There is limited research on the economic burden of low back-related leg pain, including sciatica. The aim of this study was to describe healthcare resource utilisation and factors associated with cost and health outcomes in primary care patients consulting with symptoms of low back-related leg pain including sciatica.This study is a prospective cohort of 609 adults visiting their family doctor with low back-related leg pain, with or without sciatica in a United Kingdom (UK) Setting. Participants completed questionnaires, underwent clinical assessments, received an MRI scan, and were followed-up for 12-months. The economic analysis outcome was the quality-adjusted life year (QALY) calculated from the EQ-5D-3 L data obtained at baseline, 4 and 12-months. Costs were measured based on patient self-reported information on resource use due to back-related leg pain and results are presented from a UK National Health Service (NHS) and Societal perspective. Factors associated with costs and outcomes were obtained using a generalised linear model.Base-case results showed improved health outcomes over 12-months for the whole cohort and slightly higher QALYs for patients in the sciatica group. NHS resource use was highest for physiotherapy and GP visits, and work-related productivity loss highest from a societal perspective. The sciatica group was associated with significantly higher work-related productivity costs. Cost was significantly associated with factors such as self-rated general health and care received as part of the study, while quality of life was significantly predicted by self-rated general health, and pain intensity, depression, and disability scores.Our results contribute to understanding the economics of low back- related leg pain and sciatica and may provide guidance for future actions on cost reduction and health care improvement strategies.ISRCTN62880786.13/09/2011 Retrospectively registered; The online version of this article (10.1186/s12913-019-4257-0) contains supplementary material, which is available to authorized users. Low back pain (LBP) is a common health condition worldwide  and poseThe economic burden of LBP has been investigated comprehensively, and found to be substantial , 6. To dThe objective of this study is to provide data on the distribution of healthcare usage, costs and quality of life outcomes in primary care patients consulting with low back-related leg pain according to the presence/absence of sciatica, and explores factors associated with costs and quality of life outcomes for patients with symptoms of low back-related leg pain including sciatica.Assessment and Treatment of Leg pain Associated with the Spine) study protocol [Full details of this prospective cohort study are published in the ATLAS , prescribed medication, over-the-counter treatments and secondary care attendances including healthcare professionals , investigations , and procedures such as surgery . Self-reported work-related data on time-off work were also collected in order to assess the impact of indirect costs of sickness absence due to low back related leg pain. Details of the number of study-related physiotherapy sessions attended by each participant were collected as part of the study through case report forms and costed separately from other physiotherapy visits. Study protocol-driven MRI scan costs were excluded from the analysis as these would not necessarily occur in usual practice.Total 12-month costs per person were estimated by combining resource use data with unit costs. Unit costs were obtained from the British National Formulary (BNF)  for drugAn analysis of costs and quality of life outcomes was conducted to determine the difference in costs and QALYs over a 12-month period between the group of patients with sciatica and those with referred leg pain. Multiple-imputation using chained equations was used to impute missing values for costs and EQ-5D-3 L scores for non-responders to the 4 and 12-month questionnaires . Confidep < 0.25 were carried forward to the multivariable model for each cost and quality of life outcome variables. The final models reported significance at p < 0.01, p < 0.05 and p < 0.1. All statistical analyses were performed using Stata V.13 analysis software [Separate GLMs with log link and gamma variance functions were fitted for the whole cohort, to identify factors that influence total costs and QALYs . GLM modsoftware . The basn = 452), referred leg pain (n = 157)) formed the dataset for the analysis. The mean age of participants was 50, with over half of the respondent’s female (62%); 32% were smokers and just over 13% had two or more other health problems. At baseline, 61 and 59% of respondents were in paid employment in the sciatica and referred leg pain group. An additional file describes the participant’s characteristics at baseline in more detail  total societal cost for all patients in the cohort was £1106.14 2328.54)  than in the referred leg pain group (3.1 days). This translated into higher productivity costs in the sciatica group (£882) compared to the referred leg pain group (£216), this difference was statistically significant. Table p < 0.25), none of which had a statistically significant impact on healthcare costs (Table p = 0.024 and p = 0.063 respectively). The quality of life final regression model included all pre-selected variables, seven of which were significantly associated with poor quality of life (p < 0.05), these were: poorer self-reported general health, higher low back or leg pain intensity, higher depression score, higher disability score, patient’s belief/perception that their symptoms will be long-lasting, gender, and the ATLAS care pathway defined as a referral to spinal specialist services  findings. The exception in the analysis of quality of life was that the disability and care pathway variables were no longer significant for the sciatica group  and quality of life health outcomes, and on factors associated with these, in this population.Our results from the overall cohort analyses demonstrate that healthcare utilisation from the NHS perspective is highest for health professional consultations such as physiotherapy and GPs. From a societal perspective, costs were highest for work-related productivity loss (for those in work). Similar findings were observed in the analyses for the sciatica and referred leg pain groups. An increase in the number of physiotherapy sessions (as part of the ATLAS study) and higher self-reported general health scores were significantly associated with reduced resource utilisation and costs at 12 months (approximately £1.5 and £1.2 respectively). The baseline factors associated with improvement of quality of life in this cohort were: higher scores of self-rated general health, lower pain intensity, lower depression scores, and lower disability scores. However, the disability score was not a significant predictor of quality of life in the sciatica group. A further finding was a higher number of days off work in the sciatica group within the 12 months follow-up, resulting in higher societal costs.LBP national and international guidelines have recommended early assessment, diagnosis and management of back-related leg pain in patients presenting with back-related problems, with the view to prioritise timely and appropriate management , 38. HowWe did not find any significant association between costs and age, gender, body mass Index, comorbidities, disability, pain intensity, and depression in our sample. This contrasts with more general literature which suggests that costs of musculoskeletal conditions are often associated with demographic factors such as age, and disease specific factors such as depression and disability –43. FactThe strengths of our study lie in the analysis approaches used, presentation of disaggregated results and comprehensive assessment of factors associated with costs and quality of life in patients consulting with symptoms of low back-related leg pain including sciatica. The analyses are also performed from a broader societal perspective, and therefore report important work-related outcomes that are particularly relevant for this patient group, as most are of a working age. The analysis considers a comprehensive set of potential prognostic factors influencing cost and quality of life, underpinned by previous research and clinical experience. However, there are limitations to our analysis. Resource use information was collected using self-reported data from study participants at 4 and 12 months questionnaires. A limitation of using self-report data only, is that it is subject to recall and information bias (e.g patients not able to distinguish between LBP-related resource use and others) and therefore respondents could potentially over-report or under-report resource utilisation, particularly over longer periods of recall . NeverthThe analysis reported here presents important information on costs for treating patients with back-related leg pain including sciatica. Within the ATLAS cohort, patients with sciatica pain and referred leg pain appeared to be similar in terms of quality-of-life outcomes although patients in the sciatica group had a higher proportion of consultation visits, medication and time-off work. The productivity costs incurred by individuals in this cohort as a result of back-related leg pain were substantial. Therefore it is important that the cost-effectiveness of interventions used for patients with low back-related leg pain and sciatica, are investigated from a perspective of both, the health provider and society.The regression analyses showed that patient self-rated general health and the number of physiotherapy sessions received (as part of the ATLAS study) were important predictors of resource utilisation and costs, possibly indicating that initial comprehensive treatment seems to reduce future need for health care use and costs. However, the study’s observational design precludes any causal inferences. Baseline low levels of disability, pain intensity and depression were associated with changes in quality of life as measured by the EQ-5D-3 L. The generalizability of the findings in this research is supported by the inclusion of eligible patients with any level of intensity and duration of pain, as this broadens the population beyond patients presenting with only the most severe symptoms.In conclusion, in 1 year, resource utilisation for primary care patients with low back-related leg pain and sciatica showed that health care and societal costs were highest for visits to physiotherapists and GPs and in relation to work-related productivity loss. Health-related quality of life was low at baseline for the overall cohort and for both the sciatica and referred leg pain groups, but improved across all time points. The type of care received and patient self-reported general health were important variables for predicting future costs. Similarly to other musculoskeletal conditions, quality of life was significantly influenced by characteristics such as levels of disability, depression and pain intensity. Our study contributes to understanding the economics of low back-related leg pain and sciatica care and has important implications for health care policy resource allocation in this patient group.Additional file 1:List of the preselected sets of variables used in the analysis. This additional file includes variables that have been preselected and included in the models. (DOCX 19 kb)Additional file 2:Health care resource use unit costs. This additional file includes details of unit costs for variables used in the cost analyses. (DOCX 14 kb)Additional file 3:Baseline characteristics for the whole group and for the sciatica and referred leg pain subgroups. This additional file provides a summary of baseline characteristics for the whole group. (DOCX 15 kb)Additional file 4:Sensitivity analysis: Generalised linear regression model with NHS costs at 12 months  for the sciatica group. This additional file reports model results of the sensitivity analysis of NHS costs for the sciatica group. (DOCX 15 kb)Additional file 5:Generalised linear regression model with total QALYs at 12 months for the sciatica group. This additional file reports model results of the sensitivity analysis of total QALYs for the sciatica group. (DOCX 15 kb)Additional file 6:Generalised linear regression model with NHS and Societal costs at 12 months complete-case. This additional file reports model results of the sensitivity analysis of NHS and societal costs for the complete-case analysis. (DOCX 16 kb)Additional file 7:Generalised linear regression model with total QALYs at 12 months (complete-case). This additional file reports model results of the sensitivity analysis of total QALYs for the complete-case. (DOCX 17 kb)


The optimal perioperative analgesic strategy in video-assisted thoracic surgery (VATS) for anatomic lung resections remains an open issue. Regional analgesic concepts as thoracic paravertebral or epidural analgesia were used as systemic opioid application. We hypothesized that regional anesthesia would provide improved analgesia compared to systemic analgesia with parenteral opioids in VATS lobectomy and would be associated with a lower incidence of pulmonary complications.The study was approved by the local ethics committee (AZ 99/15) and registered . A retrospective analysis of anesthetic and surgical records between July 2014 und February 2016 in a single university hospital with 103 who underwent VATS lobectomy. Comparison of regional anesthesia  or thoracic epidural anesthesia (group TEA)) with a systemic opioid application ). The primary endpoint was the postoperative pain level measured by Visual Analog Scale (VAS) at rest and during coughing during 120 h. Secondary endpoints were postoperative pulmonary complications , hemodynamic variables and postoperative nausea and vomiting (PONV).p < 0.004). There were no significant differences on secondary endpoints. Intraoperative Sufentanil consumption was significantly higher for patients without regional anesthesia (p < 0.0001 vs. TPVB and vs. TEA). The morphine equivalence postoperatively applicated until POD 5 was comparable in all groups (mean ± SD in mg: 32 ± 29 (TPVB), 30 ± 27 (TEA), 36 ± 30 (PCA); p = 0.6046).Mean VAS values in rest or during coughing were measured below 3.5 in all groups showing effective analgesic therapy throughout the observation period. The VAS values at rest were comparable between all groups, VAS level during coughing in patients with PCA was higher but comparable except after 8–16 h postoperatively .The study was registered (germanctr.de;  Video-assisted thoracic surgery (VATS) is considered as the standard minimal invasive surgical procedure for anatomic lung resections . The advThe optimal perioperative analgesic strategy after VATS lobectomy remains contradictory. Thoracic epidural analgesia (TEA) is commonly considered as the gold standard for pain relief after open thoracotomy and is preferred by the majority of clinicians. In times of enhanced recovery and fast track concepts after surgery thoracic paravertebral block (TPVB) is an upcoming regional anesthesia technique in thoracic anesthesia. It can be used as single injection or continuous technique. However, there are also anesthesiologists in the field of thoracic anesthesia preferring patient-controlled analgesia (PCA) instead of the regional anesthesia techniques –7. RegioAfter implementation of VATS as a standard for anatomic lung resection in our department the procedure-specific pain protocol was based on multimodal systemic analgesia with non-opioid and opioid drugs. Although less invasive, the thoracoscopic approach, resulted in unexpectedly high intensity of postoperative pain . In thisAccordingly, we wanted to analyze and undertook a retrospective analysis to establish whether thoracic regional analgesia  would provide improved analgesia compared with systemic analgesia with parenteral opioids and non-steroidal analgesics leading to a reduction postoperative pulmonary complications such as atelectasis, pneumonia, hypoxia or pulmonary dysfunctions.The study was approved by the local ethics committee (AZ 99/15) and registered . Inclusion criteria were age older than 18 years and anatomic lung resection via VATS approach. Exclusion criteria were conversion to open thoracotomy, non-anatomic (“wedge”) lung resections and additional chest wall resections. Data were retrospectively collected between July 2014 und February 2016. Patients signed a written informed consent approving their data could be used for scientific purposes. From July 2014 until January 2015 all patients received either a TPVB or a TEA. From January 2015 the perioperative analgesia was changed by interdisciplinary institutional decision and included systemic opioid application with piritramide as patient controlled analgesia .− 1. The Bispectral Index of the encephalogram (BIS) was monitored  and the propofol concentration was decreased to 2.2 μg/ml at the lowest, if the BIS value decreases to below 30. Propofol concentration was increased to 4 μg*ml− 1 to avoid arterial blood pressure values above 20% of baseline and BIS values above 60. Core temperature was kept above 36.0 °C using a forced-air warming system. All patients were endotracheally intubated with a double-lumen endobronchial tube for one-lung ventilation.The perioperative anesthetic regimen is standardized. Pre-medication before arrival in the operating room was performed with midazolam (3.75–7.5 mg p.o.). The responsible consultant preoperatively decided indication and choice for TPVB or TEA. Three experienced anesthesiologists performed all TEA and TPVB following the same protocol. Patients in the group TEA received an epidural catheter, using an 18G Tuohy needle, the epidural catheter (20G) will be placed at T4/5, T5/6, or T6/7 interspace (depending on the site of surgery) using the midline approach and hanging drop technique , 19. AftVATS lobectomy was performed using a utility incision of 5 cm length entering the 4th intercostal space regardless which lobe was resected. Two further incisions of 1–2 cm were placed in posterior and anterior axillary line at level of the diaphragm in the 7th or 8th intercostal space. At the end of the procedure a 24 Fr chest tube was placed exiting the anterior lower incision in the 7th or 8th intercostal space. Following the same protocol two thoracic surgeons performed all procedures . Chest tubes were removed when there was no air leakage for 6 h and the pleural fluid amount for 24 h did not exceed 200 ml.http://americanpainsociety.org/uploads/education/PAMI_Pain_Mangement_and_Dosing_Guide_02282017.pdf).In the author’s institution surgical patients were preoperatively instructed in the use of the visual analog scale (VAS). The VAS Score consisted of an unmarked 10 cm line, with 0 cm representing no pain and 10 cm the worst imaginable pain. Postoperatively all patients received a basic analgesic therapy containing either metamizole 4 × 1 g per day or acetaminophen 3 × 1 g depending on comorbidities  and oxycodone 2 × 20 mg per day directly in the intermediate care unit. When the pain intensity exceeded 3 cm a bolus of piritramide 1.5 mg was applicated and repeated until the pain level decreased below 3 (VAS) again. Patients of the PCA group were directly connected to an i.v. PCA device, delivering piritramide bolus doses of 1.5 mg with a lockout time of 5 min and a total dose of 40 mg in 4 h. Nursing staff assessed pain intensity on the intermediate care unit in intervals of 4 h until 24 h after surgery, following once a day until 5th postoperative day. Morphine equianalgesic conversion was calculated using the calculator based on the American Pain Society guideline  and paresthesia were checked twice daily during the morning and afternoon round of the medical staff on the intensive care unit.Primary endpoint was the postoperative pain intensity assessed by the VAS in cm at different times after the procedure. VAS scores (0–10) were assessed by the nursing staff at the beginning of the shift routinely at rest and during coughing on ICU. When transferred to the ward after 24 h, pain scores were documented once daily during the morning round of the nursing staff. Secondary outcome parameters were pulmonary  and surgical complications  as well as side effects of the analgesic therapy . Atelectasis was defined by radiological criteria, pneumonia as fever, radiologic infiltration, positive microbiology or leukocytosis requiring antibiotic treatment.Data were presented as mean and standard deviation (± SD) or median and IQR if not indicated otherwise. Patient characteristic data were compared by analysis of variance (ANOVA) for multiple comparisons with Tukey post-hoc test. Comparisons of serial measurements (VAS for pain) were performed with repeated-measures ANOVA. Ranked data were analyzed with the Kruskal–Wallis and Mann–Whitney U-tests when appropriate. Categorical data were examined by Fisher’s exact or Chi-square test. Probability values under 0.05 were considered significant.From July 2014 to February 2016, 103 patients who underwent VATS lobectomy for oncologic reasons were examined retrospectively and initially included. In 62 patients analgesia was performed by regional anesthesia (28 patients with TPVB and 34 with TEA). From May 2015 patients were scheduled without regional anesthesia due to change in local procedures and 41 patients underwent VATS lobectomy with systemic opioid-based analgesia (PCA). Four patients were excluded due to conversion to systemic analgesia because of postoperative catheter dislocation, inadequate data sheet or open thoracotomy. The patient’s demographic data are described in Table p < 0.0001; mean dose 67 ± 4 μg for the PCA group vs. 47 ± 3 μg vs. patients with TPVB and 34 ± 2 vs. patients with TEA). The postoperative morphine equivalence dose applicated postoperatively until postoperative day 5 was comparable in all groups .Mean VAS score was measured below 3.5 in all groups showing effective perioperative analgesia Figs.  and 2. TSecondary endpoints showed no difference between the three groups Table . HemodynThis retrospective study analyzed two regional analgesic concepts (TPVB and TEA) and one systemic concept via opioid application using a PCA for postoperative analgesia in patients undergoing VATS lobectomy or VATS anatomic resections. The main findings can be summarized as follows: (i) TPVB, TEA and systemic analgesia provided effective analgesia (VAS < 4) during the perioperative period; (ii) the postoperative pain relief was comparable with similar opioid doses in all groups with the exception of 16 h postoperative while coughing favoring regional anesthesia; (iii) secondary outcome measures as respiratory or surgical complications did not differ among the three groups.There are two major issues influencing the postoperative fast track concept in thoracic surgery demanding an optimal pain relief. First, early effective pain relief augments early mobilization with possible reduction of pulmonary complications  leading to early discharge and reduced health costs . SecondlFor VATS resections the reports on different analgesic strategies are still very heterogeneous , 23, 24.In this study, TEA, TPVB, and PCA provided a comparable pain relief. Two studies compared TEA with systemic opioid analgesia for thoracoscopic lobectomy. Kim et al. demonstrated in a non-blinded RCT of 37 patients that there were no differences in pain scores, supplementary analgesic requirements or adverse events . Yie et There were no differences with respect to the pain intensity between opioid PCA and TEA or TPVB. The cost implications of a regional analgesia concept, TEA or TPVB, compared with i.v. analgesia is well documented. The cost difference is mainly caused by the professional manpower costs and the treatment of complications .In addition to the comparable pain relief we found no difference between the secondary outcomes  not supporting our hypothesis that there would be less pulmonary complications using a regional anesthetic procedure.This study had some limitations. The trial was not a prospective, randomized, and double-blinded clinical study, but technique and expertise in TEA or TPVB was very homogeneous and performed exclusively by three consultants and reflects clinical practice. In addition, pain assessment was routinely evaluated only at the described time points. Secondly, the small sample size limited the possibility of drawing a definitive conclusion. Thirdly, the sample size of the study was not calculated due to the retrospective design and therefore to small to evaluate the secondary outcomes of respiratory function, pulmonary complications, nausea and vomiting, degree of sedation, hypotension, and pruritus. Finally, assessment of the level of analgesic effect or sensory block of the TEA and TPVB were not routinely performed.In conclusion, our findings indicated that application of systemic opioids via PCA device was an effective and acceptable alternative to regional anesthesia with TEA or TPVB for postoperative pain relief for patients undergoing VATS lobectomy.


Peripheral nerve block and local infiltration analgesia (LIA) provide good analgesia after knee replacement. This study evaluated the additional analgesic efficacy of continuous adductor canal block (ACB) added to single-dose LIA after medial unicondylar knee arthroplasty (UKA). We hypothesized ACB would lower pain scores and facilitate postoperative ambulation.Forty-six patients were enrolled into this double-blind, randomized, placebo-controlled trial. UKA was performed and all patients received single-dose LIA intraoperatively. Patients were randomized into two groups: Group RP receiving 0.2% ropivacaine or Group Con receiving normal saline. A flow at 6 mL/h was administered for 48 h through a catheter in the adductor canal. Primary outcome was movement pain score at 24 h using the numeric rating scale (NRS-11). Secondary outcomes included serial postoperative pain scores, rate of patients with NRS>3 at rest and movement within 24 and 48 h postoperatively, time to breakthrough pain, quadriceps motor strength, ambulated distance, catheter related infection and patient satisfaction.P = 0.002), serial pain scores at rest and with movement and rate of patients with NRS>3 with movement after surgery were significantly lower. Quadriceps motor strength was equivalent, however, ambulated distance on postoperative day 1 and 2 in Group Con was significant less .Forty-two patients were analyzed. Pain scores with movement at 24 h postoperatively were significantly lower in Group RP than that in Group Con . Compared with Group Con, breakthrough pain occurred later in Group RP (18.5 vs 10.0 h, Continuous adductor canal block added to single-dose LIA offered better analgesia and facilitated ambulation without motor weakness after medial UKA.ChiCTR-IOR-16008720; Registered 25 June 2016.Clinical Trial Registration:  Similar to total knee arthroplasty (TKA), moderate to severe pain caused by surgical trauma and early functional rehabilitation is anticipated after medial unicondylar knee arthroplasty (UKA) . OptimalThe anterior cutaneous branches of the femoral nerve, the saphenous nerve, and branches of the obturator nerve travel through the adductor canal in the medial part of the thigh and innervate the surgical area involved in a medial UKA –15. PrevTherefore, this prospective, randomized, double-blind, placebo-controlled trial compared the effects of continuous ACB added to an intraoperative single-dose LIA after medial UKA. We hypothesized that a continuous infusion ACB, in addition to LIA, would lower pain scores with movement at 24 h after surgery (primary outcome). We also hypothesized that this would improve serial pain scores, preserve quadriceps motor strength during physiotherapy, and facilitate ambulation within 48 h after surgery (secondary outcomes).Chictr.org.cn (code: ChiCTR-IOR-16008720) on June 25, 2016, and written informed consent was obtained from all participants before enrollment.Approval was obtained from the Institutional Review Board of Xuanwu Hospital, Capital Medical University, code: 2017(074). The study was prospectively registered at This prospective, randomized, double-blind, placebo-controlled trial was conducted from March 2017 to February 2018. Patients between 55 and 75 years of age were included if they were scheduled for medial UKA under spinal anesthesia (SA) with the American Association of Anesthesiologists (ASA) physical status of I-II. Patients were excluded if they had a history of opioid addiction, allergy to any of the study medications, a contraindication to ACB  and/or a contraindication to SA (coagulopathy and recent anti-coagulant medication use).Randomization was carried out using a computer-generated randomization list. Patients were randomized into two groups; one receiving 0.2% ropivacaine (Group RP), and a control receiving normal saline (Group Con) via the adductor canal. Each patient received a consecutive study number and treatment assigned by the randomization list. The list was stored and only two nurses, who prepared the study medications were allowed access. They had no interaction with the patients. All other medical personnel, participants and outcome assessors were blinded to the interventions.All patients received spinal anesthesia through a median or para- median approach using a 26 or 27 G Whitacre needle with 2.0 ml 0.5% bupivacaine at the L3/4. Sedation with propofol and fluid therapy were administered intraoperatively by an anesthesiologist. Surgical technique was identical for all patients and all procedures were done in a bloodless field by use of a femoral tourniquet. Unless contraindicated, all patients were given oral preoperative multimodal analgesic medications including 400 mg celecoxib and 1000 mg acetaminophen, according to the patients’ weight. Ondansetron 4 mg intravenous injections were administered prophylactically to prevent postoperative nausea and vomiting.All patients received LIA, consisting of a total of 100 ml 0.2% ropivacaine, 10 mg oxycodone and 0.5 mg adrenaline. All solutions were prepared under aseptic conditions. This is routinely performed by the surgeon for all medial UKAs before prosthesis implantation and wound closure. Using a similar method described previously , 20, 40 Upon completion of the surgery, patients were transferred to the post-anesthesia care unit, where standard monitoring was provided and continuous ACB was performed before spinal anesthesia had worn off.A total of 300 mL (280 ml for infusion and a 20 ml bolus injection) of study solution, either 0.2% ropivacaine or normal saline, was prepared by either of the two unblinded nurses immediately after surgery.The adductor canal was identified at mid-thigh level under ultrasound guidance and an 18-gauge Pajunk needle was inserted into the canal. A 20 mL bolus of the study drug  was administered. A bolus injection of 20 mL is required to fill the canal without risking retrograde flow to the femoral triangle , 21. A 2All patients received a multimodal pain regimen postoperatively: oral acetaminophen 1000 mg and oral celecoxib 200 mg every 12 h. In addition, rescue analgesics were available with oral fast-release oxycodone ≤10 mg every 4 h or as needed. If intolerance of oral medication, the patient was given, IV morphine 2.5 mg every 1 hour or as needed.Demographic data were collected preoperatively. The preoperative maximum range of knee motion was assessed. Surgical and spinal block duration, and the length of surgical incision were also recorded. Research personnel blinded to group assignment performed all pre- and postoperative assessments and data collection.The primary end point was pain scores with active knee flexion in the operated knee at 24 h after surgery. At the time of the assessment, patients were instructed to record their pain on NRS-11 . The numPain scores using the NRS-11 and the numbers of patients with NRS>3 at 8, 12, 24, and 48 h after surgery were measured at rest and with movement. Additionally, the investigators recorded the first time point of postoperative pain at rest greater than 3 (NRS > 3), known as breakthrough pain. Opioid consumption during 0–24 h and 24–48 h postoperatively was retrieved from the electronic medical record and oral oxycodone converted to IV morphine equivalents for analysis , 24. As p < 0.05 was considered to be statistically significant.Statistical analysis was performed using IBM SPSS 20 . According to a pilot study of 12 patients receiving LIA without continuous ACB in our hospital, the mean pain score on movement at 24 h after surgery was NRS = 4.8 . This value has been reported by other, similar studies , 25. OurP > 0.05, Table Sixty patients were approached for participation in this study. Forty-six patients were finally included and randomized to the treatment group or control group. Forty-two patients completed the study and were analyzed for outcomes. Four subjects were excluded due to protocol violations Fig. . Of the P<0.001) (Table P = 0.002) (Table P < 0.05). As for the consumption of IV morphine, there was no significant difference between groups 0–24 h after surgery. However, Group RP consumed significantly less IV morphine at 24–48 h postoperatively compared to Group Con    (Table There was no difference between groups for quadriceps muscle strength assessed at different postoperative time points (05) Fig. . HoweverP = 0.617; 81% vs 75%, P = 0.437)  and compared the rates after surgery. We found the major difference of pain scores between groups occurred during movement. Similar to this study, previous studies had suggested that continuous ACB combined with single dose LIA can reduce pain scores (at rest and with movement) and opioid consumption after total knee replacement , 34. AndPatient satisfaction was assessed as “satisfied” or “unsatisfied” at 24 and 48 h postoperatively. Essving (2009) reported that pain scores at rest and with movement were acceptable for patients who underwent medial UKA with intra-articular LIA combined with perioperative oral analgesics within 24 h postoperatively . This isMotor block caused by peripheral nerve block in the lower extremities is a well-known adverse effect that compromises rehabilitation and even causes a risk of falling , 39. TheThe use of an invasive placebo may raise ethical concerns for some readers. Although it has been debated that invasive placebos are not consistent with ethical practice , 43, theAlthough there are limitations to a continuous catheter approach , 45, sucIn this study, the initial dose of ropivacaine for LIA was less than the maximal dose (225 mg) indicated by drug label , howeverThere are several limitations to this study. In order to guarantee all staff and study participants were blinded to the treatment group, we did not assess the success rate of the block. In that way, we cannot confirm that the blocks were all functioning accurately. However, Saranteas et al. has shown about 95% success rate of ACB using a similar approach . In addiThis study suggests that continuous ACB added to single-dose LIA provides sufficient pain treatment after medial UKA and promotes early ambulation. Further studies are needed to address the additional effects that ACB provides to LIA on the day of surgery with a primary focus on ambulation abilities.


Musculoskeletal (MSK) pain represents a considerable worldwide healthcare burden. This study aimed to gain consensus from practitioners who work with MSK pain patients, on the most appropriate primary care treatment options for subgroups of patients based on prognostic risk of persistent disabling pain. Agreement was sought on treatment options for the five most common MSK pain presentations: back, neck, knee, shoulder and multisite pain, across three risk subgroups: low, medium and high.n = 20) using Nominal Group Technique, a systematic approach to building consensus using structured in-person meetings of stakeholders which follows a distinct set of stages.Three consensus group meetings were conducted with multi-disciplinary groups of practitioners ; and “consider referral for surgical opinion” . “Consider referral to rheumatology” was agreed for patients at medium and high risk who have multisite pain.In addressing the current lack of robust evidence on the effectiveness of different treatment options for MSK pain, this study generated consensus from practitioners on the most appropriate primary care treatment options for MSK patients stratified according to prognostic risk. These findings can help inform future clinical decision-making and also influenced the matched treatment options in a trial of stratified primary care for MSK pain patients. Musculoskeletal (MSK) pain represents a considerable worldwide healthcare burden  and, in Current usual primary care for MSK pain in the UK commonly follows a ‘stepped, wait and see’ approach, with patients initially given low intensity and low cost treatments, moving onto higher intensity or more costly treatments if needed . An alten = 1890) [Given findings that similar prognostic factors predict outcome across different body region pain sites , the Str = 1890)  – the STThis paper reports on an expert consensus groups study, the findings of which informed the matched treatment options tested as part of the trial. The aim was to gain consensus from a range of practitioners who work with MSK pain patients on the most appropriate primary care treatment options, in a UK National Health Service (NHS) context, for patients consulting with the five pain presentations of interest across the three different risk subgroups, based on prognostic risk of persistent disabling pain. Consensus group methods are particularly useful in fields where scientific evidence is uncertain or inconclusive . The appThis study uses a consensus groups method; an approach commonly employed in the development of healthcare interventions, due principally to their capacity to ‘harness the insights of appropriate experts to enable decisions to be made’ . The conWe invited stakeholders from a range of clinical backgrounds, including general practice, physiotherapy, rheumatology, orthopaedics, clinical psychology and pain medicine . Participation in the study was entirely voluntary. Participants’ travel expenses were reimbursed, but beyond this they received no financial incentive for taking part. Written consent was obtained prior to each NGT meeting.Three NGT meetings, each focusing on one of the three patient risk subgroups , were conducted between April–May 2015. Groups were convened at Keele University. Meeting 1 focused on agreeing matched treatment options for patients at low risk of persistent disabling pain, for all five MSK pain presentations. Meetings 2 and 3 focused on matched treatment options for patients at high and medium risk, respectively.The meetings each followed the same set of stages see Fig. . First aParticipants first silently reviewed the resources provided in order to identify relevant treatment options they felt were missing from the list of UK NHS evidence based treatment options. Participants were encouraged to focus on first-line actions that could be taken by a GP, rather than treatment decisions made further along the treatment pathway, e.g. specific surgical procedures. Participants took turns to share any additional treatment options within their small group, which were noted on a flipchart by the facilitator. Once all additional ideas had been recorded, each additional treatment option generated through this initial stage (i.e. not including the existing options on the evidence-based lists) was discussed in turn within the small groups. Those that were agreed upon after discussion – in terms of their appropriateness for the given pain presentation and risk subgroup, and those available on the NHS – were added to the treatment options list. Participants then silently and anonymously rated, on a 7-point Likert scale, the appropriateness of each treatment option on the group’s list for the MSK pain presentation and risk subgroup being considered (e.g. appropriateness for patients with shoulder pain classified at low risk). The mean appropriateness score was then calculated for the group for each treatment option on the list by members of the research team. Options were then organised in rank order, i.e. the option with the highest mean ranked number 1, and so on.All participants then joined together with others for a full group discussion of the treatment options for each MSK pain presentation. The full group was presented with the list of treatment options for each pain presentation in rank order. All participants then had the opportunity to ask questions and suggest further relevant treatments they felt were missing. All suggested options were written on a flipchart and discussed in turn by the full group. Participants then voted via a show of hands as to which treatment options should be added to the final treatment option list .Using the final list, all participants silently and anonymously rated, again on a 7-point Likert scale, the appropriateness of each treatment option (for the MSK pain presentation and risk subgroup). The consensus process described above was repeated for all five MSK pain presentations and for each risk subgroup.Following the three group meetings, the mean scores were calculated across all participants for each MSK pain presentation and each risk subgroup. A list of treatment options identified for each pain presentation in each risk subgroup was compiled and sent to participants via email to consider and resolve any inconsistencies and approve the finalised list of treatment options. Through discussions within the research team, as well as considering consensus thresholds used in previous NGT studies reported in the research literature, it was decided that a mean rating of > 50% signalled an acceptable level of consensus for a treatment option to be included in the final list. This cut-off point reflected the challenge in gaining consensus from a multi-disciplinary group compared to a group from a single health professional discipline –23. Addin = 18 participants; group 2: n = 16; group 3: n = 12). Participants had a range of clinical backgrounds, with a mix of experience levels/ length of time in practice . They also came from a range of geographical areas within the UK, giving a breath of knowledge on the diversity of existing treatments available within the NHS nationally ”; “consider referral to MSK interface clinic”; “consider referral to psychosocial intervention or multidisciplinary pain management service”; “address comorbidities, distress and frailty”; “opioids”; and “consider referral to expert patient programme”. “Occupational Health/work place assessment and advice” was agreed for patients at high risk with back, knee and neck pain, respectively, but not for shoulder or multisite pain. “Atypical analgesia” reached consensus for all presentations with the exception of knee. “Corticosteroid injection” reached consensus only for knee and shoulder pain for high risk patients. “Refer for surgical opinion” was included for all presentations for high risk except for multisite pain; however, multisite pain was the only presentation for which “refer to rheumatology” was included for high risk. Two other treatment options were agreed only for one of the pain presentations and none of the others: “personalised exercise programmes” (multisite) and “refer for lifestyle intervention e.g. dietician, slimming world etc.” (knee). The full list of agreed treatment options for all five pain presentations across the three risk subgroups is displayed in Table This study generated an acceptable level of consensus  for each treatment option, as discussed further below), among a group of practitioners who work with MSK pain patients about appropriate matched treatment options for each of the five most common MSK pain presentations  according to the patient’s risk of persistent disabling pain. Seventeen treatment options in total reached our predefined level of consensus – four for patients at low risk, 10 for medium risk and 15 for high risk, with some variation observed in treatment options reaching consensus across different MSK pain presentations. It was reassuring to note that as the risk of persistent disabling pain increased, the suggested treatment options also increased in both number and intensity. This would be expected given that patients at higher risk will likely have more complex needs− either due to high pain intensity, psychological or social factors, or a combination of these− and it is therefore appropriate for GPs to have a range of treatment options to choose from depending on the individual needs of the patient, including more intensive or invasive options if necessary. The final agreed matched treatment options appear to be both clinically appropriate and in keeping with the risk profiles for each of the three risk subgroups.The agreed treatment options for patients at low risk principally involve GP-supported self-management, and do not include referral for further treatment, reflecting the aim of stratified care to avoid over-treating patients with a good prognosis . The addAs well as the treatment options agreed for low risk, medium risk included the addition of onward referral options across all five MSK pain sites: “consider referral to physiotherapy” and “consider referral to MSK interface clinic”. Including options for onward referral reflects the increased need of patients at medium risk, who may experience higher levels of pain and greater functional limitations compared to low risk patients. There was also some variation in agreed treatment options for patients with different MSK pain-site presentations who are at medium risk of poor outcome. For instance, “consider referral to psychosocial intervention or pain management service” was included for back and multisite pain, but not for the other three pain sites; this may reflect the higher prevalence of psycho-social issues associated with these pain sites, e.g. both are strongly associated with an increased risk of developing co-morbid depression , 26. OthThere was some overlap in the matched treatment options that reached consensus for patients at medium and high risk of poor outcome, although additional options were agreed for patients at high risk across all five pain presentations. Two treatment options reached consensus for all five MSK pain presentations for patients at high risk, but did not reach consensus for any of the MSK pain presentations for patients at medium risk: “opioids” and “refer to expert patient programme”. That opioids were agreed only for patients at high risk of poor outcome reflects current UK practice guidelines– primary care clinicians are encouraged to prescribe non-opioid based analgesia where possible, and only prescribe opioids for patients with high pain levels or who have an inadequate response to paracetamol and/or nonsteroidal anti-inflammatory drugs . The expThis study innovatively combined NGT with pre-elicitation techniques of patient vignettes derived from epidemiological data and supported by a rigorous review of the available best evidence  see Fig. The mulThe UK focus of the study represents both a strength and weakness. Whilst the geographical spread of participants enabled us to produce a list of recommended treatment options that is likely to have good representativeness across the UK, the applicability beyond the UK depends on treatment availability in other settings. However, the majority of treatment options that reached consensus are not UK-specific; therefore, findings can have wider applicability beyond the UK context and may be useful for informing research and practice in other settings.A limitation is that the use of a consensus group methodology resulted in the exclusion of newer or less widely used treatment options. However, as previously mentioned, we included a wide range of clinicians to avoid missing any treatment options considered to be best practice, even if not always supported by available evidence. It was not considered to be appropriate to recommend untested treatment options; these treatment options would require further research and testing. A further limitation of this study is that we did not include patient representatives in our expert groups. Whilst we recognise that expert patients would have valuable input for decisions about treatment options, it was felt that this study was specifically about clinical expertise and therefore was limited to clinician input. Extensive patient representation has been included in the broader research programme , and theA group of multi-disciplinary practitioners generated consensus about appropriate matched treatment options for risk subgroups of primary care MSK pain patients . This information informed the matched treatment options in a trial of stratified primary care for patients with MSK pain. The results can also be helpful for clinicians and patients to support greater consistency in the management of MSK pain, addressing the issue highlighted earlier that current variability in management can lead to some patients, at least initially, receiving suboptimal care including inappropriate treatment referrals. Supporting greater consistency in management can help ensure the right patient receives the right treatment at the right time.


Due to advances in hip arthroscopy, the number of surgical procedures has increased dramatically. The diagnostic challenge in patients with longstanding hip and groin pain, as well as the increasing number of hip arthroscopies, may lead to a higher number of patients referred to tertiary care for consideration for surgery. Therefore, the aims were: 1) to describe the prevalence of hip-related groin pain in patients referred to tertiary care due to longstanding hip and groin pain; and 2) to compare patient characteristics and patient-reported outcomes for patients categorized as having hip-related groin pain and those with non-hip-related groin pain.2)), results from the Hip Sports Activity Scale (HSAS), the SF-36, the Copenhagen Hip and Groin Outcome Score (HAGOS), and pain distribution (pain manikin) were collected. Parametric and non-parametric statistics were used as appropriate for between-group analysis.Eighty-one patients referred to the Department of Orthopedics at Skåne University Hospital for longstanding hip and groin pain were consecutively included and categorized into hip-related groin pain or non-hip-related groin pain using diagnostic criteria based on current best evidence . Patient characteristics (gender (%), age (years), BMI (kg/mp < 0.01), were categorized as having hip-related groin pain. The hip-related groin pain group had a higher activity level during adolescence (p = 0.013), and a higher pre-injury activity level (p = 0.034), compared to the non-hip-related groin pain group. No differences (mean difference (95% CI)) between hip-related groin pain and non-hip-related groin pain were observed for age ), BMI ), any HAGOS subscales (p ≥ 0.318), any SF-36 subscales (p ≥ 0.142) or pain distribution (p ≥ 0.201).Thirty-three (47%) patients, (30% women, 70% men, Only half of the patients referred to tertiary care for long-standing hip and groin pain, who were predominantly men with a high activity level, had hip-related groin pain. Self-reported pain localization and distribution did not differ between patients with hip-related groin pain and those with non-hip-related groin pain, and both patient groups had poor perceived general health, and hip-related symptoms and function. Hip and groin pain is a common problem among athletes participating in high-impact sports –4, and cDiagnostics is a challenge in patients with LHGP due to the probable multi-structural origin of the pain where both intra- and extra-articular lesions may be present and even coexist , 10. A rThe most common causes of hip-related groin pain are femoroacetabular impingement syndrome (FAI syndrome), chondral lesions, and labral lesions , 13. FemTreatment of hip-related groin pain involves education, modification of activity level, and exercise-based therapy, with the potential benefit of arthroscopic hip surgery , 19. DueTherefore, the aims of this cross-sectional study were: 1) to describe the prevalence of hip-related groin pain in patients referred to tertiary care; and 2) to compare patient characteristics and patient-reported outcomes between patients categorized as having hip-related groin pain and those categorized as having non-hip-related groin pain.www.strobe-statement.org).Our reporting for this exploratory cross-sectional study adheres to the STROBE statement (n = 156) to the Department of Orthopedics, Skåne University Hospital, Sweden, were consecutively recruited and screened for eligibility according to the inclusion and exclusion criteria as described in Table During October 2014 to January 2017, all patients referred for non-arthritic hip and groin pain  who was not involved in the care of the patients. The alpha angle and LCE angle were identified and analyzed in accordance with a report by Clohisy et al. . The LauThe alpha angle was calculated by drawing a line from the center of the femoral head to the center of the femoral neck. A second line was drawn from the center of the femoral head to the point where the head loses its spherical appearance antero-laterally. The angle was then calculated between these two lines and values ≥60 degrees were used as the cut-off defining a cam morphology . For fivTo calculate the LCE angle, a first line was drawn connecting the inferior part of the acetabular teardrops, and a second line was drawn perpendicular to the first and through the center of the femoral head. Finally, a third line was drawn from the center of the femoral head through the sclerotic part of the superolateral sourcil of the acetabulum. The angle between the second and third line was calculated; an LCE angle ≥40 degrees indicated the presence of a pincer morphology and an LCE angle ≤20° indicated hip dysplasia .In a preliminary analysis of the first 67 patients included in the study, excellent inter-observer agreement was observed between two raters  using our protocol for measurements of alpha angle  and LCE angle  in plain radiographs.Fifty-four patients underwent MRI examination. Records of any labral tear or chondral lesions visual on MRI were extracted from the patient’s medical record. Nineteen patients underwent arthroscopic examination and data on any findings of hip morphology , acetabular labral tear or chondral lesions from the arthroscopic examination were extracted from the patient’s medical record.All injections were performed by the senior orthopedic surgeon under fluoroscopic guidance. The intra-articular position of the needle was confirmed by injection of 1 ml of contrast agent johexol  prior to the blockage injection of a mixture containing 2 ml triamcinolon , 4 ml ropivacaine (Narop 10 mg/ml) and 4 ml lidocaine (Xulocain 10 mg/ml). The patients were asked to score pain on a VAS, from 0 (no pain) to 100  mm prior to injection, and one, two, and four hours later. During this period the patients were instructed to perform activities that would normally provoke pain in order to determine any improvement in symptoms . A decreAll patient-reported outcomes, except pain distribution, were collected using the electronic survey software SUNET ; this was made available to the patients via a link sent by e-mail prior to the clinical examination. The patients rated the perception of their pain, disability and associated problems using the disease-specific questionnaire Copenhagen Hip And Groin Outcome Score (HAGOS), which includes six subscales; pain, symptoms, activities in daily living (ADL), physical function in sport and recreation (Sports/rec), participation in physical activity (PA), and quality of life (QOL). The HAGOS has been proven as a reliable and valid tool in the assessment of LHGP in a young to middle-aged population . The scoThe patients rated their activity level during adolescence, pre-injury, and current activity level on the Hip Sports Activity Scale (HSAS), which is a valid and reliable questionnaire for assessing activity level in this patient group . To rateTo describe pain distribution, each patient completed a pain drawing on a full-body manikin, viewing the front and back separately. The patients were instructed to outline the area of their pain. The pain manikin was then divided into 9 separate areas as previously described :1) lowerThe Regional Ethical Review Board in Lund approved the study (Dnr 2014/12) and the participants provided written informed consent to participate.CI =  ± 1.96 × SE). For between-group analysis of the HSAS score, the Mann-Whitney U-test was used. Pain distribution was calculated as frequency, percent and 95% confidence interval using the formula All calculations were performed in SPSS for Windows, version 22.0 . All variables were tested for skewness. The independent t-test was used for between-group analysis of the HAGOS and the SF-36. Comparison of the HAGOS and SF-36 scores of the patients and normative data was performed by calculating the 95% confidence interval for all groups . No differences between groups were observed for any other patient characteristics (Table The mean age was 36 years and the mean BMI was 24.82 kg/mThe most common body areas with pain reported by the patients were the groin (98%) and the buttock (68%). Thirty three percent of the patients reported pain in the anterior thigh, and 23% reported low back pain. Pain was less prevalent in the posterior thigh (16%), anterior knee (10%), posterior knee (6%) and anterior lower (3%) leg. No differences were noted between the hip-related and non-hip-related groin pain groups Fig.  Table 4.Fig. 4Pp < 0.001)    3–7) and the activity level during adolescence  was higher compared to the current activity level  (01) Fig. . The gro34) Fig. . No diff34) Fig.  (Table 534) Fig. .Fig. 5AThe worst score on the HAGOS was reported for the subscale Quality of Life  1.7) and the best score was reported for the subscale Activities of Daily Living . No differences were found between the groups in any HAGOS subscale, however, compared to normative data the patients had worse score in all subscales Fig. .Fig. 7HFor SF-36, patients reported the worst score for the subscale physical role functioning  and the best score for the subscale Physical functioning . No differences were observed between the groups in any SF-36 subscale, however, compared to normative data the patients reported worse score in all subscales Fig. .Fig. 8SIn this exploratory, cross-sectional, study, 47% of the patients with LHGP referred to tertiary care, of which 70% were men, were categorized as having hip-related groin pain. All of the patient groups had a lower current activity level compared to pre-injury. Patients with hip-related groin pain had a higher activity level during adolescence, and a higher activity level pre-injury, compared to those with non-hip-related groin pain. The patients had worse patient-reported outcomes in terms of generic health and disease-specific symptoms and function compared to normative data, but no differences were noted between the patients with hip-related and those with non-hip-related groin pain. The most common pain localizations were the groin and buttock, followed by the anterior thigh and lower back, with no differences between the groups.The prevalence of approximately 50% of hip-related groin pain in our cohort is in line with a study by Larson et al. . They reIn that study , the autThe Warwick agreement provides the current best criteria for identifying hip-related groin pain and suggests that a combination of clinical symptoms, signs, and radiological findings should be used . HoweverIn the present study, more men than women were categorized as having hip-related groin pain. The prevalence of FAI morphology, especially CAM morphology, has been reported to be higher in men than women . One potThe patients in our study reported worse outcomes with significant impairments in both the HAGOS and the SF-36 compared to healthy people of the same age. The patients reported the worst score on the HAGOS subscale quality of life. Reduced quality of life has also been shown in patients 12–24 months post hip arthroscopy . PerceivThe patient reported pain distribution in our cohort, with predominantly proximal pain (groin and buttock) and pain to the anterior thigh and knee, is similar to the distribution of pain described by patients with hip osteoarthritis . The paiA strength of our study is that we consecutively included patients referred to the Orthopedic Department of a University Hospital serving a regional area (Skåne county) with a population of approximately 1.3 million residents, and the absence of any private clinics offering arthroscopic hip surgery. Therefore, the patients are likely to be representative for the clinical setting in tertiary care. However, 11 patients were not categorized due to missing data, which might have influenced the results regarding the prevalence and the comparison between the two patient groups. A limitation is that the prevalence of hip-related groin pain is not generalizable to primary care. The majority of the patients included in this study were referred to the orthopedic surgeon for assessment for hip surgery. Therefore, the probability of patients having hip-related groin pain in this group is expected to be higher compared to the population with LHGP in primary care. Another strength is that we used the current best evidence to categorize the patients as having hip-related or non-hip-related groin pain , 17. HowOnly half of the patients referred to tertiary care for long standing hip and groin pain, who were predominantly men with a high activity level, had hip-related groin pain. Self-reported pain localization and distribution did not differ between patients with hip-related groin pain and those with non-hip-related groin pain, and both patient groups worse perceived general health, and hip-related symptoms and function compared with healthy people of the same age. To further optimize treatment management for patients with LHGP, diagnostic criteria should be implemented in primary care, so that appropriate patients are referred to tertiary care. Also early optimal treatment options, especially exercise-based treatment, for all patients are needed to improve general health and improve hip-related symptoms and function.


People living with persistent pain in Australia often cannot access adequate care to manage their pain. Therefore, as the most accessible healthcare professionals, community pharmacists have an important role to play in helping to improve patient outcomes. Hence, it is important to investigate patient needs and expectations in terms of counseling interactions with pharmacists, along with pharmacists’ approach to counseling interactions with these patients.The nature of patient–pharmacist counseling interactions was explored with seven patients (one focus group), and 10 practicing pharmacists . The themes identified informed the development of an online survey that was advertised online to patients and pharmacists across Australia.A total of 95 patients and 208 pharmacists completed the survey. Overall, more than half of patients (77/95) were satisfied with the care provided by their pharmacist, but only a third (71/205) of pharmacists were satisfied with the care they provided to patients. The majority of patients (67/94) reported that pharmacists provided good information about medications. This aligned with pharmacists’ responses, as most reported focusing on medication side effects (118/188) and instructions for taking pain medication (93/183) during patient interactions. However, when asked about empathy and rapport from pharmacists, only half to two-thirds (48–61/95) of patients expressed positive views. Overall, half of the patients (39/75) wanted a caring, empathetic, respectful, and private conversation with the pharmacist, and nearly half (40/89) perceived the pharmacist's role as providing (new) information on alternative pharmacological and non-pharmacological therapies, including general advice on pain management.There was a disparity in the nature of the interaction and information that patients wanted from pharmacists, compared to what was provided by pharmacists. Training and education may help pharmacists to better engage in patient-centered care when interacting with people living with persistent pain, thereby improving health outcomes for these patients. Inadequately managed pain is strongly associated with negative health outcomes for patients. Medicines are the most common treatment offered to people with persistent pain, but instead of being the solution, they can sometimes become the problem. People who take medicine for persistent pain may experience social stigmatisation and discriminationdue to a lack of understanding about the nature of persistent pain. Pharmacists can increase understanding of persistent painand improve patient outcomes by providing health information, and supporting people by being aware of their pain management needs. This study highlighted differences between the expectations and needs of people living with persistent pain, and the pharmacists' perceptions of the care and support required. That is, patients wanted pharmacists to be empathetic, to provide information on other treatments and general advice on pain management in addition to general medicines information. However, pharmacists focused on medicine side effects and how to take the medicine. Clearly pharmacists’ perception and understanding of pain management, needs to be realigned with patients needs. Unless change occurs, pharmacists may not provide the most adequate and appropriate care to patients living with persistent pain.Persistent pain is Australia’s third most expensive health problem, costing the economy AU$48.3 billion annually.4Access to adequate care in persistent pain management is limited by the number of sufficiently trained healthcare professionals.8Persistent pain is complex, and a multimodal approach is required, including considerations around biopsychosocial factors unique to each patient.15Pain is subjective and is whatever the experiencing person says it is, existing whenever the experiencing person says it does.16Hence, when people do not fulfill the sick role, e.g., by not looking or appearing sick as per the stereotype, feelings of delegitimization and stigmatization can arise.19Pharmacists have an important role to play in supporting patients living with persistent pain, particularly where patients cannot easily access the multidisciplinary team needed to advise on the biopsychosocial aspects of pain.28Despite the patient–pharmacist counseling interaction being a fundamental role for pharmacists, it lacks recognition by physicians and patients and is often undervalued.This was a mixed-methods study conducted in two phases. The first phase consisted of focus groups and semi-structured interviews, the results of which informed the development of the second phase, which was an online survey.Ethics approval was obtained from the University of Queensland, School of Pharmacy Human Research Ethics Committee . Each participant in the focus groups/semi-structured interviews provided written informed consent, while completion and submission of the online survey was taken as implied consent.Using purposive snowball sampling recruitment, practicing pharmacists who had worked in a variety of practice settings were invited to participate through the research team’s personal contacts. Patients living with persistent pain were invited to participate through Chronic Pain Australia (CPA) and the Australian Pain Management Association (APMA). Immediately before each focus group/semi-structured interview, participants were asked to complete a short survey. The survey captured demographic information, and contained questions similar to the seeding questions used in the focus group/semi-structured interviews in the form of a five-point Likert scale with the anchors “strongly agree” to “strongly disagree”. These questions were to encourage responses that might be lost under the pressure of discussion with peers. Seeding questions  were used in the focus group/semi-structured interviews to facilitate discussion, maintain consistency, and reduce potential for interviewer bias. The focus groups and interviews were audio-recorded and transcribed verbatim.Patients' and pharmacists' perceptions and expectations of their interaction with each otherThe role of a pharmacist in providing care for people living with persistent painBarriers and facilitators to pharmacists providing careThe surveys were tailored to the pharmacist and patient respondent groups. The themes identified from the focus groups/semi-structured interviews were collated and used to develop the survey about the patient–pharmacist counseling interactions, in particular:Demographic information was also collected, together with background data pertaining to the counseling provided by pharmacists. A combination of multiple-choice questions and five-point Likert scales with anchors “strongly disagree” to “strongly agree” was used. Respondents were also invited to share their views and opinions on how the counseling interaction between pharmacists and patients could be improved, in free-text open-ended questions. Surveys were piloted on a group of pharmacists for readability and understanding.A link to the online version of the survey for patients with persistent pain was placed on the CPA website and emailed to APMA members, while a link to the survey for pharmacists was included in the Pharmaceutical Society of Australia e-bulletin, which was emailed to members nationwide.The background and demographic information collected from the survey prior to the focus groups/semi-structured interviews was analysed using descriptive statistics . Transcripts from the focus groups/semi-structured interviews were manually coded and thematically analyzed to identify emergent themes.Cronbach’s alpha coefficient was used to evaluate the internal consistency reliability of the five-point Likert scales. The alpha values for the pharmacist and patient groups were calculated separately using SPSS 21.0 software , with nine and 10 questions included in the calculation, respectively. The five-point Likert scale was collapsed into a three-point scale: agree/positive , impartial/neutral, and disagree/negative responses , to analyze the respondents’ level of agreement with the statements for reporting purposes. The remainder of the questions were analyzed using descriptive statistics , while the responses to the free-text open-ended questions were manually coded and analyzed to identify emergent themes. Some pharmacists and patients did not answer all questions, so the response for each question was calculated based on the actual number of respondents.All seven patients with persistent pain took part in one focus group. The pain types reported were: persistent postoperative pain (2/7), persistent pain following multiple fractures (1/7), neuropathic pain (1/7), complex regional pain syndrome (1/7), and unknown or undiagnosed pain (2/7). Most of the people with persistent pain were female (5/7), aged 50–90 years (median 56 years), and had experienced persistent pain for 4–29 years (median 9 years).Almost all patients would speak to their doctor if they had concerns about their pain or pain medications, (6/7), followed by the pharmacist (4/7), physiotherapist (2/7), support group members (1/7), and family members (1/7). Similarly, when seeking information about pain or medications, they would obtain information from their doctors (7/7), pharmacists (6/7), the internet (2/7), and their physiotherapists (1/7). Almost all of the patient participants (6/7) were comfortable talking about their condition and medications with a pharmacist, were confident about managing their medications after listening to the pharmacist, and felt that the pharmacist understood when they spoke about their condition. The remaining participant expressed an impartial or neutral view.In the pre-focus group/semi-structured interview survey, when starting a new medication, the majority of the patients reported that pharmacists spent 1–5 minutes (4/7) speaking to them about new pain medication, which then reduced to <1 minute (5/6) with repeat medications. Patients wanted and expected pharmacists to help with medicines information, e.g., how to use the medicine, side effects, and contraindications. They also expected the opportunity to have questions about their pain and medicines answered, and to be followed up if any changes in their care occurred. A holistic and patient-centered approach to pain management was also wanted, i.e., incorporating non-pharmacological treatment options, the ability to discuss issues in private counseling areas, and to be believed when they spoke about side effects.“I think one of the biggest problems is they [the pharmacist] don’t listen [to the person with the pain]. It was a matter of they know more because they’ve been educated, but that’s my body, I know more.”“He [the pharmacist] takes a lot of time with people and I guess I do feel like I can ask him questions, whether they are silly questions or not, if it is something a bit concerning, I know I can ask him.”In terms of the overall experience and interactions with the pharmacist, patients reported different experiences. While some noted negative interactions with their pharmacist, others were comfortable about approaching their pharmacist with questions.“… pharmacists are the medication experts and so … that’s who I expect to be able to go to if I’ve medication sort of questions.”Similar themes were generated during the focus group discussions, in that patients perceived the role of the pharmacist to be the medicines expert, and relied on them to help with answering questions about medicines.“Pharmacists have to be careful too when just pushing paper out to patients. It’s very easy to just print them out and shove them to the patients.”“I had to change one medication that I was on and he [the pharmacist] printed out all the stuff from the pharmaceutical company. He monitored what I was getting … and made sure I understood too.”Some patients also indicated that the pharmacist was a valuable source of information for understanding about, and management of, their pain condition. However, it was evident that the manner in which this information was presented, collated, and explained was extremely important in terms of patient receptivity and rapport building.“I don’t think I was aware that pharmacists know more about medications than the doctors so I think that’s something the pharmacists should let the community be aware of. Promote it.”Other recommendations suggested by patients in terms of the role that pharmacists could play in the management of persistent pain were to increase awareness and understanding of persistent pain and its management, and to promote how pharmacists could help with medicines.Two focus groups  and three semi-structured interviews were conducted with the pharmacists. Most of the pharmacists were females (9/10), aged 25–60 years of age (median 0 years), and had practiced as pharmacists for 2–40 years (median 10 years), with many working across several fields of practice in community pharmacy (n=7), hospital pharmacy (n=5), research (n=4), academia (n=2), and government (n=1).In the pre-focus group survey, most pharmacists indicated that they spent 5–10 minutes speaking about new pain medications (4/9) and 1–5 minutes on repeat medications (7/10). Most participants believed that their role was to provide information on medication (9/10), advise on side effects and their management (7/10), review pain control (5/10), and provide treatment alternatives (2/10). Some other less common responses were providing reassurance, detecting drug interactions, and providing the consumer medicines information leaflet. All of the pharmacist participants were comfortable and confident about counseling people with persistent pain, but many (7/10) were hesitant about dispensing large amounts of opioids to patients with persistent pain, and the remainder held an impartial or neutral viewpoint. The majority were also comfortable listening to patients talk about their pain and medications (9/10), with 1/10 expressing an impartial or neutral opinion. Similarly, 9/10 believed that every persistent pain patient is unique, with one respondent disagreeing with that view.“So a patient’s or a customer’s perception of what value are they gonna get from that interaction. So if they assume they are not gonna get, so “Look, I go to my specialist for help with my pain, what do you know?” And maybe it’s from past experience that they haven’t really got appropriate advice or condescending, or restricted supply without really knowing why.”“… even if you ask open-ended questions, they give you closed answers like “yes” and “no”, then it’s very difficult to take the conversation any further. If they are receptive, then you can go further into it.”Similarly to the patient respondents, some pharmacists described positive interactions with patients, while others found patients to be defensive and non-receptive.“I actually did find most of them are quite a unique group of people in that they get on internet and find information about their drugs, what’s available for them, what they can have and that sort of stuff.”“The number of patients who are confused or have misunderstanding about paracetamol and its many other preparations and the role of paracetamol continues to astonish me. That is something simple that you can do.”Pharmacists also noted differences in patient health literacy and self-efficacy to manage their pain and pain medications, which would then influence what pharmacists perceived their role to be in providing care and information for patients with persistent pain.“I don’t think I ever give the poor little old lady with arthritis sufficient empathy because I hadn’t experienced it, I couldn’t appreciate it so perhaps we really need to train young pharmacists in the school, about pain but then, at that age, are we really being receptive?”“… they [persistent pain patients] will say “They just think I’m drug addict, they just think I’m drug seeking or seeking opioids, they don’t realize I’m in pain.” So there is still this stigma associated with being on opioids in the community …”Some respondents recognized that many pharmacists lacked empathy when interacting with patients with persistent pain, and the potential/perceived stigma that these patients faced when doubted about the genuineness of their pain condition.“Those short interactions could definitely be improved unbelievably so especially with the referral to other healthcare providers whether to a multidisciplinary pain clinic or having a bit more understanding of what their conditions are.”“You have that knowledge … but it is the way you delivering that actually gives any benefit to the patient.”“And time constraints, in the community pharmacy, if you’re the only pharmacist and they don’t have enough technicians to help you … and there’s no way I can really have a good conversation with them, absolutely not.”Pharmacists' recommendations on optimizing interactions with patients living with persistent pain included more education and specialized training for pharmacists; ability to make referrals; building empathy, relationships, and rapport with patients; and ensuring adequate resources to allow meaningful interactions.A total of 208 pharmacists and 95 people with persistent pain completed the survey. Survey responses were reliable in both the pharmacist and patient surveys . The majority (79/93) of the patient respondents were female, with just over half (50/95) aged between 41 and 60 years (median age range =41–50 years). Approximately half of the people with persistent pain (43/84) had lived with persistent pain for 1–10 years, with the median being 6–10 years . The ageAll patients spoke to their doctor  about concerns with their pain or medications, of whom approximately half (45/95) would speak to a pharmacist in combination with their doctor. However, none would speak to the pharmacist only, and 20/95 would seek information from other sources. These included combinations of complementary and alternative medications or therapies, eg, traditional Chinese medicines; massage therapists; allied health professionals, including physiotherapists and psychologists; pain clinics; and the internet or telephone help lines.In terms of seeking information about their pain or medications, the most popular source of information was the doctor  (81/95), followed by the internet (65/95), then the pharmacist (59/65). Overall, 19/95 of patients sought information from “other” sources, these being allied health professionals, support groups, complementary and alternative therapists, books, patient medicines information leaflets, and the National Prescribing Service’s Medicine hotline.Almost all patient respondents (89/95) agreed that pharmacists knew a lot about medications . The majThe majority of pharmacists were comfortable listening to people speak about their pain condition (179/206), and were comfortable and confident about providing counseling to patients with persistent pain (164–176/207) . HoweverPatients were most frequently concerned about side effects from their medications (33/89), which is what pharmacists thought they focused on during their interactions (118/188) . HoweverThe general consensus between patients and pharmacists was that between 1 and 5 minutes were spent talking about new pain medications . HoweverThe most common barrier identified by pharmacists was that patients harbored negative feelings and were defensive or non-receptive to interactions, and the strategy offered to overcome this was to build rapport, communicate, and show empathy for patients . A littlOverall, patients indicated that pharmacists could improve in their interactions with patients. Patients generally held positive views about the medication information provided by pharmacists, but were less satisfied with the empathy and rapport aspect of the interaction . Therefo35The pharmacist survey responses suggest a gap in knowledge, since almost half of the pharmacist respondents believed that all patients with persistent pain had similar issues . PersistPatients and pharmacists held different views about the pharmacist's role in assisting people with persistent pain. There were also differences between the perceptions of patients and pharmacists in terms of what was discussed during a typical interaction. While pharmacists thought they were focusing on medication side effects, which was what most patients were concerned about, what patients took away from the interaction was general medicines information, including instructions on how to take the medication. Similarly, patients thought that a pharmacist could help with their pain management by providing information about a holistic approach to pain management, particularly new information about pharmacological and non-pharmacological options, and emphasized wanting sufficient time and empathy from the pharmacist .Not unexpectedly, much of what patients wanted was relevant and personalized information regarding their medications.31As well as differing perspectives on the contents and nature of the interaction, there were apparent differences between the amounts of time perceived to be spent during the counseling interactions . Pharmac37This breakdown in communication could contribute to the lack of satisfaction with care given and received by pharmacists and patients, respectively, and also contribute to an increased burden of persistent pain for individuals.40The most common barriers identified by pharmacists were patients’ negative feelings, defensiveness, and non-receptivity to interactions. This is akin to the dissatisfaction voiced by patients with regard to the lack of empathy and rapport encountered during their interactions with pharmacists. It is well documented that fear of being stigmatized for taking opioids, concerns around pain management, and fear of addiction can cause patients to become defensive and unreceptive to pharmacist counseling.41The most commonly identified facilitator was therefore to build rapport, communicate, and show empathy for patients, as preconceived beliefs and previous experiences can become barriers to effective pharmacist counseling.31Pharmacists reported a lack of time and privacy as another major barrier to counseling. Many pharmacists did not have enough time to spend with patients, and patients also reported that they typically had little or no interaction with the pharmacist. Despite this lack of time and interaction, the majority of pharmacists did not want other pharmacy staff (who were not pharmacists) to provide counseling for patients with persistent pain, suggesting that pharmacists had some awareness of the complexities associated with the management of persistent pain. Therefore, in addition to increasing the knowledge of healthcare professionals, adequate resourcing is required to ensure that appropriately trained staff are able to spend sufficient time to have meaningful counseling interactions with patients living with persistent pain.The main limitation of this study is the small sample size, which was related to the channels available to be used for recruitment at the time of the study. Similarly, a sampling bias could have occurred as only interested participants would have voluntarily completed in the survey, and it was not possible to ensure or verify the identity of the respondents. Also, while these data were originally collected in 2011, and only Australian patients and pharmacists were invited to participate, it is unfortunate that the findings are still relevant and are still issues that have yet to be addressed for patients.In highlighting the gaps between expectations and needs of patients with persistent pain, and the approach and focus of pharmacists’ attention, it is apparent that a realignment in the understanding of persistent pain is required. Pharmacists focus on the provision of medication information, while patients with persistent pain would like information on other treatments and general advice on pain management. Inadequate knowledge by pharmacists with regard to persistent pain leads to pharmacists’ low level of confidence in counseling patients and a perceived lack of empathy from patients with persistent pain. Further education and training for pharmacists may help to improve their care and management of these patients. Similarly, empathy and patient-centered care need to be incorporated into pharmacists’ interactions with patients with persistent pain, in order to build rapport and trust relationships with patients and improve patient outcomes.Focus group seeding questions/interview guideCan you tell me about your chronic pain? How is your pain managed?How do health professionals help you with your pain and medications?In terms of your medicines, what do you need help with?Who do you usually go to for help or information? Why?Tell me about what happens when you go to a pharmacy. Does the service differ from one pharmacy to the other?What do you think about the interaction that you experienced before? What do you think was good about it? Is there anything else that you think the pharmacist can help you with?Patients living with persistent pain:Can you describe a typical counselling session you’ve had with a chronic/persistent pain patient? ie, environment, duration, contentCan you describe the nature of your relationships with patients with chronic/persistent pain?How do you think you can contribute to chronic pain patients’ management of their condition? How often do you do this? How well is it accepted by the patients?What do you usually focus on when counselling a chronic/persistent pain patient? Are there any issues about counselling chronic pain patients that you encounter/are worried about? ie, communication (level of understanding), dependence issue, authenticity of prescriptions, need for opioids, time constraint, etcIs there any improvement or change that you think will be useful in optimising a counselling session (with a chronic/persistent pain patient)?Community pharmacists:


However, we found that there were 29.4% and 24.6% successful responders with moderate and severe foraminal stenosis, respectively. Attempting balloon neuroplasty in refractory lumbar foraminal stenosis, especially mild grade, may be worthwhile.Epidural neuroplasty, often called percutaneous epidural adhesiolysis, is often performed in refractory patients with chronic lumbar radiculopathy or neurogenic claudication. Recent studies have showed that decompressive adhesiolysis with an inflatable balloon catheter  is efficient in patients who experience refractory pain from epidural steroid injection or even epidural neuroplasty with a balloon-less catheter. However, exact indications or predictive factors for epidural balloon neuroplasty have not been fully evaluated. Therefore, to assess associated factors that could affect a favorable outcome, we analyzed a prospectively collected multicenter cohort of patients with chronic refractory lumbar foraminal stenosis after balloon neuroplasty. At the 6-month point in follow-up, 92 (44.4%) patients among 207 subjects were classified as successful responders according to a robust combination of outcome measures. Multivariate logistic regression analysis also showed that mild grade lumbar foraminal stenosis may be an independent factor associated with a successful response 6 months after balloon neuroplasty (odds ratio = 2.829; 95% confidence interval = 1.351–5.923;  Epidural steroid injections are suggested to provide short-term symptom relief in patients with lumbar radiculopathy or neurogenic claudication, but benefits are not seen in all patients or are still inconsistent ,2. HowevHowever, exact indications or predictive factors for epidural balloon neuroplasty have not been fully evaluated. Therefore, we aimed to assess associated factors and preprocedural findings that could affect the outcome of decompressive adhesiolysis and neuroplasty with an inflatable balloon catheter procedure in spinal stenosis patients with chronic refractory pain.We analyzed a prospectively collected multicenter cohort to evaluate associated factors with successful outcome after epidural balloon neuroplasty . Data waBetween July 2015 and April 2018, a total of 317 patients with chronic lumbar foraminal spinal stenosis, aged 20 years or older, suffering from intractable lumbar radicular leg pain and/or lower back pain for more than 3 months were examined to ascertain their eligibility. A comprehensive assessment of medical history and a physical examination were done on every patient to exclude confounding disease as another cause of pain. To ascertain the diagnosis of spinal stenosis and determine the grade or level of spinal stenosis, lumbar magnetic resonance imaging (MRI) was performed on all patients. The degree of lumbar foraminal stenosis was analyzed based on MRI findings, as described in a previous study . In brieWe analyzed data from patients who underwent the ballooning decompressive adhesiolysis procedure in the stenotic foramina and retrodiscal area of the lumbar spine by the methods described below.The inclusion criteria were as follows: patients who had been diagnosed with foraminal stenosis from lumbar MRI with a related chronic (more than 3 months) lumbar radicular pain, with or without lower back pain; those who were refractory to conservative treatment; and those who had failure of interlaminar epidural steroid injection or transforaminal epidural block (less than 50% pain improvement or lasting less than one month) are enrolled in this study.The exclusion criteria were as follows: patient refusal to participate in this study, age less than 20 years old, axial pain such as in lumbar facet syndrome or myofascial pain syndrome, previous steroid injection within 12 weeks prior, progressive neurological deficits or motor weakness, uncontrollable or unstable opioid use, previous side effects to steroids, coagulopathy, signs of infection, pregnancy or nursing, allergy to local anesthetics or contrast dye solutions, history of previous spine operation, or an unstable medical or psychiatric condition.®, JUVENUI, Seoul, Korea) was advanced via the guide needle to the filling defects or pathologic featured area determined based on MRI findings and comprehensive assessment of symptoms before the procedure. The planned sites were confirmed to be symptom-related filling defects by epidurogram and were targeted by mechanical adhesiolysis and balloon decompression via catheterization using the ZiNeu catheter. The epidural adhesiolysis and balloon decompression were performed via side-to-side positioning of the catheter with intermittent balloon inflating  was injected under the skin and soft tissue. A 10-gauge guide needle, specially designed for preventing various types of potential damage by a catheter during catheter manipulation, was advanced through the sacral hiatus. The guide needle was gently introduced via the sacral hiatus under fluoroscopic image guidance. Consequently, about 8 mL of diluted contrast medium  was injected using the guide needle. The diluted contrast medium was prepared by mixing 4 mL of pure contrast medium and 4 mL of 1% lidocaine. If intravascular injection was detected, the needle was repositioned. After suitable identification via an epidurogram of the target areas, a catheter , and medication quantification scale (MQS) were obtained for analysis. The outcome evaluation was performed 6 months after the procedure. All participants were instructed and evaluated using the following scales: an 11-point numerical rating scale from 0 (no pain) to 10 (worst possible pain) to determine the intensity of both leg and lower back pain; the Korean version of the 10-item ODI questionnaire  to determine physical functional status; and the Beck depression inventory to assess emotional status. The MQS III was also measured to assess changes in the usage of medication . The gloWe define a responder group according to previous studies ,11, witht-test or the Mann–Whitney U-test and were documented as means with standard deviations or medians with interquartile ranges as appropriate. Categorical demographic data were compared using a chi-square test or a Fisher’s exact test. By using univariate and multivariate regression, the factors associated with a successful response 6 months after adhesiolysis with an inflatable balloon catheter were analyzed. The most relevant factors associated with successful responses were included in the univariate logistic regression analysis. The inclusion of variables in the final multivariate logistic regression analysis to evaluate independent factors associated with successful responses was based on biological plausibility, clinical importance, and statistical considerations. The quality of fit of the model was assessed with the Hosmer-Lemeshow test. A two-tailed p-value < 0.05 was considered to indicate a statistically significant difference. The data were analyzed by using the Statistical Package for the Social Sciences Version 21.0 .Continuous demographic data from the non-responders and successful responders were compared by using the Student’s n = 28), central stenosis without radiating pain (n = 71), and procedure failure (n = 11). Finally, 207 subjects were enrolled in analysis. Six months into follow-up, 115 (55.6%) patients were classified into the non-responder group and 92 (44.4%) patients were classified into the responder group according to the definition described above . We found three statistically meaningful factors: age (p = 0.078), mild foraminal stenosis grade (p = 0.003), and ODI (p = 0.003). After adjusting demographic differences for multivariate regression analysis, the association between mild grade foraminal stenosis and the responder group showed a statistically significant (p = 0.006) association (p = 0.006) (The demographic characteristics of non-responders and responders are summarized in ociation . The ass= 0.006) . CumulatSeveral studies have reported on the effectiveness and clinical outcomes of percutaneous decompressive adhesiolysis with an inflatable balloon catheter in patients with refractory lumbar spinal stenosis ,10,11,16Previously, various studies have reported certain factors associated with the effectiveness of percutaneous epidural adhesiolysis. Patients with conditions including spondylolisthesis, previous lumbar spinal surgery, and foraminal stenosis may be expected to have a lower probability in reaching satisfactory outcomes with percutaneous epidural neuroplasty with a balloon-less catheter ,17. In pThis study has some limitations. Firstly, we did not evaluate neurogenic claudication, which is a representative symptom of lumbar foraminal spinal stenosis . It has Attempting percutaneous decompressive adhesiolysis using an inflatable balloon catheter in refractory lumbar foraminal stenosis regardless of severity may be worthwhile. Particularly, mild grade lumbar foraminal stenosis seen in MRI may be a favorable independent factor associated with a successful outcome after percutaneous balloon neuroplasty.