Furthermore, the multimodal pain management protocol included paracetamol, non-steroidal anti-inflammatory drugs, and metamizole as a rescue drug. The primary outcomes included pain scores , while the secondary outcomes included consumption of the rescue drug, anxiety, postoperative side effects, and patient satisfaction. The observation period lasted from postoperative day 0 to postoperative day 3. Results. Median average and maximal pain scores at rest, during deep breathing, and coughing were significantly lower in the intravenous group compared to the epidural group (p < 0.05). The effect size was medium (Cohen’s d ranged from 0.5 to 0.7). Patients receiving morphine required significantly lower numbers of metamizole doses than in the epidural group . Anxiety, postoperative side effects, and patient satisfaction were similar in both groups (p > 0.05). Conclusions. An intravenous infusion of morphine may offer better postoperative analgesia than a thoracic epidural infusion of ropivacaine with fentanyl. Objective. To compare the efficacy of analgesia with intravenous infusion of morphine and thoracic epidural infusion of ropivacaine with fentanyl in pediatric patients after the Ravitch procedure. Methods. Postoperative analgesia was achieved by intravenous morphine infusion with a dose of 0.02–0.06 mg/kg per hour (intravenous group,  Pediatric thoracic surgery also focuses on treating patients with malformations of the thoracic wall, such as pectus excavatum, pectus carinatum, or mixed excavatum-carinatum deformity. Anomalies include both the sternum and the adjacent chondrocostal structures and are more prevalent in males. Pectus excavatum, the most common chest-wall deformity, is a depression of the sternum, while pectus carinatum, considered the second-most common cause of thoracic malformations, is a protrusion of the sternum . One of This modified Ravitch procedure is an open surgery normally performed during adolescence. Postoperative pain originates from surgical damage to the skin, muscles , and the sternum or ribs . Pain also comes from the presence of a chest tube in the lower pole of the surgical wound or pleural cavity (in the case of pneumothorax) . The sevPractical guidelines for perioperative analgesia in the pediatric population  recommenThere is evidence that epidural analgesia provides superior pain relief compared to intravenous analgesia . HoweverTypically, the choice of a management strategy depends on patient preference and the experience of the physician. There is no consensus as to an ideal analgesic strategy. Thus, the current study aimed to compare the efficacy of nurse-controlled analgesia with intravenous infusion of morphine and epidural infusion of ropivacaine with fentanyl in pediatric patients undergoing the Ravitch procedure.This was a single-center cohort study conducted at the Department of Thoracic Surgery of the Institute of Tuberculosis and Lung Disease, Rabka Zdroj Branch, from May 2017 to December 2020. The study was prospectively registered at ClinicalTrails.gov (ID: NCT03393702) as randomized, blinded, placebo-controlled to investigate the usefulness of gabapentin as a component of a multimodal analgesic regimen in the postoperative period in pediatric patients whose pain was treated via an intravenous and epidural route. The study protocol was in compliance with the Declaration of Helsinki and was approved by the Local Bioethics Committee at the National Institute of Tuberculosis and Lung Diseases in Warsaw .All patients 9–17 years of age who were to undergo a scheduled Ravitch procedure, with postoperative chest drainage, in whom postoperative analgesia with intravenous morphine or epidural analgesia with ropivacaine/fentanyl was used and whose parents signed informed consent were included. Consent was also obtained from patients 16 years of age. Exclusion criteria were: American Society of Anesthesiologists (ASA) physical classification ≥3, postoperative intubation, oncological patients, inability to communicate pain, known drug allergy to local anesthetics or opioids, history of chronic pain or preoperative analgesic use, those patients suffering from mental illnesses or epilepsy.The multimodal protocol for the perioperative and intraoperative administration of drugs in the intravenous and epidural groups is shown in An epidural catheter was used in the anesthetized patients in the lateral decubitus position at the thoracic levels—a T4–T7 sensory level is appropriate for the Ravitch procedure. Using a median approach, the epidural space was identified by loss of resistance to air with an 18-G or 20-G Tuohy needle (children up to 10 years of age). A 20-gauge or 24-gauge catheter, respectively, was inserted through the needle up to 3–4 cm in the cephalic direction and tunneled laterally from the initial puncture. Next, the place of catheter insertion was secured with a sterile transparent dressing. To protect against infective material anti-bacterial filter was inserted at the junction of the epidural catheter and infusion line. Furthermore, the epidural infusion was labeled ‘Epidural,’ and the label, epidural catheter, syringe, and tubes for infusion lines were yellow. Patients after surgery were hospitalized in the intensive care unit for three postoperative days at a minimum. Immediately upon admission to the ward, the Simplified Post-Anesthetic Recovery Score scale, ranging from 0 to 6, as described by Steward, was used. Fully recovered patients received 6 points  .During the observation period, blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature were continuously monitored. Pain scores and sedation scores were measured at the same time intervals as the degree of motor block in the epidural group . The pain was scored using the Numeric Rating Scale (NRS) according to three steps: at rest, during deep breathing, and when coughing . Scores Sedation was assessed based on the motor responsiveness of the patient using a modified Ramsay’s Sedation Scale. This scale uses a numeric score from 1 to 5 . Monitoring the level of sedation helps to detect opioid-induced respiratory depression (scores 4 or 5 = oversedation). The motor blockage was graded using the Bromage scale  . The incThe state and trait components of anxiety were measured by the State-Trait Anxiety Inventory for patients between 9 and 14 years of age (STAI-C)  and oldeSatisfaction from patient postoperative pain management was assessed using the NRS scale four times: on the day of surgery, on postoperative day 1, postoperative day 2, and postoperative day 3. Scores ranged from 0 (completely dissatisfied) to 10 (completely satisfied), with the higher scores indicating greater patient satisfaction. The mean average score was calculated for each patient over postoperative days 0–3.A solution of morphine or ropivacaine with fentanyl was prepared and administered using programmable infusion pumps by trained nursing staff—only anesthesiology nurses were authorized to administer drugs via the epidural route. The infusion was maintained until the chest tube was removed.In the case of inadequate pain relief (NRS ≥ 3), analgesia was modified by increasing the flow rate of the infusion of morphine or ropivacaine with fentanyl by 10–30% and/or administration of these analgesics in a bolus . Intravenous metamizole was given as a rescue drug.The primary outcome measurements were average and maximal pain scores. Secondary outcome measures included the number of doses of metamizole, anxiety, side effects profile of postoperative analgesia, and patient satisfaction.®, Krakow, Poland). A p-value of 0.05 or lower was considered statistically significant.Categorical variables were summarized as absolute numbers and percentages, and continuous variables as median, lower and upper quartile. The analysis of the existence of an association between categorical variables was performed with the Chi-square test or the Fisher exact test. The Mann–Whitney test was used to analyze the continuous variables . Statistical analysis was carried out using the Statistica 13 program  who fulfilled the inclusion and exclusion criteria. Fifty-six patients were in the intravenous, and 40 patients were in the epidural group .n = 82; n = 12), while mixed pectus deformities were recognized in only 2 patients (2.1%). p < 0.05) were observed regarding ASA, preoperative heart rate, and systolic/diastolic blood pressure, as well as the duration of surgery.Pectus excavatum and carinatum were the reasons for operation for 85.4% and 12.5% of patients, respectively (n = 20) were inserted at the Th6–7 nerve root level, 27.5% (n = 11) of the catheters at the Th5–6, 17.5% (n = 7) were inserted at the Th4–5, and two catheters (5%) below the Th7. The success rate was 60% (n = 24) after the first attempt, 27.5% (n = 11) of patients required two attempts, and in the remaining patients, three (n = 3), four (n = 1) and five (n = 1) attempts were made. A vascular puncture through a needle occurred in one patient. The paramedian approach was used for one patient.In the epidural group, 50% of the catheters (p > 0.05).In the postoperative period in all patients, the median heart rate was 77  beats/min, systolic and diastolic blood pressure was 109  mmHg and 61  mmHg, respectively, and oxygen saturation was 96% . Patients received oxygen through the nasal cannula with a flow of 1–2 L/min—median oxygen supplementation was 31  hours. There were no significant differences between the intravenous and epidural groups regarding the above-mentioned variables  .p > 0.05) were observed in patient pain scores (average/maximum) between the groups only on the day of surgery and on the second postoperative day when the pain was measured during deep breathing and coughing.It should be noted that no significant differences (p = 0.69), number of bolus  and number of increasing/decreasing infusion rate . In addition, on the third postoperative day, when the infusion of morphine and ropivacaine with fentanyl was stopped due to removal of the chest drainage, two patients in the intravenous group and four patients in the epidural group received tramadol.Over the whole period of observation, the median consumption of morphine in the intravenous group was 20,000  μg, while the epidural group consumed 270  mL 0.2% ropivacaine and 1287  μg fentanyl. There were no significant differences between the groups in number of hours of intravenous and epidural infusion . In the epidural group, patients required a larger number of doses of metamizole than in the intravenous group: the median was 3  vs. 1 ; Z = −2.93; No statistically significant differences were found between the intravenous and epidural groups regarding trait anxiety and preoperative/postoperative state anxiety .p = 0.05), we did not find any significant differences in the median numbers of these side effects . Nausea and vomiting (one or two episodes) were observed mainly on the day of surgery and postoperative day 1. There were no significant differences between groups in the administration of antiemetic drugs (p > 0.05). Other side effects, such as urinary retention, pruritis, bradycardia, and dizziness, also presented no significant differences between the intravenous and epidural groups (p > 0.05).Side effects associated with postoperative analgesia are reported in n = 26, 46.4% vs. n = 13, 32.5%; χ2 = 1.88; p = 0.17).This study reported no cases of oversedation. The only incidence of a sedation score of 3  was noted on the day of surgery, with a similar frequency in the intravenous and epidural groups . Therefore, we did not consider respiratory depression as a side effect of postoperative analgesia.Harmless neurological complications were documented in patients treated by the epidural route. Numbness and sensory disturbances in the upper limbs were reported by seven patients (vanished spontaneously), while anisocoria and Horner’s syndrome were documented in five and three patients, respectively (resolved after decreasing the infusion of ropivacaine with fentanyl). The occurrence of the above complications did not prevent the continuation of epidural analgesia.p > 0.05). Patients were very satisfied with their postoperative pain management  on postoperative days 0–3. The minimum satisfaction score was 5/10 in the epidural group and 7/10 in the intravenous group. In the postoperative period, 50% (on the day of surgery) to 61% of the patients (on postoperative day 2) were completely satisfied (NRS = 10).The mean average satisfaction scores on the day of surgery and consecutive postoperative days and total satisfaction scores were similar in both groups  than patients after Ravitch repair in a study conducted by Mangat et al. (median discharge pain ranged from 1.5/10 to 4.5/10)  or PilkiExcellent pain relief was reflected in the high satisfaction of all our patients. Schwenkglenks et al.  reportedAnalgesia provided by a nurse was not only effective but also safe. We did not find any serious complications. Postoperative nausea and vomiting (PONV) were most common—about 40% of the patients had at least one incident of this side effect up to postoperative day 2, despite antiemetic prophylaxis. Our patients had a high risk of PONV because they were older than 3 years, received opioids, and underwent surgery that lasted longer than 30 min ,36. The In patients treated via the thoracic epidural route, we observed harmless and very rare reported in medical literature neurological complications, such as anisocoria and Horner’s syndrome ,38,39. AThe study was randomized and blinded, but not to compare the efficacy of intravenous and epidural analgesia but to assess whether perioperative gabapentin use has an impact on the intensity of the pain (primary outcome) in each study arm. The estimated test power indicates that the sample size was sufficient to show that the differences between the intravenous vs. epidural group are statistically significant (the significance level of α = 0.05) only in the case of average/maximum pain at rest (power: 0.89/0.95) and maximum pain when deep breathing (power: 0.85). The test power is low in the case of average pain during deep breathing and average/maximum pain during coughing .The lack of a standardized tool to assess satisfaction with postoperative analgesia is also a limitation of the study, as is the fact that the cohorts come from one treatment facility (a single-center cohort study).Continuous intravenous morphine may provide superior pain control but was comparable with a thoracic epidural infusion of ropivacaine with fentanyl for secondary outcomes. Randomized studies are needed to support this conclusion.The results of pain intensity and the adverse events profile suggest that both intravenous morphine and epidural ropivacaine/fentanyl, the main components of multimodal analgesia, are effective and safe, provided that patients’ health condition is closely monitored and analgesia is modified by nurses. Differences in pain intensity at such a low level (average NRS < 1/10) seem to be clinically insignificant. However, the validity of using this invasive method in our clinical practice should be considered due to the potential risk of serious adverse events related to the insertion of an epidural catheter, its maintenance, and the administration of local anesthetics. We plan to conduct a randomized clinical trial to definitively determine whether intravenous analgesia provides better pain control than epidural analgesia.


Patients with suspected carpal tunnel syndrome (CTS) often undergo nerve conduction studies (NCSs). Although patients sometimes complain of NCS-related discomfort, including severe pain, pain evaluations during such NCSs are lacking. We aimed to measure the pain experienced by patients with CTS during NCSs.This prospective study included 30 patients with CTS who underwent NCSs between April 2018 and March 2019. Pain because of electrical stimulation during NCSs was evaluated using a visual analog scale, and we statistically analyzed pain-related factors such as age, sex, complications, severity grading scale, the intensity of maximum stimulation, and examination time.The mean visual analog scale score for NCSs was 5.2, and the visual analog scale score increased as the intensity of maximum stimulation and examination time increased.We measured the pain because of electrical stimulation experienced by patients with CTS during NCSs. Our findings indicate that medical staff must be mindful of the potential pain experienced by patients during NCSs and educate patients regarding the necessity of the examination and its procedures.Diagnostic Ⅳ. In carpal tunnel syndrome (CTS), the most common nerve entrapment syndrome, the median nerve is entrapped at the wrist. Patients with CTS often undergo nerve conduction studies (NCSs). Nerve conduction studies can objectively evaluate nerve function and severity of neuropathy and help determine the indication for surgery and assess postoperative function.,However, some reports have suggested that NCSs are unnecessary for CTS because CTS can be diagnosed solely based on physical examinations and clinical symptoms.In this study, we hypothesized that the intensity of electrical stimulation, examination time, and patient background would affect pain caused by NCS. In this study, we aimed to measure the pain experienced by patients with CTS during NCSs and statistically analyze factors related to the pain that should be recognized by the medical staff.This study was approved by our institutional review board, and we obtained written informed consent from all patients. All procedures in this study were performed in accordance with the Declaration of Helsinki. This prospective study included 30 patients suspected by hand surgeons of having CTS and who underwent NCSs between April 2018 and March 2019. All subjects met the following inclusion criteria: (1) symptoms of CTS ; (2) CTS confirmed on physical examination by a positive Phalen or Tinel sign; and (3) CTS confirmed by NCS .Nerve conduction studies were performed on both hands by trained clinical technicians, with the patients in the supine position and a relaxed state. The skin temperature of 32 °C was obtained on the dorsum of the hand. Nerve conduction study recordings of the bilateral median nerve were performed using an evoked potential/EMG system  with a bandpass filter set at 10 Hz to 5 kHz for motor nerve recording and at 20 Hz to 2 kHz for sensory recording. In sensory NCSs, the sensory nerve action potential was antidromically recorded with a pair of cup electrodes placed over the distal and proximal interphalangeal joints of the index finger. Square-pulse supramaximal electrical stimulation was delivered at the palm, wrist, and elbow. We used palm stimulation to diagnose local conduction disorders in our hospital and calculated the sensory nerve velocity between the palm and wrist. In motor NCSs, the compound muscle action potential was recorded with a pair of surface cup electrodes placed over the abductor pollicis brevis muscle. Square-pulse supramaximal electrical stimulation was delivered at the wrist and elbow. Sensory and motor nerve action potentials were measured separately. Each stimulation was performed twice to confirm reproducibility . We set the maximum stimulation as the intensity at which the amplitude of the waveform does not change even when the stimulus intensity is increased. For severe cases in which the recordings were not derived using these conventional methods, a second lumbrical-interosseous comparison method was employed, and such cases were also included in this study. The NCS results were classified according to the Bland classification, which is based on electrophysiological severity.Pain because of electrical stimulation during the NCSs was evaluated using the visual analog scale (VAS) immediately after the examination.Based on previous study, we considered a score of 2.0 on the VAS for pain as clinically meaningful when identifying differences in NCS pain.,P < .05 was considered to reflect statistical significance. We added multiple regression analysis for items that showed a significant difference in the Mann-Whitney U test.We analyzed factors related to NCS-induced pain. The Mann-Whitney U test was used to identify differences between 2 independent groups for the following factors: age , sex , diabetes mellitus, the severity of CTS based on the grading scale , the intensity of maximum stimulation , and examination time .P = .272) (The demographic features of patients are presented in  = .272) . The VAS = .272) D and whe = .272) E (Table  = .272) . We perfIn this study, we measured the pain because of electrical stimulation experienced by patients with CTS during NCSs. The VAS score was significantly higher for stronger maximum stimulation intensities and longer examination times.In our results, the mean value of VAS was 5.2. This is similar to the pain of VAS after carpal tunnel release surgery performed under regional venous anesthesia, which has been reported in the past.Several previous studies have attempted to research NCS-related pain. A report of 96 patients with peripheral neuropathy undertook a 6-step survey on pain during NCS/EMG; however, the details of the disease conditions were unclear.In a study investigating the association between the VAS scores for pain during NCSs and patient background information  in 108 patients, no obvious factors related to pain were found.Our study has several limitations. First, in this study, the VAS after NCSs is compared with the VAS after carpal tunnel release surgery from previous reports. For an accurate comparison, the VAS after NCSs and after carpal tunnel release in the same patient should be compared. Second, in this study, we did not examine the VAS before NCS. For an accurate evaluation, the VAS should have been examined before the test as well. Third, in this study, we did not take the effect of the patients’ ongoing medications into account. The effect of analgesic medication on a patient’s pain ought to be considered.In conclusion, we assessed pain because of electrical stimulation during NCSs in patients with CTS. The mean value of VAS was 5.2, and the VAS score was higher when the intensity of maximum stimulation was high and when the examination time was prolonged. These findings are important in counseling patients and ensuring that medical staff performs NCS with lower stimulation in a shorter amount of time. Physicians should also inform patients why studies are necessary and beneficial.


Intravenous regional anesthesia is an easy and reliable anesthetic technique, but its use is limited by tourniquet pain. Clonidine is effective in overcoming this shortcoming when used with intravenous regional anesthesia at a dose of 1 μg/kg. Dexmedetomidine has also been used successfully at a dose of 0.5 μg/kg.Based on the potency ratios of clonidine and dexmedetomidine (8 to 1) we hypothesize that a lower dexmedetomidine dose would provide patients with 50 min of pain free tourniquet time.50 of dexmedetomidine was calculated using the modified up-and-down method.After informed consent, patients received intravenous regional anesthesia with lidocaine and dexmedetomidine following a sequential allocation scheme. The first patient received a dose of 0.5 μg/kg of dexmedetomidine. The dose was then adjusted in 0.1 μg/kg gradients for the following patients depending on the success of the previous block. If a patient experienced tourniquet pain prior to 50 min, the next patient received a higher dose. If not, the dose was decreased. Recruitment continued until 6 independent crossovers were observed with a minimum of 20 patients. The median effective dose ED50) that provides 50 min of tolerance to the tourniquet during a lidocaine intravenous regional anesthesia by a sequential Dixon up-and-down allocation study.The median effective dose of dexmedetomidine .Clinicaltrials.gov: Retrospectively registered ( Intravenous regional anesthesia or Bier block was first introduced more than a hundred years ago by August Bier . Since tMany pharmacologic agents have been added to the local anesthetics of the Bier block to decrease tourniquet pain and improve postoperative analgesia with varying degrees of success. These adjuncts include but are not limited to opioids , 4, non-50) that provides 50 min of tolerance to the tourniquet during a lidocaine Bier block with dexmedetomidine as an adjuvant.The aim of this double blind non-randomized Dixon up-and-down sequential allocation design study was to determine the median effective dose of dexmedetomidine  Once written informed consent was obtained 20 patients were recruited to participate in the study and trained to use the numeric rating scale (NRS) for reporting pain intensity from 0, indicating no pain at all, to 10, indicating the worst pain imaginable.Ethics approval for this study (ANES.CZ.01) was provided by the American University of Beirut Institutional Review Board, Beirut, Lebanon  on August 13, 2012. After securing approval, American Society of Anesthesiologists physical status (ASA) I or II patients aged 18 to 70 years old, scheduled electively to undergo unilateral minor forearm and hand surgery  at the American University of Beirut Medical Center (AUBMC) were approached to participate in this study. Patients with Raynaud’s disease, sickle cell anemia, heart block, allergy to any of the anesthetic drugs used, and weight greater than 100 kg were excluded as were patients on alpha adrenergic agonists, with ASA physical status III or IV, or undergoing emergency surgery or pregnant patients. This study was not registered prospectively on clinical Prior to establishing the block patients were taken to the induction room where two venous cannulas were placed: one 22-gauge cannula was placed in a vein in the dorsum of the operative hand for the block and the other one was placed in the opposite hand for crystalloid infusion and systemic intravenous (IV) drug administration (the size of the catheter was left to the discretion of the anesthesiologist). Two mg of midazolam were administered at this time. Once in the operating theatre, standard ASA monitors were placed on the patients and all of them received 3 L/min of supplemental oxygen via nasal cannula or face mask.0) was defined by the inflation of the distal tourniquet cuff. Time 1 (T1) was defined by the deflation of the tourniquet at the end of the procedure and Time 2 (T2) as time of arrival at the post-operative care unit (PACU).The operative arm was elevated for 3 min and then exsanguinated using a 10 cm Esmarch bandage and a double pneumatic tourniquet was placed around the upper arm. The proximal cuff was inflated to 250 mmHg. Circulatory isolation of the arm was verified by the absence of a pulse. Intravenous regional anesthesia was achieved using 3 mg/kg of actual body weight of lidocaine diluted with saline to a total volume of 40 ml together with the study drug. The solution was injected over 90 seconds by a blinded anesthesiologist with constant monitoring for signs and symptoms of toxicity. Once the injection was completed the 22-gauge cannula was removed and a small dressing applied. After sensory and motor block were achieved (verified 5 min after the injection) the distal tourniquet cuff was inflated at 250 mmHg followed by the release of the proximal tourniquet cuff. The patient’s arm was then surrendered to the surgical team. Time 0  and the patient was transferred to the PACU for monitoring. Patients were excluded if tourniquet times were shorter than 50 min.0 until T1 by the blinded anesthesiologist using the NRS. Boluses of fentanyl 50 μg were administered as rescue analgesics when NRS score was more than 3. The time to the first fentanyl dose was recorded as were the NRS score at the first fentanyl dose and the total amount of fentanyl used throughout the procedure. All measurements were recorded by a blinded anesthesiologist unaware of the drug allocation scheme.Tourniquet pain scores were assessed and recorded every 15 min from T0 + 50 min the next patient received a higher dose. If a patient did not experience pain at T0 + 50 min of tourniquet time the dose for the following patient was decreased. Identical syringes containing the solution mix were prepared by the principal investigator and handed to the blinded anesthesiologist in the room. Stopping rules were set at 6 independent crossovers in the same direction (no pain to pain or pain to no pain), with a minimum number of 20 patients. The mean and standard deviation of the ED50 of dexmedetomidine were calculated using the modified up-and-down method, which uses the average dexmedetomidine dose of all independent pairs of patients involved a crossover to calculate the mean and the standard deviation of the ED50 (main outcome). Basic demographic data recorded included sex, age, height, weight, ASA physical status and type of surgery. Data recorded in the PACU included degree of sedation measured by the modified Observer’s Assessment of Alertness/Sedation score (OAA/S) score, NRS pain scores, blood pressure and heart rate measurements recorded every 15 min for the first hour then every 30 min until discharge in addition to time to first analgesic requirement in PACU, NRS at that time, and any local or systemic complication arising throughout the study period. In addition, demographic and clinical data were analyzed comparing patients who experienced tourniquet pain versus those who did not with non-parametric tests, namely Mann Whitney U test for continuous data and chi-square test for categorical data. Statistical significance was set at P values less than 0.05 and results were analyzed using non-parametric tests with IBM SPSS Statistics for Windows, version 27 .Following a sequential allocation scheme, the dexmedetomidine dose for each patient was determined by the Dixon up-and-down method. The dexmedetomidine dose for the first patient was 0.5 μg/kg, which according to Memis et al. is sufficient to provide a mean of 53 min of analgesia  so the m50 of dexmedetomidine was 0.30 ± 0.06 μg/kg according to the up-and-down method. None of the patients experienced hypoxemia (O2 saturation less than 93%), hypotension , bradycardia (heart rate less than 55 bpm) or other signs of local anesthesia toxicity. During their stay in the PACU none of the patients experienced marked sedation. Comparative analysis between groups revealed that patients having experienced tourniquet pain had higher systolic and diastolic blood pressures at all times and had higher NRS pain scores at T0 + 30 and T0 + 45 min. There were no differences between groups for the other variables. The dose used by Memis et al [83 in our data.Twenty-five patients were assessed for study eligibility and 23 were approached. Recruitment took place over a one-year period during the year 2012–2013. Twenty-one patients provided informed consent; one patient was excluded when the surgery was completed in less than 50 min of tourniquet time. A flow diagram for the Dixon’s up-and-down method is presented in Fig. Tourniquet pain is described as a dull achy pain that causes increasing levels of discomfort over time at the level of the tourniquet despite adequate intravenous regional anesthesia. This pain is relieved immediately upon deflation of the tourniquet but is replaced with reperfusion and surgical site pain if more long-term analgesia has not been provided prior to deflation , 16. TheAlpha-2 adrenergic agonists are widely used in anesthesia for their sedative, analgesic, anti-emetic, and anesthesia sparing properties. They have been utilized in particular as adjuncts in regional anesthesia such as intrathecal, caudal and peripheral nerve blocks to prolong anesthesia duration and improve the quality of the blocks –23. LuriThree studies used dexmedetomidine as an adjuvant to lidocaine in intravenous regional anesthesia. Esmaoglu used 1 μg/kg of dexmedetomidine added to lidocaine in his prospective randomized trial and found that the combination improved the quality of the anesthetic and decreased analgesic requirements intraoperatively and postoperatively without tackling the issue of tourniquet pain explicitly . Memis u83 in our data as the dose necessary to permit tolerance to a tourniquet time of 50 min. This dose is higher than what we expected based on the relative alpha-2 adrenergic receptor selectivity of dexmedetomidine compared to clonidine. Alpha-2 adrenergic receptors are ubiquitous in the body and are present in the central nervous system, sympathetic peripheral nerves, and vascular smooth muscles among other places. Although alpha-2 adrenergic receptors located at nerve endings may have a role in the analgesic effect of clonidine through a decrease in peripheral perineural inflammation, this mechanism of action seems less likely in our patient population given the relatively long time necessary to produce this effect. Clonidine has been found to prolong the action of local anesthetics through alpha-2 adrenergic receptor mediated vasoconstriction and subsequent decreased local anesthetic systemic absorption [Our study found that the dose chosen by Memis corresponds to approximately EDsorption . This vasorption , and whisorption ; this mesorption . This al50 of dexmedetomidine that provides 50 min of tolerance to the tourniquet during lidocaine intravenous regional anesthesia was 0.3 μg/kg which is higher than we expected based on the relative alpha2-adrenergic receptor selectivity of dexmedetomidine compared to clonidine. Precise determination of the clinically relevant ED95 of dexmedetomidine as an adjuvant to intravenous regional anesthesia to increase tourniquet tolerance time to 50 min should be undertaken using the Dixon up-and-down method with a biased coin design.The ED


Patients in both groups received their program three times/week for 3 months. Pain, cardiorespiratory fitness, functional ability, and quality of life were assessed through the visual analogue scale, cardiopulmonary exercise test, 6 min walk test, and PedsQL scale, respectively, just before and after treatment. Results: Pain (p = 0.001), cardiorespiratory markers , functional ability (p = 0.002), and overall quality of life (p = 0.007) improved significantly in the experimental groups compared to the control group. Conclusion: Incorporating Pilates exercises into CPT is likely more effective for decreasing pain intensity, improving cardiorespiratory fitness, augmenting functional ability, and promoting quality of life in children with JIA than CPT alone.Objective: This study intended to examine the effects of Pilates exercise on pain, cardiorespiratory fitness, functional ability, and quality of life in children with polyarticular juvenile idiopathic arthritis. Methods: Forty children with polyarticular JIA aged 10–14 years old were randomly allocated into two groups: the control group ( Juvenile idiopathic arthritis (JIA) is one of the most common chronic childhood inflammatory diseases and is characterized by permanent joint inflammation attributable to immune system disturbance . The infChildren with JIA often present with pain, morning stiffness, and swelling in the involved joints. They also experience muscle weakness and atrophy around the inflamed joints and activity limitations . MoreoveImpaired aerobic fitness and lower levels of physical function during the active stage of the disease lead to functional declines among children with JIA . FurtherTherapeutic exercises play an essential role as a non-pharmacologic treatment for children with JIA. They have been effectively used to reduce pain, improve muscular function, increase physical activity, and promote quality of life in children with chronic musculoskeletal disorders . PilatesAlthough evidence is mounting for the beneficial effects of Pilates exercises on the cardiorespiratory fitness and physical activity level in healthy people and different patients  ,16,17, sThis randomized, controlled clinical trial was conducted between August 2020 and July 2021 in the physical therapy outpatient clinic at the College of Applied Medical Sciences, Prince Sattam bin Abdulaziz University (PSAU), Saudi Arabia. PSAU’s Physical Therapy Research Ethics Committee (No: RHPT/0020/0035) provided ethical approval. Study measures were performed in agreement with the Declaration of Helsinki 1975 ethical standards for medical research. Before enrollment, all procedures were fully demonstrated to all patients and their caregivers. They were then requested to sign a consent form. A researcher who was not aware of treatment assignment evaluated pain severity, cardiorespiratory fitness, physical activity level, and quality of life before and after the intervention. This trial was registered at ClinicalTrials.gov (ID: NCT05231057).Patients were enrolled from the Maternity and Children’s Hospital and King Khalid Hospital (Pediatric Rheumatology Department) in Al-Kharj, Saudi Arabia. Inclusion criteria were as follows: polyarticular JIA according to the classification of International League of Associations for Rheumatology , age rann = 20), while Pilates exercises plus the conventional physical therapy program were administered to the experimental group (n = 20). An independent researcher used a simple randomization approach in which sealed non-transparent envelopes included a code for one of the two experimental sets . These were drawn to determine intervention assignment for each participant. Forty patients met the criteria. Following the baseline examination, they were divided into two equal-sized groups at random. Conventional physical therapy (CPT) was administered to the control group , with 0 demonstrating no pain or discomfort and 10 indicating the strongest pain experience. Participants were instructed to cut the line at a point that represented how much pain they felt at rest and/or during activity .2), maximum heart rate (HRmax), and breath-by-breath minute ventilation (VE) according to the McMaster incremental cycle protocol [A graded cardiopulmonary exercise test was used to assess cardiopulmonary fitness. An electromagnetic cycle ergometer with electronic braking  was used to assess the peak oxygen uptake . It assesses nine domains: dressing, grooming, getting out of bed, eating, ambulation, self-hygiene, grip reach, activities, and extra-curricular events. The results were transformed to a CHAQ disability score ranging from 0 to 3 (a higher mark indicates a higher level of disability) .The self-reported Pediatric Quality of Life Inventory was used to assess quality of life (PedsQL). PedsQL is a 23-item multidimensional measure of health-related quality of life (HRQL) in children and adolescents and is divided into 4 areas . This questionnaire has been approved for usage with kids and adolescents aged 2 to 18 years old . On a 5-All children in the two groups underwent the conventional PT program , which was delivered by a pediatric physical therapist. The key priorities were reliving pain, increasing flexibility and mobility, improving muscle strength, and promoting proprioceptive awareness as well as increasing aerobic fitness. In general, the program consists of pain reliving modalities, stretching exercises, active range of motion activities, weight bearing activities, aerobic exercises on a treadmill or a bicycle, and isometric exercises ,24,25.Pilates exercises  were administered to patients in the experimental group by a pediatric physical therapist. Mats, Pilates bands or elastic bands, and Pilates ball are some of the several types of equipment used in Pilates exercises to attain various goals ,27. Detad = 1.04; as calculated in a pilot study of eight children who received similar interventions). The significance level was 0.05 using a two-sided independent t-test. To account for a potential dropout rate of 20%, the sample size was increased to 40 .The analysis was conducted using G*Power program version 3.0.10 . A group sample size of 16  was needed to achieve 81.23% power to reject the null hypothesis of zero effect size on pain intensity when the population effect size is too small (Cohen’s t-test (for continuous data) and a Chi-square test  were used to assess baseline differences between the IMT and control groups. The analysis of covariance (ANCOVA) test was used to calculate the post-treatment differences between the two groups (for primary and secondary outcome variables). To compare the two groups, the pre-treatment values of the dependent outcome variables were employed as covariates. The partial eta-squared equation was used to calculate the effect size (ES) for the significant ANCOVA. For all statistical tests, the level of significance was set at p < 0.05.Data analyses were conducted with SPSS version 21 . The Kolmogorov–Smirnov test was used to determine data normality. An independent The children involved in the current study were screened for eligibility. Out of 61 possibly eligible children, 40 participants met the criteria for inclusion and were randomly assigned to either the control or the experimental group. Three children did not complete the study . The CONSORT flow chart is explained in p = 0.001, ES = 0.92), which were in favor of the experimental group. In addition, there were large significant differences in the cardiopulmonary fitness between the two groups, as measured by the peak VO2  = 8.45, p = 0.008, ES = 0.81), VE  = 11.16, p = 0.002, ES = 0.90), and HRmax  = 6.39, p = 0.004, ES = 0.84), where the experimental group showed better cardiopulmonary fitness than the control group.p = 0.002, ES = 0.89), as the mean CHAQ score was lower in the experimental group in comparison to the control group. Still, there were significant differences in the quality-of-life domains between both groups: the physical dimension  = 7.21, p = 0.011, ES = 0.74), psychosocial dimension  = 5.17, p = 0.029, ES = 0.59), and total scores  = 8.20, p = 0.007, ES = 0.79) were all in favor of the experimental group.Further, there was a large significant difference between the two groups concerning their functional status  = 10.75, The current study was designed to evaluate the influence of Pilates exercises besides conventional physical therapy on pain, cardiorespiratory fitness, physical activity level, and quality of life in children with polyarticular JIA. Our results revealed that combining Pilates exercises with a conventional physical therapy program yielded favorable outcomes regarding the reduction in pain perception, the improvement of cardiorespiratory fitness, increasing the physical activity level, and the enhancement of quality of life.The role of Pilates exercises in relieving pain may be attributed to the breathing exercises, which are a main component of Pilates, as breathing exercises improve lung capacity, blood oxygenation, and circulation. Pilates also encourages the brain to release normal endorphins and opiates, which reduces pain and stress . IncreasOne possible explanation for the constructive effect of our results is the weekly exposure to the exercises, as the two interventions (Pilates + CPT) were delivered to improve cardiorespiratory fitness. The strengthening of the lumbopelvic region and core muscles that occurred during the exercises may have led to a better movement pattern in the limbs and better strength in the expiratory muscles . Another2 max and ventilatory thresholds in sedentary women with decreased respiratory capacity levels [The results of our study are also in line with the study conducted by Souza et al. to investigate the effect of cardiorespiratory adaptation to Pilates training. They concluded that 15 successive weeks of Pilates training has a positive impact on cardiorespiratory factors such as VOy levels . Our resy levels .Our results also showed that 3 months of clinical Pilates exercises in adolescents with JIA improved their functional status. This improvement may be associated with reduced pain intensity and improved aerobic capacity. We verified this claim through a finding of a study by Limenis et al., who studied the association between physical activity levels and functional status with pain in JIA children and concluded that there was an inverse relationship between pain severity and functional activity level . A studyThe results of our current study revealed that there was enhancement in the HRQOL in children with JIA, and these results are consistent with the results of Calik et al., who stated that clinical Pilates exercises increase mobility in children and adolescents with JIA, making them more active in daily activities. This has enables them to improve their overall quality of life . Our resAlthough the results of this study are mostly positive, there are some limitations that affect the generalizability of the results. First, the lack of long-term follow-up means further research is required to study the effects of Pilates exercises after 6–12 months. Second, a small sample size and relatively low power mean further studies are required to examine the influence of Pilates exercises on a large sample, thus resulting in more solid conclusions. Special consideration should be given when generalizing these findings, as this study was conducted on patients with only one specific type of polyarticular JIA and in one specific age group. As such, more research is desirable to explore the impact of Pilates exercises combined with a conventional physical therapy program on other types of JIA and on different age groups of children with JIA.Notwithstanding the relatively limited sample, this work suggests that the incorporation of Pilates exercises into physical therapy programs is likely an effective strategy for decreasing pain intensity, improving cardiorespiratory fitness, augmenting the physical activity level, and promoting HRQOL in children with JIA. However, large randomized controlled trials could provide more definitive evidence.


BackgroundPostoperative pain control irrespective of the magnitude of surgery has always remained a challenge for clinicians and healthcare workers. Good postoperative pain control is pivotal for unremarkable recovery and shorter hospital stays. Unfortunately, there is no uniform approach across the globe to address postoperative pain control. This provoked our thought to conduct a prospective observational study in our center to assess the already existing efficacy of pain management.Materials and methodsThis is a prospective observational study conducted in a tertiary care center in Coimbatore, India. The aim of this study is to assess the efficacy of an ongoing pain management system to compare it with standards in the literature to introduce changes and re-examine the results. A total of 100 patients who underwent major surgical procedures from various specialities were included after satisfying the inclusion criteria. The study was conducted over a period of four months to collect data from patients in the postoperative ward. Data were collected, pain-related variables were tabulated, and deficits were identified. Standardized pain assessment tools were not used. The results suggested the need for a policy change for quality improvement. This article gives reports on initial study results and plans to address the deficits in the current pain management system. A systematic and schematic approach for the implementation of the policy change and the framework for the new acute pain service team aiming at quality improvement have been discussed in detail.ResultsThe results show that 28 patients were prescribed only routine paracetamol and rescue nonsteroidal anti-inflammatory drugs (NSAIDs). At rest, 56 patients had some pain, and 29 complained of moderate to severe pain. On movement, only seven patients had no pain, 48 had mild pain, and 45 had moderate to severe pain. Only 12 patients out of 100 had good sleep, 27 had moderate, and 43 had little sleep. Twelve patients had no sleep due to continuous ongoing pain in spite of ongoing pain control modalities. Sixteen patients complained of undue delay in receiving their analgesics. Twenty-two patients were dissatisfied, and 44 suggested the need for improvement of current pain control strategies. These data clearly suggest that the pain control strategies are inadequate and need improvement undoubtedly for quality improvement. The Wendy Hirsch model is chosen to create a framework for implementing a new change, and a detailed report is done to present to the hospital quality control department. These changes will be done after the approval, and a post-implementation outcome will be studied.ConclusionGood postoperative pain control is of paramount significance for both patients and healthcare professionals. With the current availability of various pain relief modalities, one should consider establishing a pain control pathway, if possible an acute pain team with a systematic approach. These measures not only improve patient satisfaction but also improve postoperative outcomes and better ways of utilizing healthcare resources. Postoperative pain after major surgeries such as laparotomy needs a multimodal approach for patient comfort, complication prevention, early ambulation, rehabilitation, recovery, and discharge ,2. Most The Faculty of Pain Medicine from the United Kingdom published core standards for pain management services in 2021, which state that all patients with acute pain must have an individualized plan for pain control appropriate to their clinical condition that is effective, safe, and flexible with a review at frequent intervals . It alsoAny deficiency in patient care is not evident until it is studied with valid methods such as patient questionnaires, feedback, audits, or statistical studies. A detailed review of the literature shows that there is no ideal system that is flawless and acceptable to all settings . Every hWe did a prospective observational study in our hospital to assess the efficacy of pain management, associated complications, and patient comfort score in postoperative patients. The results warranted establishing a new policy for pain management in this group of patients. Under the guidance of a team of experts, recommendations have been put forward for an initial experiment. A pragmatic approach to the implementation of suggested changes has been made in a stepwise manner . The resThe study is a single-center prospective observational study done in a tertiary care regional-level referral hospital in India. A total of 100 patients who underwent laparotomies in various specialities were included. Approval from the Kovai Medical Center and Hospital (KMCH) Ethics Committee was obtained to undertake the study . No new interventions were done. Data were collected from the patient files and feedback forms rather than from the patients themselves. Consent from the medical director and medical records department was obtained to collect these data. None of the patients’ personal details were recorded. The inclusion criteria were defined by any patient having an open laparotomy for surgical access. Patients between 18 and 80 years old were included in the study as the extremes of age will have confounding factors in assessing pain. Patients with chronic pain syndromes and disseminated cancer requiring palliative surgery are excluded from the study. Patients having relook laparotomies are excluded for the risk of duplication of data. The anesthetic doctors and surgical doctors were blinded for the study as this might make the clinicians more vigilant, and so, they might tend to prescribe more analgesics than their routine, which will cause a potential bias.A data collection sheet is designed prior to conducting the study to include patient demographic details  such as age, sex, comorbidities, history of chronic pain syndromes, use of any pain modulators, any contraindications for any analgesic technique  in renal dysfunction), drug allergy to analgesic medications, details of the surgery , postoperative pain control variables , and complications due to pain control medications , respiratory depression, and hypotension requiring treatment).Data were collected between December 2016 and March 2017 to include the first 100 patients from the start date who satisfy the inclusion criteria. Data were recorded into an Excel sheet  for further analysis. Data were then analyzed and interpreted in the context of the efficacy of pain management for assessing the standard of quality against the standards laid by the Faculty of Pain Medicine . The picThe proposed change was agreed upon by the team and gained acceptance among the postoperative care providers at various levels: doctors, nurses, physiotherapists, and patients. This article gives a concise report on the initial study results, the deficits in the pain control policy, and the schematic approach for implementing the suggested change of policy aiming at quality improvement.The demographic details of the patients were recorded. The mean age of the patients and sex ratio were also recorded. The patients were broadly classified based on specialities to include representation from all different types of laparotomies as they were the patients cohorted together in the postoperative ward. This data could not be subjected to subgroup analysis as the sample size in the individual groups was less to undergo a univariate analysis. General surgery, colorectal surgery, hepatobiliary surgery, endocrine surgery, urology, gynecology, and surgical oncology are the specialities included. The type of incision might have an influence on pain quality and severity. The type of incision is also included in data collection, again for the fact that it represents all different types of laparotomies. The demographic details of the included patients are shown in Table The previously existing pain management strategies were clinician-based and differ from patient to patient undergoing similar surgery. The analgesic plans were regional nerve blocks (most commonly transversus abdominis plane (TAP) block), intravenous (IV) analgesics , transdermal fentanyl patches, and epidural analgesia with continuous infusion. These strategies were used either as a sole technique or in combination. Almost all patients received intravenous (IV) paracetamol round the clock with rescue analgesics such as diclofenac or ketorolac. The pain-related variables are listed in Table The results from Table Transdermal fentanyl patches are used by more than half of the patients and have been useful. Only six out of 100 patients received an epidural, revealing the fact that the anesthetic population is moving away from central neuraxial techniques due to the potential complications associated with it, particularly when there are safer alternatives available -12. EvenFifteen patients had no pain at all at rest, while 56 had some pain and 29 complained of moderate to severe pain. On movement, only seven patients had no pain, 48 had mild pain, and 45 had moderate to severe pain. The movement may be for positioning on the bed, rolling over in the bed, mobilizing to a chair, ambulating for physiotherapy, mobilizing to the toilet, etc. Only 12 patients out of 100 had good sleep, 27 had moderate sleep, and 43 had little sleep. Twelve patients had no sleep due to continuous ongoing pain in spite of ongoing pain control modalities.Sixteen patients complained of undue delay in receiving their analgesics. This could be possibly because of poor nurse:patient ratio or unavailability of any rescue prescriptions and the time consumed to contact a doctor for prescriptions due to being out of hours. Twenty-two patients were dissatisfied, and 44 suggested improvement of current strategies.The study included all types of laparotomies and most of the common incision types. The representation seemed adequate from a variety of patients that would usually get admitted to the postoperative ward on a daily basis.An ideal hospital system for postoperative patient care should aim at zero patients with severe pain, predefined plans for pain control particularly to facilitate mobilization and physiotherapy, adequate patient comfort including good sleep, and no PONV or other symptoms related to inadequate or overdoses of painkillers ,9. This These data clearly suggest that the pain control strategies are inadequate and need improvement undoubtedly for quality improvement when compared to the standards set by the Faculty of Pain Medicine . The corNew pain management involved the formation of an acute pain team, regular monitoring and documentation of pain, escalation when needed, encouraging the use of regional techniques, patient-controlled analgesia (PCA) techniques, etc.Existing ward practiceThe postoperative ward had general ward units with eight beds in a room and units that have two patients in a room and single-patient rooms. The ward capacity can accommodate a maximum of 40 patients at a time. The ward had a dedicated nurse-in-charge and senior and junior nursing staff and nursing assistants around the clock taking care of patients. The nurse:patient ratio is 1:8 to 1:10. One junior medical officer is available to address the key issues of the patient immediately but will be floating across other wards on the floor. The anesthetic and surgical resident doctors are available in-house whenever their advice is needed. They may be caught up in overnight emergency surgeries, which might cause some delay in advice or patient review if needed. Doctors visit the postoperative patients in the ward the next day morning after the surgery. Postoperative orders are given along with operative notes before the patient leaves the theater. This has been the routine practice before the study.Quality control meetingThe hospital conducts regular audit meetings, quality control meetings, and patient safety meetings as a part of institutional policy. The results from the abovementioned study regarding the current levels of acute postoperative pain services in the hospital and the deficiencies where current practice modification is required were discussed, and recommendations were laid on the implementation of policy change in acute pain services. The meeting included the audit committee members, anesthetic and surgical doctors, postoperative ward nurses, matrons, physiotherapists, quality control board directors, and stakeholders of the hospital. The list of recommendations is suggested and submitted for approval from the quality control and the hospital management team.The summary of the recommendations can be found in Table A comprehensive approach for change of practice to construct a local hospital-based pain management serviceThe framework for change implementation is shown in Figure Components Components are the tools and techniques to be used to implement a change. Components provide structure, being the backbone of the framework ,16.The “Desired Outcome” or the “vision” is obviously a quality improvement in acute postoperative management. The rationale and need for the change came from the quality control team to address patient feedback on previous postoperative pain control.The “Innovation” of the framework was targeted at the standards laid by the Faculty of Pain Medicine affiliated with the Royal College of Anaesthetists, United Kingdom, to be the criterion standard for designing the new pain management service in the institution. The Faculty of Pain Medicine published the standards and guidelines/recommendations on pain control. The first edition in 2015 has been revised, and recently, the second edition was published in 2021 with recent updates to pain medicine .“Measurement and Monitoring” should be approached at two levels: from the patient perspective and the institutional level. Pain should be considered the fifth vital sign, as widely accepted now. There should be subjective and objective variables that will be documented at hourly or two-hourly intervals at least for the first postoperative day. The use of validated pain assessment tools such as the visual analog scale, numerical rating scale, and verbal rating scale should be encouraged to avoid disparity and ambiguity . Pain shIt is advisable that the anesthetist assigned to the pain team, particularly during out of hours, is trained and has the capacity to perform the common regional nerve block under ultrasound guidance without supervision and is competent to assess, prescribe, administer, and monitor other techniques such as epidural and PCA. From an institutional point of measurement of targets, the quality control department should assess the outcome change from a broader perspective, collect data from medical records to analyze any improvement even if it is minimal, conduct regular audits, regular reports, and meeting from the acute pain team, analyze patient feedback forms, and suggest any further improvement .“Training and Coaching” involves regular continued medical programs on pain and regular formal and informal teaching for ward nurses, ward doctors, matrons, anesthetists, and surgeons. The scope of teaching will include a broader context of pain control such as understanding the pain pathway, assessing severity, troubleshooting, and managing the pain and complications associated with it ,17. Othe“Infrastructure” is one of the important components without which any implementation change should fail . Special“Communication” is an integral part of the change implementation framework. Communication should be multiway, clear, concise, and objective, use empathy, cultivate confidence, and be anonymous if required. The acute pain team should have a permanent mobile contact facility such as a bleep or phone available around the clock, and everyone in the postoperative ward should be given access to contact the pain service team. Freedom of raising concerns should be ensured, and systems such as Datix should be encouraged to learn from mistakes and build a constructive outlook . A writtRoles (who)People play various distinct roles to “make the change happen” in an organization, including end users, leadership, management, or part of an implementation team. Role allocation is one of the key factors that leads to the target achievement in any process ,20. RoleThe “Implementation Team”shall be named as the acute pain team in this context. This team is set up at three levels of hierarchy. The executive arm of the acute pain team should implement the change at the field level. This will include the ward nurses, matrons, physiotherapists, and the ward doctors/medical officers. They are the people who are involved in the direct care of patients. The tasks of this team involve measurement and monitoring of pain, documentation, troubleshooting any complications, and escalation to appropriate seniors of the next hierarchy whenever necessary. Adequate manpower and appropriate formal and informal training will lead to a successful executive team. They should have access to a reporting system, and freedom of expression needs to be ensured for the executive team.The next level of hierarchy is the managerial arm of the acute pain team, which will consist of the duty anesthetic resident doctor, duty surgical resident doctor, anesthetic consultant on-call, surgical consultant on-call, chief nursing supervisor, and matron of the hospital ,15. The The “Leadership” team is the top hierarchy in the acute pain team ,21. ThisThe “Stakeholder” in this context would refer to the hospital management. The management, with views of maintaining delivery of good quality medical service to the community, should review the reports from the authorities and encourage audits on pain control and conduct regular training sessions to develop a positive and constructive outlook on patient feedback to enhance the quality. The infrastructure should be excellent, and it is the stakeholder’s responsibility to ensure this quality ,23.“End Users” in this context will be the postoperative patients. In another context, everyone from the hospital enjoys the benefits of a better pain management. The nurse taking care of the postoperative patient and the doctor in charge of the ward will be able to discharge their duties better and have peaceful shifts, the anesthetic resident gets training, and the hospital gets a good reputation ,21. The Phases (when)Effective change management process is a multiphased, iterative effort rather than a straightforward, linear progression from “start” to “finish.” Thinking of it as such better enables the planners to focus on the right things at the right time. It also helps set appropriate expectations for what is expected to happen when and at what speed ,16.According to the Wendy Hirsch model of change implementation framework, the phase is a process of continuous steps but can go in either direction . The phaThe acute pain management team, once approved, will be decided, and a framework will be prepared. The “Execute,” “Improve,” and “Maintain” phases are to be expected. However, these phases need to be observed with targeted outcomes such as improvement in patient satisfaction score, reduction of complications, and reduction in the incidence of pain complaints. The data should be collected and audited to be compared with the baseline. Any improvement is appreciated, any unwarranted change can be withdrawn, and further changes can be suggested and made. Cost-effective analysis also needs to be done at the “Execute” or “Improve” phase ,25.Context (where)Context is the system or where the change is to be implemented, and outcomes will be observed . Since tProposal of policyThis schematic proposal was submitted by the audit committee to the board of quality control members and the hospital management. This was considered by them for approval and has been in practice with various post-implementation changes in the next few years. The results are being collected and will be compared with the pre-implementation data for quantifying the success of the policy change. This report aims at giving a schematic approach to designing an acute pain team in a regional center hospital adopted from core standards published by the Faculty of Pain Medicine of the Royal College of Anaesthetists .LimitationsThis is a single-center experience with a low volume of patients. The post-implementation study is not discussed in this study as it is beyond the scope of this article. Although this implementation plan would help a tertiary care hospital with a large volume of patients, smaller hospitals with resource-limited settings might not be able to implement this approach effectively.Adequate pain control is one of the basic rights of patients and one of the basic duties of physicians/surgeons, particularly in the postoperative period. Modern medicine and techniques give us a variety of pain control strategies that are safe and effective. A systematic and strategic approach to the implementation of a pain control policy will be the most efficient means of generating consistent and optimum results. This report will be a useful tool or guide for setting up an acute pain service team in larger hospitals.


Fragility fractures of the sacrum (FFS) have been detected more and more frequently in recent times, and the incidence will continue to increase due to increasing life expectancy. The aim of this study was to compare the clinical outcome of conservative, interventional and surgical treatment of FFS.Retrospectively, 292 patients  with confirmed FFS were followed up over a period of 2 years. The age of the women was Ø 81.2 (58 - 99) and that of the men Ø 78.1 (76 - 85) years. The pain was quantified using a VAS. Fractures were classified in accordance with the Rommens and Hofmann and with the Denis classification using conventional X-rays, CT and MRI. A QCT of the lumbar spine was performed to quantify bone mineral density. Concomitant diseases of every patient were recorded. An interdisciplinary case conference determined the individual treatment concept considering the age, type of fracture, pain level and comorbidities with classification into conservative, interventional (any type of sacroplasty) or surgical treatment. Over the course pain and independence were measured, complications and patient satisfaction were documented. A vitamin D determination was done, and existing comorbidities were included.Patients with a pain level of ≤5 benefited from the conservative therapy measures, with pain levels > 5 significantly delaying the development of mobility. After sacroplasty, the pain reduced significantly, which caused a rapid improvement in mobility without any significant difference being found between vertebro- (VSP), balloon (BSP), radiofrequency (RFS) and cement sacroplasty (CSP). In terms of pain reduction and mobilization, the surgical treated patients benefited from osteosynthesis, although more complex fracture types with lumbopelvic stabilization took longer. Overall, there were no deaths during the hospital stay. Mortality after 12 months was 21.7% for the conservative, 8.4% for the interventional and 13.6% for the surgical therapy group; the differences are significant. For patients in the conservative therapy group who were difficult to mobilize due to pain, the mortality increased to 24.3%. Over 24 months, patients achieved the best independence after sacroplasty. At 12 and 24 months, subjective satisfaction with the therapies was best after sacroplasty, followed by osteosynthesis and conservative measures. All patients had a pronounced vitamin D deficiency and manifest osteoporosis. Cardiovascular pathologies were the main concomitant diseases.Patients with FFS with a low level of pain benefit from conservative therapy measures, whereby complications and mortality increase significantly in the case of persistent immobilizing pain. Patients with an unacceptable level of pain resulting from non-dislocated fractures benefit significantly from sacroplasty. Patients with unstable and displaced fractures (Rommens and Hofmann type III and IV) should be operated on promptly. Different techniques are available for sacroplasty and osteosynthesis, which lead to an improvement of independence and a reduction in mortality. Fragility fractures of the sacrum  are increasingly being found in patients with reduced bone quality, rheumatoid arthritis, condition after radiotherapy on the pelvis and after cortisone medication, whereby older postmenopausal women with osteoporosis show the highest risk profile –8. In paThe aim of the present study was to compare the feasibility and clinical outcome of conservative, interventional and surgical treatment of FFS.Patients with tumour-related osseous destruction or pathologic fractures and courses after high-energy trauma were excluded. Retrospectively, 292 patients  with confirmed FFS were followed up over a period of 2 years after therapy, consultation of the patients took place every 6 months. The recruitment period was from January 2014 until June 2019. The age of the women was Ø 81.2 (58 - 99), that of the men Ø 78.1 (76 - 85) years. Immobilizing pain was quantified on a visual analogue scale (VAS) .On the basis of conventional radiographs , CT  and MRI examinations of the pelvis , a classification of Fragility Fractures of the Pelvis (FFP) according to Rommens & Hofmann  and cateAn interdisciplinary case conference determined the individual treatment concept with classification for conservative, interventional or surgical treatment, taking into account the fracture morphology, pain, concomitant diseases and the will of the patient.Depending on the intensity of pain, the conservative treatment included bed rest, adjuvant medicinal pain therapy according to the WHO schedule  and mobiThe various different methods available for interventional treatment by means of sacroplasty are described by Andresen et al.  and thosPain intensity was measured with the VAS score at different time-points after diagnosis, self-reliance was measured by means of a modified Hamburg Barthel Index . The Mann Whitney test was used for unpaired samples to compare the individual therapies and the Wilcoxon rank sum test was used for paired samples to determine changes over time. The students t-test was used to compare means between two groups  or vitamin D values between patients with a unilateral and bilateral fracture). For comparisons between individual groups , the one-factor analysis of variance (ANOVA) was used. At the same time, the effect sizes were calculated according to Cohen and values < 0.5 were assumed to be a small effect, between 0.5 and 0.8 a medium effect and > 0.8 a large effect. Statistical significance was marked as significant = According to the classification of Rommens & Hofmann, FFP type II with unilateral and/or bilateral fractures  was found in 250 of 292 (85.7%), FFP type III c in 14 of 292 (4.8%) and FFP type IV (type IV b and type IV c) in 28 of 292 (9.5%) of the patients treated  had unilateral and 201 (68.8%) had bilateral FFS, totalling 493 FFS.As an indication of the different ages of the FFS, the bilateral fractures usually showed varying degrees of oedema and in some cases laterally differentiated sclerosis in the area of the fracture zones on CT and MRI imaging Fig. .Fig. 2AxWith a distribution of 208 out of 493 of the FFS, 42.4% were found to have a Denis type 1, 21 out of 493 or 4.2% had a Denis type 2, 0 out of 493 or 0% had a Denis type 3, 214 out of 493 or 43.3% had a Denis type 1 – 2, and 50 out of 493 or 10.1% had a Denis type 1 - 2 - 3 fracture zone  and 100 patients with a pain level > 5 (Group 2) were included. Patients with a pain level of ≤5 benefited from the conservative therapy measures, whereby pain levels > 5 significantly delayed the development of mobility Fig.  a and b.A threshold for pain at 5 score points is marked in the graph by a solid horizontal line.The patients in Group 2, starting from a high level of pain, only fell below a pain threshold of 5 score points after 6 months on average.A total of 88 out of 114 (77.2%) patients could still be contacted after 24 months.p < 0.001. After 24 months, the scores increased to 76 +/− 13, with score points remaining significantly different (p < 0.05) between Group 1 and Group 2 at all-time points, with significantly lower scores for Group 2 patients.Comparison of the mean HBI values of patients with moderate (Group 1) and moderate to severe immobilising functional impairments (Group 2). The mean HBI of all patients was 55 +/− 15 at baseline, with a significant difference of 65 +/− 10 for Group 1 and 48 +/− 14 for Group 2, at Over the course of the study, 36  out of 150 (24%) patients were referred for interventional (10 out of 36) and osteosynthetic therapy (26 out of 36), due to increasing fracture extension, pain > 7 and pronounced immobility , which quickly allowed a marked improvement in mobility, with no significant difference found between vertebro- (VSP), balloon (BSP), radiofrequency (RFS) and cement (CSP) sacroplasty  reduction in pain as early as the second post-interventional day with a stable sustained effect over time, with no difference between groups.Patients in Groups 3 to 6 showed a significant  patients treated could still be contacted after 24 months.p < 0.001) improvement, with a sustained effect over 24 months. There was no significant difference between Groups 3 to 6 at p > 0.87.The average HBI of all patients was 37 +/− 6 at baseline and 83 +/− 6 after 24 months. After 6 days, there was a significant , transsacral screw fixation 8 times, a transsacral positioning rod 3 times, percutaneous plate osteosynthesis once, lumbopelvic stabilisation 8, and an internal fixator with additional transiliac screw fixation once.In terms of pain reduction and mobilisation capacity, patients benefited from osteosynthesis, although more complex fracture types with lumbopelvic stabilisation performed required a longer period of recovery Fig.  a and b.A threshold value for pain at 5 score points is marked in the graph by a solid horizontal line.Baseline pain is most pronounced in patients with more complex fractures (Group 9 - FFP type IV), with pain declining less rapidly over the postoperative course compared to Group 7 - FFP type II and Group 8 - FFP type III, the differences were not significant. After 12 months, the pain levels were more or less evened out at a low level. Forty five of 59 (76.3%) patients could still be contacted after 24 months.The average HBI of all patients was 35 +/− 4 at baseline and 84 +/− 6 after 24 months, with no relevant difference between the groups at these points.The patients in Group 9 - FFP type IV were significantly less mobile on postoperative day 6 than the patients in Group 7 - FFP type II and Group 8 - FFP type III.Material loosening occurred in 8 of 59 patients, but this did not require revision.There were no deaths during the hospital stay.In the assessment of self-reliance, patients achieved an average of 76 score points after conservative therapy, 83 score points after sacroplasty and 84 score points after osteosynthesis at the end of 24 months.However, of the 292 patients treated, only 81 patients (27.7%) achieved the same physical fitness as before the fracture event.The mortality rate after 12 months was 21.7% for the conservative, 8.4% for the interventional and 13.6% for the surgical therapy group; the differences are significant. In patients in the conservative therapy group who were difficult to mobilise due to pain, the mortality rate increased to 24.3%  lower than 30 nmol/l ≙ 12 ng/ml in all patients. Vitamin D levels were 8 - 28 (Ø 14.1) nmol/l ≙ 3.2 - 11.2 (Ø 5.6) ng/ml in unilateral fractures and 0 - 18 (Ø 7.2) nmol/l ≙ 0 - 7.2 (Ø 2.9) ng/ml in bilateral, more complex fractures .The vitamin D level was significantly (p < 0.05).The BMD was 12-74 (Ø 44.3) mg/ml in the patients with a unilateral fracture and 2 - 54 (Ø 31.3) mg/ml in the patients with a bilateral fracture Fig. , the difIn 128 of 292 (43.8%) patients in total, at least one previous sintering fracture was found in the thoracic and lumbar spine. Other osteoporosis-associated fractures such as distal radius, proximal humerus, femoral neck, rib and sternal fractures were found in 142 of the 292 (48.6%) patients. Hypocalcaemia was found in 35% and secondary hyperparathyroidism in 48% of all patients. Additional lung disease was found in 23.6%, cardiovascular disease in 45.2%, hypertension in 77.1%, renal insufficiency in 34.2%, diabetes mellitus type II in 72.8%, PAOD in 70.3% and obesity in 60.2% of all patients. A varying degree of nicotine consumption was reported by 48.3% of all patients.Up to our knowledge, this is the first study which compared the outcome of three different therapy options for the treatment of FFS.As in other publications, the risk factors confirmed in our patient population with sacral insufficiency fractures were advanced age , 12, 30,The fracture types found most frequently were a Denis 1 in 42.4% and Denis 1-2 in 43.3% and an FFP II in 85.7%, this distribution also being found by other working groups , 36. WitPatients with baseline pain ≤5 (Group 1) on the VAS experienced a reduction in pain Fig. a and an In comparison, after sacroplasty , the patients experienced a rapid and significant reduction in pain  showed the worst development under conservative therapy, which was already found to be comparable elsewhere . PatientA comparison of the mortality rates yielding significant effects appears to be possible for a time span of 12 months after the start of therapy, and they can be reliably assigned to the different therapies, see Table A mortality rate of 21.7% in the conservative group  was also found by other research groups , 71, 72.Patients in Groups 3-6 benefit considerably from the significant, short-term reduction in pain and the resulting rapid mobilisation after sacroplasty; the 12-month mortality rate was 8.4% on average. A similar tendency was already shown in a preliminary study comparing conservative therapy with a mortality of 23.5% against BSP with a mortality of 3% after 12 months . There wPatients in Groups 7-9 also seem to benefit significantly from surgery compared to conservative therapy, with an average 12-month mortality of 13.6%, despite an initial situation with more complex fractures, a higher pain level and poorer HBI. This is also in line with the results of Bible et al. , who werThe benefit of our study is the multicenter design and the comparison of three different treatment modalities for addressing FFS with outcome measurements over a period of 24 months.Limitations are the retrospective study design, the treatment of different fracture types and a bias due to the selection of the type of treatment .In order to avoid consecutive disablement, prompt diagnostics and multimodal, interdisciplinary therapy are necessary in patients with FFS. Patients with a low level of pain can be treated conservatively . Patient


In patients with postherpetic neuralgia (PHN), the effectiveness of epidural block and the benefits of adjuvant hypertonic saline (HS) have not been fully determined. Therefore, we investigated these issues in this study.  At a tertiary medical center's single pain clinic in Seoul, Republic of Korea, patients complaining of PHN even after 4 months of herpes zoster onset were enrolled and randomly assigned to either the HS or normal saline (NS) group. After epidural block with adjuvant HS or NS administration according to each protocol, outcomes were assessed at baseline and one and three months after the intervention. The primary outcome was pain intensity on the numerical rating scale (NRS). The secondary outcomes were the insomnia severity index (ISI), the medication quantification scale (MQS), and the global perceived effect of satisfaction (GPES). P < 0.001), without a significant group difference. The estimated ISI and MQS were not significantly different at 1 month compared with baseline but significantly decreased at 3 months in each group , without group differences. In addition, there was no difference between the groups on the GPES scale at one and three months after the procedure.  Thirty-six patients  were included in the intention-to-treat analysis. The estimated pain intensity decreased in both groups at one and three months after the procedure (KCT0002845. Epidural steroid injection may have the advantages of short-term pain relief, improved sleep quality, and decreased medication usage in patients with PHN. In addition, adjuvant HS administration with epidural steroid injection did not show beneficial effects in patients with PHN. Further studies are needed to clarify the potential effectiveness of HS in treating neuropathic pain such as PHN. This trial is registered with  As a sequelae of acute herpes zoster (AHZ) in sensory neurons, postherpetic neuralgia (PHN) often lasts from several years to a lifetime. The incidence of PHN is 7%–50% at 3 months and 5%–32% at 6 months after AHZ . These pAlthough several pharmacologic treatment options for PHN, such as anticonvulsants, antidepressants, opioids, topical lidocaine, and topical capsaicin, can be used, they are sometimes insufficient to control the pain. In this case, interventional treatments such as epidural or intrathecal block with or without steroid injection, spinal cord stimulation, and sympathetic block can be considered , 4, 5. TIn general, the analgesic effect of epidural injection with local anesthetics and steroids is mediated by inhibiting the synthesis of inflammatory mediators and decreasing neural excitability. Previously, it has been shown that the administration of adjuvant hypertonic saline (HS) for epidural block has the benefits of decreasing pain intensity and extending the duration of pain relief in patients with other types of chronic pain, such as pain due to spinal stenosis –9. AlthoTherefore, the present study aimed to investigate the effectiveness of adjuvant HS administration for epidural block in patients with PHN.https://cris.nih.go.kr/KCT0002845) [This study was a randomized, double-blind, active-controlled clinical trial. The Institutional Review Board of our institution gave its consent for this study to be conducted . Each patient who took part in this trial provided their written, informed permission. Participants' confidentiality and privacy were upheld in every way. In addition, this study was performed in compliance with the Helsinki Declaration and filed with the Clinical Research Information Service (0002845) . In repoWe evaluated the eligibility of PHN patients who visited our center's pain management clinic between May 2018 and December 2020. The following were the criteria for inclusion: (1) patients who complained of PHN even after 4 months of herpes zoster onset ; (2) patExclusion criteria were as follows: (1) patients who refused to participate in this clinical trial; (2) patients whose PHN was located in the head or face; (3) patients who underwent any interventional procedure such as an epidural steroid injection, paravertebral block, pulsed radiofrequency, or spinal cord stimulation within 3 months; (4) patients who were pregnant or lactating; (5) patients who had hypersensitivity to local anesthetics, steroids, contrast dyes, or HS; (6) patients who had a coagulopathy; (7) patients with red flag signs ; and (8) patients with uncontrolled medical or psychiatric diseases, including opioid disuse.Participated patients were randomly assigned to one of two groups: the HS group  or the normal saline (NS) group . Based on a computer-generated randomization method, an impartial data manager divided the patients among the groups. Each patient's randomization number was concealed from both the trial participants and the outcome assessor, an independent pain specialist. From the time of the procedure to the follow-up period, the interventional pain physicians remained unaware of which group the patients belonged to.Two pain physicians with more than ten years of experience conducted every procedure in this study. No premedication or sedatives were used in all participants. In patients selected according to the inclusion criteria, the target site of injection was the epidural space of the nerve affected by herpes zoster, through the parasagittal approach. All epidural steroid injection procedures were performed under fluoroscopic guidance. All epidural blocks were performed under a fluoroscopy system . During the procedure, each patient was placed in the prone position, and vital signs  were monitored. Sterile preparation and draping of the injection area were performed. Regarding the parasagittal interlaminar approach, the anteroposterior (AP) radiographic view was obtained to confirm the targeted vertebral level. Then, the image intensifier was cephaladly or caudally tilted to make the targeted interlaminar space more visible. After deciding the appropriate needle insertion point, local infiltration with 2 mL of 1% lidocaine was performed on the skin and soft tissues. A 20-gauge Tuohy needle was gently advanced under guidance by fluoroscopy. After placing the needle tip between the laminae, being ipsilateral to the symptomatic side of the patient on AP view, the needle was gently advanced using the lateral or contralateral oblique view while confirming the depth by visualizing the spinolaminar line or ventral interlaminar line, respectively –14. UponAll study participants' baseline characteristics were gathered. Assessments of the procedure's outcome were made at the baseline, 1 month, and 3 months later. Before the procedure, all study participants were instructed on how to use the 11-point NRS (0 = no pain and 10 = worst possible pain) to assess the pain intensity of their PHN, along with the insomnia severity index (ISI), a 7-item self-report questionnaire with a total score ranging from 0 to 28, to rate their quality of sleep –17. FurtThe primary outcomes were the mean difference of NRS scores in pain intensity from baseline at one month and three months. The secondary outcomes included changes in ISI, MQS, and GPES and adverse events in each group over the course of the follow-up. At each follow-up evaluation, the differences from baseline in pain intensity, ISI, and MQS were assessed. If procedural complications occurred, they were recorded. Also, any adverse events were further assessed during the follow-up period.All patients were informed of this guideline before participating in the trial. According to the patients' residual pain intensity at each follow-up, the prescription doses of each analgesic were either decreased or increased.The study sample size was determined on the basis of a previous publication , in whicχ2 test or Fisher's exact test appropriately. The Student's t-test or the Mann–Whitney U test was used to evaluate continuous variables, as applicable, to compare data between groups. All observed data were analyzed by intention-to-treat (ITT) analysis, despite loss to follow-up or dropout from the study. Given that data loss resulting from loss to follow-up was anticipated, a linear mixed-effect model was used to analyze and compare changes in continuous variables  at baseline and one month and three months after the procedure within and between groups. SPSS version 21  and Stata version 13.1  were used for all data handling and statistical analysis. A statistically significant difference was determined to exist when the two-tailed P value was less than 0.05.Absolute numbers and percentages are used to represent categorical variables. Continuous variables are displayed as medians with interquartile range or means with standard deviation or 95% confidence intervals. The categorical variables were evaluated by the Between May 2018 and December 2020, 88 consecutive patients diagnosed with PHN were screened for eligibility to be included in this study. A total of 40 patients who fulfilled both the exclusion and inclusion criteria agreed to participate in this study. Seven patients did not meet the inclusion criteria, 20 patients met the exclusion criteria, and 21 patients declined to participate. After randomization, 20 patients were assigned to the NS group and 20 patients were assigned to the HS group. Among the 20 eligible NS group patients, 1 patient did not receive the allocated intervention because of improved symptoms and 2 patients refused to participate after randomization. Among the 20 eligible HS group patients, 1 patient did not receive the allocated intervention because he refused to participate in the study. Finally, a total of 36 patients (17 in the NS group and 19 in the HS group) were included in the ITT analysis. All 36 patients were assessedat 1 at one and three months after the procedure, two NS group patients dropped out, whereas no HS group patient dropped out. At 3 months after the procedure, one NS group patient and three HS group patients dropped out . The reaP < 0.001 and P < 0.001, respectively), without a group difference (P = 0.380). We did not find significant interactions in the NRS between groups and time (P = 0.942). Changes in ISI and MQS are shown in Tables P < 0.001 and P < 0.001, respectively), without group differences (P = 0.123 and P = 0.899). No significant interactions in ISI and MQS were observed between groups and time . In addition, the GPES scales at one and three months after the procedure were not significantly different between groups  of patients with PHN in the spinal area in Korea . HoweverThe pain relief achieved in both groups implies that epidural block with local anesthetics and steroids would be effective for PHN regardless of adjuvant HS administration. The sensory nerve affected by a neuropathic condition such as PHN has altered ion channel functioning and is usually sensitized with a lower threshold for action potentials. This produces disproportionate responses to stimuli and even spontaneous discharges. Local anesthetics block the generation and propagation of action potentials by inhibiting voltage-gated sodium channels. Generally, the affinity for ion channels in depolarized membranes is higher in neuropathic conditions . The resEpidural injection of HS was reported as an effective treatment in other neuropathic pain syndromes. In previous studies, epidural adhesiolysis with HS has shown favorable outcomes for short-term and long-term pain relief in patients with spinal stenosis, postspine surgery syndrome, and radiculopathy of any etiology, with moderate evidence –30. FurtAs a conceivable reason, the chronicity of the disease might be a contributing factor. The mean total duration of pain was 26.6 (9.0–38.0) months in total participants, without substantial difference between the groups. According to the previous literature, nerve block in the acute stage of herpes zoster helps prevent PHN , 31. GenThis pilot study has several limitations. First, the 16.7% follow-up loss rate with a small sample size may be criticized. Because this study was conducted in one of the largest hospitals in Korea, a considerable percentage of the patients came from various cities. The extent of follow-up loss may have been influenced by the high percentage of patients from remote areas. Although an ITT-based analysis and a linear mixed model were utilized to adjust for missing variables, the 3-month follow-up period in the present study may have been insufficient to evaluate the long-term clinical effectiveness of the epidural block. Therefore, it is necessary to further evaluate the long term treatment effect beyond 3 months. Second, the volume of injectate in the parasagittal interlaminar epidural injection in the present study was decided at 6 mL arbitrarily. Although the suggested volume of injectate for epidural injection varied in a few literature reports, the optimal volume is still to be determined –37. HoweEpidural steroid injection may have advantages of short-term pain relief, improved sleep quality, and decreased medication usage in patients with PHN. In addition, adjuvant HS administration with epidural steroid injection did not show beneficial effects in patients with PHN. Further studies are needed to clarify the potential effectiveness of HS in treating neuropathic pain such as PHN.