In the medical literature, thoracic disc protrusion has traditionally been considered a rare occurrence. We hypothesise that the incidence of such protrusions and their abdominal symptoms is higher than is generally believed and that their presence may account for a significant proportion of chronic non-visceral abdominal pains. Accordingly, the present study was designed to identify and quantify the symptoms experienced by patients with thoracic disc protrusion and to assess the relative risk of these symptoms being presented, compared to the general population.We conducted a cross-sectional study with a control group. The following comparison groups were analysed: case group, consisting of 100 patients diagnosed with thoracic disc protrusion in our hospital between February 2007 and October 2012, and control group consisting of 100 subjects from the general population, chosen at random. To compare the symptoms observed in each group, the following tests were applied to all study subjects: clinical examination, gastrointestinal-related quality of life (GIQLI) questionnaire and DN4 questionnaire. We also reviewed the subjects’ medical records for the previous 3 years.The subjects in the case group had a significantly higher incidence of digestive-urologic symptoms, a poorer gastrointestinal quality of life and greater need of medical care than those in the control group. The differences were statistically significant for all the parameters studied. Almost all the case group subjects suffered chronic abdominal pain and/or digestive-urologic symptoms. We term this group of symptoms “chronic abdominal syndrome due to nervous compression”. Nevertheless, in most cases, no neurologic aetiology was suspected, and therefore the treatment given was ineffective. In view of the results obtained, we propose a diagnostic-therapeutic algorithm for such patients.Thoracic disc protrusion, as well as having a non-negligible incidence, is often associated with a digestive-urologic clinical syndrome, and this factor should be taken into account in all cases of chronic abdominal pain and other digestive-urologic symptoms when standard tests are negative, so that appropriate treatment may be given. Chronic abdominal wall pain is often mislabelled as being visceral in origin and so inappropriate complementary tests are performed, unsatisfactory treatment is prescribed and unnecessary costs are incurred. The prevalence of this condition in everyday medical practice is unknown, but some researchers have estimated that it affects about 10 % of the patients presenting with chronic idiopathic pain at a gastroenterology consultation.The dorsal roots facilitate abdominal cutaneous innervation and visceral innervation of the colon, bladder and pelvic structures. Therefore, any dysfunction can produce abdominal pain and gastrointestinal symptoms , urologic complaints (such as dysuria or polyaquiuria) and pain at diverse metameric levels .–It has traditionally been considered that the incidence of thoracic disc protrusion (TDP) is very low, amounting to less than 1 % of all disc protrusions.,Despite this high incidence, only 0.5–0.8 % of cases are considered symptomatic.Therefore, the problem could be addressed like this: neither the orthopaedic surgeon nor the neurologist see patients with chronic abdominal pain; on the other hand, the gastroenterologist, the gastrointestinal surgeon, the gynaecologist and the urologist do see patients with chronic abdominal pain, but they do not usually suspect the fundamental cause to be located in the spine and therefore do not ask for magnetic resonance imaging (MRI) of this area. In consequence, we are faced with a pathology of a neurologic-traumatologic nature but with gastrointestinal-urologic-gynaecologic symptoms, which makes diagnosis very difficult. As a result, to date, this body of symptoms has been considered to constitute a pathology with a low incidence. However, we believe that what is really infrequent is the diagnosis, not the condition.,Given these premises, in two recent papersTaking into account the above results, the aim of the present study was to examine the syndrome complex presented by 100 patients with TDP, to assess whether they are being properly diagnosed and treated, to compare these patients with a control group and, finally, to propose a diagnostic and therapeutic algorithm for this type of patient.p = 1) and age .We conducted a cross-sectional study with a control group. Thus, two groups of 100 subjects were compared: group 1 (cases) consisted of 100 patients diagnosed with TDP between February 2007 and October 2012 in our hospital and group 2 (controls) consisted of 100 patients randomly selected from the general population . Both groups had similar characteristics in terms of sex  signed an informed consent form and underwent a clinical test  to evalu,The GIQLI was presented in 1994 by Eypasch et al.We used the DN4 questionnaireThe DN4 questionnaire was adapted into Spanish and its psychometric properties  were evaluated by Pérez et al. Finally, we reviewed the clinical record, for the previous 3 years, of the subjects in each group, including treatment at the hospital’s emergency department, consultations with specialists, complementary tests performed and hospital admissions.Chronic pain, and its intensity, in the abdomen, back, genitals and/or lower limbs Percentage of abdominal pain of a neuropathic nature (DN4 questionnaire)Digestive-urologic symptomatology Gastrointestinal quality of life (GIQLI questionnaire)Need for emergency department treatment, consultation with a specialist or hospital admission during the last 3 years Percentage of patients whose symptoms were attributed to TDP Medical treatment conducted Outcome of medical treatment conducted These tests and the review of medical records enabled us to evaluate the following parameters for the patients with TDP:We compared the results for these patients (cases) with those for the randomly selected control group, to assess the deterioration of gastrointestinal quality of life and the relative risk of these patients presenting with the symptoms described, with respect to the general population.From the results obtained, and our experience with these patients in previous studies, we will describe the clinical picture presented and the inclusion criteria applied. We will also review recent literature in this respect and propose an algorithm for diagnostic and treatment action.In a descriptive analysis of the study variables, the values of the continuous variables are presented as the mean and the corresponding standard deviation. Categoric variables are presented as absolute and relative frequencies. The results are shown stratified by groups (case/control).To test whether the data—the observed differences in the frequencies of the variables of interest—are statistically significant, Fisher’s test was used to assess the qualitative variables. In addition, the prevalence ratio was calculated, at a 95 % confidence interval.t test was applied for two independent samples. This was done assuming the normal distribution of the variables in each group, which was confirmed by the Shapiro-Wilk test. When non-normality was observed, the Mann-Whitney non-parametric test was used.To analyse the differences between the continuous quantitative variables in two independent groups, Student’s The statistical analysis was performed by the FIMABIS AMEC Unit, Málaga (Spain), with software R project version 3.0.3.The 100 subjects in the case group presented a total of 236 TDP. In 77 % of these, the subarachnoid space was occupied, and in 8.89 %, there was contact with the bone, but only in 1.69 % was there injury to the nerve root. Of the protrusions, 70.76 % were below the T7 level , but in all cases, the pain persisted after surgery. In 50.64 % of cases, the patients commented that the pain occurred when certain postures were adopted, 49.35 % related it to physical effort and 12.99 % referred to a prior traumatic injury.Of the patients in the case group, 95 % presented one or more digestive-urologic symptoms, but only 3 % reported having had a diagnosis of TDP as the cause of their symptoms. With respect to the medical treatment prescribed for their abdominal pain, 25 % had not been given any treatment, 68 % had been treated with NSAIDs and only 7 % had received treatment for neuropathic pain .In response to the question, “What changes have you noticed after the treatment prescribed by your doctor?”, 8 % of the patients stated that the pain had disappeared, 12 % had obtained a significant improvement, 21 % had obtained a moderate improvement, 31 % had obtained a slight improvement and 28 % had obtained no improvement or a worsening of the pain.On comparing the two groups, we observed that both the pain and the digestive-urologic symptoms were significantly more frequent in the case group, with statistical significance in all items Table .Table 1CThe subjects in the control group who had abdominal pain reported it to be most frequently located in the central areas, especially periumbilical locations (zone 5) (32 %), while in the case group, the abdominal pain was most often located in lateral and lower areas, especially in zone 7 (in the right iliac fossa) (33 %).Both the duration and the intensity of the pain Table  were greVisits to the hospital’s emergency department, consultation with specialists and hospital admissions in the previous 3 years were all more numerous in the case group, with statistical significance in the latter two cases  had a positive result in the DN4 test, with an average score of 4.27 (SD 2.1), However, among the subjects with abdominal pain in the control group (n = 25), only 8 % had a positive result in this test. They had an average score of 1 (SD 1.08), and the differences were statistically significant with respect to positive test results (p = 0.000) and average score (p < 0.001).Finally, 84.42 % of the subjects in the case group with abdominal pain , is commonly encountered in current clinical practice and is normally classed as idiopathic gastroparesis or functional disorder .This problem continues to present a challenge to all currently known methods of diagnosis and treatment.In 30 % of all patients with chronic abdominal pain, it is located in the abdominal wall.However, it was Carnett, an English obstetrician, who first attributed this pain to the structures of the abdominal wall, and in 1926, he described the sign that bears his name, and which remains in use today in clinical examination.The patient is not usually able to interpret the degree of superficiality of the pain, and therefore the physician must take into account the clinical history and perform a careful examination in order to determine the metameric source of the pain. An algorithm for evaluating chronic abdominal pain, using Carnett’s sign and the infiltration of the trigger points , has been suggested by Gallegos and HobsleyIn a study conducted by Constanza et al. of physicians treating patients with chronic abdominal pain, only 4 % of respondents considered pain originating in the abdominal wall as an initial diagnostic possibility.Gómez Rodríguez et al.Since symptomatic TDP was first described by Key in 1938, this uncommon pathology has posed a challenge to spinal surgeons.–Visceral and somatic afferent fibres in the dorsal columns, spinothalamic and spinocerebellar tracts and the dorsal and ventral horns have been observed at different levels of the spine.,,In agreement with our results, Arce and Dohrmann,,From our review of the medical literature in this respect, we conclude that in most cases, symptomatic TDP has a mild to moderate clinical impact, producing thoracic or abdominal pain, sensory disturbances–However, recent necropsy studies of the spine have suggested that the prevalence may be as high as 10 %.This strongly suggests that we are facing a disease with a high incidence among the population, and therefore many patients are currently undiagnosed. For example, in the catchment area for our hospital, with a population of about 100,000, according to the above studies, there must be between 10,000 and 37,000 people with TDP. The question then arises: what percentage of these people present well-developed abdominal pain with gastrointestinal, gynaecologic or urologic symptoms and yet are undiagnosed and therefore not being treated properly? To put it another way, how many patients with chronic abdominal pain and symptoms, in cases in which organic pathology has been excluded, and who are normally classified as suffering irritable bowel syndrome or a functional pathology, might actually be suffering a thoracic spine pathology, which is the true cause of their condition? Answers to these questions can only be properly obtained by carrying out a prospective multicentre study with a large number of patients. Contrary to the findings of previous research in this field, our study shows that patients with TDP very often suffer abdominal pain (77 %), accompanied by digestive-urologic symptoms (95 %) and a significant deterioration in their gastrointestinal quality of life. It seems, therefore, that a significant number of patients could benefit from the diagnostic and therapeutic algorithm proposed in this study.When we asked our patients with TDP about the diagnosis they had been given, only 3 % mentioned neuropathic pain. In view of the long-standing nature of the condition (mean duration 50 months) and the fact that most of these patients had not received a definitive diagnosis, there remains an important knowledge gap to be filled. In addition, it should be taken into account that 25 % of these patients were not treated and that 68 % had had a treatment that did not correspond to the scale of neuropathic pain. Furthermore, only 20 % reported being pain-free or having achieved a significant improvement after treatment. It must be concluded that a large portion of these patients were inadequately treated; no aetiological diagnosis of nervous compression was made, and therefore the outcome was unsatisfactory. In our previous two studies, when patients were diagnosed with disc pathology as being responsible for the pain, this was treated by considering the neuropathic pain scale, and the pain was reduced or significantly alleviated in 61.11 and 53.33 % of cases, respectively.Carnett’s sign +Trigger point infiltration +DN4 questionnaire +Taking into account the data obtained in the present study and the findings of previous research by our group, we term the symptoms presented by these patients “chronic abdominal syndrome due to nervous compression” (CASNC). We define this syndrome as one in which there is chronic abdominal pain, often accompanied by back pain and digestive-urologic symptoms, with no apparent cause of an organic nature being revealed by the complementary tests; moreover, TDP has been observed and at least one of the following criteria is met:–The ideal treatment for neuropathic pain would be to address and resolve its cause. However, this is often not possible, and when it is undertaken, the pain may only be alleviated in part or even not at all. In such cases, excepting the peculiarities of very specific types of pain, the pharmacologic treatment of neuropathic pain is carried out in stages, using different pharmacologic groups. In our opinion, this is the approach that should be followed in patients diagnosed with CASNC. However, there is no consensus as to the drugs that should be employed at each stage, and CASNC patients form a highly specific group. Therefore, we decided to adapt the pain scale for the treatment of CASNC taking into account our own previous studies and the latest guidelines for the treatment of neuropathic pain , together with recent studies in this respect.In summary, both TDP and its symptoms are much more common than has been thought. The majority of these patients present a long-standing clinical situation, with pain in the back (90 %), abdomen (77 %) or other locations , always at a considerable level of intensity and frequently accompanied by digestive-urologic symptoms (95 %). These symptoms provoke a significant deterioration in the gastrointestinal quality of life and lead patients to be offered a large number of complementary tests, consultations with specialists and even hospital admission. Nevertheless, after all these studies, the patients’ condition is usually summarised as being of a functional nature, and so inadequate treatment is provided and the results obtained are unsatisfactory.As treatment strategies vary according to whether the pain is nociceptive or neuropathic, it is important to identify the neuropathic component, even when the pain is heterogeneous. Therefore, the possible presence of CASNC should be considered in all cases of chronic abdominal pain and symptoms with negative test results, so that appropriate treatment may be given.


In smokers, this was transcribed in higher VAS-pain (P = 0.04) and TP count (P = 0.03), lower pain threshold (P = 0.01), since NpY levels were directly related to the pain threshold (rho = 0.414) and inversely related to TP counts (rho = −0.375). This study shows that patients with FM have no increase of NpY levels in response to smoking despite the low levels of leptin. Deregulation of the balance between leptin and neuropeptide Y may be one of the essential mechanisms of chronic pain in FM.Smoking deregulates neuroendocrine responses to pain supporting production of neuropeptide Y (NpY) by direct stimulation of nicotinic receptors or by inhibiting adipokine leptin. Present study addressed the effect of cigarette smoking on adipokines and pain parameters, in 62 women with fibromyalgia (FM) pain syndrome with unknown etiology. Pain was characterized by a visual analogue scale, tender point (TP) counts, pressure pain threshold, and neuroendocrine markers NpY and substance P (sP). Levels of IGF-1, leptin, resistin, visfatin, and adiponectin were measured in blood and cerebrospinal fluid. Current smokers ( Adipose tissue is recognized as an active endocrine organ homing several metabolic and immunologically active cell types including fat cells, macrophages, endothelial cells, and stromal cells. Adipose tissue releases a vast number of biologically active growth factors, cytokines, chemokines, and hormone-like molecules also called adipokines , 2. AdipIt has become obvious that adipokines are transported across the blood-brain barrier to the central nervous system and have prominent role in the central control of body functions. Leptin and adiponectin enter brain through the circumventricular organs interacting with the receptors in the hypothalamic nuclei, hippocampus, cortex, cerebellum, and spinal cord regulating neuronal function . Leptin Tobacco smoking remains the leading prevalent cause of morbidity and mortality worldwide.Epidemiological studies show that cigarette smoking is associated with increased chronic pain . CigaretFibromyalgia (FM) is a chronic widespread pain syndrome with an estimated prevalence of 2–4% , 24. TheIn the present study we assess the role of adipokines in smoking related changes of clinical and neuroendocrine parameters of pain in patients with FM. We show that patients with FM have no increase of NpY levels in response to smoking despite the low levels of leptin. Deregulation of balance between leptin and neuropeptide Y may be one of the essential mechanisms of chronic pain in FM.The study consisted of 62 patients with FM as defined by the ACR 1990 criteria  . The criPressure pain thresholds were measured in kPa, using an algometer  with pressure rate increases of 50–60 kPa/s, as previously described . Pain thSerum samples were acquired from all 62 patients by venipuncture of the cubital vein. Of these, 32 patients provided cerebrospinal fluid (CSF) samples, which were collected by lumbar punctures of the L3/L4 interspace. The collected blood and CSF samples were centrifuged at 800 ×g for 10 min, aliquoted, and stored frozen at –70°C until use.Biological markers were analyzed by sandwich enzyme-linked immunosorbent assays (ELISAs) using a pair of specific antibodies for human adiponectin , human leptin , human resistin , and human free bioactive IGF-1  which were all purchased from RnD Systems . Assays specific for human visfatin  were purchased from Adipogen Inc. . Neuropeptide Y (NpY) and substance P were measured by fluorescent EIA kits . All assays were performed according to the instructions of the manufacturers. Ordinary colorimetric ELISAs were read with a Spectramax 340 from Molecular Devices  and fluorescent ELISAs were read with a Mithras LB940 from Berthold Technologies .NCT00643006).The Ethical Committee of the Sahlgrenska University Hospital approved the study (220-09). Written and verbal information was given to all patients and written consent was obtained from all patients. The trial is registered at ClinicalTrials.gov  were measured in the studied cohort of FM patients. Leptin levels in the CSF were significantly higher than levels in serum, while the levels of adiponectin were lower .P < 0.0001, and rho = 0.374, P = 0.0072, resp.). Only smokers had correlation between BMI and the serum levels of resistin  and visfatin .Leptin is known as the main regulator of hunger and body weight by passing across the blood-brain barrier and modulating activity of neurons in the arcuate nucleus of hypothalamus stimulating production of appetite-suppressing neuropeptides POMC and CART and inhibiting transcription and release of appetite-inducing peptides NpY and agouti-related protein . Indeed,P = 0.039) and in CSF . Serum levels of resistin were inversely correlated to VAS-pain  and this correlation was stronger in nonsmokers . CSF levels of resistin were inversely correlated to TP counts . Consistent with our findings, the levels of leptin have been previously reported to correlate with pain in patients with spinal injury [Leptin has been recently identified as an essential indicator of pain sensitivity in animal models and in clinical observational studies. It is locally produced in the perineural adipose tissue in response to neuropathic pain and the mice deficient in leptin have low pain sensitivity . In the l injury , acute cl injury , 41. Resl injury , 43 and l injury . In the The modulation of pain by leptin is suggested to occur in the thalamus through the NpY-dependent mechanism , 46. InjMost of the studied patients received analgesics , antidepressants , or a combination of those two groups of drugs , while the remaining 5 patients (8%) had no medication for FM. The comparison of pain evaluation revealed no significant differences in VAS, TP counts, and pain threshold between the FM patients of the four groups indicated above. To study the effect of medications on the levels of adipokines, we compared the groups having a combination of analgesics and antidepressant drugs with the FM patients having no medication. The serum levels of leptin and NpY were 27% higher in the treated patients  compared to those having no medication ; however, these differences reached no statistical significance. The levels of resistin, adiponectin, visfatin, and IGF-1 showed no differences between the treated and nontreated FM patients.Stress-related analgesia and reduced pain perception are described in smokers being more pronounced in women . These pSmoking is reported to deregulate neuroendocrine responses to pain by supporting production of NpY . In animThe serum and cerebrospinal fluid (CSF) levels of NpY and substance P were similar in the current smokers, ex-smokers, and nonsmokers . Thus, tn = 18) had a lower pressure pain threshold compared to nonsmokers  and to ex-smokers , and higher VAS-pain  and TP counts  when compared to ex-smokers. The clinical measurements of pain correlated to the serum levels of NpY , while no such correlation was found in the serum levels of substance P. This allowed suggesting that the pain alleviating effects of NpY are observed in the studied FM patients, since the levels of NpY had an inverse correlation to the TP counts and positive correlation to pressure pain threshold, indicating that sensitivity to NpY was not reduced in FM patients. Our findings are consistent with the previously shown inability of FM patients to response pain by adequate production of NpY and altered NpY release [The current smokers  and inversely related to fatigue , and to serum levels of visfatin .Smoking inhibits IGF-1 levels –61. We oThe molecular mechanisms of IGF-1 suppression by nicotine are now quite understood. The levels of IGF-1 are connected with the function of the hypothalamus and IGF-1 may be locally produced in the accurate nucleus. The injection of leptin  and the To summarize, patients with FM have low levels of neuropeptide Y. Smoking is associated with low levels of leptin, which is expected to increase NpY levels and to alleviate pain. However, this does not occur in FM and smoking is associated with higher VAS-pain and lower pain threshold. Deregulation of balance between leptin and neuropeptide Y may be one of essential mechanisms of chronic pain in FM.


Although not well known, post-laminectomy syndrome (PLS) is an important cause of chronic back pain, which may lead to decreased quality of life, disability and psychological disorders. This study aimed to evaluate the clinical characteristics and prevalence of PLS, to estimate its impact on the quality of life and to determine its association with anxiety, depression and disability in patients at public hospitals in São Luís, MA.Cross-sectional, descriptive and analytical study. Eighteen patients characterized as having PLS were selected, and their clinical, epidemiological and psychological characteristics, their quality of life and their levels of physical fitness were evaluated through clinical evaluations, Beck questionnaires, the Short Form-36 (SF-36), the Rolland-Morris questionnaire and the Douleur Neurophatique 4 questions. The multidimensional pain evaluation was performed using the McGill Pain Questionnaire.The prevalence of post-laminectomy pain was 60 %. Most of the patients assessed in this study were male and received a family income of up to minimum wage; their mean age was 45 years. All of the patients presented with chronic, intense pain that had lasted an average of 7.22 years. The prevalence of neuropathic pain was 89.9 %. The physical appearance and functional capacity domains of the SF-36 were classified as unsatisfactory in 94.4 and 83.3 % of the patients, respectively. None of the patients exhibited high levels of physical fitness. The average score was 21.33 for anxiety and 18.88 for depression. There was a strongly positive and significant relationship between the anxiety and depression scores. Additionally, there was a moderately positive and significant relationship between the disability and anxiety scores. Regarding the correlation between the pain intensity and the quality of life, there was a moderately significant relationship between the patients’ mental health and their vitality.PLS exhibits a high prevalence and significance, and it causes high levels of morbidity in patients. Furthermore, PLS features intense levels of pain, reduced quality of life and greater physical and occupational disability.The online version of this article (doi:10.1186/s13104-015-1400-9) contains supplementary material, which is available to authorized users. The pain associated with lumbar radiculopathy is caused by a combination of ischemia and inflammation of the nerve root, both of which are due to local pressure and to the release of inflammatory neurochemical factors present within the intervertebral disc .The surgery to correct disc herniations is most commonly performed as an elective procedure in the patients who fail conservative treatment and who experience worsening of their lower limb pain and disability . StudiesLumbar laminectomy is one of the surgical procedures used to treat intervertebral disc (IVD) protrusions. It consists of removing the vertebral lamina to expose and allow access to the IVD that is responsible for the nerve root compression. Although the vast majority of lumbar sciatic pain is mechanical in nature, the surgical procedure is required in only 1–3 % of cases .International Association for the Study of Pain (IASP) as back pain, with or without referred or radiating pain, that is located mainly in the lower limbs, is of unknown origin and persists or begins after surgical procedures are performed to treat lumbar disc herniations [Post-laminectomy syndrome (PLS), or “Failed Back Surgery Syndrome” (FBSS), is defined by the niations . Althougniations .Compared with other models of chronic pain, PLS patients with neuropathic pain experience intense levels of pain, lower quality of life, greater disability and higher rates of unemployment .The pain stems from the involvement of various anatomical structures and manifests itself in various and unique ways in each patient . ChronicDespite numerous studies addressing the prevention and treatment of PLS, little has been published nationally or internationally on the correlation between the anxiety, depression, disability and quality of life of individuals with PLS. We found no publications on this subject that are based in our region.Therefore, the present study aimed to evaluate the clinical characteristics and the prevalence of PLS and to estimate its impact on the quality of life and its association with pain, anxiety, depression and disability in the patients at public hospitals in São Luís, Brazil.We selected patients who had undergone at least one lumbar spine surgery to treat disc herniations in a period of 1 year and who did not show improvement of the original symptoms. The subjects were of legal age and were able to understand the questionnaires and to report their answers precisely.The following participants were excluded from this study: patients with oncologic or chronic inflammatory diseases, pregnant women and individuals with severe psycho-behavioral impairments that could jeopardize the collection of the necessary information.In the studied period, 188 spinal column surgeries were performed for various reasons at the reference hospitals of the public system of São Luís . Of these surgeries, 73.9 % were performed at the University Hospital of the Federal University of Maranhão. The medical records of these patients were solicited, of which 18 (9.5 %) were not found. From the available medical records, 78 patients (45.9 %) were excluded from the study because they had undergone surgeries to treat etiologies  other than lumbar disc herniations. The remaining 92 patients had undergone the procedure of interest.Of these 92 patients, 32 lived in cities far from greater São Luís, and 24 had no working telephone number. Therefore, a total of 36 patients were analyzed. From these 36 patients, 6 16.7 %) were lost from the study because they refused to participate in the survey or had changed their address. Consequently, 30 (83.3 %) patients were contacted, and only 18 met the inclusion criteria and remained in the sample for analysis  under the supervision of doctors who were pain specialists.The evaluation consisted of a clinical interview and the use of questionnaires validated for Brazil. The data were obtained by the researchers themselves, with support from the staff of the institution where the study was conducted and from the members of the Academic League of Pain of Maranhão.The questionnaire Short Form-36 (SF-36) , which wThere are contradictions in the literature regarding the cutoff point of the SF-36 questionnaire; however, for the sake of this study, scores below 50 were considered as unsatisfactory, between 50 and 70 as satisfactory and equal to or greater than 70 as excellent.Physical fitness was assessed using the Roland-Morris questionnaire , whose sAll of the patients were evaluated and followed up according to the assessment protocols for back pain that were written at the chronic pain department of the President Dutra University Hospital. The patients’ responses were documented regarding their pain’s onset, character, intensity, location, radiation, time of exacerbation, frequency, triggering factors, improvement factors, worsening factors and other associated characteristics; data were also collected from the neurological and musculoskeletal examinations.The multidimensional characteristics of the pain were assessed by the reduced McGill Pain Questionnaire, which was validated for the Portuguese language . The totThe presence of neuropathic pain was investigated using a DN4 questionnaire validated for the Portuguese language , for whiThe psychological evaluation aimed to quantify the patients’ anxiety and depression based on the Beck Inventory . The orip value <0.05 were considered statistically significant. The data were analyzed using the STATA 10.0 software.The analysis of the qualitative variables was performed using the absolute and relative frequencies and averages. Spearman’s correlation was used to correlate the various questionnaires and their components with the intensity of the pain. The following values were considered for the strength of association: strong (0.9–1), strong (0.75–0.9), moderate (0.5–0.75), weak (0.25–0.5) and very weak (0.0–0.25) . AssociaAll of the patients had previously signed an informed consent form and were examined by a multidisciplinary team. The appropriate follow-up was offered to these patients without incurring any additional burden to them. This work was approved by the University Hospital Research Ethics Committee in accordance with Resolution 196/96 under number 502/2009-80.Of the 30 patients assessed, 18 reported persistent pain after surgery. Therefore, the prevalence of PLS was 60 % in the present study.The mean age was 45 ± 12.46  years. Most of the patients had dark complexions (55.6 %), were male (66.7 %), were married (77.8 %), had up to a primary education (72.2 %) and earned a family income of up to minimum wage (50 %), as presented in Additional file Only one patient reported that the pain did not affect his professional activity, and 27.8 % of the patients assessed were receiving health aid benefits. The majority reported not having changed jobs because of the pain (88.9 %).All of the patients experienced chronic pain (greater than 3 months in duration), with an average duration of 7.22 years. The pain was predominantly of insidious onset (77.8 %), was moderately intense at the time of the appointment (38.9 %) (3.77 ± 3.15), was intense at its most severe point (83.3 %) (8.67 ± 2.00), was intense in general (50 %) (6.77 ± 2.48) and was continuous in its frequency (61.1 %) , pain on flexion (88.9 %) and extension 72.2 %) of the lumbar spine and a positive Valsalva maneuver (16.7 %). The Lasègue maneuver was positive in only 22.2 %. The prevalence of neuropathic pain as assessed by the DN4 questionnaire was 89.9 % (6.1 ± 2.0 points)  occurred in areas with the lowest rates of surgery, whereas the worst outcomes occurred in areas with the highest rates of surgery . ImproveIt should also be noted that this subject is controversial. Some investigations have shown beneficial results from surgery. A prospective non-randomized observational study  suggestsThe main limitation of the present study was the small number of patients who were assessed. This restriction was due to the loss of patient contact by telephone and to the failure of some patients to meet the inclusion criteria. Another obvious limiting factor was the possible lack of follow-up and rehabilitation of these patients after surgery, which was caused by the inadequate management of the responsible medical team, by a public health system that was deficient in the rehabilitation sector or by obstacles (such as difficulty in movement) that were inherent to the patients. These factors negatively contributed to the postoperative pain control in the long term and were reflected in the results observed in this study. Future longitudinal studies are needed to better understand the relation among all these evaluated factors and pain.Despite evident progress in the treatment of degenerative diseases of the spine, many problems remain unresolved. Furthermore, the rate of PLS after surgical decompression of the nerve root remains considerably high , 23, cau


Persistent pain is a serious problem that often contributes to a poor quality of life in pancreatic cancer patients. Medical management by opioid analgesics is often accompanied by side effects and incomplete pain relief. A celiac plexus block is a simple treatment which relieves pain, but the procedure demands a certain degree of proficiency and the duration of the effects obtained can be rather limited. Transhiatal bilateral splanchnicectomy achieves a certain denervation of splanchnic nerves, but it requires a laparotomy. Unilateral thoracoscopic splanchnicectomy is a minimally invasive procedure to cause definite denervation. Bilateral thoracoscopic splanchnicectomy is recommended for unsatisfactory cases or recurrent pain occurring after the initial unilateral splanchnicectomy. It is important to select the most suitable treatment depending on patients' actual medical state and the predicted outcomes. Persistent pain is a serious problem that often contributes to anorexia and a poor quality of life for pancreatic cancer patients . MoreoveThe greater, lesser, and least splanchnic nerves carry sympathetic pain innervation to the upper abdominal viscera, including the pancreas, from the 5th to 8th, 9th to 10th, and 11th thoracic ganglia, respectively . To treaCeliac plexus nerve block (CPB) was first described by Kappis in 1914 . A doublAs a mechanical neurolysis of splanchnic nerves, the left unilateral splanchnicectomy by laparotomy in patients with chronic pancreatitis was introduced by Mallet-Guy in 1942 . SplanchIn this review article, we focused on mechanical splanchnicectomy as a treatment of intractable pain control for pancreatic cancer patients.The procedure for transhiatal bilateral splanchnicectomy (TBS) was first described by Sastre et al. and by us , 19. AftSastre et al. reported on 51 patients treated with transhiatal bilateral splanchnicectomy for intractable pain caused by unresectable pancreatic cancer . TBS aloWe have previously reported on the beneficial effects of TBS . TBS wasWe reviewed the previously published articles on TBS and the data is shown in Tables Worsey et al.  and TakaLonroth et al. reported that unilateral TS treatment showed significant effectiveness for reducing the pain of 4 patients with pancreatic cancer, 1 with duodenal cancer, 3 chronic pancreatitis, and 1 portal vein thrombosis . They usPietrabissa et al. reported on 24 patients treated with unilateral TS . Four TSLeksowski graded the degree of pain reduction after unilateral left TS in 26 pancreatic cancer patients based on detailed scoring factors including worst pain, least pain, general activity, mood, walking ability, relations with other people, sleep, and the enjoyment of life . This stRecently, there have been several reports on TS , 34–36 tThe usefulness of Bilateral TS for pain reduction in cases with pancreatic cancer was examined by Lin et al.  and Cuscn = 3) and chronic pancreatitis (n = 5). They demonstrated that the posterior route provided an excellent visual exposure of the mediastinum, chest wall, and sympathetic and splanchnic nerves without using single lung anesthesia.Cuschieri et al. introduced a bilateral TS performed through a posterior thoracoscopic approach . They inIhse et al. reported bilateral TS in a prone position . They inKang et al. reported on 21 upper abdominal cancer patients treated with bilateral TS . They alSaenz et al. reported on 13 patients treated with unilateral TS and 11 with bilateral TS . AlthougGiraudo et al. reported on combining TS and laparoscopic gastrojejunostomy as a palliative treatment for unresectable advanced pancreatic cancer patients with uncontrollable pain and gastric outlet obstruction  . The meaLe Pimpec Barthes et al. described the effectiveness of contralateral TS as an additional treatment in cases of insufficient pain reduction after unilateral TS . They peKatri et al. investigated the pain reductive effects of left- and right-sided TS performed for 12 pancreatic cancer patients . They apBilateral TS is not necessarily recommended as an initial palliative treatment for intractable cancer pain. The left-sided TS is mainly applied as a unilateral procedure, though it may be better to select either the left or the right unilateral TS depending on the actual location of the pain. A contralateral TS is recommended if the initial unilateral TS is not effective or the recurrence of the pain appears.Some studies compared the effectiveness of CPB and TS. Stefaniak et al. investigated the intensity of the pain, quality of life, and opioid intake for 35 patients treated with CPB and 24 with unilateral TS . They coOn the other hand, Johnson et al. compared the efficacy of bilateral CPB, bilateral TS, and appropriate medical management alone among 65 patients with pancreatic or upper abdominal cancer . In thisIn general, the prognosis for advanced pancreatic cancer patients is extremely poor. Therefore, normally it is quite difficult to predict whether or which splanchnicectomy will lead to significant pain reduction and contribute to the quality of life of the patients. CPB is a simple procedure which brings pain relief, but it requires proficient skills and the duration of its effects may be limited. TBS can achieve a certain denervation of splanchnic nerve, although it necessitates a laparotomy. TBS can be also used as an additional operation when abdominal surgery is required for patients. Unilateral TS is a lesser invasive method than TBS to achieve a certain denervation level. Bilateral TS may be recommended for unsatisfactory cases or recurrent pain after the initial unilateral TS. There are lots of modalities to treat the intractable pain of pancreatic cancer patients. It is very important to select the most appropriate treatment depending on the individual patients' actual medical condition and predicted outcomes.


Chest pain is a common clinical syndrome. However, there is a paucity of African studies describing the causes, prevalence, aetiology, and disposition of patients with chest pain presenting in the emergency department (ED).The aim of this retrospective descriptive study was to determine the prevalence, causes, demographics, and disposition of all adult patients with the main complaint of chest pain presenting at the ED of a regional hospital in South Africa.Records of all patients 18 years and older presenting with the complaint of chest pain from 1 December 2011 through 10 April 2012 were assessed. A data collection sheet capturing patient demographics and disposition from the ED was used. The diagnosis was subdivided into groups: cardiovascular, respiratory, gastrointestinal, musculoskeletal, psychiatric/psychogenic, other, and unknown.Of the 312 patients presenting with chest pain, 210 patient files were retrieved. The prevalence of non-traumatic chest pain was 1.66%. Respiratory disease was the most common cause (36.19%), with pneumonia the most common diagnosis (24.40%). Logistic regression showed diagnoses of acute cardiovascular disease or respiratory disease, older age, and transport by ambulance as being associated with admission.The main cause of acute chest pain was found to be respiratory disease, followed by musculoskeletal disorders. In the African context, the aetiology of acute chest pain differs from that in first world countries. Health workers should therefore pay special attention to respiratory conditions during diagnosis and management in African patients with acute chest pain. As expected, the prevalence in primary care is less, with an estimation of 1–2%.5Chest pain is quite common and ‘up to 25% of the general population experience it’ in some form during their lifetime.4 It may be broadly categorised as somatic or visceral in origin. Somatic pain includes pain from the musculoskeletal structures, coverings of major organs, and dermal tissues, whereas visceral pain includes pain from structures like the heart, stomach, and so forth.5Acute chest pain is a clinical syndrome that may be caused by almost any condition affecting the thorax, abdomen, or internal organs.6 These causes are acute coronary syndromes, aortic dissection, pulmonary embolism (PE), ruptured aortic aneurysm, and tension pneumothorax.7 The most common of these is myocardial infarction (MI), or ischaemia.8 In patients with non-life-threatening chest pain, it may be only after a complete workup, including a comprehensive history, physical examination, and some further investigations, that a diagnosis is reached.7When a patient presents with chest pain in the ED, the first priority is to consider potentially life-threatening causes.3 Then again, 50–80% of patients are discharged without a diagnosis or with a diagnosis of a non-cardiac condition.8 Non-cardiac chest pain is defined as chest pain that is not related to coronary artery disease. Population-based studies on the epidemiology of non-cardiac chest pain have reported that the prevalence of non-cardiac chest pain in the community ranges from 23 to 33%,9 and there seem to be no differences between males and females. Furthermore, roughly 2–5% of all presentations to hospital EDs are for non-cardiac chest pain.1Cardiovascular conditions  are diagnosed in more than half of patients presenting to the ED with chest pain.3 might improve with better knowledge of the wide spectrum of etiology of non-cardiac chest pain’.5 These conditions include musculoskeletal syndromes, pulmonary disease, psychological disorders  and disorders of abdominal viscera.8The diagnostic approach to chest pain, which is ‘a “risk avoidance” and a “rule out coronary heart disease” strategy,5 In primary care, musculoskeletal conditions account for 21–49%10 of causes of chest pain, but only 7% in the ED.10A confident diagnosis of musculoskeletal chest pain can be challenging because no clear reference standard exists.10 of the patients with chest pain in the ED, with PE, pneumonia, spontaneous pneumothorax, and pleuritis as main causes.8Pulmonary diseases account for 12–14%8Studies have reported that patients with non-cardiac chest pain and normal coronary arteries suffer from various psychiatric disorders, most commonly panic disorder, anxiety, and depression.2An audit showed that overall 61% of patients with chest pain of all causes were assessed and discharged home by ED doctors without recourse to a second opinion. Of patients thought by the ED doctors to have chest pain of cardiac origin, who were referred to the duty medical registrar or cardiologist, 88% were admitted.The literature usually focuses on how to evaluate patients with acute chest pain in different clinical settings, but few articles describe the range of conditions that present with chest pain. In addition, there is a lack of South African studies on the prevalence, aetiology, and disposition of patients with chest pain presenting in the ED.The aim of the current study was to determine the prevalence, causes , demographics, and disposition of all adult patients with the main complaint of chest pain presenting at the ED of a regional hospital in South Africa.A retrospective descriptive study of all ED patients with chest pain was done at the ED at Kalafong Hospital, to which 49 200 new patients present every year. Kalafong Hospital is an academic hospital affiliated to the University of Pretoria. It delivers mostly secondary-level services with some primary and tertiary services available. Most of the population that Kalafong serves have no access to a community health centre or district hospital, and so Kalafong is the only after-hours medical service available to them.The study population consisted of all patients 18 years and older with the main complaint of chest pain from 1 December 2011 through 10 April 2012.Records of all patients presenting with the complaint of chest pain in the time frame were assessed. A data collection sheet was used. Data included patient demographics and disposition from the ED. The diagnoses were subdivided into the following groups: cardiovascular, respiratory, gastrointestinal, musculoskeletal, psychiatric/psychogenic, other, and unknown. Cardiovascular causes were subdivided into ischaemic and non-ischaemic diseases. Somatoform disorders constituted a group of psychiatric disorders with predominantly physical symptoms that were not fully explained by a general medical condition.t-test was used for continuous data. For multivariate analysis, logistic regression was used. All variables identified in the univariate analysis with p-values up to 0.2 were tested in the model to determine significance and identify confounders.Univariate statistical analysis was done to assess the characteristics and demographics of participants. Stata software  was used for data analysis. Student’s The ethics committee of the Faculty of Human Health Sciences of the University of Pretoria approved the study . The study was carried out according to the ethical principles of the Declaration of Helsinki and the Declaration of Geneva of the World Medical Association.The prevalence of chest pain in the ED was found to be 1.82% (traumatic and non-traumatic). The prevalence of non-traumatic chest pain was 1.66%. According to the ED register, 312 patients with chest pain presented between 1 December 2011 and 10 April 2012. The characteristics of these patients are presented in Of the 312 patients, it was possible to retrieve 210 patient files. Respiratory disease  was the Other causes of chest pain were diabetic ketoacidosis, urinary tract infection, alcoholic liver disease, renal failure, pyelonephritis, and intracranial bleeding. Respiratory disease (46.32%) and cardiovascular disease (43.16%) were also the most common cause for admission by specialists. Of the patients admitted with respiratory disease, 70.45% (31/44) were diagnosed with pneumonia. Of the pneumonia patients, 29.4% were known to be HIV positive before admission. Pulmonary tuberculosis was diagnosed in 7.8% of patients with respiratory disease.Regarding age, patients with cardiovascular disease tend to be older than the average age, with a mean age of 55.07 (SD 16.04) years. Patients with psychological disorders were younger than average, with a mean age of 29.86 (SD 6.79) years. The mean age for patients with respiratory disease was 43.21 (SD 16.58) years and for musculoskeletal problems 35.74 (SD 10.83) years.Cardiovascular disease patients were more often male (66.67%) and utilised ambulance transport (53.66%) more frequently than patients with other causes of chest pain.Patients with psychological disorders were most often females patients (85.71%) and were transported to hospital by their own or public transport (80%). Co-morbidities of hypertension (61.36%) and diabetes mellitus (13.63%) were the most prominent in the cardiovascular disease group.African patients were dominant in all the aetiology groups except cardiovascular disease (40%), where white patients were more prevalent (51%) .p < 0.0001), with a probability of 91%. Patients with respiratory disease were more likely to be admitted than discharged , with a probability of 58%. The odds of being discharged were the highest for musculoskeletal disorders , with a probability of 93.48%.Regarding disposition, 63.46% of patients were discharged, of which 56.09% were discharged by the ED doctors. A third of patients were admitted to the hospital, one patient was transferred to a central hospital, six patients absconded, and three died in the ED. The odds of being admitted were highest for patients with cardiovascular disease (odds ratio (OR) 21.07, 95% confidence interval (CI) [7.01–83.91]; p < 0.0001. Forward and backward analyses were conducted. There was no interaction between the variables.Further analysis by logistic regression was done to assess clinically relevant and statistically significant variables identified in the univariate analysis regarding disposition. The final model  consisteThis was a retrospective descriptive study, investigating the overall case mix of patients presenting with traumatic and non-traumatic acute chest pain in an academic hospital ED in South Africa. The aim of our study was to describe the prevalence, spectrum of causes, demographics, and disposition of acute chest pain patients specifically in an African context. To date, this was the first African study on the aetiology of acute chest pain with major differences to first world publications.3 The mean age of chest pain patients was 42.41 years, much younger than in other studies, for example Knockaert et al.3 and Buntinx et al.10 with a mean age of 60 years, Henderson et al.11 with a mean age of 53 years, and Aguilera et al.12 with a mean age of 53 years. This difference could be explained by the high prevalence of respiratory disease (mean age 43.21 years [SD 16.58]) and musculoskeletal disorders (mean age 35.74 year [SD 10.83]) found in our patients. The unique profile of our chest pain patients may partly be a result of our setting, as there is no district hospital to serve patients with primary-level respiratory and musculoskeletal disorders needing hospitalisation or after-hours care. Our subgroup of patients with cardiovascular disease had a mean age of 55 years, however, which is comparable to the other studies’ findings.The prevalence of chest pain in the unit was 1.66% for non-traumatic chest pain - lower than the 2.7% found in a Belgian study.3 found 14.2% and Buntinx et al.10 12.1%, respectively. The high occurrence of respiratory disease in patients with chest pain in our unit may be explained by the high prevalence of HIV. Regarding demographics, 41.5% of our black African patients had respiratory disease. In comparison, Aguilera et al.12 also found cardiovascular disease at 20.5%, in contrast with Lee and Goldman13 (45–50%), Knockaert et al.3 (51.7%), Buntinx et al.10 (54.3%), and Fothergill et al.2 (41%).The most common cause of acute chest pain was found to be respiratory disease (36.19%), followed by musculoskeletal conditions (21.9%) and cardiovascular disease (21.43%). Our finding regarding the prevalence of respiratory disease (36.19%) was in contrast to all other studies: Knockaert et al.14 who found a prevalence of 21–49%, but differed from other studies, which found 7%.14Most of our patients were black Africans (75%), but most of the patients with cardiovascular disease were white people (51%). The proportion of musculoskeletal conditions (21.9%) found in our study compared well with that of Ayloo et al.,3 In particular, cardiovascular patients were transported more by ambulance than by their own or private transport, similar to a study done in Gothenburg.15The proportion of transport by ambulance (37%) concurred with other studies.11 where only 15.6% of patients were discharged, and Fothergill et al.,2 who found 61% were discharged. Ultimately, 33% of all chest pain patients were admitted.Regarding disposition, 56% of chest pain patients were managed and discharged by the ED doctors without recourse to a second opinion. This figure falls within the widely differing findings of Henderson et al.,12 where 76% of admitted patients had cardiovascular disease and 11% had respiratory disease.Logistic regression in our study identified diagnosis of acute cardiovascular disease, diagnosis of respiratory disease, older age, and transport by ambulance as being associated with admission to a hospital ward, whereas diagnosis of musculoskeletal disorders was associated (93.8%) with discharge from the hospital. Only 9% of patients with cardiovascular disease were discharged, in comparison to 42% with respiratory disease. Admitted patients mostly had respiratory disease (43%). These findings are very different from Aguilera et al.,Although 112 patient files could not be retrieved, data on a large number of variables were available from the emergency unit register, including disposition. The decision was made not to remove those cases with incomplete data, as it would produce biased parameter estimates. The sample of 210 complete patient records was sufficient to achieve statistical power of more than 80% for the study.Diagnoses were often made based on clinical assessment with limited special investigations or specialist input. It is problematic that the diagnosis of gastrointestinal disease was made after clinical assessment and limited investigations, especially in discharged patients. Psychological diagnoses were also made without the opinion of a specialist in the field.Although the power of the study was sufficient, the study period was relatively short and a year might have given more reliable results.The main cause of acute chest pain in the ED of Kalafong Hospital, South Africa, was found to be respiratory disease, followed by acute cardiovascular disease. The mean age of chest pain patients was younger than in any other study. The probability of being admitted was highest for patients with acute cardiovascular disease, acute respiratory disease, older age, and patients transported by ambulance, whereas the probability of being discharged was the highest for patients with musculoskeletal disorders.In the African context, the aetiology of acute chest pain differs widely from first world countries. Health workers should therefore pay special attention to respiratory conditions during diagnosis and management in African patients with acute chest pain.


Painful legs and moving toes (PLMT) is a rare syndrome characterized by spontaneous neuropathic pain and peculiar involuntary movements in the lower limbs, especially the toes and feet. As it is a relatively rare disorder worldwide, the exact pathophysiology still remains a mystery. Until recently, numerous methods of clinical treatments have been tried; however, the success rate of the therapies is still very low. Here, we report a case of PLMT and also summarize the recent clinical and research literatures regarding clinical presentation, electrophysiological features, etiology, treatment methods, and prognosis of this disorder. Doctors should be aware of this rare syndrome in a patient with painful and/or restless legs. On the other hand, multiple clinical treatments should be tried, even those which usually produce a poor outcome. The painful legs and moving toes (PLMT) is a syndrome which was first described by Spillane et al. in 1971 . In thisA 29-year-old female was referred to our department with the chief complaints of aching pain and involuntary movements in her feet. Her right ankle was sprained two years ago (July 2011), resulting in the persistent swelling and pain in the injured region. Later, this burning pain with 8/10 intensity in her right ankle and foot was spread to the right leg, which has been worsened in the cold weather or after walking while being relieved in the warm temperature or in the condition of resting. Six months later (January 2012), the onset of involuntary flexion-extension movements of all her right toes was observed at rest. The movements were intermittent in the conscious period and disappeared in sleep. Moreover, in July 2013, the patient described tearing pain that occurred in her left ankle while walking, along with involuntarily abnormal movements presented in her left toes which were similar to those in her right toes. Walking was difficult for her due to the pain. As the symptoms could not be alleviated after resting in bed for four to five weeks, the patient was referred to our hospital.http://dx.doi.org/10.1155/2014/581402). The neurological exam was normal. Additional tests including routine and biochemical studies of blood, urine, and stool, thyroid function, serum ceruloplasmin, serum iron level, serum vitamin B12, antinuclear antibody, SSA, SSB, and serum protein electrophoresis showed results that were physiologically normal. CT scan of the head, MRI of the spine, EEG, EMG, and nerve conduction studies did not display pathological finding. MRI of the right ankle revealed soft tissue swelling and joint effusion in that region. The patient was treated by oral baclofen (10 mg three times daily) and gabapentin (300 mg three times daily) for one week. As no significant improvement was obtained, the patient discontinued the treatment. A telephone follow-up for the patient was conducted once every three months. After discharge from our hospital, she accepted the treatment of traditional Chinese medicine and the acupuncture, and also no improvement was observed. We performed the latest follow-up in September 2014, the pain and involuntary movements in her feet still persisted, and the patient attempted to take the botulinum toxin type A injection in Peking Union Medical College Hospital.The patient was generally healthy in the past and there was no history of psychiatric illness or use of neuroleptics. Our clinical examination found arrhythmic flexion-extension movements of bilateral toes repetitively in the resting condition, which could be reduced when touching the dorsum of the foot  is a rare syndrome which was first reported in 1971 , 3, inclPLMT is characterized by pain in the foot or calf and involuntary movements of the toes, which can be developed unilaterally or bilaterally. Pain is noted in 95% of patients and usually precedes the onset of abnormal movements by days to years. The pain usually continuously occurred in the foot or leg with tingling, tearing, shooting, or burning sensation, which brings more suffering to patients compared to the annoyance of the involuntary movements , 3. HoweMost commonly, the involuntary movements occur in the distal parts of the lower limb. In the literature, toe movements appear in all patients, which consist of flexion/extension, adduction/abduction, clawing/straightening, and fanning/circular movements. The proximal muscles of the limb and even the thigh muscles in individuals could be affected when the involuntary movements are severe. The movements are usually continuous, or intermittent in some cases, varying in different patients but tending to be stereotypical to a particular individual . MoreoveIn a small number of the patients, the clinical presentation of PLMT, pain and involuntary movements, has involved other parts of the body, leading to the development of some PLMT variants including painful arm and moving fingers (PAMF), painful hands and moving fingers (PHMF), painful limbs/moving extremities (PLME), and a few cases without pain, which is called painless limbs/moving extremities . TypicalThe abnormality of the somatosensory evoked potential (SEP) has been found in some patients, specifically showing the prolonged latency and decreased conduction, which indicate the pathological damage in the peripheral to central sensory pathway. The velocity of the peripheral nerve conduction could be normal and the indications of peripheral neuropathy or radiculopathy could be presented as well. In addition, EMG examination is able to reveal two types of activities: one is the random, unpredictable, irregular bursts which can last 80–1000 ms and the other is the semicontinuous bursts with a similar duration. The latter is also associated with cocontraction of antagonistic and contiguous muscles of which the frequency is 1.5–200 Hz .The cause of PLMT syndrome is still not fully understood. In addition to a few patients with idiopathic onset , its posThere are still controversies regarding the origin and pathophysiological mechanism of the pain and the movements. The two retrospective studies conducted by Hassan et al. and by Liu et al. demonstrate that both neuropathy and radiculopathy are the most common causes of PLMT , 3. The Currently, there is no evidence that PLMT syndrome can be spontaneously resolved over time. Although a vast array of drugs has been used for the treatment, the success rate of the therapies is still limited. The drugs include baclofen, benzodiazepines, antidepressants, antiepileptics, NSAIDs, and levodopa. The GABAergic agents, such as gabapentin and pregabalin, are known to inhibit calcium influx through voltage-gated calcium channels in the dorsal root ganglia and spinal cord and, therefore, interrupt the series of events that lead to neuropathic pain. They also can centrally inhibit GABA in the basal ganglia to suppress centrally generated movements. The GABAergic agents are found to be effective in attenuating the pain and the movements in PLMT patients, possibly via both central and peripheral mechanisms , 17, 18.Although a list of therapeutic options is available, it is worth noting that many patients still had poor responses to the therapies, and a few had symptoms aggravated gradually along with the progression of the disease. Among all these patients, there are no unique characteristics in the aspects of their sex, age of onset, nature of pain, and neurologic examination .PLMT is a rare syndrome. Until recently, only more than 70 cases have been reported worldwide , includiThe involuntary flexion-extension movements presented in the right toes of the PLMT patient, which could be reduced when touching the ankle or the dorsum of the foot.


Menstrual migraine is a big challenge for the migraine expert. Severity and duration of hormonal stimulation determines the gravity and duration of menstrual attack.Various prevention therapy try to alleviate these attacks, usually long half-life triptans and-or anti-inflammatory drugs, combined with caffeine, magnesium, but however is very difficult to find the right drug in particular in women with uterine fibroids or endometriosis.To support this limited class of patients, we considered to use the Oxycodone/Naloxone Extended Release (O/N-ER) for its favourable mechanism of action on neuropathic pain, long half life and well documented gastrointestinal safety. Although the drug has an indication for chronic pain, many reports in literature support its use in acute pain.Recruitment is only for patients non-responders to classical preventive therapy. Will be collected informed consent, headache diary and a satisfaction questionnaire on therapy, those data will compared with the one recorded in the previous quarter, pharmacoeconomic analysis will provided.Patients will use O/N-ER exclusively for menstrual attacks and for three consecutive periods, with the possibility of use a triptan at the start of attack followed by O/N-ER bid for 3-5 days.Of the 8 patients that have completed the study , 70% of the patients showed a mean reduction in intensity of attacks from 8 to 4 on a NRS scale, grade of satisfaction was 8/10, without significant side effects. More data will come from the analysis of the entire group of the enrolled patients.No conflict of interest.


To date, there are no prospective randomized studies that compare the outcome of endoscopic repair of primary versus recurrent inguinal hernias. It is therefore now attempted to answer that key question on the basis of registry data.In total, 20,624 patients were enrolled between September 1, 2009, and April 31, 2013. Of these patients, 18,142 (88.0 %) had a primary and 2482 (12.0 %) had a recurrent endoscopic repair. Only patients with male unilateral inguinal hernia and with a 1-year follow-up were included. The dependent variables were intra- and postoperative complications, reoperations, recurrence, and chronic pain rates. The results of unadjusted analyses were verified via multivariable analyses.p = 0.849); however, there were significant differences in the postoperative complications , the reoperation rate due to complications , pain at rest , pain on exertion , chronic pain requiring treatment , and the recurrence rates . Multivariable analysis confirmed the significant impact of endoscopic repair of recurrent hernia on the outcome.Unadjusted analysis did not reveal any significant differences in the intraoperative complications (1.28 vs 1.33 %; Comparison of perioperative and 1-year outcome for endoscopic repair of primary versus recurrent male unilateral inguinal hernia showed significant differences to the disadvantage of the recurrent operation. Therefore, endoscopic repair of recurrent inguinal hernias calls for particular competence on the part of the hernia surgeon. The proportion of recurrences in the National Swedish Hernia Registry is 11.2 % –7. The lOn the basis of the meta-analyses, the European Hernia Society recommends endoscopic inguinal hernia techniques for recurrent hernias after conventional open repair . Likewisp = 0.03). The postoperative complication rate was identical in the two groups, amounting to 5.1 and 5.7 %, respectively. No differences were found between the two groups on 1-year follow-up.To date, there is only one prospective study, published in German language, with 338 patients comparing endoscopic repair of primary and recurrent inguinal hernias in TEP technique . In the By analyzing data from the Herniamed Registry , this paThe Herniamed Registry is a multicenter, internet-based Hernia Registry  into whiIn total, 20,624 patients were enrolled between September 1, 2009, and August 31, 2013. Of these patients, 18,142 (88.0 %) had a primary endoscopic repair and 2482 (12.0 %) had a recurrent endoscopic repair. All the patients had to have a 1-year follow-up (follow-up rate: 100 %).2), ASA classification  as well as EHS classification  , larger defect size , and higher age [10-year OR 1.133 ] were conducive to onset of postoperative complications  and primary operations  significantly reduced the risk of onset of a postoperative complication. With an overall prevalence of 3.3 %, there would thus be 29 postoperative complications for every 1000 primary operations compared with 36 postoperative complications for every 1000 recurrent operations.On the other hand, a 5-point higher BMI [5-point OR 0.782 ] as well as a lateral EHS classification [OR 0.645 ] reduced the risk of postoperative complications. Likewise, a medial EHS classification . Here, too, scrotal EHS classification emerged as the strongest influence factor. The reoperation risk was significantly increased for scrotal EHS classification . A 5-point higher BMI was shown to be preventive here with regard to the reoperation rate . Likewise, primary operation significantly reduced the reoperation risk . With an overall reoperation rate of 0.9 %, that thus corresponds to around seven reoperations for every 1000 patients with primary operation compared with 11 reoperations for every 1000 patients with a recurrent operation.The results of analysis of the reoperation rate are shown in Table p = 0.021] as well as a higher age  significantly increased the reoperation risk.Conversely, larger hernia defect sizes . Likewise, medial EHS classification significantly increased the recurrence rate on follow-up . The ASA status, too, had a significant effect on the recurrence rate on follow-up, something which, however, cannot be unequivocally specified in the categories (p = 0.039). Conversely, for a primary operation only a tendentially predictive effect could be demonstrated .Table p < 0.001). That was highly significantly influenced by the operation type (p < 0.001). A primary operation reduced the risk of pain at rest [OR 0.661 ]. With an overall prevalence of 4.3 %, that corresponds to 35 patients with pain at rest for every 1000 primary operations compared with 51 patients with pain at rest for patients with recurrent operations.The results of multivariable analysis of pain at rest on 1-year follow-up are summarized in Table p < 0.001). A higher BMI increased the risk of pain at rest [5-point OR 1.284 ]. On the other hand, a larger defect size reduced the risk of pain .Likewise, BMI and hernia defect size had a highly significant impact , was highly significantly influenced by the operation type (p < 0.001).Equally, pain on exertion on follow-up, whose results are summarized in Table Conduct of a primary operation was associated with highly significantly less pain on exertion [OR 0.667 ]. With an overall prevalence of 8.4 %, that corresponds to onset of pain on exertion in around 68 out of every 1000 patients with primary operations compared with 99 out of every 1000 patients with recurrent operations.p < 0.001). In this regard, the probability of occurrence of pain on exertion declined with higher age [10-year OR 0.834 ] as well as in the presence of larger hernias . Conversely, a 5-point higher BMI increased the risk of pain [5-point OR 1.175 ].Likewise, age, hernia defect size, and BMI exerted a highly significant impact on pain on exertion . There is hardly any difference between these results and those obtained for pain on exertion. Here, too, the hernia defect size, BMI, operation type, and age played a highly significant role . A larger defect size , primary operation [OR 0.605 ], and older age [10-year OR 0.880 ] reduced the risk of chronic pain requiring treatment. Conversely, the risk of pain was increased by a 5-point higher BMI [5-point OR 1.405 ].The results of analysis of pain requiring treatment are shown in Table With an overall prevalence of 2.5 %, the impact of the operation type on onset of pain requiring treatment would mean that some 19 out of every 1000 patients with primary operation suffer from pain requiring treatment compared to 31 out of every 1000 patients with recurrent operation.p > 0.001) showed that only for medial EHS classification was a significant relationship identified. Here, the risk of intraoperative complications was reduced for patients with medial EHS classification [OR 0.564 ]. No significant impact was identified for any of the other parameters.Analysis of the intraoperative complications  .Certain conclusions can be drawn, with regard to onset of inguinal hernia recurrences, from the proportion of these risk factors implicated in the two comparison groups. For example, this present analysis did not identify any significant difference between the two comparison groups in terms of mean BMI, proportion of smokers, and immunosuppressed patients. However, significant differences were found between the primary and recurrent inguinal hernia groups with regard to age, proportion of patients with a history of COPD, diabetes mellitus, and aortic aneurysm as well as patients who had to take platelet aggregation inhibitors.p = 0.849), but definitely were for the postoperative complications  and the complication-related reoperation rates . Likewise, multivariable analysis confirmed that the recurrent operation, in addition to scrotal hernia, larger defect size, higher age, and higher BMI, had a negative impact on postoperative complications. That was also true for the complication-related reoperation rates. And while the differences between the two groups are significant in view of the large sample size, the absolute values clearly show that even recurrent hernias can be operated on with a very low perioperative complication rate when using an endoscopic repair technique. Accordingly, patients should be informed in an informed consent discussion that the risk associated with endoscopic inguinal hernia repair is higher for a recurrent operation compared with a primary operation.On comparing the perioperative outcome of endoscopic repair of primary versus recurrent male unilateral inguinal hernias, no significant difference was discerned with regard to the intraoperative complications , pain at rest , pain on exertion , and chronic pain rate requiring treatment . However, multivariable analysis identified the significant impact exerted by the recurrent operation on the recurrence rate only as a trend. Rather, a higher BMI value, higher ASA classification, and medial hernia classification were responsible for re-recurrence.Equally, significant differences were seen for all criteria in the results of 1-year follow-up for endoscopic primary repair of primary versus recurrent male unilateral inguinal hernias. For example, significant differences were noted in the recurrence rates (0.94 vs 1.45 %; Multivariable analysis identified the significantly negative impact exerted by a recurrent operation on pain at rest, pain on exertion, and pain requiring treatment. Furthermore, a higher BMI value, smaller defect size, and younger age were implicated in onset of pain after endoscopic inguinal hernia repair.The present data thus clearly demonstrate that even when an endoscopic recurrent operation is performed in accordance with the guidelines, a poorer outcome must be expected because of the previous operation.In the vast majority of cases, this is due to the fact that even when operating in another anatomic layer for the recurrent operation only rarely is no scarring encountered from the previous operation. As such, the conditions under which a recurrent operation is conducted are generally worse than those prevailing at the time of the primary operation, i.e., not just following previous endoscopic primary hernia operations. Therefore, a recurrent operation, i.e., also following previous open suture and mesh repair, calls for a particularly experienced surgeon. Accordingly, recurrent operations should always be performed by very experienced endoscopic hernia surgeons.In summary, this present analysis of data from the Herniamed Registry is the first such analysis to demonstrate on the basis of a large prospective patient group the differences in outcome for up to 1 year between endoscopic repair of primary and recurrent inguinal hernia. Even when proceeding in compliance with the guidelines of the international specialist societies, more unfavorable outcomes must be expected for recurrent inguinal hernia. Hence, repair of recurrent hernias calls for particular expertise on the part of the endoscopic hernia surgeons.


To compare the analgesic effect of ultrasound-guided Transversus Abdominis Plane (TAP) block versus Continuous Wound Infusion (CWI) with levobupivacaine after caesarean delivery.We recruited parturients undergoing elective caesareans for this multicenter study. Following written informed consent, they received a spinal anaesthetic without intrathecal morphine for their caesarean section. The postoperative analgesia was randomized to either a bilateral ultrasound guided TAP block (levobupivicaine = 150 mg) or a CWI through an elastomeric pump for 48 hours (levobupivacaine = 150 mg the first day and 12.5 mg/h thereafter). Every woman received regular analgesics along with oral morphine if required. The primary outcome was comparison of the 48-hour area under the curve (AUC) pain scores. Secondary outcomes included morphine consumption, adverse events, and persistent pain one month postoperatively.P = 0.4) and 190 [130–240] versus 160 [112.5–247.5] (P = 0.5), respectively. Morphine consumption (0 [0–20] mg in the TAP group and 10 [0–32.5] mg in the CWI group (P = 0.09)) and persistent pain at one month were similar in both groups (respectively 29.6% and 26.6% (P = 0.73)).Recruitment of 120 women was planned but the study was prematurely terminated due to the occurrence of generalized seizures in one patient of the TAP group. By then, 36 patients with TAP and 29 with CWI had completed the study. AUC of pain at rest and during mobilization were not significantly different: 50 [22.5–80] in TAP versus 50 [27.5–130] in CWI (In cases of morphine-free spinal anesthesia for cesarean delivery, no difference between TAP block and CWI for postoperative analgesia was suggested. TAP block may induce seizures in this specific context. Consequently, such a technique after a caesarean section cannot be recommended.NCT01151943ClinicalTrials.gov  Caesarean delivery is one of the most commonly performed surgical procedures and postoperative pain is a great concern for women We therefore conducted a study to compare continuous delivery of local anesthetic using a wound catheter and ultrasound-guided bilateral TAP block after elective caesarean delivery during the first 48 postoperative hours.The study began September 2010 and was prematurely stopped in July 2011 due to the occurrence of generalized convulsions a few minutes after a TAP block. This event required transient mechanical ventilation and was successfully treated using an intravenous lipid emulsion infusion. It has been considered to be the consequence of a partial systemic absorption of local anesthetic. An independent pharmaco-vigilance committee has recommended stopping the trial because this event if expected as every regional technique occurred with a high rate (1/40) that was higher than expected. Moreover, physiological changes of pregnancy may favor its occurrence and further research is required. Consequently, only 80 subjects were enrolled in the study, 39 were randomized to the CWI group and 41 to the TAP group. Ten patients did not complete the study in the CWI group and 5 in the TAP group as seen in the Consort diagram .P = 0.3). During mobilization, pain was higher but similar in both groups with an AUC at 190 [130–240] in the TAP group and at 160 [105–262] in the CWI group (P>0.9). The per-protocol analysis has given similar results with an AUC at rest at 70 [30–110] and 50 [22.5–120] (P = 0.4) and during mobilization at 190 [130–240] and 160 [112.5–247.5] respectively (P = 0.5) (P = 0.5) and pain scores with movement (P = 0.5). In both cases the time factor was significant  showing a significant change in the perception of pain along time. The time × group interaction is not significant  as we were unable to show a different time profile of effect for the two procedures.Demographic characteristics, as well as intraoperative parameters were similar . The IntP = 0.5) . The mixP = 0.21). Median oral morphine consumption was not significantly different between the groups: 0 [0–20] mg in the TAP group and 10 [0–32.5] mg in the CWI group (P = 0.09), with a large inter-individual variability. Seventeen patients of 36 (47%) in the TAP group compared to 16 patients out of 29 (55%) in the CWI group took oral morphine during the first 60 postoperative hours (P = 0.7).No woman required rescue intravenous morphine administration in the post-anesthesia care unit. Oral morphine was not required by the third postoperative hour in the TAP Block group but was required in 2 cases in the CWI group (P = 0.03). No difference was reported concerning other opioid related adverse effects (pruritus and sedation). A wound complications were seen in 2 cases from the CWI group (P = 0.19). Patient satisfaction with pain relief did not significantly differ between groups (Patients experienced nausea and vomiting more frequently in the TAP group (n groups .P = 0.9). Twenty seven patients in the TAP group (66%) and 19 patients (49%) in the CWI group responded to the postoperative interview. They reported similar rates of persistent wound pain and of neuropathic pain , were similar in both groups The limitations of the study are as follows. We did not include the whole sample of 120 patients as initially planned by the statistical analysis because of the occurrence of a major undesirable event in the TAP group. Furthermore, several patients were excluded from analysis as described above. It can be postulated that the study is underpowered; however it is unlikely that a significant difference between groups could have been found with a complete set of patients. A second major limitation is due to the fact that our study was not blinded and that patients systematically received paracetamol, ketoprofen, and nefopam. This could reduce the difference between the studied loco-regional techniques but represents our routine postoperative care. Conversely, our use of intrathecal bupivacaine with sufentanil instead of a longer acting opioid such as morphine avoids a supplementary confounding factor in our analysis of the analgesic effect and side effects. This is important as a recent study showed that TAP block is associated with greater supplemental morphine requirements and higher pain scores than intrathecal morphine after caesarean section In conclusion, our randomized trial was prematurely ended do to the occurrence of a severe adverse event following a TAP block demonstrating that local anesthetic toxicity can occur even with continuous ultrasound guidance. Despite the fact that our study is consequently underpowered, a difference in term of analgesic efficacy between TAP block and wound infiltration seems improbable regarding our results. As a consequence, use of TAP block after caesarean cannot be recommended before further pharmacological studies on the relationship between adverse effect to local anesthetic and pregnancy.This multicenter randomized clinical open trial with parallel arms was approved by an Ethic Committee  and by the French national regulatory office (Agence Française de Sécurité Sanitaire des Produits de Santé). The trial was registered on ClinicalTrials.gov as NCT01151943. The protocol for this trial and supporting CONSORT checklist are available as supporting information; see 2 and women with contra-indication to any of the study protocol analgesics . Exclusion criteria were conversion from spinal to general anesthesia owing to inadequate intraoperative analgesia, failure of the neuraxial technique, failure to site the multi-hole catheter (CWI group) and failure to visualize the intrafascial space (TAP group).Parturients were eligible if they were scheduled for an elective caesarean delivery at term with a low transverse incision (Joel-Cohen incision) under spinal anesthesia. Other criteria of inclusion were American Society of Anesthesiologists physical status 1 or 2 and a singleton fetus >37 weeks of gestation. Non-inclusion criteria were women in active labour, age<19 or >40 years old, height<155 cm, weight<50 kg or a Body Mass Index>35 kg/mSome weeks (from 4 to 10) before the caesarean delivery, a pre-anesthetic visit was performed during which oral and written information about spinal anesthesia and the study protocol were given. Written informed consent was then obtained either the day before or on the day of surgery. Upon admission to the operative room, every parturient received a standard monitoring including electrocardiogram, non-invasive arterial pressure, and pulse oximetry. At this moment, randomization was performed using a computer-generated set of scratch cards with blocks of 6 and a ratio 1∶1 for each arm, and patients were assigned to one of the two groups for postoperative analgesia TAP or CWI. Intrathecal anesthesia was standardized with a dural puncture at level L3–L4 and administration of 0.5% hyperbaric bupivacaine  plus sufentanil 5 µg. After the block was established, the caesarean section was performed. In the TAP group, a trained anesthesiologist performed US-guided TAP block just after completion of surgery In the post-anesthesia care unit, intravenous morphine was titrated if required  pain score ≥4 on a scale ranging from 0 = no pain to 10 = unbearable. VRNS pain scores ≥4 were managed with oral morphine  in the post-natal ward. Ondansetron and symptomatic treatment of vomiting was available if required. For the purpose of the study, nurses, not involved in the study, from the mobile pain unit assessed patients 3 hours post-cesarean delivery, in the evening  of the operative day (D0), in the morning (around 9∶00) and the evening (between 18∶00 and 20∶00) of the first (D1) and second (D2) postoperative days. They collected also every adverse event of the techniques for safety concern. During the assessment, the women were asked to rate pain with VRNS at rest and when moving (from supine to sitting position in bed), to report any pruritus and any nausea or vomiting (absent or present). The level of sedation  was also reported. For the purpose of statistical analysis, sedation was present if a woman had a score of two or more. Satisfaction with pain control was recorded immediately before the patient left hospital with a VRNS . Gastrointestinal function on the second postoperative day (flatus and faeces), and length of stay at hospital were also recorded.One month post−delivery, the women were interviewed by phone by an investigator blinded to the patient's group assignment. Women were asked if there was any pain in the scar area. In case of a positive answer, the incidence of neuropathic pain was evaluated using the DN4 questionnaire, such a diagnosis being made if the score was equal or greater than 4 on a 0–10 scale The primary outcome was pain over the 48 h postoperative period, i.e. period of local anesthetic in the CWI group, at rest and during mobilization using the area under the curves (AUC) of pain scores. This method allows a better precision in analgesic efficacy than individual pain score reports. AUC was calculated by the trapezoidal method The study was designed to detect a between means ratio of 1.25 in either direction for the AUC, with 85% power allowing for an attrition rate of 10%. The coefficient of variation of the means was hypothesized to be 0.4. With a bilateral significance level of 0.05, the sample size was calculated at 60 patients per group. The Intention to Treat population included all patients that were randomized to the study whatever the treatment they actually received and the Per-Protocol population includes subjects who completed the follow-up in each group.Since the AUC pain scores were skewed and not normalized by a logarithmic transformation, nonparametric tests (Mann-Whitney) were used for group comparisons. Categorical variables, expressed as numbers with frequencies (%) were compared using Chi−square and Fisher's exact tests as appropriate. Continuous variables and pain scores are reported as median with [interquartile range]. A mixed model for repeated measures with two primary factors (pain control method: CWI or TAP and time) and an interaction term was fitted. The Akaike criterion was used to select the most appropriate model. P values <0.05 were considered statistically significant. No interim analysis was planned. Statistical analysis was performed using NCSS .Checklist S1CONSORT Checklist.(DOC)Click here for additional data file.Protocol S1Trial Protocol.(DOC)Click here for additional data file.