding factors due to the associated lumbar disease and extra surgical procedures in the remaining 8 patients (8/16). The surgical technique used for this homogenous group of patients was a new modified MO-TMTP, performed bilaterally in 2 cases and reoperation for 1 patient because the bone resection was incomplete, identified at the postoperative CT scan. Intraoperative fluoroscopy was used in 6 cases (6/8) to locate the base of the enlarged TP; IONM was used in 5 patients (5/8), 3D intraoperative advanced spinal image  lower back pain; 4 patients had radicular pain associated with paramedian lower back pain; 3 had type II A with ipsilateral radicular pain; and 1 had type II B with bilateral radicular pain  for pain in the 8 patients was 6.6 (range: 5–8) and reduced to 1.5 (range: 0–3) at the latest follow-up after surgery, while the average pain score of the radicular pain before surgery was (range: 0–6) and reduced to 0.6 (range: 0–7) after the surgery 1.3.Among those 16 patients, 2 intraoperative complications happened (2/16). One patient who had isolated BS had incomplete bone resection, leaving a small bridge of bone identified by a routine postoperative CT scan, for whom it was performed another surgery 3 days later, during the same admission, to complete the bone removal, but the 3D intraoperative spinal image was not used in this case. In another case, who had bilateral transverse processectomy associated with lumbar fusion, it was noticed by a routine postoperative CT scan that the inferior part of the bone resection was too inferior, reaching the superior portion of the sacrum, but asymptomatic.L5 dermatome and evidence of hyperesthesia, but motor strength was preserved. Postoperative lumbosacral X-ray, CT, and MRI scans were performed after surgery, which did not demonstrate any significant hematoma, fluid collection, bone fragments, nor compression on the nerve roots, suggesting that it was related to an inadvertent intraoperative nerve manipulation during the transverse processectomy. The patient was treated conservatively with analgesics, physiotherapy, and lumbar spinal injection and experienced gradual relieve of his radicular pain only after 4 months of postoperative (Table Two postoperative adverse events were noticed in this series of 16 patients. In one case, where it was used a smaller surgical approach for the transverse processectomy, only + 2.5 cm, the patient experienced wound dehiscence, which was treated with surgical debridement and closure. Another patient who had transverse processectomy for chronic paramedian lower back pain, using a 3D intraoperative spinal image to check the bone removal, with no relevant nerve abnormalities noticed during the surgery by IONM, developed significant radicular pain after surgery. The pain was described as moderate to severe, sharp, burning, and constant. There was diminished sensation in the ,21]21].In our patient series type II was the most common type associated with LBP, and, the level above the transitional vertebrae was the most common level that has disc disease, same result concluded by Castellvi et al and in other study., which was used to guide the management of the patients of this study. Some attributed this pain to changes in load transmission through the spine and thus changes in bone, ligament functions and morphology, nerve compression by disc herniation or entrapment of the lumbar nerve under the mega transverse process or arthritic changes from pseudoarticulations. Bertolotti suggested LBP due to arthritic changes occurring at the site of pseudoarthrosis. Connolly et al demonstrated that 80% of young patients with low back pain and LSTV had high uptake on bone scintigraphy at the transverse process sacral articulation. In our study, it seems that the main cause of pain was the pseudo-articulating joint as all patients experienced short-term pain relief after the injection test using local anesthetic plus steroids, and a good results for most patients after the transverse processectomy which can be attributed to removal of the load from the pseudoarticulated joint, and the same for relief of the radiculopathy may be it is due to decompression of the nerve by transverse processectomy.Limited understanding of the pathophysiology and exact etiology of Bertolotti’s syndrome has led to a lack of uniformity in the diagnosis and treatment. Images alone will not help to diagnose the pain generator, recommending the use of a diagnostic block tests of the pseudo articulation or the nerve for additional diagnostic information. Almeida et al proposed a diagnostic therapeutic algorithm to help in decision making in patients with back pain associated with LSTV, and by radiofrequency ablation by creating a strip lesion at the pseudoarthritic joint. There are different surgical options for the surgical treatment of BS, including lumbar fusion or resection of the pseudoarthritic joint. Surgical resection of part of the enlarged TP, to disconnect the lumbar segment from the malformed pseudojoint, and unload the pseudoarticulation seems to be a good option in selected patients, with potential good outcomes,–31. Lumbar spinal fusion also shows a good result, according to the case and associated disc disorder. The outcome of posterolateral fusion was reported by Santavirta et al, who showed no significant differences compared with resection of the pseudoarticulation..Treatment of Bertolotti’s syndrome range from conservative treatment including trial of pain management and physical therapy until surgery for refractory cases. Temporary pain relief can be achieved by local injection of local anesthesia with steroid The article of Li Y et al, described the minimally invasive tubular resection of the anomalous TP in patients with BS, however, they suggested the bone removal to disconnect the enlarged TP in a horizontal fashion. The modified technique suggested by the authors of this study proposes to start removing the base of the TP vertically, instead, around 1 cm lateral to the pedicle, creating a bone gap of at least 5 to 10 mm, lateral to the base of the TP. After this partial bone resection lateral to the pedicle, the bone resection is re-directed inferior-medially, below the pedicle, on “ice hockey stick” shape form, around 1 cm from the base of the enlarged TP. This technique offers the advantage of cutting the bone in a more vertical manner, close to the pedicle, avoiding extending the bone removal laterally, which according to the size and shape of the malformed TP, may require an unpredictable lateral extension of the bone resection (Fig. Takata et al, describe a technique using an endoscope and burr for removal of the pseudojoint with successful pain relief.ion Fig. .While our suggested technique shown good improvement in pain score, still there is limitations of our study, the retrospective fashion of our study, the small sample number of the patients who had isolated BS and underwent only modified MO-TMTP, and relatively short period of follow up. Larger prospective studies and longer duration follow up are needed to analysis the results of this surgical technique.A new modified MO-TMTP, guided by 3D intraoperative image and IONM proposed in this paper seems to be a safe and effective procedure for selected patients with BS, refractory to conservative treatment, who experienced a temporary pain relief after injection of pseudo articulation with steroids and local anesthetic. Larger prospective studies are needed to analysis the results of this surgical technique.Conceptualization: Hatem Afana, Muhammad Raffat.Data curation: Nicandro Figueiredo.Investigation: Hatem Afana.Methodology: Hatem Afana.Project administration: Hatem Afana.Supervision: Nicandro Figueiredo.Validation: Hatem Afana, Nicandro Figueiredo.Writing – original draft: Hatem Afana, Muhammad Raffat.Writing – review & editing: Hatem Afana, Muhammad Raffat, Nicandro Figueiredo.


For the low and high ARM groups, ARM was repeated five times to hold the peak airway pressure at 30 cmH2O and 60 cmH2O for 5 s, respectively, before removal of the trocar. Conventional methods to reduce post-laparoscopic pain, such as intraperitoneal saline irrigation, hemovac drainage, and gentle abdominal compression were performed in all patients, regardless of the assigned group. Results: Shoulder and surgical site pain scores 24 h postoperatively and rescue meperidine requirement were similar between the groups . The quality of recovery 40 (QoR40) score 24 h postoperatively was similar between the groups (p = 0.755). Postoperative pulmonary complications were similar between the groups (p = 0.124). Conclusion: Application of a low- or high-pressure ARM in addition to conventional methods to remove remnant peritoneal CO2 gas did not reduce postoperative shoulder or surgical site pain or improve the quality of recovery after laparoscopic sleeve gastrectomy. Background: This study aimed to evaluate whether a low- or high-pressure alveolar recruitment maneuver (ARM) might reduce postoperative pain and improve the quality of recovery after laparoscopic bariatric surgery. Methods: 90 patients with a body mass index > 30 kg/m Carbon dioxide insufflation for pneumoperitoneum at 16–18 mmHg and a 60° reverse-Trendelenburg position was adopted.No sedatives or analgesics were administered as premedication. Standard anesthetic monitoring, including a non-invasive blood pressure monitor, electrocardiogram (ECG), pulse oximeter, and bispectral index (BIS) were employed in the operating room. For anesthetic induction, lidocaine, propofol, remifentanil, and rocuronium were administered, and for maintenance of anesthesia, sevoflurane and remifentanil were used while targeting a BIS of 40–60. The mechanical ventilator setting was s volume-controlled mode with an inspired oxygen fraction  was provided for 48 h with fentanyl 0.15 µg × [ideal body weight + (0.4 × excess weight)]/cc in normal saline 100 mL, . Ramosetron 0.3 mg was administered intravenously before the end of surgery to prevent postoperative nausea and vomiting.All patients underwent an intraperitoneal saline irrigation before trocar removal, and a hemovac drainage tube was placed through the trocar site. At the end of the surgery, the abdomen was gently compressed to remove COMean arterial pressure, heart rate, oxygen saturation, and vasopressor use were recorded pre-induction immediately before ARM, and 1, 3, and 5 min after ARM during laparoscopy. In the postanesthetic care unit (PACU), overall postoperative pain was assessed using an 11-point numerical rating scale (NRS)  at 30 min after arrival. Because it was difficult for patients to express the pain area in detail immediately after anesthesia emergence, the severity of overall pain was investigated without dividing it into shoulder and abdominal pain . The severity of nausea, frequency of vomiting, rescue antiemetics, and requirement for rescue fentanyl were assessed. A rescue fentanyl 50 µg intravenous bolus was administered when the NRS pain score was greater than five points or as needed by the patient.At 24 h after surgery, the pain score (NRS) of postoperative shoulder pain and abdominal pain, total infused PCA volume for 24 h, and rescue analgesic requirement were evaluated. The quality of recovery (QoR) score was assessed using the 40-item multidimensional questionnaire  by one oThe low and high ARM groups might have similar effectiveness in reducing post-laparoscopic shoulder pain compared to the control group, based on a previous study . The samp-value < 0.05 was considered statistically significant except for in pairwise comparisons between the two groups. For Bonferroni-corrected significance level for multiple pairwise comparisons, a p-value < 0.05/3, was considered statistically significant.In this study, SPSS software ver. 22.0  was used for the statistical analysis. The results are presented as mean [95% confidence interval], median [interquartile range], or number of patients. The Kolmogorov–Smirnov test was used to assess the normality of the continuous variable distribution. One-way ANOVA or a Kruskal–Wallis test with Bonferroni correction was used according to the normality test. Categorical variables were analyzed using the chi-squared test. A Among the 90 enrolled patients, one in the high ARM group was excluded from the analysis because of patient refusal . The pat2, or the frequency of vasopressor use during surgery.The intraoperative hemodynamic changes and vasopressor requirements are shown in p = 318 and 0.993, respectively). The severity of postoperative nausea and the frequency of vomiting and rescue antiemetic use were similar between the groups .The data in the PACU are presented in p = 0.141 and 0.101, respectively). The number of patients with shoulder pain that was more severe than abdominal pain was not statistically significant (p = 0.196). The rescue meperidine requirement and total infused PCA volume for 24 h were also similar between the groups . The total score and each dimension score of QoR at 24 h postoperatively were similar between the groups. Postoperative pulmonary complications, including atelectasis and pulmonary edema, were observed in 4 patients in the control group, 2 patients in the low ARM group, and 0 in the high ARM group, without statistically significant difference (p = 0.124). There were no patients whose symptoms were severe enough to delay discharge or require additional treatment, and the length of hospital stay did not differ between the groups (p = 0.339).Postoperative pain and QoR scores during the postoperative 24 h are demonstrated in 2O or 60 cmH2O at the end of laparoscopy was found to neither reduce postoperative shoulder nor abdominal pain, and did not improve QoR after anesthesia, in patients undergoing laparoscopic bariatric surgery. In this prospective study, additional application of ARM with a peak airway pressure of 30 cmH2 gas were employed in 280 (49%) patients, ARM application significantly decreased shoulder pain for postoperative patients at 48 h [A previous study comparing ARM with multiple levels of peak inspiratory pressure with no ARM demonstrated that all levels of ARM had a beneficial effect in improving post-laparoscopic shoulder pain . In addi at 48 h . Another at 48 h . 2 or less than in BMI > 30 kg/m2 [2 gas, so that the anatomy of the liver and diaphragm could be clearly seen, whereas patients with obesity had less space for storing gas because the anatomy in the same location was covered by the omentum [2 pneumoperitoneum occurs less in patients with obesity, it can be assumed that the pain-reducing effect of ARM was also attenuated in this study. Contrary to the aforementioned studies in patients without obesity, the current study on patients with obesity did not demonstrate any beneficial effects of ARM in decreasing postoperative shoulder or abdominal pain or improving QoR, even when low or high peak airway pressure was applied. In a risk analysis of shoulder pain after laparoscopic infertility surgery, postoperative shoulder pain showed a negative correlation with BMI , and the pain score was significantly higher in BMI of 30 kg/m30 kg/m2 . Patient omentum . As such2 remaining in the abdominal cavity, which may decrease postoperative pain on the day of surgery; however, the use of rescue analgesics did not decrease [2 into the blood stream [2 remaining in the abdominal cavity causes pain after laparoscopic surgery. Another study showed that intraperitoneal saline irrigation was superior to preoperative oral acetazolamide administration in reducing post-laparoscopic pain and rescue fentanyl use [2 [Several strategies have been suggested to reduce the need for post-laparoscopic surgery. Intraperitoneal saline irrigation during laparoscopic cholecystectomy reduced the concentration of COdecrease . Acetazod stream . From thanyl use . Hemovacanyl use , and intanyl use . Gentle l use [2 . Rettenml use [2 . 2 gas as possible, and how this is achieved does not seem to matter. There are studies showing that ARM reduces postoperative pain in laparoscopic surgery for non-obese patients [In this study, conventional methods to reduce post-laparoscopic pain, such as intraperitoneal saline irrigation, hemovac drainage through the trocar site, and gentle abdominal compression during trocar opening, were performed in all patients, regardless of the assigned group. It can be considered that these procedures not only reduced the postoperative pain score of the control group, but also reduced the pain score differences between the control and the ARM groups. The reason for reducing postoperative pain with ARM may be to evacuate as much COpatients ,6,7. HowThe QoR questionnaire, a widely used self-report questionnaire, was used to evaluate the quality of postoperative recovery, and includes emotional and psychological status as well as the most uncomfortable postoperative situations, such as pain, nausea, vomiting, and possible breathing problems . In this2 gas did not reduce postoperative shoulder or surgical site pain or improve the quality of recovery after laparoscopic sleeve gastrectomy in patients with obesity. Thus, ARM application may have no additional benefit after laparoscopic bariatric surgery if safe and effective methods to remove remnant CO2 from the abdominal cavity are included. In conclusion, the application of a low- or high-pressure ARM in addition to conventional methods to remove remnant peritoneal CO


Increased social distance is one of the manifestations of social impairment. Chronic low back pain (CLBP) is one of factors associated with increased social distance and social withdrawal. Exercise therapy is an effective means to social impairment. However, whether exercise could reduce social distance in patients with CLBP remains unknown. This study aimed to investigate the effect of exercise on social distance in middle-aged and elderly patients with CLBP.The longitudinal intervention recruited 29 middle-aged and elderly patients with CLBP from various communities in Yangpu District, Shanghai, China. The participants received exercise intervention for 8 weeks. The assessments were conducted before and after the intervention, including social distance, pain intensity, unpleasantness of pain, Roland-Morris Questionnaire (RMDQ), Self-Rating Anxiety Scale (SAS), and Self-Rating Depression Scale (SDS). Intention to treat analysis was performed.p < 0.05). The scores of pain intensity, unpleasantness of pain, RMDQ, SAS, and SDS also decreased and were significantly different between pre- and post-intervention (p < 0.05). In addition, the social distance, pain intensity, unpleasantness of pain, RMDQ, SAS, and SDS scores of the moderate CLBP group decreased more after the intervention compared with those of the mild CLBP group.After the 8-week exercise intervention, the social distance of patients with CLBP was shorter than that before intervention and showed significant difference (The 8-week exercise intervention cannot only shorten the social distance in middle-aged and elderly patients with CLBP but also relieve pain, disability, and negative emotions. Low back pain (LBP) is a common symptom experienced by people of almost all ages, and it is one of the main reasons for seeking medical health care . The lifSocial distance is mediated by comfort or discomfort resulting from the distance between individuals and others. Appropriate social distance is the basis for establishing effective communication and good interpersonal relationships, while too short social distance will cause discomfort and anxiety . The incMost guidelines recommend exercise therapy as an intervention for CLBP . ExercisTo our knowledge, a limited number of studies explored the benefits of exercise on social psychology in patients with CLBP. Whether exercise can improve social withdrawal and reduce social distance in patients with CLBP remains unknown. Thus, we conducted a longitudinal intervention study to investigate the effect of exercise on social distance in patients with CLBP over an 8-week intervention period.We conducted an 8-week exercise intervention to explore the effect of exercise on social distance in patients with CLBP. Two rounds of assessments, including those for social distance task, pain intensity, unpleasantness of pain, Roland-Morris Questionnaire (RMDQ), Self-Rating Anxiety Scale (SAS), and Self-Rating Depression Scale (SDS) were completed pre- and post- intervention.The effect size was calculated to be 0.67 in accordance with the study by Assessments were performed at baseline and after the 8-week exercise intervention, including social distance, pain intensity, disability, unpleasantness of pain, anxiety, and depression.max), average pain intensity (NRSavg), pain intensity at rest (NRSrest), and pain intensity at the moment (NRSnow) during the last 3 days. The NRS is an 11-grade rating scale: 0, “no pain at all”; 1–3, “mild pain”; 4–6, “moderate pain”; 7–9, “severe pain”; 10, “maximum pain.” This scale has good validity and reliability (unavg) and unpleasantness of pain at the moment (NRSunnow) during the last 3 days. The levels of anxiety and depression were evaluated by the 20-item SAS and the 20-item SDS, respectively. The total scores of both scales are 20–80. A high score means serious anxiety or depression  Part the Wild Horse’s Mane; (2) Fair Lady Works at Shuttles; (3) Brush Knee and Twist Step; (4) Pull, Block and Pound; (5) Grasp the Peacock’s Tail; (6) Step Back and Whirl Arms on Both Sides; (7) Golden Rooster Stands on One leg; (8) Cloudy Hands . It adopp < 0.05 was considered statistically significant.All results were analyzed by the IBM SPSS Statistics 26. Quantitative variables were presented as mean ± standard deviation (avg > 3), and mild (NRSavg ≤ 3) CLBP group. The inter-group comparison of baseline data, the result of pre-intervention, and post-intervention—pre-intervention were compared by the independent sample t-test, Mann-Whitney U-test and Chi-Square test. Paired sample t-test or Wilcoxon signed-rank test was selected to detect the intra-group differences pre- and post-intervention. All the results were analyzed by intention-to-treat, and the method of regression estimation was performed to fill in the missing values. Subjects who had an attendance rate of less than 75% or failed to attend the assessment were considered to have been dropped out.Based on the average pain intensity, we divided the data into three groups, namely, overall, moderate . Compared with the mild CLBP group, the moderate CLBP group had more marked changes, and the inter-group differences of post-pre CD1 : –31.28 to 17.47), CD3 , and UD3  were statistically significant (p < 0.05)  .max, NRSavg, and NRSrest between the two groups . Compared with the mild CLBP group, the moderate CLBP group had a greater improvement, and the inter-group difference of post-pre NRSrest  was statistically significant . Compared with the mild CLBP group, the moderate CLBP group had more marked changes, but the inter-group difference of post-pre disability was not statistically significant . Compared with the mild CLBP group, the moderate CLBP group had more marked changes, but the inter-group difference of post-pre disability was not statistically significant (p > 0.05, All data of negative emotions are presented in This study explored the effect of an 8-week exercise intervention on social distance and CLBP symptoms in subjects with CLBP. We observed that the social distance of subjects with CLBP was shorter than that in pre-intervention. In addition, the pain intensity, unpleasantness of pain, disability, anxiety, and depression were reduced compared with those before the intervention.The study showed that the subjects with CLBP shorten social distance after receiving exercise intervention. The decrease in interpersonal distance reflects the alleviation of social withdrawal and the improvement of social interaction and function. Similar findings have also been reported in other papers. A systematic review conducted by After 8 weeks of Tai Chi intervention, the pain, disability, and negative emotions of subjects with CLBP decreased. The effect of Tai Chi on CLBP has also been confirmed in different studies. A meta-analysis of Tai Chi for LBP showed that Tai Chi can relieve pain and improve physical function . Hall etOn the other hand, compared with the mild CLBP group, the moderate CLBP group showed more improvement in all aspects, and such result may be due to the more severe pain, disability, and negative emotions. Our previous study on CLBP and social distance revealed that pain, disability, anxiety, and depression were positively correlated with social distance . The impThis study had several limitations. First, only one experimental group was included. Therefore, waitlist or other intervention control groups should be considered in future research. Second, we did not perform follow-up after 8 weeks of exercise intervention. Thus, we should continue to explore the maintenance effect of exercise on the social distance of CLBP patients. Third, a narrow age range of the recruited subjects was used and there were imbalances in the gender sample size. Thus, future research designed for a stratified age and gender is needed.CLBP is one of the most common chronic diseases, and causes serious harm to physiological, psychological, and social functions. However, its damage to psychosocial health is usually ignored. Patients with CLBP show increased social distance and withdrawal, reflecting the impairment of individual psychosocial health. This outcome is one of the hazards of CLBP that cannot be ignored. Through a longitudinal intervention experiment, we observed that exercise not only alleviated the symptoms related to CLBP but also improved psychosocial health. Therefore, for the management of this disease in the future, we should also pay attention to the psychological problems and consider exercise therapy as a complementary means of psychological and physiological rehabilitation. In addition, future research can be combined with neuroimaging technology to detect changes in brain activity to explain the underlying neural mechanism of exercise in improving abnormal social distance regulation behavior. It can provide a basis for CLBP to formulate more targeted intervention methods.The 8-week exercise intervention cannot only shorten the social distance and improve the abnormal behavior of social distance regulation of middle-aged and elderly patients with CLBP, but also relieve pain, disability, and negative emotions. In addition, follow-up will be conducted in the future to explore the long-term effects of exercise intervention, and further work is required to determine whether this new finding applies equally to other types of exercise.The original contributions presented in this study are included in the article/The studies involving human participants were reviewed and approved by the Ethics Committee of Shanghai University of Sport. The patients/participants provided their written informed consent to participate in this study.L-MW and X-QW conceived and designed the study. L-MW, RW, Q-HY, T-TC, C-CW, W-LL, S-HD, and Y-CW collected the data. L-MW and RW analyzed and interpreted the data and revised the manuscript for important intellectual content. L-MW drafted the manuscript. All authors discussed the results, commented on the manuscript, and approved the final manuscript.