This study aimed to assess the quality of life of 113 Caucasian patients with intervertebral disc (IVD) degeneration of the lumbosacral (L/S) spine who qualified for microdiscectomy during a 12-month period after surgery. Based on magnetic resonance imaging before the surgery, the degree of radiological advancement of the degenerative changes was determined according to the Pfirrmann grading scale from 1 to 5. To assess pain intensity, the Visual Analog Scale (VAS) was used; the Satisfaction with Life Scale (SWLS) was used to evaluate quality of life; and to assess the degree of ability, the Oswestry Low Back Pain Disability Questionnaire (ODI) was employed. The level of pain, assessed using the VAS, significantly changed in the months following the surgery, with the highest values noted before surgery and the lowest a year after. In turn, the results of the SWLS questionnaire revealed a significant increase in satisfaction with life in the subsequent stages of the study. The conducted correlation analysis revealed significant dependencies in terms of quality of life in regard to pain as well as degree of disability. The level of pain and degree of disability were closely related to the degree of radiological advancement of degenerative changes according to the Pfirrmann grading scale. IVD degeneration is treated conservatively using pain-relieving and anti-inflammatory medication, most often nonsteroidal anti-inflammatory drugs (NSAIDs), as well as rehabilitation. Surgical treatment is used when previous conservative treatment does not lead to an improvement or when degenerative changes are extensive enough that surgery is the treatment of choice4.Intervertebral disc (IVD) degeneration is a significant and potentiating therapeutic as well as social problem6.The occurrence of IVD degeneration of the lumbosacral (L/S) spine section is predisposed by several factors: significant reduction in physical activity; remaining in a position that is unfavorable for the spine for long periods of time, including sitting; microtrauma that damages the intervertebral disc; obesity; heavy lifting; and old age. Genetic predisposition is also an important factor, such as family history of the disease. Environmental factors, including smoking, diabetes, vascular diseases, infections, chronic stress, depression, type of professional work and poor physical fitness, also increase the risk of back pain6. Undoubtedly, symptoms associated with IVD degeneration significantly reduce quality of life7.The predominant symptom of IVD degeneration is pain in a specific section of the spine, which is estimated to occur in 70–90% of some populations over 40 years of age5.Chronic and recurrent spine pain can affect up to 60% of the population and constitutes one of the most common reasons for contacting family doctors in our country. However, the fact that respondents often attribute pain in the back region to an affliction of the spine, regardless of a correct diagnosis or identification of the true cause, should be borne in mind9. Furthermore, the patient’s social life suffers, as at times, patients are forced to limit their social life in addition to engaging in long-term medication (mainly pain medication) use. Due to pain, patients may resign from their current work and hobbies, remaining in bed until symptoms subside10.At times, when disease symptoms are significant enough that they prevent the leading of a so-called “normal life”, patients must change or resign from their current work and thus transfer to disability pension11.Moreover, it should be borne in mind that progressive IVD degeneration limits movement capacity. Due to the chronicity of symptoms and the period of exacerbation, patients are discouraged from being physically active, ultimately leading to a reduction in quality of life12. This means that quality of life depends on the person, on their hierarchy of values and needs by which they lead themselves and which are important for them. Based on this definition, it can be determined that quality of life has different meanings for everyone, and different elements and situations will influence its assessment. Quality of life is a subjective value, and according to the WHO, it depends on physical state, mental state, social relations, environment, religion, beliefs, convictions, and views14. The Satisfaction with Life Scale (SWLS) is a questionnaire used in the self-assessment of life satisfaction, relating to mental health, subjective quality of life, and the likelihood of suicide attempts15. Since 1995, tools for the assessment of health-related quality of life have been used in ill individuals experiencing lumbosacral spine pain as well as sciatica and in patients undergoing surgery due to a prolapsed disc in the lumbosacral spine. A specific tool for the assessment of pain in the L/S segment is the Oswestry Disability Index (ODI)17.The issue of quality of life  has been present among people since the existence of civilization. In 1994, the World Health Organization (WHO) defined quality of life as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns”The aim of this prospective study was to assess the quality of life and disability of patients with IVD degeneration of the L/S spine section with regard to the radiological advancement of degenerative changes who qualified for microdiscectomy in the 12-month period following the procedure.In all patients, pain continued for at least 1 year; moreover, it was observed that the occurrence of advanced degenerative changes was significantly related to the period of time that pain persisted, more frequent receiving of NSAIDs and the ability to work and partake in sports .The level of pain felt was assessed using the VAS scale and significantly changed in the months following the procedure, with the highest values being noted before the operation, while the lowest were noted a year after the procedure. There were no statistically significant differences between men and women. The average assessment of pain at the moment the study started was 6 on a scale from 1 to 10. This assessment was taken into account later as a point of reference for the division of results using the VAS scale. The number of obtained points on the ODI scale was considered to indicate a downward trend, even in the case of patients with the highest degree of radiological advancement of degenerative changes (degree 5), according to the Pfirrmann scale. Furthermore, the results of the SWLS questionnaire reveal a significant increase in satisfaction with life in the subsequent stages of the study. Bearing in mind specific stages of the study, significant differences in the assessment of pain, disability, and satisfaction were observed in specific groups based on the Pfirrmann scale Table .Table 2AThe conducted correlation analysis revealed significant dependencies in the assessment of quality of life in regard to pain and degree of disability Table . A higheThe level of pain and the degree of disability were closely related to the degree of radiological advancement of degenerative changes according to the Pfirrmann scale Table . ImproveAmong all the respondents, the percentage of patients in whom there was an improvement in quality of life increased in the months following the operation in the group of people who classified their pain below 6 on the VAS scale Fig. .Figure 1The initial data showed that the chance of satisfaction with life significantly decreased with an increased assessment of pain above a score of 6 . Similar results were observed after 3 months—OR 0.83; 95% CI 0.045–0.268, 6 months—OR = 0.15; 95% CI: 0.049–0.482, and 12 months—OR 0.12; 95% CI 0.037–0.388.In the months following the surgery, alongside an improvement in the quality of life, increasing participation from patients with higher fitness was also visible Fig. . The iniThere have been numerous RCTs and systematic reviews conducted with the same research purposes and even larger numbers of patients; however, the vast majority of these studies have concentrated on assessing quality of life, IVD degeneration, and patient disability before surgery and at specific postoperative periods, without considering the degree of radiological advancement of degenerative changes, according to the Pfirrmann scale, as a criterion.When we conducted the assessment of available literature using the PubMed database, using the key words “quality of life” AND “Pfirrmann scale” OR “radiological advancement of degenerative changes”, the total number of articles from 1977 to 2022 was 226.22. It is also notable that none of these articles involved the Polish population. We followed the same procedure when searching the database using the words “disability” AND “Pfirrmann scale” OR “radiological advancement of degenerative changes”, which allowed us to initially indicate 287 articles, of which 256 were in English, 242 were available as full-text articles and 190 regarded humans. However, this time, none of these articles touched on the target topic.Using the generally accepted exclusion criteria, the number of articles in English totaled 202, of which there were 189 full-text articles available, and when the criterion of human studies was applied, 143 articles were initially qualified. Next, we (Rafał Staszkiewicz and Beniamin Oskar Grabarek) independently analyzed these 143 articles, finding that only 5 were directly related to our study objectiveTherefore, we believe that the analysis we conducted is very significant and constitutes an important supplementary study in terms of quality of life and disability  among patients with degeneration of the L/S spine section.In our study, we assessed quality of life among patients whose degree of radiological advancement of degenerative L/S spinal changes and pain led to qualification for neurosurgical microdiscectomy of the L/S spine.The first part of the analysis we conducted confirmed that an increase in the advancement of IVD degenerative changes in the L/S spine section was accompanied by a statistically significant increase in the frequency of taking NSAIDs. Significantly, almost all patients (81.8%) with degree 5 degenerative changes took pain medication every day. This indicates that the patients' daily lives were marked by considerable pain and suffering.23. In turn, smoking cigarettes is an unfavorable prognostic factor for IVD degeneration, as confirmed by Chen et al.24.However, we did not find that habitual consumption, such as alcohol consumption or cigarette smoking, has an influence on the occurrence of IVD degeneration of the L/S segment. This is in line with the observations of Zhang et al., who critically reviewed the literature and reported that moderate alcohol consumption is a factor preventing IVD degenerationWe then assessed pain intensity, quality of life, and degree of disability among patients, both before the neurosurgical procedure and in the 12-month period following it. First, we noted that the greater the degree of IVD degeneration, the more patients reported pain of a higher intensity. It should be noted that patients with degree 5 degenerative changes declared maximum pain intensity (10 points), which decreased by only 2 points 12 months after the operation.25. Research by Chin et al. among patients with atypical changes and low back pain confirmed a statistically significant improvement in terms of pain and level of disability after microdiscectomy. Patients, both with and without steatosis and edema of the spinal bone marrow, showed a significant improvement in the postoperative VAS score for low back pain26.In most patients, pain was a daily occurrence. This pain was of moderate or strong intensity in nature. These studies confirmed that unfortunately, pain is an inherent element of degenerative spine disease and affects the lives of both patients and their families27.Our results correspond with the data of other authors who studied pain intensity in relation to IVD disease using the VAS scale. It should be noted that both the observation period and data collection vary, which makes comparing results more difficult. Puolakka et al. analyzed risk factors for absence from work caused by L/S spine section pain in patients after surgery. The observation period in these patients was 5 years after surgery, while 2 months after the operation, data on pain intensity were collected based on the VAS scale. A significant reduction in pain following the procedure was reported28. It follows that regardless of the observation period, the surgical procedures performed due to IVD degeneration of the L/S section result in a noticeable reduction in pain.In turn, Solberg et al. conducted a study that aimed to assess pain intensity among patients with IVD degeneration of the L/S spine section before a neurosurgical procedure and 12 months after. In the case of pain in the L/S spine region, the pain intensity decreased from 5.17 to 2.13 (p < 0.001), whereas in the case of appendage pain, it decreased from 6.34 to 1.68 (p < 0.001). In both assessments, the reduction in pain was significant and noticeableFurthermore, using a dedicated ODI questionnaire for the assessment of the degree of disability caused by degenerative changes in the L/S spine section, we determined that overall, microdiscectomy resulted in a decrease in disability, assessed at the beginning from 18 points (moderate disability) to 12 points . None of the patients declared full disability; however, the more intense the radiological changes were, the lower the fitness of the patients was.29.The observations described by Middendrop et al. confirmed that the degree of radiological advancement of IVD degenerative changes of the L/S spine section positively correlates with decreased fitness in patients. These authors found that the ODI results of the patients fluctuated, ranging from 0 to 91.11% (arithmetic mean 32.77% ± 17.02%). The largest group of patients (48.39%) had moderate functional disability (ODI result between 21 and 40%)22. In our study, the largest number of patients had degree 3 (38.1%) and degree 4 (28.3%) IVD degenerative changes.Additionally, Hasanović-Vučković et al. assessed the fitness of 100 patients with degenerative disease of the L/S segment, noting a distribution close to ours for the number of patients at individual degrees of radiological advancement of degenerative changes, according to the Pfirrmann scale 22. In turn, Gautschi et al. assessed the relationship between the degree of radiological advancement of degenerative changes and postoperative pain intensity, impairment of functionality, and health-related quality of life (HRQoL) among 336 patients. These authors did not indicate a direct relationship between radiological advancement of radiological changes and clinical evaluation30. Additionally, Corniola et al. did not confirm a relationship between the radiological advancement of changes in the L/S spine in patients qualified for surgical treatment and the scores on commonly used pain scales. However, in patients with degree 4 and 5 radiological changes, there was a clear tendency for a higher pain intensity and a reduction in quality of life18.These authors reported a statistically significant correlation between the degree of advancement of changes and VAS (r = 0.16) and ODI (r = 0.24) scores20.Significantly, from the viewpoint of the importance of our research, Mazza et al. demonstrated the effectiveness of conservative treatment among patients with degree 3 and 4 advancement of degenerative changes of the L/S segment, according to the Pfirrmann scale, in a group of only 23 patients. They determined a reduction in pain during the 24-week observation21.Nonetheless, Grasso et al. confirmed effectiveness, reduction in pain, and improvement in quality of life among patients in whom hybrid surgery was conducted due to radiculopathy or cervical myelopathyWe also indicated that the best results for the surgery were achieved at the lowest degrees of advancement of degenerative changes. Furthermore, we confirmed a strong correlation between the level of pain, disability, and quality of life. A higher level of satisfaction was correlated with a lower level of pain as well as a higher level of fitness. Improvement in the quality of life was significantly more often observed among people with a lower degree of disease advancement, although larger differences in quality of life between the subsequent observation months were noted for higher degrees of disease advancement. The percentage of patients with improved quality of life increased in the months following the operation in the group who classified their pain below 6 on the VAS scale. It follows that pain plays a large role in how well-being is perceived by patients, and its reduction or elimination is a particularly important issue.In the case of the initial data, the chance of being satisfied with life significantly decreased with a 1-point increase in the result for the SWLS questionnaire.31.Kurowska et al. proved that people who have diseases of the lower segment of the spine and have developed depression experience chronic pain of a much greater intensity33. Of course, it should be remembered that the microdiscectomy procedure alone did not have an influence on the improvement in quality of life; it is likely that the rehabilitative treatment after surgery, coordinated by a rehabilitation specialist, also played a role.Other authors also noted a significant improvement in the quality of life and life satisfaction after surgery due to IVD degeneration of the L/S spine section-sectional area, cross-sectional area difference index (CDI) and fat infiltration rate (FIR) of the multifidus, erector spinae and psoas major at the apical vertebral level were measured using MRI. The visual analogue scale (VAS) score, Oswestry Disability Index (ODI) and 36-item Short Form Health Survey (SF-36) score were used to evaluate patient quality of life. Correlations between the degree of asymmetric muscular degeneration and quality of life were analysed. The CDI of the multifidus, erector spinal and psoas major was higher in the DLS group compared with that in the control group. The CDI of the multifidus was found to be positively associated with the Cobb angle of lumbar scoliosis. Similar results were obtained for fat infiltration between the two groups. In addition, the CDI and FIR difference index of the multifidus was positively correlated with the VAS score and ODI but negatively correlated with the SF-36 score. The quality of life significantly decreased with increasing asymmetric atrophy and fat infiltration in the multifidus. Thus, strategies to enhance the function of the multifidus may have a positive impact on quality of life22. The first limitation of our study is the observation period of 12 months after microdiscectomy. Of course, it would be very interesting and cognitively important to assess the quality of life in this group of patients over a period longer than 1 year. The second limitation is the fact that this was a single-center study, in which the number of patients representing the individual degrees of IVD degeneration was not uniform. Although the total number of patients may seem small, our statistical analysis indicated that 113 cases constituted a sufficiently representative group, allowing for analysis to be conducted and a reliable result to be obtained. Furthermore, pain and its influence on everyday functioning is a subjective feeling that is dependent on many factors. Its perception is influenced by emotional, pathological, genetic, and other cognitive elements. Of course, the obtained results might also have been influenced by the fact that we used only one questionnaire that is commonly employed to assess quality of life. However, using a questionnaire consisting of a larger number of questions, such as the SF-36, would allow us to assess quality of life with consideration of other criteria. Nevertheless, when comparing the strengths and weaknesses, conducting our study can be determined as justified, as it contains valuable research findings. It is a milestone study in research regarding quality of life and disability in patients following a microdiscectomy procedure due to IVD degeneration of the L/S spine.Our study has both strengths and weaknesses. A strength of this study is that the analysis was conducted on a relatively large number of respondents who underwent microdiscectomy in one clinical center, considering that different surgical methods are also used for treating IVD degeneration of the L/S segment. Additionally, pain intensity, degree of fitness, satisfaction with life, and the success of neurosurgical treatment based on the degree of advancement of degenerative changes in the IVD of the L/S spine section according to the Pfirrmann scale were also evaluated. In the available literature, there are few observations on the quality of life among patients with IVD degeneration of the L/S spine section depending on the degree of radiological advancement of lesionsIn summary, the pain level, which was assessed using the VAS scale, significantly changed in the months following the surgery, with the highest values noted before the surgery and the lowest a year after the operation. The results of the SWLS questionnaire revealed a significant increase in satisfaction with life in the subsequent stages of the study. When considering individual stages of the study, significant differences in the assessment of pain, disability, and satisfaction were observed in individual groups based on the Pfirrmann grading scale. MRI is a significant component in the diagnosis of degenerative disease, while microdiscectomy is an effective surgical method for the treatment of degenerative changes in the IVDs of the L/S spine. Furthermore, our analysis indicated that the highest chance of returning to fitness, at a level equal to or close to the level prior to the occurrence of IVD degeneration, after the microdiscectomy procedure occurs in patients at early degrees of radiological advancement, such as 2 and 3. Therefore, patients should not delay the decision to undergo surgery when there are clinical grounds for it. The role of the neurosurgeon is to explain to the patient in detail the essence of the disease, possible treatments, advantages, and possible side effects of surgery. Therefore, the physician must partner with the patient and exhibit highly developed communication skills.34 and are presented in Table In this study, 113 Caucasian patients, consisting of 55 women (48.7%) and 58 men (51.3%) who were qualified for surgical treatment of intervertebral disc degeneration of the lumbosacral spine (microdiscectomy) were enrolled. The surgeries were carried out in the period from March 2020 to April 2021, always by the same team of neurosurgeons, under the leadership of Rafał Staszkiewicz. The observation period ended in May 2022. All patients were treated and underwent surgery in the same clinic, Department of Neurosurgery, 5th Military Clinical Hospital with the SP ZOZ Polyclinic in Krakow, 30-901 Krakow, Poland. The inclusion and exclusion criteria were the same as in our previous paperEach patient underwent a neurological examination including an assessment of muscle strength; passive movement; muscle tension; patellar, ankle, plantar, Babinski sign, and Rossolimo sign reflexes; surface and deep sensation; gait; mobility; and L/S spine pain. The study excluded cases of patients who presented with loss symptoms, as such patients required emergency neurosurgical intervention; we undertook evaluation only among stable cases Table . All patIn all patients, before the microdiscectomy procedure, a magnetic resonance imaging examination was conducted  using the projections SE T1, SE T1 FLuid-Attenuated Inversion Recovery (FLAIR), FSE T2 and Short Tau Inversion Recovery (STIR) sequences in transverse and sagittal sections in 3 mm and 4 mm thick layers. This allowed for the determination of the degree of radiological advancement of degenerative changes, according to the Pfirrmann scale from 1 to 5  patients, radiological changes were classified as grade 2 degeneration; in 43 (38.1%) patients, they were classified as grade 3; in 32 (28.3%) patients, they were classified as grade 4; and 11 (9.7%) patients were classified as having grade 5 advancement of changes on the Pfirrmann scale. Furthermore, qualification for surgery consisted of conducting a neurological examination as well as conducting physical and subjective examinations in each patient.After being discharged from the Department of Neurosurgery, patients were required to report themselves to the Neurosurgery Clinic within 4 weeks of the procedure for routine inspection. Subsequently, patients were recommended rehabilitation and were informed about subsequent proceedings.Patients were asked to complete all questionnaires before surgery (month 0) as well as 3, 6 and 12 months after it was carried out.In each patient, the microdiscectomy procedure was performed under general anesthesia in the abdominal position. A 2–4 cm skin incision was made over the affected interbody space, identified intraoperatively by fluoroscopic X-ray. Once the right space was identified and the skin incision was made, the posterior surface of the vertebral arches was exposed with the help of special surgical instrumentation, holding the previously separated spinal muscles. This was followed by an incision of the yellow ligament, which was lifted in a small space, opening the lumen of the spinal canal. After assessing the intracanal conditions and exposing the hernia, the IVD and IVD sequestrator were removed. After the procedure was completed, a drain was placed at the wound site to drain accumulated blood, which was then removed after 24 h. Patients were verticalized on the first postoperative day, and early rehabilitation in the Neurosurgery Department was included. The patient's length of stay, including preoperative diagnosis, anesthesia consultation and early postoperative period, was 5 days.The respondents answered 5 questions, which were measured using a 7-point scale, wherein 1 on the scale signified “definitely disagree” with the statement, while 7 signified “definitely agree” with the statement. The test has high internal consistency and test–retest correlations.Unchanged state (20 points)Decrease in quality of life (1–19 points)Increase in quality of life (21–25 points)In our study, the SWLS questionnaire on quality of life was assessed for 3 possible situations:38  in the form of a line, on which the examined individual indicated their pain intensity on a scale from 0 to 10, where 0 signified no pain and 10 signified intense pain38 Fig. .Figure 4The patient answered 10 questions regarding (1) pain intensity; (2) self-handling ; (3) picking up items; (4) walking; (5) sitting; (6) standing; (7) sleeping; (8) sex life (if applicable); (9) social life; (10) travel. The result is presented on a point scale  or on a percentage scale.39:Using the 5-point scale, an assessment of the degree of disability was performed as shown below0–4 points—lack of disability;5–14 points—little disability;15–24 points—moderate disability;25–34 points—serious disability;Above 35 points—complete disability.Using the 6-point percentage scale, ODI factors were determined and interpreted as follows:0–10%—no disability;10–20%—minimal disability;21–40%—moderate disability;41–60%—severe disability;61–80%—immobility;81–100%—bed-bound patients.2 independence and Fisher tests were used. Numeric data were presented as the mean with a standard deviation (X ± SD) in the case of a normal distribution; otherwise, they were presented as a median with quartiles—M (Q1–Q3). Compliance with a normal distribution was verified using the Shapiro‒Wilk test. The significance of differences in groups was checked using the Mann‒Whitney U test, the Kruskal‒Wallis test and the Friedman test for repeatable measurements. Correlation analysis was conducted using Spearman’s correlation coefficient with a significance test. Additionally, odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated based on univariate logistic regression models. A p value below 0.05 was considered statistically significant.Analysis of the data was conducted using the procedures of the Statistica 13.3  program. Categorical variables were presented using numbers and percentages of cases in each group. The χhttps://www.naukowiec.org/dobor.html (accessed on 21 March 2020)40. For this population, the maximum error value was estimated at 9%. Therefore, assuming a p value < 0.05, the required number of respondents in the study was 119 . In turn, according to data obtained from the European Health Survey in 2019, 25.8% of adult Poles above 18 years old  suffered from pain in the L/S section of the spine41. For this population, the maximum error value was estimated at 9%, and the required number of participants in the study was 100 .According to data published by the Central Statistical Office (GSO) in 2019, the number of inhabitants of Poland was 38,383,000. The number of participants in the study was determined using the statistical tool available at This study was performed in accordance with the guidelines of the 2013 Declaration of Helsinki on human experimentation. Approval of the Bioethical Committee operating at the Medical University of Silesia, no KNW/022/KB/42/15 24 February 2015 and at the Regional Medical Chamber in Krakow, No. 162/KBL/OIL/2021 11 June 2021, was obtained for this study.Written informed consent was obtained from all patients.


As a chronic wasting disease, cancer can lead to metabolic and physiological changes in patients, resulting in severe malnutrition. Therefore, accurate assessment of nutritional status and adoption of scientifically sound nutritional interventions are of great importance for patients with cancer. This study aimed to assess the necessity of implementing the Nutrition Risk Screening 2002 (NRS 2002) tool in conjunction with the Patient-Generated Subjective Global Assessment (PG-SGA) in patients with cancer.This retrospective study collected the clinical data of cancer patients from November 2011 to December 2018 in the Department of Oncology, Cancer Center, First Hospital of Jilin University. The NRS 2002 and the PG-SGA were used as screening tools for malnutrition. Clinical characteristics and laboratory results were detected. Anthropometric indices including hand-grip strength (HGS), visceral fat area (VFA), calf circumstance (CC), and appendicular skeletal muscle mass index (ASMI) were also collected. The diagnostic results from the NRS 2002 were compared to the malnutrition diagnosis using the PG-SGA.Of the 2,645 patients included in this retrospective study, the nutritional risk was found in 1763 (66.6%) patients based on the PG-SGA, and in 240 (9.1%) patients based on the NRS 2002, respectively. Among the 240 patients evaluated by the NRS 2002 for risk of malnutrition, 230 were also assessed by the PG-SGA as malnourished. There were no significant differences observed in the clinical characteristics and laboratory parameters between the two groups.The PG-SGA is effective and had a higher positive rate in screening malnutrition for patients with cancer. The NRS 2002 is not necessary for patients who are to be assessed with the PG-SGA. The pre22.1This retrospective study collected data on cancer patients admitted from 2011 to 2018 at the First Affiliated Hospital of Jilin University. The NRS 2002 and the PG-SGA were performed within 48 h of admission. The NRS 2002 combines disease severity, nutritional score, and age adjustment, with a total score ≥3 indicating risk . ClinicaPatients>65 y of age;Pathologically diagnosed with malignant tumor; andThe Nutrition Risk Screening 2002 and the Patient-Generated Subjective Global Assessment completed within 48 h after admission.No nutritional support treatment prior to nutritional assessment and laboratory testing.Exclusion criteria included the following:Patients who had two or more coexisting types of tumors;Those who had incomplete records of necessary indexes.Patients who died within 3 d after admission.2.2Clinical-pathological variables include age, sex, weight, height, BMI, tumor types, TNM stages (AJCC 7th edition), and Karnofsky Performance Status (KPS). Laboratory examination results including total protein (TP), albumin, prealbumin (PAB), transferrin (TFN), C-reaction protein (CRP), neutrophil to lymphocyte ratio (NLR) and platelets to lymphocyte ratio (PLR) were collected. Anthropometric indices including hand-grip strength (HGS) and appendicular skeletal muscle mass index (ASMI) were measured by bioelectrical impedance analysis.HGS was examined in all subjects using a Jamar hydraulic grip dynamometer . Patients were comfortably seated in an upright position with the shoulders tucked in, neutral rotation, 90° elbow flexion, and the forearms and wrists in a neutral position. The patient gripped the dynamometer with maximum strength. The test is performed three times in a row, with a 1-min rest at the end of each set, and the maximum grip strength is recorded.The skeletal muscle mass (SMM) was examined by the multifrequency bioelectrical impedance body composition analyzer InbodyS10 . Patients were required to empty their bladder, fast for 2 h, and rest before the measurement. Patients were asked to wear light clothes and were contacted with eight electrodes during the measurements. ASM was the sum of SMM in four limbs according to the formula of InbodyS10. The appendicular skeletal muscle mass index was calculated by ASM/height(m).2.3The NRS 2002 and the PG-SGA nutritional assessments were completed within 48 h of patient admission.In particular, the NRS 2002 total score consisted of the sum of three components, i.e., Disease Severity Score + Nutritional Status Hypoplasia Score + Age Score. A total score of ≥3 indicates that the patient is at nutritional risk . The scoThe PG-SGA begins with a self-assessment form (A score) completed by the patient, which includes four dimensions: body mass, feeding status, symptoms, activity, and physical function. Among them, the highest score option was selected for this score for feeding situation, and the symptoms were cumulative scores. The relationship between disease and nutritional requirements, metabolic needs and physical examination were then assessed by the medical staff. Patients’ disease status (B score) and stress status (C score) were cumulative scores, and physical examination (D score) determined patients’ fat, muscle, and fluid sub-item scores according to most parts of the body, and the muscle loss score was used as the final score for the physical examination items. The total A-D 4-item scores were summed, and a score of ≥2 was defined as being at nutritional risk. The scoring criteria are shown in 2.4t-tests. Continuous variables that did not follow a normal distribution after data transformation were expressed as median (interquartile range) and compared between groups using the two-sample Kolmogorov–Smirnov test. Categorical variables were expressed as percentages, and two or more groups of unordered categorical variables were tested using the χ2 test. p < 0.05 was regarded as statistically significant.Analysis was performed using SPSS 26.0 statistical software. Data normality and chi-squareness were verified by the one-sample Kolmogorov - Smirnov test. Continuous variables that were normally distributed were expressed as mean ± standard deviation (x bar ± s), and comparisons between groups were made using independent samples 33.1p < 0.05). The malnutrition incidence was higher in older patients and patients with advanced tumors, and patients with digestive tumors were more likely to be screened for nutritional risk (p < 0.05), as shown in A total of 2,645 patients with cancer were included in the analysis. Two hundred and forty cases were screened with nutritional risk by the NRS 2002 (NRS ≥ 3 points) and 1993 cases were screened with nutritional risk by the PG-SGA (PG-SGA ≥ 2 points), and the incidence rates of malnutrition risk were 9.1 and 66.6%, respectively, as shown in 3.2Nutrition-related indicators of patients screened for malnutrition risk by both the NRS-2002 and the PG-SGA and those screened for malnutrition risk by the NRS-2002 were analyzed, and there were no statistically significant differences between the two populations in terms of grip strength, albumin, and muscle index, as shown in 3.3p < 0.05), as shown in Prognostic analyses of those not screened for nutritional risk by the NRS-2002 and those not screened for nutritional risk by the PG-SGA were performed, and the results of the survival analyses showed that the prognosis of those not screened for nutritional risk by the PG-SGA was better than that of those not screened for nutritional risk by the NRS 2002 (4Many patients with cancer are at risk for malnutrition and nutritional assessment is a vital aspect of cancer care . While nThe PG-SGA identified more patients at nutritional risk than the NRS 2002 in this study. Among patients not classified as high risk by the NRS 2002, those additionally identified as malnourished by the PG-SGA had poorer survival. The PG-SGA non-risk group had a better prognosis than the NRS 2002 non-risk, suggesting the NRS 2002 may miss patients with risk. Our study indicates the PG-SGA screens cancer patients more comprehensively for nutritional risk than the NRS 2002.4.1The much higher prevalence of nutritional risk by the PG-SGA implies it is more sensitive than the NRS 2002 in this population , 18. ThiThis study confirms the high sensitivity of the PG-SGA as a nutritional risk screening tool optimized specifically for cancer patients. Its cancer-specific derivations such as patient-reported symptom impact likely underlie its superior prognostic utility over the generic NRS 2002, supporting its preferential use for prospectively assessing malnutrition risk in this population , 14. Tho4.2The NRS 2002 was designed for hospital inpatients generally, while the PG-SGA was optimized specifically for cancer populations. The PG-SGA’s cancer-specific design underlies its superior sensitivity in detecting nutritional risk over the more generic NRS 2002. The PG-SGA captures extensive information about reduced oral intake and symptom impacts like anorexia, nausea, vomiting, and dysphagia that are highly prevalent in cancer patients but not addressed in the NRS 2002 , 15. The4.3As a single-center retrospective study, the results may not generalize to other cancer populations. Additional studies should validate findings in other geographical and ethnic groups . Future 5In cancer patients, the PG-SGA provides more comprehensive nutritional risk detection than the NRS 2002, with prognostic utility. Relying solely on the NRS 2002 risks overlooking at-risk patients who may benefit from nutrition support. The high sensitivity of the PG-SGA underscores its value for identifying malnourishment requiring intervention in cancer populations. Clinicians should be aware that patients classified as non-risk by the NRS 2002 may still be at nutrition-related risk detectable by the in-depth PG-SGA. Implementing the PG-SGA’s cancer-specific approach is vital for optimal nutritional risk screening and assessment in oncology settings. The NRS 2002 is not necessary for patients who are to be assessed with the PG-SGA.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving humans were approved by First affiliated hospital of Jilin University. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.XC: Formal analysis, Investigation, Methodology, Writing – original draft. XL: Conceptualization, Funding acquisition, Methodology, Resources, Supervision, Validation, Writing – review & editing. WJ: Conceptualization, Data curation, Investigation, Writing – review & editing. YZ: Data curation, Formal analysis, Methodology, Writing – review & editing. YH: Data curation, Formal analysis, Methodology, Writing – review & editing. YL: Data curation, Investigation, Software, Writing – review & editing. QL: Data curation, Formal analysis, Software, Writing – review & editing. HS: Project administration, Supervision, Writing – review & editing. JC: Project administration, Resources, Supervision, Writing – review & editing.


Standard medical therapy (SMT) in children with functional abdominal pain disorders (FAPD) includes cyproheptadine and amitriptyline. While percutaneous electrical nerve field stimulation (PENFS) has shown benefit, no study has compared outcomes of PENFS to SMT. We aimed to examine changes in abdominal pain, nausea and disability before and after treatment and compare outcomes between treatments.The records of FAPD patients ages 11–21 years, treated with 4 weeks of PENFS, cyproheptadine or amitriptyline were reviewed. Outcomes were evaluated using validated questionnaires  at baseline and follow-up within 3 months (FU).p = 0.001), NSS (p = 0.059) and FDI (p = 0.048) were significantly lower at FU. API (p = 0.034) but not NSS and FDI (p > 0.05) decreased significantly at FU in the amitriptyline group. API, NSS and FDI did not change significantly with cyproheptadine at FU (p > 0.05). FU API scores were lower in PENFS vs. cyproheptadine (p = 0.04) but not vs. amitriptyline (p = 0.64). The FDI scores were significantly lower in the amitriptyline vs. cyproheptadine group (p = 0.03).Of 101 patients, 48% received PENFS, 31% cyproheptadine and 21% received amitriptyline. Median ages were 17 (15–19), 16 (15–18) and 15 (11–16) years respectively and the majority were females . In the PENFS group, API (Therapy with PENFS showed improvements in abdominal pain, nausea and disability while amitriptyline showed improvements in abdominal pain within 3 months of treatment. PENFS was more effective than cyproheptadine in improving abdominal pain. Amitriptyline improved disability scores more than cyproheptadine and showed promise for treatment. PENFS may be a good non-pharmacologic alternative for FAPD. Functional abdominal pain disorders (FAPD), namely irritable bowel syndrome (IBS), functional dyspepsia (FD), abdominal migraine, and functional abdominal pain—not otherwise specified (FAP-NOS) have increased disability and an extensive health care cost burden –3. ChronThere has been a recent shift towards non-pharmacologic management, particularly in children, where chronic medication use can be problematic. Percutaneous electrical nerve field stimulation (PENFS) is an emerging minimally invasive approach to treat patients with chronic abdominal pain. It modulates central pain pathways through stimulation of the auricular branches of cranial nerves after just 4-weeks of treatment, with sustained efficacy . SeveralAbdominal Pain Index (API): The API is validated for children to determine the frequency, severity, intensity and duration of abdominal pain over 2 weeks . We usedNausea Severity Scale (NSS): The NSS, is a validated tool to determine the number of days, daily episodes and duration and intensity of nausea over 2 weeks . This meFunctional Disability Inventory (FDI): The FDI is a 15 item validated instrument to measure daily physical and psychosocial functioning . It deteAfter obtaining institutional review board approval, the electronic medical records of patients ages 11–21 years who met the Rome 4 criteria for a FAPD and had been treated with 4 weeks of PENFS, cyproheptadine or amitriptyline between January 2019 and December 2021 were retrospectively reviewed. Patients with organic gastrointestinal conditions known to cause abdominal pain were excluded. Demographic data and medical history were obtained from the medical record. Outcomes were evaluated using validated questionnaires that were prospectively collected routinely as part of clinical care at baseline and follow-up visit within 3 months (FU). These included:Categorical variables were presented as frequency counts and percentages while continuous data were presented as mean (95% CI) or median (IQR). Outcomes were assessed for each group using Chi Square test. Outcomes were evaluated from baseline to FU in each group, as a three-way comparison between groups as well as pairwise comparisons between groups.p ≤ 0.05 to be statistically significant using SAS version 9.4 .Outcomes were compared between groups at 3 months via linear mixed modeling with subject as random effect. Baseline demographic differences between groups were accounted for during linear mixed modeling. Results were presented as Least Squares Mean (LS Mean) and 95% confidence interval. All analyses were conducted as two-sided test with p = 0.02 and p = 0.008 respectively) but no significant differences were noted in racial distribution between the groups.Demographic details are presented in p = 0.001), NSS (p = 0.059) and FDI (p = 0.048) were significantly lower at 3-month FU compared with baseline. API scores decreased significantly at FU in the amitriptyline group (p = 0.034). However, NSS and FDI scores did not change significantly at FU in the amitriptyline group. All scores decreased but were not significant in the cyproheptadine group. Examining each outcome longitudinally, the API and NSS scores were lowest in the PENFS group. The FDI scores, however, were lowest in the amitriptyline group.p > 0.05). There was a trend for decrease in FDI in the amitriptyline group compared with both PENFS and cyproheptadine (p = 0.097). p = 0.04) but not between PENFS and amitriptyline (p = 0.64). The NSS scores did not differ between the groups (p > 0.05). The FDI scores were only lower in the amitriptyline vs. cyproheptadine group (p = 0.03).This is the first study to compare outcomes of PENFS with standard medical therapy (amitriptyline or cyproheptadine) in adolescents with FAPD. Compared to pre-treatment,we found that PENFS significantly improved both abdominal pain and disability, with a trend for improvement in nausea, while amitriptyline significantly improved abdominal pain. PENFS was more effective than cyproheptadine in improving abdominal pain scores but did not differ from amitriptyline. Amitriptyline improved disability scores more than cyproheptadine.Multiple biopsychosocial factors affect outcomes in FAPD. In this study, we chose to measure changes not just in abdominal pain, but also disability and nausea. This is important because FAPD are heterogenous conditions that include comorbidities once not considered as important . In factp = 0.63). Interestingly, while amitriptyline was not better than placebo in improving pain scores in that study, it was better for reducing anxiety scores than placebo, even at the lower doses (p < 0.05). In contrast, a smaller double blind RCT (n = 33) showed overall improvement and reductions in abdominal pain as well as diarrhea in the amitriptyline group compared to placebo (p < 0.05 for each). In another study, 61% of children with FAP receiving TCA demonstrated decreased pain or improved daily functioning (p = 0.003). TCAs, like many other antidepressants, have an FDA black box warning and can be associated with side effects such drowsiness, constipation, and worsened mood including suicidal ideation , pain intensity (p = 0.001) and frequency (p = 0.002). Similarly, a retrospective review of 80 children with dyspepsia treated with cyproheptadine showed a 55% response rate and 30% adverse event rate (Cyproheptadine is a serotonin (5HT3) receptor antagonist with antihistaminic and anticholinergic effects, commonly used to treat FAPD in children. Doses in the range of 0.2–0.6 mg/kg/day or 4 mg up once or twice daily have been used . It can ent rate . In content rate . Common ent rate , this adent rate  and it iAuricular PENFS is the only FDA cleared treatment for IBS and associated abdominal pain conditions. It accesses central pain pathways and has been shown to modulate the limbic system in an animal model of IBS . More spIn our study, 59% of the patients in the PENFS group had failed prior SMT. It is possible that the PENFS group may have more severe, refractory symptoms compared to SMT groups which could have affected treatment outcomes. Similarly, the higher ratio of males to females in the PENFS group could also impact the results of our study.It is interesting to consider how PENFS differs mechanistically from medications like amitriptyline that are considered “neuromodulators”. While the exact mechanism for the therapeutic effect of these drugs is not known, some have suggested different central pathways for PENFS and SMT. A recent study investigated connectivity differences between PENFS and standard medical therapy in adults with fibromyalgia . In thatThis is the first study to compare treatment outcomes of PENFS with SMT. We had a moderate sample size in each group allowing for meaningful comparisons. We used validated, pediatric questionnaires that provided objective assessments however, the modified versions over 1 week were not validated compared to the standard questionnaires assessing symptoms over 2 weeks. Unfortunately, the study design did not allow us to evaluate baseline psychological comorbidities that could theoretically impact treatment outcomes. Similarly, the retrospective study design precluded assessment of other biopsychosocial factors that could contribute to symptoms. Also, data were assessed at 3 months, and it would have been ideal to have a longer follow-up with the entire cohort. Only a prospective head-to-head trial would allow for this longer follow-up since medications are typically discontinued if there are no benefits after proper dose adjustments. Future trials should also include prospective analysis of adverse event comparisons between PENFS and SMT.In conclusion, PENFS improved abdominal pain and disability in adolescents with FAPD with a trend for improvement in nausea when assessed three months after treatment. Amitriptyline also improved abdominal pain compared to baseline. PENFS showed a trend for greater improvement in disability compared to SMT. PENFS was superior in decreasing abdominal pain compared with cyproheptadine while amitriptyline was superior to cyproheptadine in improving disability. These findings may help guide provider choices when considering pharmacotherapy in children with FAPD, particularly in cases involving patients that have side-effects to medications or drug interactions. Several studies now support PENFS as an effective treatment option to pharmacotherapy with a relatively safe side-effect profile.


After six weeks, weight-bearing was allowed, but the trend did not change—the NPRS continued to be low (average 1.4 on 12-month follow-up) and the total KOOS increased 44.6 points from the baseline (average 78.0 on 12-month follow-up). The Whole-Organ Magnetic Resonance Imaging Score improved from 66.1 ± 19.4 prior to surgery to 58.0 ± 15.9 (p < 0.001) after 3 months. In our study, there was no control group, randomisation was not performed, and the sample size was relatively small. A combination of core decompression and the intraosseous injection of ACP into the affected subchondral area proved to be a safe and effective procedure that provides rapid pain relief and a significant increase in joint function up to one year postoperatively.The purpose of this prospective case series was to determine the effectiveness of using a combination of the core decompression and injection of autologous conditioned plasma (ACP) for the treatment of symptomatic knee bone marrow lesions (BML), as well as to report on the preliminary clinical results based on magnetic resonance imaging (MRI) and patient-reported outcomes (PROMs). Patients with OA-related BML who failed to improve on conservative treatment for three months underwent an identical procedure consisting of arthroscopy, core decompression, and the intraosseous injection of ACP and were followed up for 12 months. A statistically significant reduction in pain and an improvement in function, as measured by the Numeric Pain Rating Scale (NPRS) and Knee Injury and Osteoarthritis Outcome Score (KOOS), was observed at one-week follow-up (8.3 ± 0.8 to 1.5 ± 1.0;  Bone marrow lesions (BMLs) are changes in subchondral bone marrow signal intensity on magnetic resonance imaging (MRI). These changes are mainly characterised by a high signal on fluid-sensitive sequences such as T2-weighed, fat-suppressed, and short tau inversion recovery sequences. However, a low signal can occasionally be detected on T1-weighed images . Indeed,One of the most common varieties is the osteoarthritis (OA)-related BML, characterised by the alteration of subchondral bone remodelling . IncreasThe use of ACP in the treatment of focal lesions in subchondral bone represents a promising new approach, although it has yet to be tested in terms of its long-term effectiveness through appropriate clinical trials. Our research allows us to see the potential benefit of using ACP in the treatment of BML and opens up the possibility of setting new hypotheses for further research.The present study aimed to assess the efficacy of core decompression combined with the intraosseous injection of autologous conditioned plasma (ACP) and arthroscopy to achieve pain relief and improve the quality of life in patients with OA-related BMLs.Hypothesis: core decompression combined with the intraosseous injection of ACP will achieve statistically significant pain relief and improve quality of life in patients with OA-related BMLs.The local ethical committee reviewed and approved the study, and all patients provided signed informed consent before the treatment. The study population consisted of 20 consecutive patients who failed to improve after three months of conservative treatment and met all of the inclusion criteria. There were no drop-offs during the study. The conservative protocol in this study is a slight modification of the one used by Simon et al. . It cons®  specimens were collected according to the previously described protocol [® Double-Syringe for a single spin in a centrifuge at 1500 rpm for 5 min. The volume of available ACP varied from 5 to 7 mL, and in all cases, the total volume of 5 mL of ACP was subsequently used for direct application into BML. ACP is considered a leukocyte-poor platelet-rich plasma (LP-PRP) with concentrations of platelets around 2–3× that of the whole blood.Arthrex ACPprotocol . BrieflyThe procedure was performed on a radiolucent table with a patient in the supine position. A thigh tourniquet was applied. The operative knee was positioned to facilitate arthroscopy and intra-operative radiographic image acquisition . StandarFollowing the procedure, the patients were instructed to bear only 10% of the weight with crutch assistance for the next six weeks and then to increase weight-bearing by 10% each day during the next ten days. Physical therapy was initiated 10 to 14 days after the surgery, and a return to complete activities was allowed eight weeks postoperatively. All patients were advised to take 1000 international units (IU) of vitamin D3 per day and 1 g of paracetamol if needed for pain control.For each patient, the baseline measures for NPRS, KOOS , and WORMS were obtained before the procedure. The total KOOS score was calculated as the mean of all subscores. To assess the knee functionality and pain of the patient after the procedure, KOOS and NPRS were collected from each patient 1 week, 3 weeks, 6 weeks, 3 months, 6 months, and 12 months postoperatively. MRI and WORMS were repeated three months after the procedure. According to previous studies, we set the minimally clinical important difference (MCID) for NPRS as 2.0 . SimilarThe analyses per time point were conducted using repeated-measures ANOVA with LSD test for pairwise comparisons between time points. In cases of violation of Mauchly’s sphericity assumption, a Greenhouse–Geisser correction was applied. The analysis for the WORMS variables was conducted using paired samples t-test, since these variables were only measured at two time points. All analyses were performed using R Statistical Software .  with rstThe sample consisted of 20 consecutive patients who were treated with core decompression combined with the intraosseous injection of autologous conditioned plasma (ACP) and were monitored for 12 months after the surgery. In one patient, knee pain and swelling were observed at one-week follow-up, and no other complications were noted in the remaining patients. As summarised in p ≤ 0.001). Another statistically significant decrease in the pain score was observed between week one and week three . After six weeks, weight-bearing resumed, but the curve stayed well below two points at the 3-, 6-, and 12-month time points. In addition, clinically meaningful improvement was observed in the KOOS pain subscore. There was a statistically significant improvement of the KOOS pain subscore in weeks one and three . The KOOS pain subscore reached a plateau at the 3-month time point and remained stable over the 6- and 12-month time points postoperatively.The average baseline NPRS score for the cohort was 8.3 ± 0.8. p < 0.001 and 70 ± 12.6; p < 0.001, respectively). At week six, the score further improved to 72.0 ± 15.7 (p > 0.05). Another statistically significant improvement was observed at the 3-month follow-up, where the score rose to 80 ± 13.1 (p < 0.01) and then remained stable at 6- and 12-month time points (84.1 ± 12.2 p > 0.05 and 78 ± 17.9 p > 0.05 respectively).The total KOOS score showed a statistically significant improvement over the observed period . At admiApart from the pain subscore, the KOOS scale consists of four additional subscores, which were assessed separately. Those four additional subscores were: activities of daily living (ADL), quality of life (QoL), sports and recreation, and symptoms. Further results and statistics regarding KOOS subscores can be found in p < 0.001 and 9.3 ± 9.7 p < 0.001).In the overall WORMS scale, the average score at admission was 66.1 ± 19.4, and the subscore for SBM abnormality was 14.2 ± 11.4. As seen in The main finding of our study was that patients with knee OA-related BML treated with a combination of core decompression and injection of ACP demonstrated rapid and significant improvements in pain and function, which persisted over the next 12 months. These overall results indicate that it is a feasible biologic option for the initial treatment of patients with BML and a potential alternative for postponing a total knee replacement (TKR).It has been shown that OA patients with BMLs have a higher risk of rapid advancement toward end-stage disease requiring arthroplasty. In a prospective study by Tanamas et al. , the autA very high level of pain is the hallmark symptom of BMLs, and it does not correspond with normal pain levels in patients with knee OA without BML. From the work of Uchio et al. , we knowPlatelet-rich plasma (PRP) can be used as an addition to the core decompression to facilitate the recovery of the affected bone. The main advantages of this biologic approach are that it is entirely autologous, has no immune response, and is cost efficient. Adding growth factors and chemokines to the core decompression provides the BML region with the requisite signals for tissue recovery and regeneration .Sanchez et al.  introducIn a three-way randomised control trial (RCT), Su et al. tested the hypothesis that the addition of the intraosseous injection of PRP to traditional intraarticular treatment with PRP or hyaluronic acid (HA) would add a positive effect. They used a leukocyte-rich-platelet-rich plasma (LR-PRP) preparation method with a mean platelet concentration 5.61-fold greater than that of the whole blood. The first group of patients received two intraosseous injections of 2 mL of LR-PRP and two intraarticular injections of LR-PRP 14 days apart. The second group received two intraarticular injections of 6 mL of LR-PRP 14 days apart. The third group received an intraarticular injection of 2 mL of commercially available HA . They concluded that the combination of intraosseous and intraarticular injections resulted in significantly superior clinical outcomes within 18 months of follow-up.The most recent addition to the ongoing development of the method is a prospective cohort study performed by Lychagin et al. . The stuAlthough all of the mentioned studies are rather heterogeneous in terms of the study design, PRP preparation method used, and PROMs measured, they all resulted in a significant decrease in pain and increase in functional scores. Indeed, our study has comparable outcomes in that respect. Within a few weeks, the patients in this study reported a statistically significant decrease in pain and statistically significant improvement in all functional subscores. We believe this rapid improvement is initially due to the synergistic effect of core decompression (lowering the intraosseous pressure) and non-weight-bearing . The sustained positive effect, which reaches a plateau around six months postoperatively, might be attributed to the action of instilled PRP (anabolic and anti-catabolic effect of growth factors and cytokines). The slight reduction in the functional parameters between month 6 and month 12 might be due to the effective return to the activities of daily life and repetitive biomechanical overload from being overweight. The twelve-month follow-up T2-weighted knee MRI of one of our patients shows an improvement in the medial femoral condyle BML .Similar to other studies, our study observed a high prevalence of overweight patients in the cohort. The BMI was 30.0 ± 4.4, and only 2 out of 20 patients (10%) were in the normal range for age and gender. This implies significant biomechanical overload, which contributes to the development of BMLs and the deterioration of knee OA.MRI is crucial for adequately diagnosing OA-related BMLs, and it should be considered part of the routine diagnostic protocol in those OA patients with unusually high pain levels. It is best detected on T2-weighted (T2w), or proton density-weighted (PDw), fat-suppressed (FS) fast spin-echo (FSE), or short tau inversion recovery (STIR) sequences and is characterised by areas of high signal intensity . The WORAnother interesting biologic option is to use bone marrow concentrate (BMC) as an addition to core decompression. BMC is an autologous product rich in progenitors and has been successfully used as the intraosseous delivery option in bone fracture healing and the treatment of femoral head avascular necrosis . Hernigon = 66) treated with SCP, Cohen and Sharkey [Finally, in an attempt to address the structural integrity of subchondral bone, which is the leading site of the pathological process, a subchondroplasty (SCP) procedure has been introduced . SCP is  Sharkey  reported Sharkey  reported Sharkey , in a mo Sharkey  reportedThis study has important limitations. There was no control group, randomisation was not performed, and the sample size was relatively small. Although we made an effort to apply exactly 5 mL of obtained ACP, no additional analysis to determine the exact number of applied cells and concentration of growth factors was performed. Furthermore, NPRS and KOOS are based on patient-reported, inherently subjective data. To offset this limitation, we performed MRIs, but only at one time point. The long-term observation of this cohort is still ongoing, and we hope to provide better insight into the true potential of the proposed method in the years to follow.p < 0.001, p < 0.001, and p < 0.001, respectively). The beneficial effect of the procedure was the most remarkable during the first three months and the measured outcomes remained stable for the length of the study. The procedure is simple, reproducible, and safe, with only one minor complication observed during the study.MRI is mandatory for the diagnosis and development of an adequate treatment strategy for BML patients. This study showed that core decompression along with the injection of ACP into the affected subchondral area after only one week provides rapid pain relief and statistically significant improvement in joint function and quality of life, as assessed by NPRS, KOOS, and WORMS (


Nonspecific back pain (NSBP) contributes greatly to the overall burden of disease from musculoskeletal conditions. Digital therapeutics (DTx) aims to address the excess demand for movement and exercise therapy resulting from this spectrum of conditions. This study aims to investigate the differential therapeutic response of NSBP to different use profiles of a digital home exercise program. Methods: This study used a PSM model to comparatively assess the achievement of a clinically relevant pain improvement among patients who exhibit a high use (HU), intermediate use (IU), low use (LU), or sub-LU use profile. Sensitivity analyses with commonly accepted thresholds for clinically relevant improvements were conducted. Results: Higher use profiles show a higher probability of achieving a clinically relevant improvement of self-reported pain intensities. Additionally, the achievement of any higher use level is associated with a significant increase in the probability of achieving a clinically relevant improvement. Conclusion: To enable the optimal effectiveness of DTx home exercise programs, an HU use profile should be pursued. This finding is in line with earlier guidance for the achievement of optimal therapeutic benefit from conventional movement and exercise therapy and underscores the importance of a cross-disciplinary effort from patients, healthcare professionals and system stakeholders alike to maximize the therapeutic effect from DTx. Nonspecific musculoskeletal pain of the back is one of the leading drivers for burden of disease worldwide ,2. BeyonBeyond general therapeutic principles such as motivating patients to maintain an active lifestyle and providing condition-specific educational measures, the strongest therapeutic recommendation for the non-pharmacological management of nonspecific back pain consists of movement and exercise therapy, as outlined in international treatment guidelines ,4. MovemAs conventional movement and exercise therapy is typically administered by a qualified therapist , patientAdvances in the field of digital therapeutics (DTx) have opened up the opportunity to fill these capacity shortages with effective therapeutics that can be used independent of time and space and could therefore contribute to meeting the overall demand for care in the spectrum of conditions discussed above .Yet, as with all long-term therapies, therapeutic adherence  has a significant effect on the clinical effectiveness of any DTx . While tThe data included in this study were collected during the preliminary market approval phase of the DTx ViViRA as a DiGA in the German healthcare system between 20 October 2020 and 17 February 2022. As a DiGA, ViViRA is a medical device classified as risk class I under the Medical Device Directive (MDD) and is available to the entire patient population of the statutory health insurance (SHI) system upon prescription by a qualified healthcare professional. Once the DiGA is activated, it provides a guided home exercise program that undergoes a stepwise personalization for each patient to account for progress, symptom development and potential movement limitations. A prescription is valid for 90 days and grants daily access to the full spectrum of functions of the DiGA, which extends beyond the therapeutic elements  by providing educational content to improve the digital and health literacy of patients, as well as habit-building elements  to promote a physically active lifestyle. The recommended therapy consists of at least three routines per week with one routine consisting of four consecutive movement exercises. Patients are encouraged to complete all exercises of one routine in one session. All exercises and accompanying educational material are presented with text, video and audio guidance to enable unsupervised training. After the completion of every exercise, patients provide binary feedback on movement limitations and pain sensations, which drives the personalization of the exercise program. The progression algorithm maintains a sufficiently high training stimulus by increasing the intensity of the exercise  first, before the complexity of the exercise increases . Additionally, patients are prompted to report their current pain intensity on a verbal–numerical rating scale (VNRS) on a weekly basis, while the functional status  is assessed each month. The VNRS employed is an 11-point scale that extends from 0 to 10 in five categories  and is based on previous research for the assessment of non-malignant pain ,14. The Under the provision of article 4 of the DiGA regulation (DiGAV), the acquisition of performance and outcome data is allowed during the preliminary market approval phase once informed consent by the respective patient has been given. The regulation specifies that this consent can be obtained digitally. Patients received a prescription for ViViRA—and access to the digital movement and exercise therapy—at the sole discretion of a qualified healthcare professional once the respective patient was diagnosed with a nonspecific or degenerative back pain from the spectrum of medical conditions ViViRA has obtained market approval for . The manufacturer and the authors of this study, therefore, did not have any influence on the enrollment of patients. Hence, this analysis is based on real-world-use data. Ethics approval was obtained from the ethics committee of the University Medical Center, Freiburg on 5 April 2022 under the reference 22-1104-retro. The study was registered in the Deutsches Register Klinischer Studien (DRKS), a WHO-affiliated study registry, on 21 July 2022 under the reference DRKS00028920.Inclusion criteria were an age of ≥18 years, completion of at least one exercise and submission of any pain intensity of >0/10 on the VNRS at baseline and least one pain intensity after the baseline assessment. Access to the DiGA was provided only after (a) a prescription was issued by a qualified healthcare professional with consecutive approval by the respective SHI, or (b) after a patient approached their SHI independently and received approval on the basis of a prior confirmation of the diagnosis addressed.Use of the exercise program was stratified as either a high use , an intermediate use , or a low use  profile. Baseline demographics were compared between the use profiles . The outTo account for potential confounding through patient characteristics in the observational data, we employed a propensity score (PS) matching approach, which has been described elsewhere . In brien = 5 between exposed and unexposed in each stratum. Sampling with replacement was used. Primary results were adjusted for multiple testing using the Bonferroni method. All calculations were performed in Stata 17.We estimated a PS using a logistic model based on the baseline covariates of gender, concomitant physical therapy and/or pain medication at baseline, and the chronicity of the pain at baseline . As the The reporting in this article follows the adjustment of the STROBE guidelines for PS-based analyses proposed by Yao et al. , a reporIn total, 7628 patients who enrolled in the home exercise program for back pain between 20 October 2020 and 17 February 2022, completed at least one exercise and reported at least one pain score were included in this retrospective study. Owing to the automated data collection upon consent and activation of the DiGA, all potentially eligible patients could be included and analyzed. Overall, we see an overrepresentation of female patients in the sample . While tPrior to PS-matching, the probability of achieving a clinically relevant improvement in their pain intensity at the individual time of termination of use among patients with an HU profile is 39.2% . IU, LU Patients with HU consecutively have a 9% (95%-CI 6.7–11.5%) higher probability of achieving a clinically relevant reduction in their pain intensity in comparison to all other use profiles  . SimilarSensitivity analyses were conducted with other commonly accepted thresholds for clinically relevant benefits. Both sensitivity analyses supported the results above and showed a significantly higher probability of achieving the respective clinically relevant improvement once patients adhered to IU or HU use profiles. Similar to the primary analysis, no significantly higher probability of a clinically significant benefit could be detected when comparing the LU use intensity and the sporadic  use profile. Tabulated results of the sensitivity analyses can be found in The main result of this analysis supports the primary hypothesis that the achievement of a clinically relevant improvement in pain intensity is dependent upon the maintenance of sufficient therapeutic adherence . SpecifiFor conventional movement and exercise therapy, an association between a sufficiently high therapeutic intensity  and the therapeutic benefit has been well established ,22. As bLong-standing guidance from the World Health Organization (WHO) underscores that therapeutic adherence is “a primary determinant of the effectiveness of treatment, because poor adherence attenuates optimum clinical benefit” . This isBeyond these, however, the thorough exploration and consequent implementation of health system-related , socioeconomic , patient-related  and condition-related factors  is required to achieve the best possible benefit from DTx for both individual patients and the healthcare systems employing them.We see that the required collaborative approach towards facilitating the best possible therapeutic adherence has not yet been pursued in the German healthcare system. Specifically, the notion of suboptimal therapeutic adherence as a unidimensional indicator for poor quality of the respective DTx, as put forward by some system stakeholders, defies the existing body of evidence on adherence and prevents the thorough integration of the novel field of DTx into the existing healthcare infrastructure ,31. Yet,The study at hand aims to assess the effect of higher frequencies of use of the DiGA ViViRA on its therapeutic effectiveness in reducing nonspecific back pain. While this effect could be demonstrated and while the findings are in line with prior research in this field ,34,35, cThis work presents a PS-matched analysis of the effect of different use profiles on the achievement of a clinically relevant pain improvement in patients with nonspecific back pain. While a positive effect of relatively higher use profiles on nonspecific musculoskeletal conditions in general and nonspecific back pain in particular has been reported for conventional movement and exercise therapy before, our work indicates a similar effect for DTx and DiGA. To achieve sufficiently high use profiles—corresponding to a sufficient therapeutic adherence—among patients under care with a DTx, however, a multi-stakeholder effort is required. As it was proposed for conventional therapeutics in a hallmark paper of the WHO decades ago, further research should revisit the five dimensions of adherence in the light of DTx in order to maximize the individual and system-wide benefits of such novel therapies.


Chronic pain affects up to 20% of the population, impairs quality of life and reduces social participation. Previous research reported that pain-related perceived injustice covaries with these negative consequences. The current study probed whether chronic pain patients responded more strongly to disadvantageous social inequity than healthy individuals.n = 102) and healthy controls (n = 101). Anonymised, and in truth experimentally controlled, co-players proposed a split, and our participants either accepted or rejected these offers.We administered the Ultimatum Game, a neuroeconomic social exchange game, where a sum of money is split between two players to a large sample of patients with chronic pain disorder with somatic and psychological factors  decision making .Our findings indicate that chronic pain is associated with anomalies in social decision making  and hypersensitivity to social inequity that is likely to negatively impact social partaking and thereby the quality of life. Approximately 20% of adults suffer from chronic pain  and matched healthy controls (n = 101). In this two-player game, one player (‘the proposer’) splits a sum of money between themselves and the other player (‘the responder’), who in turn decides to accept or reject the split offer. In case of a rejection, neither player gets any money. All participants were assigned to the responder role, and, unbeknownst to them, the proposer was computer-controlled and the proposed offers were predetermined. For the responder, the most lucrative choice is to accept all offers larger than zero. However, a multitude of previous studies have shown that offers with too large inequity in the split are perceived as unfair and rejected by most individuals  and 101 healthy controls  participated in this study. Chronic pain patients were recruited from the outpatient Pain Clinic at the St. Vinzenz Hospital in Düsseldorf, where they received interdisciplinary treatment based on the biopsychosocial model. Healthy controls were recruited through advertisement at the University Düsseldorf and the Verbund Katholischer Kliniken Düsseldorf. All participants received a monetary pay-out based on one randomly selected trial of the UG. Healthy controls were additionally reimbursed a fixed rate of €80 for their participation in the larger protocol.One hundred and two chronic pain patients . The entire assessment lasted approximately 90 min including breaks, and was conducted in one or two sessions. We extracted four measures that allowed us to statistically control for cognitive and affective factors that could influence and confound choices on the UG from this larger assessment: two tests of executive functioning (the Go-No-Go Task and the Tower of London), one depression questionnaire . All participants provided written informed consent. All procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.t = −4.48, p < 0.001), age was added as a covariate of no interest to this analysis. TOL performance, depression and fatigue scores were also added as covariates into this model, to statistically account for group differences in, and control for potentially confounding influences of, executive functioning and affective state. When the assumption of sphericity was violated, Greenhouse-Geisser corrections were applied. Differences in UG acceptance rates could result from a shift in equity aversion or simply from increased randomness in the choice behaviour. To investigate these two potential mechanisms, we ran a computational model over participants’ trial-by-trial decisions. This model provided two estimated parameters reflecting participants’ sensitivity to inequity  and their choice consistency , that were then compared between chronic pain patients and healthy controls with two separate ANCOVA . Since sample distributions of i parameters were right-skewed , cube root transformation was applied prior to this analysis . Additionally, Spearman correlations tested whether inequity aversion (transformed) and choice consistency were systematically related to current and average pain levels in the chronic pain group.In order to compare social decision making of chronic pain patients and healthy controls, we first analysed accept/reject decisions on the UG with a repeated measures analyses of covariance (rANCOVA), with the factors offer (six levels), group (patients/controls), and offer × group interaction. Given that chronic pain patients were on average 9 years older than healthy controls , the square transformation was applied prior to the ANCOVA .To test for potential differences in risk-sensitive decision making, overall betting and risk adjustment on the RBT were compared between chronic pain patients and healthy controls with ANCOVAs, again accounting for age, depression scores, fatigue scores and TOL performance. Since sample distributions of risk adjustment were left-skewed  and of 0.025 in the case of the group comparisons of RBT outcomes (two ANCOVAs). Follow-up pairwise comparisons of acceptance rates at each offer level of the UG were likewise corrected for multiple comparisons. To allow readers to assess the statistical significance of effects with ease, we provide Bonferroni-corrected p-values using the denotation pcorr in the Results section.Our statistical analyses thus comprised two separate families of tests . Within each of these families of tests, Bonferroni-corrections for multiple comparisons were applied and obtained All statistical analyses were computed in JASP and are reported two-sided.U(offer) represents the utility of the proposed offer, Mself is the amount offered to the responder , and Mother is the amount allocated to the proposer , and the estimated parameter i (restricted to vary between 0 and 10) indicates how strongly the offer's utility is reduced by disadvantageous inequity (i.e. how much worse the proposer is off then the responder).i = 0, the subjective value is equivalent to the amount offered to the responder and not affected by inequity. As i increases, responders become increasingly inequity averse, and the offer's utility is diminished and even becomes negative. Trial-by-trial utility estimates were transformed into a probability of offer acceptance using a softmax function:μ is an inverse temperature parameter that characterises the choice consistency. The larger μ, the more consistent participants were in their reject/accept decisions for a given offer. Or vice versa, the smaller μ, the more varied was a participant's response to a given offer .We modelled participants’ trial-by-trial reject/accept decisions on the UG as:n = 84, 82%) suffered from chronic pain disorder with somatic and psychological factors (ICD-10-GM F45.41), characterised by persistent, severe, and distressing pain triggered by somatic disease but with causative influences from psychosocial factors. The remaining patients were diagnosed with dorsopathies (n = 6), gonarthrosis (n = 5), fibromyalgia (n = 3), polyneuropathy (n = 2), rheumatism (n = 1), and myalgia (n = 1). Chronic pain patients reported considerable levels of current and average pain  and pain-related disability  = 29.208, p < 0.0001, ηp2 = 0.130, a significant main effect of group, with chronic pain patients rejecting significantly more offers than healthy controls, F(1/195) = 11.297, pcorr = 0.002, ηp2 = 0.055, Mpain = 62%, SEpain = 1.8%, rangepain = , Mcontrols = 49%, SEcontrols = 2.1%, rangecontrols = , and a significant offer × group interaction, F(3.353/577.98) = 3.532, p = 0.015, ηp2 = 0.018. Follow-up level-wise t tests showed that healthy controls accepted significantly more offers with a 1:9, 2:8, 3:7 and 4:6 split than chronic pain patients, all t(199) ⩾ 2.957, pcorr ⩽ 0.021, whereas acceptance rates of offers with a 0:10 and 5:5 splits did not differ significantly between patients and controls, both t(199) ⩽ 1.30, pcorr = 1.00 .Observed and modelled acceptance rates of UG offers are displayed in i (untransformed): Mpain = 2.290, SEpain = 0.289, rangepain = , Mcontrols = 1.049, SEcontrols = 0.174, rangepain = , i (cube root transformed): Mpain = 1.113, SEpain = 0.050, rangepain = , Mcontrols = 0.844, SEcontrols = 0.040, rangecontrols = , F(1/195) = 12.471, pcorr = 0.0001, ηp2 = 0.060, see β: Mpain = 3.98, SEpain = 0.34, rangepain = , Mcontrols = 4.37, SEcontrols = 0.40, rangecontrols = , F(1/195) = 0.888, pcorr = 1.00, ηp2 = 0.002. Neither inequity aversion nor choice consistency was significantly influenced by depression scores, fatigue scores, TOL performance, or age  or systematically related to patients’ current or average pain levels . Together, these model-based results corroborate that the increased offer rejection rate of chronic pain patients was due to a systematic shift in the subjective valuation of unequal offers, rather than increased randomness in their choices.Model-based results showed that chronic pain patients were more inequity averse than healthy controls, Mpain = 54.66, SEpain = 1.186, rangepain = , Mcontrols = 49.95, SEcontrols = 1.354, rangecontrols = ) nor risk adjustment  differed significantly between chronic pain patients and healthy controls, F(1/193) = 1.611, pcorr = 0.412, ηp2 = 0.008 and F(1/193) = 0.211, pcorr = 1, ηp2 = 0.001, respectively. No systematic influences of age, fatigue scores or TOL performance upon average betting or risk adjustment were found, all F(1/193) ⩾ 1.42, p ⩾ 0.235 (see online Supplementary Table S5 for full stats). The degree of risk adjustment was lower in those with higher depression scores, F(1/193) = 5.143, p = 0.024, ηp2 = 0.026.Observed betting responses on the RBT are shown in The results of our study indicate a systematic difference in the social decision making and social interaction behaviour of patients suffering from chronic pain and healthy individuals. Chronic pain patients rejected unequal offers on the UG significantly more often than healthy controls, displaying an inflated aversion to disadvantageous inequity and a higher willingness to forgo own monetary winnings to punish their opponents for unfair offers. Prior investigations found patients with fibromyalgia and chronic regional pain syndrome to be less accurate in recognising affective mental states on photos of human eyes (Di Tella et al., Social withdrawal is often observed in chronic pain patients (Baker et al., unrelated to the chronic pain condition itself are also systematically altered in chronic pain patients compared to those observed in healthy controls. This is relevant to the question of the nature of the relationship between perceived injustice and health outcomes. While previous studies are almost exclusively correlational in nature and lack a guiding conceptual framework, the dominant view in the literature is that injustice perceptions arise from experienced violations of human rights, equity norms or just word beliefs (McParland & Eccleston, Our findings also critically extend the existing literature on perceived injustice and pain outcomes. This growing body of research suggests that questionnaire scores of perceived injustice related to the origin and consequences of acute and chronic pain are correlated with a higher disability, greater pain severity, lower social functions, and a higher prevalence of depression (e.g. Scott & Sullivan, Consistent with the idea that chronic pain may affect the processing of other information, systematic changes in the activation and functional connectivity patterns of multiple brain areas, including the insula, have been observed in chronic pain patients during cognitive tasks (e.g. Baliki, Geha, Apkarian, & Chialvo, Chronic pain patients’ and healthy controls’ decisions on the RBT did not differ systematically. This secondary decision-making task acted as a control task, assessing value-based choices outside of social context. While a lack of a statistically significant difference does not prove the absence of an effect, this finding nonetheless supports our conclusion that the increased rejection rates of chronic pain patients on the UG arose from hypersensitivity to inequity, rather than a domain-independent shift in valuation processes. In contrast, a handful of previous studies in chronic pain patients found poorer self-reported real-word decision outcomes (Attridge et al., v. Attridge et al. (A related alternative explanation worth discussing is whether the observed anomalies in our patients’ UG choices could have emerged from a general deficit in higher cognitive functions. Whereas previous research on the impact of experimental acute pain on higher cognitive functions and reasoning have yielded inconsistent results , studiee et al.  [albeit,e et al.  for a nue et al. .There are two limitations to the current study: Firstly, our patients suffered from chronic pain of mixed aetiology. Future studies need to investigate pain subtypes, such as musculoskeletal pain, neuropathic pain, chronic headache, etc., to determine whether anomalies in social decision making and other social cognitions are specific to certain pain syndromes. Secondly, we focused on responder behaviour on the UG, which is a well-established approach to investigate behavioural, affective, and cognitive reactions to perceived unfairness in social exchanges. To complement our understanding of social interaction behaviour in chronic pain, future studies might investigate proposer behaviour on the UG in clinical samples.In conclusion, this study indicates that social decision making differs systematically between chronic pain patients and healthy controls. Compared to our sample of healthy individuals, our chronic pain patients were hypersensitive to disadvantageous inequity in propositions made by their interaction partners. Given that socio-economical inequities are ubiquitous in our society and everyday life, such hypersensitivity is likely to impact social partaking and thereby might in the long term reduce quality of life . Social cognitions should become part of the neuropsychological diagnostics of chronic pain patients and potentially addressed by multidisciplinary pain therapy.


Patients with various aetiology of pain who underwent erector spinae plane block at different levels were evaluated at the tertiary Algology clinic. Visual analog scale (VAS) values were recorded before the block; 30 min, two weeks, and two months after the block. Medical records of fifteen patients have been obtained. The average VAS decreased from 7 ± 1 to 5 ± 3 in the second month when compared to the values before block (p < 0.01). ESP block can be an option for chronic pain in postsurgical pain syndrome and myofascial pain management. Erector spinae plane block (ESP) is an interfacial plane block that is performed by the application of local anaesthetic between the erector spina muscle and transverse process. ESP block takes effect by diffusing local anesthetic into musculofacial part over craniocaudal multiple vertebra levels . As it cth min, 2nd week, and 2nd month.Patients undergoing ESP block due to chronic pain between February 2019 and February 2021 were reviewed retrospectively. All reported research involving “Human beings” was conducted in accordance with the principles set forth in the Helsinki Declaration 2008 and local ethical approval was obtained (2021/12-05). Written informed consent was obtained from the patients for the performance of ESP block. The ESP blocks were performed by using 18 mL of bupivacaine 0.5% and 2 mL of 8 mg dexamethasone with a 22-gauge 100-mm spinal needle . The intensity of pain was evaluated by using visual analog scala (VAS) before and after the block at the 30th min, 4 ±3 in the 2nd week, and 5 ± 3 in the 2nd month. There was a statistically significant difference between baseline and post-block VAS score (p < 0.05). The patients who have myofascial pain consist of the ones showing no response to the trigger point injection. There has been a statistically significant decrease in myofascial pain intensity in the 2nd week and 2nd month compared to the before block pain level (p < 0.05) as shown in nd week compared to the before block pain level, there has not been a statistical decrease in pain level in the 2nd month (p = 0.066)  . No majoIn this study, it is found that in chronic pain, which is with no response to the medical treatment, ESP block is able to decrease the pain level. Although it is ineffective for pain due to endometrium and over malignancy, ESP block has been determined as effective in postsurgical chronic pain and myofascial pain which most patients suffer from.In a 7-patient case series, where the effctiveness of ESP blok in postthoracotomy pain was evaluded the analgesic effect losted 2–6 weeks in 4 patients, while it losted no more than 2 days in 3 patients [Piraccaniet al. have investigated the effectiveness of ESP block in patients with myofascial pain. They stated that ESP block is effective only in short term and it does not have a significant effect in long term . Tulgar ESP block is an inexpensive, easily applicable, safe, and effective technique in chronic pain. We believe that ESP block may be administered in patients and before the more complicating invasive procedures.