In our study, none of the evaluated regional blocks demonstrated an advantage over the other regarding acute postoperative pain management.Acute pain intensity related to cesarean section (CS) may be extensive and is often underestimated. This may influence mothers’ quality of life and their children’s development. Regional analgesia techniques that include transversus abdominis plane block (TAPB) and quadratus lumborum block (QLB) have proven their efficacy in the postoperative period after CS. Although several randomized controlled studies and one meta-analysis have investigated the utility of TAPB and QLB in the reduction of acute and chronic pain after CS, only one study directly compared both types of regional blocks and revealed superiority of QLB over TAPB. Our study aimed to reevaluate the effectiveness of transversus TAPB and QLB in controlling acute postoperative pain after CS. We recruited 197 women with singleton pregnancies undergoing CS under spinal anesthesia. The patients were randomized to receive either TAPB or QLB after CS. The acute postoperative pain was evaluated using the visual analog scale (VAS) at 2, 4, 8, 12 and 24 h after the operation. No significant difference in acute postoperative pain intensity between the groups was found. The patients who received TAPB had a higher demand for supplemental morphine injections ( The number of the cesarean deliveries has almost doubled between 2000 and 2015 . The autMoreover, Marcus et al. revealed that 63% of German parturients did not receive opioids in the postoperative period . SeveralThe effectiveness of transversus abdominis plane block (TAPB) has been demonstrated as a part of multimodal analgesia after cesarean delivery; however, its action may be limited to somatic pain and apparently only when intrathecal morphine is not administered . Rafael Our study aimed to reassess the effectiveness of TAPB and QLB in acute postoperative pain management after cesarean section.This prospective randomized single-blind trial was conducted in a tertiary obstetric department. The study protocol was approved (permit number KE-0254/85/2016) by the local bioethics committee of Medical University of Lublin, in Lublin, Poland (Prof. Olajossy), and was registered at ClinicalTrials.gov (NCT02804126). Informed, written consent was obtained from every patient, and the study methods were in line with the tenets of the Declaration of Helsinki for medical research involving human subjects.We included pregnant females (singleton pregnancy) older than 18 years who were scheduled for cesarean section under single-shot spinal anesthesia.We excluded patients with coagulopathy, allergies to local anesthetics, depression, antidepressant drug therapy, epilepsy, chronic painkiller use before surgery, addiction to alcohol or recreational drugs or gestational age below 36 weeks.All the patients received single-shot spinal anesthesia with a 0.5% solution of hyperbaric bupivacaine. The patients received spinal injections from 2.0 to 3.0 mL of local anesthetic to reach a sufficient level of the blockade (T4–T6). Only individuals with an appropriate level of anesthesia could be randomized. At the end of the procedure, the participants were randomly allocated into one of the study arms : TAPB or QLB, for ultrasound-guided regional blockade . The teaWe chose the second type of QLB as described by Blanco . HoweverThe block was administered bilaterally with a 0.25% solution of bupivacaine . Every block was performed in the operating theater before the transfer of patients to the ward.Postoperative pain intensity was measured using the visual analog scale (VAS) at the 2nd, 4th, 8th, 12th and 24th hour after the patients’ referral to the postoperative care unit. VAS forms were collected by midwives who were not aware of the block type. The standard postoperative pain management included two of four intravenously administered drugs: paracetamol, ketoprofen, diclofenac and tramadol. Each painkiller was administered at the scheduled time point. In the case of severe pain (more than 40 mm on VAS), up to two dosages of subcutaneous (s.c.) morphine (5 mg) were administered based on a midwife’s discretion.t-test were used to analyze parametric data. Tukey’s honest significant difference test was used for post-hoc analysis. The results obtained using the VAS were presented as means and confidence intervals (CI). The statistics for nonparametric data were calculated using the Mann–Whitney U test or the Kruskal–Wallis test by ranks and were presented as medians and interquartile ranges. Fisher’s exact test was used to analyze the contingency tables. All the measurements were performed using Statistica 12.5 software .Analysis of variance (ANOVA) and Student’s Our sample size was calculated based on the results obtained by Blanco et al., where the use of two regional blocks in alleviating acute postoperative pain was compared . BecauseThe primary outcome of our study was to evaluate pain severity in patients after QLB and TAPB at the 2nd, 4th, 8th, 12th and 24th hour. The secondary outcomes included the consumption of antinociceptive drugs during the first postoperative day and the correlation between pain intensity and indications for the cesarean section.The study was conducted from June 2017 to February 2018. The CONSORT flowchart is presented in No difference in pain severity was found on the first postoperative day between the study groups. The VAS results are presented in p = 0.039).No statistical significance was found in the total postoperative analgesic consumption between the study groups . HoweverThe postoperative pain severity was not affected by the indication for cesarean section , Table 5The primary goal of our study was to compare two techniques of regional anesthesia, TAPB and QLB, in their effectiveness in postoperative pain management in obstetric patients. However, we did not find a difference between the methods according to the primary outcome of our study. Moreover, no difference was found in the total postoperative analgesic consumption between the TAPB and QLB groups. The only significant difference demonstrated in our study was associated with a higher number of TAPB patients who received s.c. morphine in the postoperative period in comparison to QLB.The number of techniques available to enhance postoperative pain control in puerperal patients is limited . The preTo our knowledge, only one randomized controlled trial involved the difference between the TAPB and QLB blocks in the management of acute postoperative pain . In the Although a statistical difference was found in the number of patients who received morphine, the total dose of opioids used did not differ between the groups. We suggest that this result was caused by the manner morphine was administered in the study and could be incidental. A subcutaneous route of morphine administration is controversial if other less invasive approaches, such as an oral route, are available. However, this manner was preferred by personnel of the maternity ward. The other explanation for higher morphine expenditures in the TAPB group could be a slightly lower consumption of tramadol among these patients in comparison to individuals after QLB .The total expenditure of intravenous opioids administered by a PCA pump is one of the best options to compare different analgesic technique. PCA possesses advantages, for example, in measuring the precise expenditure of opioids over time, drawing the drug–response curve and having excellent control of pain. However, as patients need to be immobilized by their connection to the pump, which is not coherent with the ERAS (enhanced recovery after surgery) protocol implemented in our Obstetric Department for elective cesarean sections, PCA was not used in our study . WithoutThe main limitation of our study was the lack of a control group without any postoperative analgesic block. We did not add any opioid through the spine, which could have affected pain severity after the procedure. We did not test the spinal block area with the pinprick technique. The other drawback of our trial was associated with the route of administration of morphine and the lack of patient-controlled analgesia techniques, which could enable a better comparison with other randomized controlled trials.In our study, none of the evaluated regional blocks demonstrated an advantage over the other in regard to acute postoperative pain management.


TM (Self-Controlled Electro Neuro Adaptative Regulation) in patients experiencing low back and neck pain. Sixty patients were included and equally assigned by randomization to a Scenar-On group and to a Scenar-Off group (sham group). All patients received a 20 min application of ScenarTM on the area where they experienced pain. The pain at rest and during movement and the sensation of stiffness were assessed using a numeric rating scale at baseline, immediately after the session and 24 h after the session. The patients’ characteristics at entry were similar between groups. The pain at rest decreased after the session in both groups (from 8 (4) to 5.0 (3) in the Scenar-Off group, p = 0.0001, and from 7 (3) to 4 (4) in the Scenar-On group, p < 0.0001). The difference was not statistically significant for the groups (p = 0.22). Similar results were observed during movement, but the sensation of stiffness was not modified. Such beneficial results did not last until the next day. No undesirable major effects were noticed. Our study does not support the fact that one ScenarTM session improves low back and neck pain better than a sham session.We aimed to demonstrate the antalgic effectiveness of Scenar The treatment of chronic pain is a major public health issue . The relTM) device was developed by Soviet space program teams in the 1970s for reducing pain. It has been authorized by many regulatory authorities including the European Community in 2006 and the FDA in 2010. This electrotherapy device, which has some features close to a Transcutaneous Electrical Nerve Stimulator (TENS), is applied to the skin on an area of pain. Despite the lack of high-level publications, ScenarTM is supposed to work similar to TENS by activating the descending pain modulation pathway and the gate control system and by liberating endorphins and endocannabinoids. Furthermore, the regular sliding of ScenarTM can cause redness and a sensation of “stickiness” of the instrument in areas of pain or in trigger areas. These areas, which seem to be the sites of cellulalgia, are the areas where ScenarTM should be applied successively for short periods of time using an individually dosed mode. In this mode, ScenarTM, which incorporates a feedback system, can measure the patient’s individual response to the electrostimulation and accordingly modify the upcoming impulses. ScenarTM also has a mode of operation that causes a contraction of visceral smooth muscles, striated muscles and vessel walls, which could be responsible for a local anti-inflammatory effect, improvement of tissue oxygenation and restoration of muscle functions. Power, frequency and mode of impulsion can be set to induce different clinical effects. For example, the frequency varies between 15 and 340 Hz and it allows for stimulation that is more or less deep, but the standard frequency is around 90 Hz.The Self-Controlled Electro Neuro Adaptive Regulation , in Switzerland (https://scenar.ch/ Accessed date: 21 July 2021) and in the European Community (http://ritm-europe.eu/ Accessed date: 21 July 2021). This explains why this device, or devices similar to this technology, is used by doctors, physiotherapists, osteopaths and sports trainers and directly by patients. Although these sites are assessed in a considerable number of publications, there have been few studies carried out with an accurate methodology on its effectiveness [Scenartiveness ,4,5,6,7.TM to treat pain, the aim of the present study was to evaluate the efficacy of a single application of ScenarTM to decrease pain in patients suffering from neck or low back pain, since it appeared difficult to propose 5 to 10 sham sessions of ScenarTM to patients. To the best of our knowledge, this type of study has never been performed.Although low back pain and neck pain have a major impact on health and social systems , only twThis single-center, two-arm, parallel-group, randomized controlled superiority study was approved on September 10, 2018 by the Ethical Committee France Est II under the number 18/588, and patient enrolment was previously registered at ClinicalTrials.gov . Patients were included in the study after they gave their informed written consent. The study took place in a nonprofit tertiary care hospital. The authors adhered to the relevant reporting elements of the CONSORT statement .TM impossible ; and low back or neck pain related to inflammatory, traumatic, oncologic, infectious or neurologic pathologies. Patients were not included if they had already had a ScenarTM session. Patients, both male and female, aged between 18 and 80 years referred to a pain clinic for common acute or chronic low back pain or neck pain were included in the study. Neck pain also included cervicobrachial neuralgia, and low back pain also included lumbar radiculalgia. The excluded patients had the following characteristics: pregnant or breast-feeding; pacemakers or defibrillators; skin conditions making the use of ScenarThe procedure used to allocate patients to the Scenar-On group or to the Scenar-Off group, which was the sham group, was managed by the sponsor (Direction of the research unit). A random allocation sequence, with a 1:1 ratio and blocks of 10, was generated using the site “Randomization.org”. Each patient received a unique patient number and a randomization number (patient code). For each subsequent patient, the investigator connected to a dedicated website using a protected password just after inclusion in the study. This system allocated the patients into groups.Each session lasted 20 min. A video recording, provided as In the treatment group, the session was conducted according to the manufacturer’s recommendations and protocol. The power level of the device was set according to the patient’s sensations for the patient to remain comfortable during the whole procedure. During the first part of the treatment, the frequency was set at 90 Hz and the therapist gently moved the device regularly and with a slight compression on the areas described as painful by the patient. During this part, specific signs such as redness or pallor of the skin, sensation of stickiness of the device or an exacerbated pain usually appeared. During the second part of the treatment, the device was applied for about 30 to 120 s successively on the area where specific signs had been individualized after the sliding. In this mode, a beep signaled the completion of each treatment, and the device was positioned in an adjacent zone until all the areas had been treated.In the control group, the procedure was identical, but the device stayed in the off position. Prior to commencement of the session, all participants were advised that they might not feel the electrotherapy during the trial, therefore minimizing any perception of a treatment occurring or not. Thus, in this single blinded study, patients were unaware if they had received sliding and successive application of the device plus electrotherapy (Scenar-On group), or sliding and successive application of the device alone (Scenar-Off group).The full trial protocol can be obtained from the corresponding author upon request.Clinical history was obtained from all individual participants included in the study and included demographic data, duration of pain, drugs and other treatments. Anxiety was evaluated using an 11-point numeric rating scale (NRS) from 0 (no anxiety) to 10 (maximum imaginable anxiety).The intensity of self-reported pain at rest and at movement was measured using an 11-point numeric rating scale (NRS) from 0 (no pain) to 10 (maximum imaginable pain). The evaluation of stiffness of the neck or low back was assessed using an 11-point numeric rating scale (NRS) from 0 (no stiffness) to 10 (maximum imaginable stiffness). All evaluation data were collected by a professional unaware of the treatment allocation. These evaluations were obtained before the session, just after the session during a brief face-to-face interview and through a telephone call 24 h after the session. The patients were questioned about possible adverse effects just after the session and 24 h after the session. At the end of the study, the person in charge of the phone call was able to differentiation between the randomization, and a real session of electro-neuro-stimulation was proposed to the sham group. TM session. The secondary outcomes included pain intensity at rest 24 h after the session, pain intensity during movement and sensation of stiffness just after the session and 24 h after, and adverse effects.The main outcome of this study was pain intensity at rest just after a ScenarTM application, the number of patients to be included was calculated at 30 per group, taking into consideration an average pain improvement of 33%  with a standard deviation of 2), a bilateral risk α of 0.05 and a power (1–β) of 0.8.The analysis of our database allowed us to consider that the average pain score of patients suffering from back pain is 6 ± 2 (SD). Given the poor knowledge of the evolution of pain after ScenarAll statistical analyses were performed on an intention-to-treat basis.t-test, while the other variables were presented as median (interquartile range) and compared between groups using the Mann–Whitney test.Categorical variables are presented as numbers (proportion) and compared between groups using a chi-square test or a Fisher’s exact test as appropriate. The distribution of continuous variables was assessed using the Shapiro–Wilk test. The normally distributed variables were summarized as mean ± standard deviation and compared between groups using the Student Repeated-measure mixed-model testing groups were performed to analyze pain parameters and changes of sensation of stiffness over time, including data obtained before the procedure, just after the procedure and the day after the procedure. A post hoc analysis was performed in case of a statistical significance.p values of less than 0.05 were considered significant. All tests were two-sided. The statistics were generated using SAS 9.4 software  and R software  and using the application GMRC Shiny Stat .TM application, just after the ScenarTM application and the day after ScenarTM application. All included patients received the treatment and were analyzed.The study took place from November 2018 to October 2020 in a tertiary private nonprofit hospital. A total of 60 patients were included in this study, 30 in the Scenar-On group and 30 in the Scenar-Off group, and were evaluated before the Scenarp = 0.41) and the sex . The cervical and low back pain locations were almost equally present in both groups. The preoperative use of painkillers was similar between the groups at baseline in this study (p = 0.51 for the comparison of pain at rest and p = 0.96 for pain during movement).The patients’ characteristics at baseline were similar between the groups, in particular the age in the Scenar-Off group (48 ± 14 years) and in the Scenar-On group  to 4 (4) in the Scenar-On group, p < 0.0001). The difference of pain at rest was −2 (−2) in both groups (p = 0.22).Pain at rest, the main outcome, decreased after the sessions in both groups (from 8 (4) to 5 (3) in the Scenar-Off group, p = 0.0007 and from 7 (2) to 5 (4) in the Scenar-On group, p < 0.0001). The difference of pain at rest was −1 (−2) in the Scenar-Off group and −2 (−3.25) in the Scenar-On group (p = 0.12).Similar results were observed during movement with a decrease in pain scores in both groups (from 8 (2) to 6 (4) in the Scenar-Off group, The sensation of stiffness was not modified . Group–time interactions were not statistically significant regardless of the variable concerned: pain at rest or during movement, or the sensation of stiffness. Interestingly, the group effect was never statistically significant, as opposed to the time effect, which was significant when considering pain at rest or during movement .Just after the session, three patients in each group reported minor adverse effects: two cases of headache and one case of increase in back stiffness in the Scenar-On group, one case of fatigue, one case of increase in pain and one case of increase in back stiffness in the Scenar-Off group. Twenty-four hours after the session, five patients in the Scenar-On group reported minor adverse effects such as insomnia (one case), abdominal pain (one case), headache (two cases) and increase in pain (one case). Three patients in the Scenar-Off group reported minor adverse effects such as fatigue (one case), increase in pain (one case) and increase in back stiffness (one case). No patient reported serious adverse effects.At the end of the study, the patients were informed of their group of treatment. Nineteen patients among the thirty patients of the Scenar-Off group asked for a real session of electro-neuro-stimulation, and fourteen patients of the Scenar-on group asked for more treatment.TM treatment, but this beneficial effect was observed in both groups and did not persist to the following day. Consequently, our study does not support the fact that one “real” ScenarTM session is superior to sham treatment in improving low back or neck pain. There was a decrease in pain in patients involved in the study after one session of ScenarTM to a sham session. Other studies compared the effect of a similar but different device but did not compare the results to a sham group or evaluate the effect of multiple sessions. Among them, three randomized studies were conducted on neck pain. Our results are close to a preliminary study where Shabrun et al. compared a single session of interactive neurostimulation therapy to a sham treatment. They also observed improvements in pain intensity and neck disability in both the treatment and sham groups [TM experienced greater reductions in the intensity of neck pain and disability and increased function and overall quality of life compared to participants receiving either TENS therapy or a sham treatment over 6 weeks [TM therapy also proved to be superior to the TENS therapy in reducing pain and disability for whiplash injury after 6 weeks of treatment but was not compared to a sham group [TM) reported a reduction in pain in 70% of cases and a functional improvement in 62% of cases [To our knowledge, our study is the first to compare a single session of Scenarm groups . Other s 6 weeks . The Sceof cases . Our results are especially marked by the similarity between the acute effects obtained by using the device in operation or not. This may be related to one of the possible mechanisms of the session, which is a “massage-like effect” due to the regular sliding of the device on a painful area. All types of manual therapy have been shown to elicit a neurophysiological response that is associated with the descending pain modulation circuit and the gate control system. Neurophysiological responses vary according to the type of therapy. The roles of endorphins, oxytocin and endocannabinoids have been advocated to explain the decrease in pain frequently described by patients ,11. ThisThe generalizability of our trial findings should not be a problem given the simplicity of the procedure, and our results could be used without difficulty by other teams while recalling that the manufacturer recommends repeated sessions and not a single session. However, some limitations should be discussed.TM that they would not sense anything, clearly those who felt electric stimulation probably understood that they were in the Scenar-On group; this limits the blindness of the method but is hard, if not impossible, to avoid.Although patients were warned before the application of ScenarTM  could have a different effect on the patients depending on the etiology of their pain. It is possible, but far from certain, that a more homogenous population could have helped us obtain clearer results.Our group of patients included those with low back pain and those with neck pain, with or without irradiation, but their numbers are too small for subgroup analysis. Furthermore, our population was not homogenous, and some patients experienced myofascial pain only, others presented a neuropathic component, and some of them were very anxious and tense. One could hypothesize that the different mechanisms that could explain the effectiveness of ScenarTM session as proposed by the manufacturer.Our methodology was that the first period of the session, with its “massage-like effect” see , was comFinally, the inclusion period was long, but this was explained by an interruption due to measures taken during the COVID-19 pandemic.TM session, does not support the fact that a single ScenarTM session improves low back or neck pain. However, since repeated use of ScenarTM is recommended by the manufacturer, new studies are needed to better define the effect of this device.Our study, using a mixed model for repeated measures  to analyze the analgesic effect of one Scenar


Objective: This study offers direction for interaction between physical therapists and patients about cancer-related pain during physical training. The study may increase awareness of rehabilitation strategies for cancer-related pain during and after cancer treatment.Methods: Qualitative study, evaluating results of two qualitative studies. Data has been collected using semi-structured interviews, in which topics were discussed with patients and physical therapists. Respondents were adult patients with cancer in the Northern Netherlands with moderate to severe pain who followed physical training with a (oncologic) physical therapist. The physical therapists were respondents specialized in oncology and working with patients with cancer in a primary care setting in in the Netherlands. Data were analyzed using thematic analysis.Results: Eighteen patients and fifteen physical therapists were interviewed. Data was categorized in statements regarding “patients' needs”, “patients' experiences” and “clinical reasoning of the physical therapist”. “Patients' needs” for education were personal and included needs for information about the cause, course and effect of pain in relation to cancer and/or medical treatment, needs for practical tools for reducing pain, needs for strategies dealing with pain in daily activities, and needs for information about additional treatment and care options. When discussing ‘patients’ experiences', patients mentioned that physical therapists are cautious to express their expectations of the progress of pain and to offer pain education with respect to the cause of pain, dealing with pain and limitations in daily life, exercising, posture, learning self-care and information about additional treatment and care options in cancer-related pain. Patients provided insight into their educational, mental, and social support relative to experiences with physical therapists. Additionally, when discussing the communication they experienced with physical therapists, patients used descriptors such as accessibility, empathy, trust, knowledge and eliminating uncertainties. Interviews with physical therapists regarding their clinical reasoning process in cancer-related pain described that they identified pain from anamnesis  and performed screening and analysis for pain secondary to cancer (treatment), as type of pain and pain influencing factors. Thoughts and experiences about pain, the use of pain clinometry, the establishment of objectives and interventions for physical therapy and multidisciplinary treatment of cancer-related pain were also described.Conclusion: Patients with cancer-related pain during physical training have personal needs regarding pain education and experience that specialized oncologic physical therapists focus on patient-centered information and self-management support. Specialized oncologic physical therapists analyze pain in the anamnesis and keep in mind the origin and impact of pain for the patient during screening and treatment. Different methods of pain management are used. It is recommended that physical therapists who give physical training take the initiative to repeatedly discuss pain. Pain is a common symptom in patients with cancer. Due to an ageing population, the worldwide incidence of cancer will increase in the coming years . As the In patients with cancer, the prevalence of pain fluctuates from 39% after curative treatment, 55% during cancer treatment and 66% in the end-of-life-phase . ModeratIn addition to physical causes of pain, psychological, social, and spiritual factors play a role in pain perception, as described in Saunders' Total pain model . The bioThe rehabilitation of patients with cancer involves a multidisciplinary and biopsychosocial approach aimed at optimizing functioning, wellbeing and participation of cancer survivors in general and pain management specifically . The phyFor patients with chronic pain there is compelling evidence that pain education can have a positive effect on pain intensity, perceived disability, catastrophism and physical performance . Pain edUntil now, the needs and experiences regarding pain education of patients with cancer-related pain during physical training in the Netherlands are unclear. Also, the clinical reasoning strategies of the specialized oncologic physical therapists behind their evaluation and treatment of cancer-related pain have to our knowledge not been published yet.Understanding of the needs and experiences of patients with cancer-related pain during physical training and the clinical reasoning process of the specialized oncologic physical therapist regarding pain can result in better communication about pain and a more effective treatment. The purpose of this study is to answer the following questions: (1) What are the needs and experiences regarding pain education of patients with moderate or severe (NPRS > 5) cancer-related pain in the Northern Netherlands, during physical therapy treatment with a physical therapist? and (2) What is the clinical reasoning process of oncologic physical therapists regarding patients with pain during and after cancer treatment in the Netherlands?A qualitative study, using thematic analysis, was designed to get insight into the needs and experiences of patients with cancer-related pain during physical training and the clinical reasoning process of oncologic physical therapists regarding patients with cancer-related pain. In two qualitative studies, individual semi-structured in-depth interviews were conducted. Interviews with patients took place, first, from October 2017 to January 2018, at a patient's home or at an agreed location. Secondly, the interviews with physical therapists took place from December 2019 until March 2020 by video calls using the program Skype .The study population consisted of two different independent groups: a patient group and a physical therapist group.The patients were respondents with moderate to severe cancer-related pain (NPRS > 5) due to the tumor or medical cancer treatment, receiving physical training by a physical therapist in the Northern part of the Netherlands. The following inclusion criteria were used: diagnosed with cancer in the curative or palliative phase, participated in physical therapy training for at least 6 weeks, moderate to severe pain at start of the training or during the training (NPRS > 5), good understanding of the Dutch language. Patients under 18 years of age, patients in end-of-life stage and patients with cognitive and physiological disorders were excluded. All physical therapists in the Northern Netherlands, who were members of the personal network of the researcher and the “Dutch Association of Lymphology and Oncology”, including “OncoNet”, were approached by email and informed about the study . PatientThe physical therapists were respondents in the Netherlands. The inclusion criteria were: a Master of Science degree in oncologic physical therapy or attending the graduation year of a Dutch oncologic physical therapy master's program, currently working with patients with cancer in a primary care setting and a good understanding of the Dutch language. Physical therapists were selected using a targeted sample. This was done taking into account enough variation in the characteristics of the participants: years of work experience, field of work and work setting. The oncologic physical therapists were recruited through the personal network of the researchers and the “Dutch Association of Lymphology and Oncology”, including “OncoNet” . PhysicaAll respondents  signed informed consent forms and provided sociodemographic data. When a respondent did not want to participate, the reason was described anonymously. Respondents were included until saturation occurred in the analysis.Formal ethical approval for the interviews with patients was waved by the Medical Ethical Committee of the University Medical Center Groningen. The study was registered under number 201700600.Topics related to patients disease perception and self-management and to the clinical reasoning process of physical therapists on diagnosis and therapy related to pain during or after cancer treatment were identified in scientific literature , 20–27. The interviews were recorded using a Dictaphone. The audio materials were transcribed into text. During the interviews, the researchers made notes of remarkable statements and of factors that might cause bias or were of interest regarding the study question. A member check was used, giving the respondents the opportunity to assess the correctness of the text and give feedback.Contact details and sociodemographic data were pseudonymized and stored separately from the interview. All files were stored in a secured safe, and will be kept for 10 years. Personal patient information and audio recording were deleted after a member check of the transcript. Descriptive analyses were used to describe characteristics of the respondents.Patient data were processed using Kwalitan (version 7.0) . PhysicaBased on the interviews, new topics and insights in the study question were discussed in the steering-board and added to the interview guides. Data collection and data analysis alternated continuously in an iterative process, each time looking at how the analysis results contributed to answering the study question. Based on this process, topics were added to the interview guide during the process.Twenty patients were enrolled. Eighteen patients were included and two patients did not meet inclusion criteria. Fifteen female patients and three male patients participated in the study. Twelve patients were treated curatively and six patients had an incurable form of cancer. The mean age of the patients was 62 years with a range of 36 to 75 years. Due to anxiety about a telephone consultation with the physician, the researcher ended one interview earlier. Fifteen physical therapists were included, of whom fourteen were female and one was male. The mean age of the physical therapists was 34.3 years (SD 8.6). The characteristics of the patients and physical therapists are shown in Thematic analysis resulted in three themes: patients' needs, patients' experiences, and clinical reasoning of the physical therapist, see code tree, Patients participated in physical training, when necessary using pain relief , to improve or maintain muscle strength, cardio- respiratory fitness, balance or range of motion. During physical training, patients had questions about pain related to cancer and medical treatment. Patients indicated a need for information on the cause and course of pain. There were patients who wanted to know how pain works. About the need for information was said:“You don't know if the pain is part of the cancer treatment or not. You also feel very insecure in terms of the pain.” (Patient 13)Patients in the palliative phase wanted information about the current pain, but did not want to look too far ahead towards possible “longer-term pain”. There were patients in the palliative phase who indicated they felt a need for information about psychological care and relaxation exercises related to pain, which had not yet been discussed with the physical therapist.Patients needed information about additional treatment and care options in cancer-related pain. Patients advocated for themselves and took responsibility in asking questions and looking for information. On the other hand, when patients were unfamiliar with complementary treatment options, they didn't know what to ask for. One patient said:“In all medical treatments and around it, you are helped. But actually, you're on your own after that. If you ask specifically, you'll get an answer. But if you don't know what to ask for, it remains unclear.” (Patient 11)It was indicated that pain limited daily activities and patients had to deal with the perceived limitations. Patients said they needed practical tools to reduce and deal with pain during daily life:“What can I do and can't do? How can I deal with pain myself in terms of reducing it?” (Patient 16)Patients needed an open dialogue to discuss pain and appointed questions by the physical therapist as desired. One patient said:“That's what I expect. Otherwise, I'd feel a little bit like I'd have to figure it all out on my own.” (Patient 5)Needs for information, instructions or guidance differed among the patients. There were patients who were adequately informed by the doctor or oncologic nurse, others stated to have gathered information on their own or that new additional information might become “too much.”Patients experienced that the physical therapist discussed pain, answered questions about pain related to cancer and were cautious about statements regarding the course of pain. Physical therapists offered information about additional treatment and care options and encouraged discussions on pain with other healthcare providers. A patient said:“They offer you all kinds of things. Why don't you go talk about this? I think she gives me a lot of support.” (Patient 1)It was mentioned that the physical therapist matched problems in daily life with instructions regarding daily activities, workload and resilience, daily schedule, work, posture instructions or recommendations regarding “exercise despite pain”. In addition, patients experienced that home exercise schedules, self-massage techniques, breathing and relaxation exercises, and conscious exercise behavior were part of self-care on pain. It was indicated:“There are all kinds of tips. You'd better do this. You'd better do it this way. If you divide your energy a little, you also suffer less from the pain.” (Patient 13)By information or instructions patients identified the educational role of physical training in recognizing boundaries and importance of continuing of moving with pain, experiencing mental and social support. About the role of physical training was said:“You have to persevere from time to time and then just feel the pain. If it's over after an hour, it's not all that bad. I've also learned to do it dosed, not to go on like crazy. I have to move because it is good for me, building up.” (Patient 5)With regard to accepting and dealing with limitations due to pain, the physical therapist discussed, supervised and showed understanding. About boundaries regarding activities and adjusting goals in case of pain, a patient said:“You get it unsolicited. Because of your conversations together, that'll come back to you. Why do I have to walk those seven kilometers? You can walk five kilometers. Then you will automatically adjust your goals.” (Patient 12)Commonly recurring in the interviews were answers like discussing, asking and telling your story. Regarding communication with the physical therapist about pain, patients experienced accessibility, knowledge, empathy, a relationship of trust, and reassurance together with discussing pain.“It is very accessible. You can ask all the questions, nothing is weird, no matter what crazy pains. Actually, they've been telling me a lot. What are some side effects and what I can possibly do about them?” (Patient 17)In addition to physical training, the physical therapists offered additional treatments to relieve pain, such as complaint specific and functional exercise therapy, stretching exercises, massage, breathing and relaxation exercises, scar treatment, medical taping, lymphedema treatment, pelvic floor training, manual therapy, and ultrasound examination.Patients were also alerted by physical therapists to additional care aimed for pain, such as psychologists, occupational therapists, hyperbaric oxygen therapy, medical pedicures, additional diagnostics or ergonomic support tools, and yoga.The physical therapists mentioned that during the anamnesis they asked for pain symptoms and pain course, for example: pain location(s), duration of pain sensations, pain description and pain score on the NPRS. They inventoried medical factors as the cancer (treatment), previous medical interventions, pain history, (pain) medication and co-morbidities. In addition, physical therapists mentioned that they asked for restrictions in activities and participation due to pain and pain relieving/exacerbating activities. The therapists also mentioned that they asked about the personal factors, as reason for physical therapy consultation and expectations, mental state, lifestyle, self-management strategies, pain coping/behavior, pain/illness perception and influence of home, work, social or health care providers on pain perception, and pain behavior.Physical therapists indicated that they screen for pain caused by cancer  or its treatment . One physical therapist said:“As a physical therapist we try to be alert on that of course. For example, if somebody doesn't have neuropathy, but is at risk, we will ask the patient every time if there are any symptoms.” It was mentioned that the physical therapists screen for the type of pain (nociceptive or neuropathic pain). A number of physical therapists indicated that they also screen for central sensitization, while others did not. In addition, to all physical therapists screening for factors influencing pain as physical activity in relation to pain behavior, emotions, social and somatic factors, and cognitions were important.The physical therapists assessed pain by inspection of the affected region and position of the body part with pain. Furthermore, palpation, examination regarding movement, muscle and nerve stretching tests, muscle strength tests and cardio-pulmonary capacity tests were performed. They also assessed aspects of pain using a pain/symptom diary.Pain and pain influencing factors in relation to activities and participation and personal factors  were assessed. Clinical reasoning with the use of pain clinometry in relation to personal factors was varied. Some physical therapists indicated that they received enough information from their interview techniques during the intake. Other physical therapists indicated that this clinometry could be used in relation to the patients' needs, as guidance for a conversation or to provide insight. One physical therapist said:“When you think now this patient catastrophizes a lot, which of course can amplify the pain, that you examine this with a questionnaire and use it as a guidance for a good conversation.” It was mentioned by the physical therapists that they advise patients with pain symptoms to contact a clinician when the pain symptoms are beyond the professional competencies of the oncologic physical therapist, when the patient is in need or in doubt, when there is unexplained pain or an abnormal pain course. In pain treatment, physical therapists collaborate with psychologists, social workers, occupational therapists, pain clinics, specialists in return to work, hyperbaric medicine, and complementary medicine. In relation to goal settings in physical therapy treatment, physical therapists stated that it is important to create realistic expectations, that goals are formulated SMART  and that the treatment phase and patients' needs should be taken into account.The following objectives in pain treatment were mentioned by the physical therapists: improvement of function and activity level, education to cope with the pain and encouragement of self-management and behavioral change to cope with pain. The physical therapists stated that pain treatment is often not the main goal, but pain management is important to achieve goals on activity and participation level. If goals were not met by physical therapy alone, multidisciplinary care would be considered.One of the interventions mentioned to relief pain was pain education. The following issues were discussed when giving pain education: consequences of cancer treatment, functioning of the pain system and impact of medication, relation between pain and coping style, role of emotions, workload and resilience, lifestyle, and behavior. There were physical therapists who involved close family and friends in the treatment process. For some physical therapists it was difficult to provide education about pain. They did not feel comfortable or competent and preferred to leave education about pain to other healthcare disciplines. One physical therapist said:“What do I tell and what not and in what way do I convey my message well?” The use of general and specialized exercise therapy as a pain intervention  and the use of graded activity or graded exposure were mentioned. Physical therapists used exercise therapy to promote movement strategies, body awareness, self-confidence and anxiety reduction. Also other interventions complementary to exercise therapy were mentioned: hands-on muscle stretching/connective tissue and joint mobilization techniques, kinesiotape and compression garments as well as relaxation therapy, hydrotherapy, heat or cold therapy and Transcutaneous Electrical Neurostimulation. Self-management was encouraged by giving the patient exercise schedules for at home or teaching the patient or partner self-management techniques.In this qualitative research, patients diagnosed with cancer, experiencing moderate to severe pain, indicated their needs and discussed their experiences regarding pain in relation to physical therapy treatment and oncologic physical therapists discussed their clinical reasoning process regarding patients with pain during and after cancer treatment.Patients need pain education concerning the cause, course, and effect of pain in relation to cancer and/or the medical treatment. They need practical tools for reducing pain, dealing with pain in daily activities and information about additional treatment and care options. Patients experience that physical therapists are cautious in expressing their expectations of the development of the pain. Their physical therapists offer pain education about the cause of pain, dealing with pain and limits in daily life, training, posture, learning self-care strategies and information about additional treatment, and care options in cancer-related pain. Patients experience educational, mental and social support in relation to physical training. Communication with the physical therapist about pain is mentioned in connection with accessibility, empathy, trust, knowledge, and removing uncertainties.Oncologic physical therapists inventory the pain, including the location, characteristics, mechanisms, expression, and function of the pain. They assess pain in relation to functional limitations, psychosocial factors, and current analgesic treatment. The physical therapists use interviewing techniques and clinometry to support the clinical reasoning process for patients' beliefs regarding pain, coping mechanisms and self-efficacy. The treatment is shaped on personal preferences and individual needs. Although the main role of the physical therapist is to restore physical function, interventions on understanding pain mechanisms and coaching on pain behavior and additional interventions to relieve pain are also implemented in the treatment.Based on the findings of this study, the researchers expect that the identification of personal needs of patients with cancer-related pain during physical training contributes to patient- oriented treatment, offering education, and self-management support, whereby a connection must be made with the person and the life he or she wants to lead . This peCancer-related pain is influenced by many factors, such as a patients' previous experience with pain or the patients' attitude towards pain and use of analgesics . To builPhysical therapists are recommended to give patients with cancer-related pain, education based on pain (neuro) science with a biopsychosocial approach to remove barriers to rehabilitation and to promote adequate pain behavior and cognitions . Why oncThis study indicates that patients during physical training find communication and a relationship of trust important when discussing pain. In the literature patient-oriented pain education is recommended, as where patients should be approached as a person with needs in physical, emotional, spiritual and relational dimensions , 41. It Treatment of cancer and insight in multidimensional health problems require a broad-based area of knowledge of physical therapists and often patients with pain require multidisciplinary treatment , 17. MasFindings in this study that indicate educational values in relation to physical training may be based on guiding and coaching skills of the physical therapist . No reprA strength of this study is the continuous peer debriefing process in both study groups: interview choices and data analysis were discussed with the peer-reviewers and a steering board. The member check of the transcripts also contributed to the validity of this study.A positive aspect of this study is that patients are included with a wide range in age, education level and during different phases of treatment and disease. It is striking that many women with breast cancer participated in this study. This is partly explained by the incidence of breast cancer and because the Dutch “Mamma carcinoma Guideline” recommends discussing physical training with each patient , 53. In The study population of included oncologic physical therapists appears to be representative for the Netherlands: they work in primary care, they work in six different provinces of the Netherlands, there is a large standard deviation in age and work experience of the physical therapist and they see patients with varying cancer diagnoses in their practice. However, only one man was interviewed. The clinical reasoning process of physical therapists with a Master in Oncologic physical therapy may be different from those in general physical therapy practice, therefore results should not be generalized to all physical therapists. The study population of the oncologic physical therapists may not be fully representative for other countries, because there may be a difference in education and options to specialize as an oncology physical therapist.The application procedure of patients respondents by physical therapists and physical therapist respondents by the researchers, the profession of the researchers  and the face-to-face interviews with patients cannot rule out that the results are subject to any selection bias or interviewer bias. To exclude confirmation bias, the transcripts of the patients interviews were reviewed by a nurse on open questioning. During the semi-structured interviews, respondents were given a lot of space to tell and explain. This may have some impact on the reproducibility of the study, but this provided a lot of insight into the needs and experiences of patients and the clinical reasoning of physical therapists regarding pain. The choice of conducting the physical therapists' interviews by video call was made because of time efficiency, as no travelling was necessary and respondents could choose by themselves where and when they wanted to be interviewed. This may have led to different interpretations of interview elements, due to less visibility of body language.A follow-up study that includes more diversity in diagnoses of cancer, has insight in the type of pain of patients with cancer and conducted in other parts of the Netherlands or other countries may lead to more specific insights.It is recommended that physical therapists, training patients with cancer, evaluate and discuss pain and its consequences in daily life and mental health repeatedly and involve other healthcare disciplines that could be helpful, to meet the needs of the patients with cancer-related pain. For optimal care, according to the principles of evidence-based practice, it is recommended for patients with cancer-related pain to consult an oncologic physical therapist with knowledge of cancer (treatment) and expertise in pain treatment.In conclusion, patients with cancer-related pain during physical training have personal needs regarding pain education and experience that specialized physical therapists focus on patient-centered information and self-management support. Specialized oncologic physical therapists analyze pain in the anamnesis and keep in mind the origin and impact of pain for the patient during screening and treatment. Different methods of pain management are used.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The study involving patient participants was reviewed and approved by Medical Ethical Committee of the University Medical Center Groningen. The study was registered under number 201700600. The patients/physical therapists provided their written informed consent to participate in this study.TE and EK: conceptualization, writing, and original draft preparation. TE, EK, and JH: literature search and data extraction. RG, MV, and JH: writing, review & editing and supervision. All authors contributed to the article and approved the submitted version.The publication of this work is partially funded by the Dutch Association for Physical Therapy within Lymphology and Oncology (NVFL) and Avans+ University of Applied Sciences, Netherlands.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To analyze characteristics associated with long-term pain relief after microvascular decompression (MVD) for trigeminal neuralgia (TGN). Description of associated morbidity and complication avoidance.One hundred sixty-five patients with TGN underwent 171 MVD surgeries at the authors’ institution. Patient characteristics and magnetic resonance imaging (MRI) datasets were obtained through the hospital’s archiving system. Patients provided information about pre- and post-operative pain characteristics and neurologic outcome. Favorable outcome was defined as a Barrow Neurological Institute (BNI) pain intensity score of I to III with post-operative improvement of I grade.p = 0.0202*) and TGN classification with classical TGN (p = 0.0372*) were the only significant predictors for long-term pain relief. Immediate pain relief occurred in 90.6% of patients with a recurrence rate of 39.4% after 3.5 ± 4.6 years. MRI reporting of a neurovascular conflict had a low negative predictive value of 39.6%. Mortality was 0% with major complications observed in 8.2% of patients. Older age was associated with lower complication rates (p = 0.0009***). Re-MVD surgeries showed improved long-term pain relief in four out of five cases.Type of TGN pain with purely paroxysmal pain (MVD is a safe and effective procedure even in the elderly. It has the unique potential to cure TGN if performed on a regular basis, and if key surgical steps are respected. Early MVD should be offered in case of medical treatment failure and paroxysmal pain symptoms. The presence of a neurovascular conflict on MRI is not mandatory. In case of recurrence, re-MVD is a good treatment option that should be discussed with patients.• Long-term analysis of pain relief after MVD.• Positive predictors for outcome: classical TGN and purely paroxysmal pain.• Presence of neurovascular conflict in MRI is not mandatory for MVD surgery.• Analysis of complications and surgical nuances for avoidance.• MVD is a safe procedure also in the elderly. Trigeminal neuralgia (TGN) is a rare disease with an estimated incidence of 12.6 in 100,000 people per year . It is cThe present study is a retrospective single-center analysis of patients with TGN that were operated by MVD. The study tries to clarify (1) the role of neurovascular contact (NVC) in preoperative magnetic resonance imaging (MRI) that has been frequently used as an inclusion criterion for MVD, as arterial compression of the trigeminal nerve root has been associated with better pain freedom rates ; (2) theAll patients who received MVD for TGN treatment at the Department of Neurosurgery at the Medical University of Vienna between January 2002 and December 2019 were eligible for enrollment in the present study. Patients underwent MVD if their pain was not sufficiently controlled by medication or if drugs were poorly tolerated as per 2019 guidelines of the European Academy of Neurology . PatientRetrospective data collection was obtained from patient admission charts, operative notes, preoperative MRT datasets, discharge letters, and follow-up reports. Preoperative characteristics of patients were documented including age, sex, onset and duration of TGN symptoms, age at surgery, pain distribution, IHS classification of TGN , category of TGN pain  , type ofAll patients underwent a preoperative MRI on a 1.5-T or 3-T scanner which included at least one T1-weighted gadolinium sequence, one time-of-flight magnetic resonance angiography sequence, and one high-spatial-resolution T2 sequence . All images were re-screened to differentiate between idiopathic and classical TGN by a board-certified neuroradiologist according to the severity of NVC in the prepontine cistern as suggested by the American Academy of Neurology in 2016 .Surgical reports were screened for the presence of NVC, the type and name of the compressing vessel, patient positioning during surgery, operation time, and complications during surgery. Surgery was performed depending on the surgeons’ experience and patient requirements in a sitting, prone, supine, or lateral park bench position. Over a retrosigmoid approach, and after opening the dura, the lateral surface of the cerebellum was retracted to open the prepontine or cerebellopontine cistern to release cerebrospinal fluid (CSF). Special attention was drawn to not harm the cerebellum due to extensive retraction or injury to the superior petrosal vein. Following trigeminal nerve exposure, the arachnoid sheet was dissected from the nerve root and the NVC was exposed. The conflicting vessel was carefully transposed and pieces of Teflon™ were placed between the vessel and the trigeminal nerve root. Absence of any offending vessel was ascertained. Surgery was completed after meticulous inspection of the trigeminal root entry zone.Immediate pain relief after surgery as well as at follow-up was the primary outcome parameter and measured by the BNI pain intensity score: (I) no pain, no medication; (II) occasional pain, not requiring medication; (III) some pain, adequately controlled with medication; (IV) some pain, not adequately controlled with medication, and (V) severe pain/no pain relief . PatientComplications were reported and graded into minor and major complications. Minor complications were defined as a BNI facial numbness score ≤ 2, postoperative systemic infections, wound healing disorders not requiring surgical or extensive medical treatment, vertigo, and dry eyes. Major complications were defined as a BNI facial numbness score > 2, hearing impairment, double vision, CSF fistulas, intracerebral/intracerebellar hemorrhage, and extensive brain swelling. Intraoperative bradycardia, which required atropine administration, was considered an expected event during fifth cranial nerve manipulation.t-test. The Mann–Whitney U-test was used for non-parametric interval-scaled variables. Chi-square or Fisher exact test was used for categorical data. Kaplan–Meier survival analyses were performed with a time interval from surgery to the date of recurring pain and/or increase of antiepileptic medication. Patients were censored at the last follow-up in the absence of recurrent pain. Several different groups were tested to differentiate significant differences in the probability of freedom of pain: types of NVC, sex, primary surgery versus follow-up surgery, TGN phenotype, affected nerve branches, side of facial pain, and age > 50 years. Survival analysis of pain recurrence was performed by using Mantel-Cox log-rank tests. A p value of < 0.05 was considered statistically significant. Statistical verifications were performed using GraphPad Prism (Version 9.1.1).Continuous variables following a normal distribution were assessed by analysis of variance and Student The study protocol was approved by the local ethics committee of the Medical University of Vienna (EK 1092/2020) and is in accordance with the Helsinki Declaration of Human Rights.Patient characteristics are outlined in Table The type of pain was paroxysmal in 94/171 (55%) patients and 38/171 (22.2%) patients experienced concomitant continuous pain. Classification could not be determined in 29/171 (22.8%) patients.The preoperative MRI scans revealed classical TGN in 67/171 (39.2%) patients and idiopathic TGN in 102/171 (59.7%) patients. Retrospective MRI scans were unavailable in two patients. Two patients suffered from multiple sclerosis but were classified as classical TGN as both MRI scans showed a NVC at the affected side in the absence of multiple sclerosis plaques in the trigeminal nuclei. TGN was classified again by the intraoperative judgment of the treating neurosurgeon. TGN was classified as classical in 129/171 (75.4%) patients and as idiopathic in 41/171 (24%) patients. One patient was not classified by the treating neurosurgeon. Taking these numbers into account, MRI had a detection sensitivity for a NVC of 52% and a specificity of 97.6%, giving a low negative predictive value of 39.6%. Intraoperatively, the NVC was caused by an artery in the majority of cases (49.7%), namely, the superior cerebellar artery (68.9%) followed by a combination of arteries and veins (33.3%) and veins only (13.3%).n = 12; 3rd surgery n = 4; 4th surgery n = 2; 5th surgery n = 1, 6th surgery n = 1, 7th surgery n = 2. Twelve patients had one or multiple prior percutaneous ablative procedures at the trigeminal ganglion, two patients had prior gamma knife radiosurgery (GKN) of the trigeminal nerve, three patients had a second MVD, and three patients had a combination of multiple MVDs and ablative procedures.A total of 149/171 (87.13%) MVD surgeries were primary surgeries for TGN. The numbers of previous procedures for TGN in the remaining 20 patients (22 MVDs [12.9%]) were the following: 2nd surgery n = 4), scaring (n = 1), and nerve distortion by Teflon™ (n = 1).A total of 5/6 patients who underwent two consecutive MVD surgeries had a favorable outcome at long-term follow-up. The patient with an unfavorable outcome experienced pain recurrence 534 days after surgery. One patient underwent a total of three MVD surgeries Fig. . In caseThe mean time for the MVD procedure was 178.7 ± 47.1 min. Patients were hospitalized for 7.3 ± 2.2 days. Patient positioning was in a lateral (82.5%), prone (12.3%), sitting (3.5%), or supine (1.7%) position as determined by the neurosurgeon’s preference. One surgery was terminated early prior to neurovascular decompression due to incorrect patient positioning in the lateral position, which resulted in insufficient venous drainage and brain swelling. Consequently, this patient was excluded from BNI pain intensity score outcome analysis.r = 0.81).Surgeries were performed by fifteen different surgeons over time Table . In totap = 0.0372*) when based on the surgeons intraoperative classification (p = 0.0202*), but not when based on preoperative MRI (p = 0.1002). The type of vessel causing the NVC (p = 0.1754), patient age at surgery (p = 0.2382), duration of TGN symptoms until MVD procedure (p = 0.1911), occurrence of postoperative facial numbness (p = 0.1953), sex (p = 0.7981), MVD as primary or subsequent surgery (p = 0.7500), side of facial pain (p = 0.3654), and involved nerve branches (p = 0.3795) were statistically not significant.Pain outcome after MVD was analyzed for 170 surgeries with a mean follow-up of 3.5 ± 4.6 years. Recurrence after MVD appeared in 67/170 (39.4%) cases with a median time from MVD to recurrence of 127 days (range 0–5932 days). A total of 35/66 (53%) patients who suffered from recurrent pain after MVD underwent a subsequent ablative procedure  at our department. Kaplan–Meier analysis of pain recurrence over time is shown in Fig. p = 0.0316*). Figure Similar results were found when patients were dichotomized into a favorable and an unfavorable outcome group at long-term follow-up Table . Of the The number of MVDs performed by a single surgeon did not correlate with the outcome nor did we see any significant changes over time.n = 56). Minor complications occurred in 42/171 (24.6%) procedures compared with 14/171 (8.2%) procedures where major complications occurred. A detailed overview is presented in Table p = 0.6874) and previous surgeries for TGN at the same side (p = 0.7230) did not affect the complication rate. Elderly patients were less likely to have complications (p = 0.0009***) but were equally affected if only major complications were taken into account (p = 0.4607). Patients with major complications (Table p = 0.0001***) with a mean duration of 13.6 ± 10.2 versus 7.4 ± 2 days. Intraoperative bradycardia requiring atropine intervention during surgical manipulation of the trigeminal nerve root occurred in 19/171 (11.1%) procedures.The mortality rate as a result of MVD in a total of 171 procedures was 0% with an overall morbidity of 32.8% n = 6. Minor The number of MVDs performed by a single surgeon did not correlate with the complication rate.The calculated MRI sensitivity and specificity in correctly distinguishing idiopathic from classical TGN were only 52% and 97.6%, respectively, when comparing preoperative MRI findings with intraoperative findings. This means that of 101 supposedly idiopathic TGN patients classified by MRI, a total of 61 (60.4%) patients showed a NVC intraoperatively. This low MRI sensitivity is partially attributed to the etiological classification of TGN as proposed by the American Academy of Neurology in 2016 . More grMultiple sclerosis is one of the most common causes of secondary TGN. Due to its uncertain pathophysiological mechanism, treatment by MVD is still under debate. In our cohort, two patients with multiple sclerosis were treated by means of MVD procedure. Both patients revealed a NVC and showed immediate pain relief after MVD, while only one patient remained pain-free at long-term follow-up. To date, only few studies investigated patients with multiple sclerosis who were offered MVD. However, all concluded that, even in the presence of multiple sclerosis, MVD is an effective treatment option that should be considered , 13, 31.p = 0.0202*), which is consistent with previous studies [Furthermore, the International Headache Society differentiates two phenotypes of TGN: (1) purely paroxysmal TGN and (2) TGN with concomitant continuous pain . In our  studies .MVD should be the surgical treatment of choice in medical refractory idiopathic and classical TGN. MVD was not performed as the first surgical intervention in 14 patients. The reasons for this were (1) rejection of MVD by the patient, (2) incorrect counseling of the patient by physicians who were inexperienced in the management of TGN, and (3) a missing NVC in cranial MRI and consecutive refusal to perform MVD by the treating neurosurgeon. All reasons indicate that patients who require surgical treatment for TGN should be counseled and treated in specialized centers that offer multiple therapy modalities. Surgeons should clarify that MVD is the sole causative treatment option that has proven to be an effective, low-risk surgery that can be performed even in the absence of a NVC in MRI.n = 11) after a successful primary surgery. They found that after second surgery, 87% and 50% of patients had an improved BNI pain intensity score of I or II, respectively, with no significant complications. In concordance with our data, the major cause for TGN was ongoing compression from an artery or vein followed by nerve distortion and displacement secondary to scarring or adhesions [Re-exploration in recurrent TGN in our cohort has shown a success rate of 66% (favorable outcome) and was not associated with a higher complication rate. Similar results have been found by Hussain et al., reporting results in 32 patients who underwent re-exploration of MVD or intraoperative neurolysis  . Even thDirect comparisons between individual studies regarding patients’ outcome after MVD are limited by inconsistent definitions for a successful surgery. The definition of pain recurrence was interpreted very strictly in our study. Every postoperative pain attack or added pain medication was rated as pain recurrence, even in the case of longer pain-free periods. In a prospective trial Sindou et al. published their long-term results of 362 patients treated by MVD. Their total cure rate was estimated to be 73.4% at 15 years . Interesn = 1334) from eight studies, could not demonstrate a significantly higher complication rate in the elderly [p = 0.0009***). This may be due to increased cerebellar atrophy in older age, which makes it easier for the surgeon to get an overview of the cerebellopontine junction. Another interesting result was with regard to the occurrence of postoperative facial hypesthesia. In contrast to destructive, percutaneous interventions, in which postoperative facial numbness may be a positive predictor for long-term postoperative pain freedom, the opposite may be the case in MVD surgery as shown in Fig. With mortality rates of less than 0.3% and low morbidity rates of approximately 7–9% , MVD is not only an effective but also a relatively safe procedure . Our mor elderly . Interesn = 4400) [Several technical implementations have been discussed by Bond et al. to avoid complications Table  such as  = 4400) . In our As in all neurosurgical procedures, patient positioning is absolutely vital. At our institution, the supine, prone, sitting, and lateral park bench positions were employed, depending on the neurosurgeon’s preference. There is certainly no exclusively optimal solution for MVD and the best option depends on various factors. These factors include, above all, the individual patient physiognomie, the surgeon’s experience, and the side of the operation. Sufficient venous drainage, which was not the case in three patients (leading to difficulties during surgery with one aborted surgery and the above mentioned AICA territory infarction), is even more crucial than the type of positioning. A lumbar drain is not mandatory to guarantee a relaxed cerebellum. Based on our experience, we suggest that the sitting position provides the best option in pyknic and overweight patients with a short neck because (1) it avoids venous congestions leading to cerebellar swelling and (2) it provides the best overview of the cerebellopontine cisterns and ameliorates surgeons comfort. A prerequisite is the surgeon’s and institutional experience with the sitting position. For the prone position as well as the lateral decubital position, it is mandatory to elevate the upper body as much as possible to avoid venous congestion. The prone position has the advantage that the patient’s shoulder comes out of the surgeon’s view, which is especially important in case of left-sided MVD and a right-handed surgeon. Taking these critical factors into account, cerebellar retraction should not be necessary in any patient.Optimization of the operative corridor starts with an optimal skin incision, which is dictated by the patient’s physiognomy and positioning. The aim should be to keep the incision as small as possible while obtaining adequate exposure for the craniotomy, a wide view of the anatomical structures, and freedom for manipulation of the cerebellopontine cistern. A craniotomy perfectly placed at the edge of the transverse and sigmoidal sinus angle does not need to be larger than 2 cm in diameter. It should clearly visualize the venous angle and allow a supracerebellar approach along the petrotentorial corridor without or minimal cerebellar retraction using cottonoids. Previous publications indicated retraction of the cerebellum tangential to the course of the vestibulocochlear nerve to be the preferable key maneuver as opposed to parallel to the nerve , 8, 23. CSF fistulas and rhinoliquorrhea due to inadequate wound closure occurred in only four patients (2.3%) and resulted in prolonged hospitalization and increased risk of infection. We propose that CSF fistulas can be avoided by a tight closure of the dura mater and closure with sealing matrices, followed by close adaptation of the muscle and a tight-layered wound closure. Opened mastoid cells should be closed with autologous muscles tissue and fibrin glue. To avoid adhesions between the dura mater and the neck muscles, which may cause pain, we recommend replacing the bone flap with bone cement. Synthetic bone substitutes have also been shown to be associated with lower rates of wound-related complications .The main limitation of this study is its retrospective nature. Furthermore, the quality of MRI images that were created on different scanners over a long period of almost 20 years differs greatly from one another and lacks a standardized protocol. The endpoint of the study represents a further limitation, because follow-up of patients was ended when pain recurrence occurred or when patients increased their pain medications. Thus, our data does not facilitate prediction of potential recurrent long-term improvements.MVD is a safe and effective treatment for refractory TGN, even in the elderly, and remains the only procedure that has the potential for cure. The morbidity profile of this procedure is low provided that the surgery is performed by a neurosurgeon trained in the surgical nuances of this special and self-rewarding operation. As patient counseling is key, TGN should be managed and treated in experienced centers that can offer all the necessary medical and surgical resources.


Spinal anaesthesia, although advantageous for conducting abdominal hysterectomy, is not the first choice amongst surgeons for fear of intra-operative visceral pain. Intrathecal adjuvants may improve quality of spinal anaesthesia. This study aims to compare efficacy of intrathecal Fentanyl and Dexmedetomidine to reduce visceral pain during abdominal hysterectomy performed under spinal anaesthesia.Sixty women undergoing abdominal hysterectomy for benign indications were randomly assigned to two equal groups in a double-blind fashion. Fentanyl 25 micrograms in group A or Dexmedetomidine 10 micrograms in group B was co-administered with hyperbaric Bupivacaine 15 milligrams for spinal anesthesia. Surgery through Pfannenstiel incision proceeded once sensory block reached eighth thoracic dermatome. The intra-operative visceral pain was assessed using a five-point scale: none, mild, intermediate, severe, and failed spinal anaesthesia. Duration of analgesia and peri-operative events were studied for 24 hours. Chi-square test, Mann-Whitney U-test and Student's t-test were used for analysis. Level of significance used was P<0.05.Fifty eight participants completed the study. Demographic variables and sensory block were similar between groups. General anaesthesia was not required in both groups. Significantly greater number of patients in group A required medications for visceral pain with Relative Risk of 2.8 (1.16–6.7). Pruritus and shivering occurred significantly higher in group A. Hypotension was significantly higher in group B. Post-operatively, group B patients showed a significantly longer duration of analgesia.Dexmedetomidine is better than Fentanyl as an intrathecal adjuvant to spinal anaesthesia in minimizing visceral pain during abdominal hysterectomy and in prolonging postoperative analgesia. However, it contributes to pain and nausea-vomiting after abdominal hysterectomy (AH).6 Dexmedetomidine, a newer alpha-2 adrenoceptor agonist, is claimed to augment local anaesthetic action in SA.8 Intrathecal Fentanyl and Dexmedetomidine are shown to enhance block characteristics and improve quality of SA in various surgical scenarios. But studies comparing their efficacy in reducing visceral pain during AH are not available.Fentanyl, when added to SA, minimizes visceral pain associated with peritoneal traction during uterine surgeries.This study aims to compare Fentanyl and Dexmedetomidine as intrathecal adjuvants to SA in women undergoing AH for benign indications. The primary endpoint was the occurrence of intra-operative visceral pain. Assessing the duration of analgesia and peri-operative events for 24 hours comprised the secondary objectives.After obtaining approval from Institutional Review Committee, a comparative study was conducted from January to September 2018 at the setting of an operating room and post-anaesthesia care unit of a teaching hospital. Informed written consent was taken from participants during pre-anaesthetic checkup performed a day before surgery.Women admitted to our hospital for undergoing elective abdominal hysterectomy for benign indications were the source of our participants. Consenting women of American Society of Anesthesiologists' physical status 1 or 2, age 30 to 65 years and who understand and speak Nepalese language well were selected for the study. When the principal surgeon was reluctant or was planning for a vertical incision, patients were excluded. Patients with following conditions were also excluded: height<150 cm, weight>100 kg, raised intracranial pressure, severe hypovolemia, moderate to severe stenotic valvular heart disease, bleeding diathesis, spinal anomalies or local infection, allergies to Bupivacaine, Fentanyl or Dexmedetomidine and, patients taking beta-blockers, antiarrhythmics, anticoagulants or anti-depressants.All the participants were thoroughly informed about the importance of immediate reporting of pain in order to receive analgesics. Specifically, they were instructed to notify any discomfort, anxiety, nausea, and pain during surgery. Numeric Rating Scale  for grading the intensity of pain was explained. Participants were kept nil per mouth of six hours prior to surgery for solid foods. Premedication included Alprazolam, Metoclopramide, and Ranitidine orally on the night before and on the morning of surgery. Regular medications were allowed as usual.Sample size was calculated using the formula,Considering hospital prevalence of 1.5% and a confidence interval of 95%, z equals 1.96 and d of 0.05, a total of 23 participants per group would be sufficient. Adjusting 30% for block failure and drop outs, the study was continued till 60 consecutive participants (30 per group) were enrolled using simple randomization. Computer-generated random number list, prepared by the principal investigator, was used for group allocation. It was concealed in serially numbered sealed opaque envelopes that were opened at the time of intervention.In operating room baseline systolic blood pressure (SBP), heart rate (HR) and respiratory rate (RR) were recorded. Intravenous (IV) access was secured with 18 G cannula to pre-load 10ml/kg Ringer's Lactate and to administer all further medications. The intra-operative fluid infusion was kept at 10 ml/kg/hr.TM: Claris Injectables Ltd, Ahmedabad, India) for SA. In addition, group A (n= 30) received 25 mcg Fentanyl  and, group B (n= 30) received 10 mcg Dexmedetomidine  intrathecally. Time of completion of injection was recorded as ‘0’ time and all times were calculated from this point. Patients rested supine immediately in a horizontal operating table. Investigators (second and third) enrolling patients, performing SA, providing care and assessing study outcomes were blinded to the group allocation and so were the participants.SA was performed under aseptic conditions in a sitting patient at L3/L4 or L4/L5 intervertebral space using a 27 G pencil-point spinal needle through midline. Total of 3.5 ml of drug solution prepared by the principal investigator in a syringe was handed over to another blinded investigator who injected it intrathecally over thirty seconds; and, 0.1 ml cerebrospinal fluid was aspirated before and after injection to confirm free flow. Both groups received three ml 0.5% hyperbaric Bupivacaine .Surgery was performed through Pfannenstiel incision. The surgical technique was not standardized, except for AH was performed with extra-fascial technique, and peritonealization of pelvis and anchoring of round ligaments to the vaginal cuff or cervical stump were avoided.10: 1=Excellent, no complaints, 2=Mild discomfort, requiring no analgesic, 3=Intermediate discomfort accompanied by nausea requiring anti-emetic, 4=Severe discomfort accompanied by pain requiring analgesic, and, 5=Failed SA, requiring GA.Visceral pain occurring intra-operatively was defined as poorly localized discomfort or dragging, pulling heaviness or unpleasant feeling or pain with or without nausea. Participants were encouraged to self-report such experience and were enquired every five minutes interval during surgery. For analysis, visceral pain outcome, as modified from a previous study, was categorized as followingThe occurrence of nausea was correlated with the decrement of SBP and/or HR and addressed first. Nausea-vomiting occurring otherwise was treated with Ondansetron, Metoclopramide, and Dexamethasone as needed. Fentanyl titrated to a maximum of two mcg/ kg was administered for visceral pain of NRS more than three. Anxiety was addressed with Midazolam (maximum three mg). If not sufficient, GA with increments of Ketamine and Propofol, titrated with vital parameters, were utilized.11HR, SBP, RR, electrocardiography, and Oxygen saturation were monitored continually and recorded at five minutes interval throughout surgery, and according to nursing protocol post-operatively. Hypotension  was treated with increasing fluid infusion rate and Ephedrine. Bradycardia (HR <50/min) was treated with Atropine. Respiratory depression (RR <eight/min) was treated with auditory stimulation and encouragement, Oxygen supplementation and respiratory support as appropriate. Level of sedation was assessed every 15 minutes using Ramsay Sedation Score for patients not receiving IV Midazolam or Fentanyl (Appendix 2).Peri-operative events including hypotension, bradycardia, respiratory depression, nausea, vomiting, shivering, pruritus, headache and any other were recorded throughout the study period. Duration of surgery, total intra-operative fluid infused, blood loss and hourly urine output were also recorded. Post-operatively, first analgesic was administered once NRS for pain exceeded three. Duration of analgesia was defined as a duration from time ‘0’ to time of first analgesic administration. The total number of analgesic doses administered over 24 hours was recorded when the study ended.For analysis, the statistical package for social science evaluation version 20  was used. Data is expressed as mean (standard deviation) standard error of mean, number (percentage), or median (range). Relative Risk  was calculated, and Chi-square test was used for comparing nominal measurements, including the primary outcome measure, the intra-operative visceral pain. Student's independent t-test was used to compare groups for the duration of analgesia and other quantitative variables. For ordinal variables, including the severity of visceral pain, Mann-Whitney U-test was used. Level of significance used was P<0.05.Eighty potentially eligible patients were examined in the study duration. Nine patients were excluded because of principal surgeon's unwillingness and eight patients were excluded because of not meeting inclusion criteria. Whereas three patients denied the consent. Sixty patients were randomized in the study in whom SA was easily performed. In group A, one participant withdrew consent immediately after SA, demanding for unawareness during surgery. Whereas, in Group B, violation of study protocol occurred in one patient due to prophylactic IV anti-emetic administration. Twenty-nine patients in each group were analyzed . There wThere was no significant difference between groups in demographic and surgical characteristics .During surgery, significantly higher number of patients from group A witnessed visceral pain as compared to those from group B . Study pThe severity of intra-operative visceral pain was significantly higher in group A .Duration of analgesia was significantly prolonged in group B; and, number of analgesic doses consumed over 24 hours in this group was significantly less as compared to group A .2 blockers for epigastric pain.Surgical complications were not observed and no patient required the blood transfusion. One patient from group A developed post-dural puncture headache at 22 hours of surgery and was effectively managed conservatively. Non-specific headache was treated in one and two patients in group A and group B respectively. Two patients in group A received HThe results indicate that Dexmedetomidine 10 mcg when added to 15 mg hyperbaric Bupivacaine in SA, significantly reduces occurrence and severity of visceral pain during AH as compared to Fentanyl 25 mcg. In addition, Dexmedetomidine in comparison to Fentanyl significantly prolongs duration of analgesia and reduces consumption of analgesics.12 Intrathecal alpha-2 agonists have been claimed to reduce both somatic and visceral pain.14 Surgeries associated with visceral handling and mesenteric traction might be well tolerable for awake patients. Intrathecal dose of 10 mcg Dexmedetomidine is shown to provide optimal favorable effects on SA characteristics without undue risks.15Dexmedetomidine, a highly selective alpha-2 agonist, has been the focus of interest for its analgesic, sympatholytic and hemodynamic stabilizing properties. Applied intrathecally it interrupts pain transmission by the depressing release of pro-nociceptive transmitters, substance P and glutamate from pre-synaptic C-fibers and by hyperpolarizing post-synaptic dorsal horn neurons in spinal cord.16 In non-obstetric patients, 10 to 25 mcg is the best risk-benefit dose range.6Fentanyl is a mu-receptor agonist opioid. In the spinal cord, it binds with opioid receptors at the dorsal horns, and may also spread rostrally for mediating analgesia. Being lipophilic, Fentanyl, possesses more rapid onset and recovery characteristics. Reduced need for analgesics and anti-emetics reflect its effectiveness against visceral pain when added to SA for cesarean section.Because several clinical studies have shown that intrathecal Dexmedetomidine prolongs and improves quality of postoperative analgesia, we were interested to find if it could reduce intra-operative visceral pain. We aimed to compare it with Fentanyl to determine which one is superior in improving the quality of SA during AH. The absence of a control group may be thought of as a limitation of our study. But, as there is higher association between SA with sole local anaesthetic and visceral pain during uterine surgeries, the absence of control group is well justified.4 No such data is available for AH. As the occurrence of anxiety, nausea, and pain and the need for their treatment were significantly lower in group B, we could conclude that intrathecal Dexmedetomidine minimizes visceral pain and results in better quality of surgical anaesthesia. Intrathecal Dexmedetomidine is shown in experiments to increase visceromotor thresholds in a dose-dependent manner.13 And, Yohimbine, an alpha-2 antagonist, could reverse those effects, proving visceral anti-nociceptive effects of Dexmedetomidine. But, clinical applications in its support have been sparse. Gupta R et al compared intrathecal Fentanyl and Dexmedetomidine but reported no difference in visceral pain.17 However, surgery was not specified, methods to assess visceral pain were not mentioned and Dexmedetomidine dose was smaller in their study.Both agents prevented the conversion of anaesthetic technique to GA in our study. However, occurrence of visceral pain was significantly higher in group A (48vs17%) with the Relative Risk of 2.8. Visceral pain during cesarean section performed under SA has been reported to be as high as 50 to 70%.19 Additive and/or synergistic action of Dexmedetomidine with local anaesthetic explains the findings. Whereas, postoperative analgesic requirement has not been shown to decrease with intrathecal Fentanyl, owing to its shorter duration of action.5 Mohamed et al have also shown that intrathecal Fentanyl did not add to the duration of analgesia provided by Dexmedetomidine.19Our study has shown that addition of Dexmedetomidine to spinal Bupivacaine significantly prolongs the duration of analgesia as compared to Fentanyl and reduces postoperative analgesic requirement. The results coincide with findings of other authors.20 A study reported higher requirement of vasopressor for hypotension, although without a statistical significance when five mcg Dexmedetomidine with 12.5 mg Bupivacaine was studied.17 This could also emphasize the dose-dependent effects of intrathecal Dexmedetomidine and Bupivacaine. As there was no difference between groups with regards to demography, sensory block and possible confounding variables in our study . Increased risk of hypotension with intrathecal Dexmedetomidine has not yet been established.ur study , we coul20 It is emphasized by our result (17vs3%), even though it did not reach statistical significance. Pruritus was observed in 41% of patients from Fentanyl group. This is reported previously with incidence reaching up to 60%.19 Occurrence of shivering was significantly low in Dexmedetomidine group. It is related to Dexmedetomidine's potential to decrease shivering threshold.22Intrathecal Dexmedetomidine and bradycardia are shown to be associated.24 It is associated with reduced risk of chronic pain after hysterectomy.25 This must have resulted from effective early post-operative pain control. Even then, apparently many have been reluctant to accept and adopt the routine use of SA for AH. Apart from the fear of intra-operative visceral pain, there are several possible reasons for this, including lack of collaboration in the surgical team and lack of awareness and failure to accept evidence-based data.SA favors post-surgical recovery, postoperative symptoms, long-term outcomes and costs as compared to GA.Some of the eligible and eager patients were excluded from our study due to unwillingness of principal surgeon. This denotes a source of potential bias and may represent a major limitation of our study. Manifestation of visceral pain is vague and we have to rely on patient's subjective expression. And, as there are no established scales for its assessment in current use, we had a modification from a previous study to match the usual clinical practice in our set up. To address the potential imprecision of the scale, the category of the patient's visceral pain was recorded from the anaesthetic chart only after the anaesthetic management was completed. Lack of evaluation of patients' satisfaction, surgeons' difficulty, and cost-effectiveness and usefulness of the technique in AH for malignancies represent added limitations in our efforts, which warrants further studies.Anaesthetic techniques have improved drastically over the last two decades. Many drug regimens have been suggested to eliminate anxiety during regional anaesthesia. Most importantly, prevention of pain reduces anxiety resulting in increased patients' compliance and satisfaction. Our study was one of the first of its kind to assess visceral pain occurring during AH in awake patients. And, the finding that intrathecal Dexmedetomidine improves the quality of SA with no remarkable adverse event might further increase the acceptance of this very popular technique not only for AH but for other intra-abdominal surgeries too.We conclude that the incidence and severity of intraoperative visceral pain was reduced markedly, but was not eliminated when an intrathecal Dexmedetomidine was compared with intrathecal Fentanyl during abdominal hysterectomy performed under spinal anaesthesia. But the pain-free postoperative period was prolonged and 24 hours analgesic consumption was also reduced with Dexmedetomidine. As provision of opioid-free analgesic regimen is rational considering relevant evidence of opioids as potent emetic agents with other undesirable effects including pruritus and possible respiratory depression, Dexmedetomidine seems to be the better alternative as an intrathecal adjuvant to Fentanyl, especially when surgery is anticipated to be prolonged and associated with peritoneal traction and visceral stimulation.