To evaluate head and cervical posture in individuals with or without temporomandibular disorders (TMDs) and to assess the correlations between pain, severity of symptoms, and posture.  A total of 384 patients  was included. The Fonseca Anamnestic Index (FAI) was used to assess the severity and prevalence of TMD and the presence of temporomandibular joint (TMJ) pain. Patients were divided into three groups: the TMD-free group, TMD without TMJ pain group, and TMD with TMJ pain group. Subsequently, the patients with TMJ pain were further divided into mild TMD and moderate/severe TMD groups. Nine parameters were traced on cephalograms to characterize the head and cervical posture. B = 3.099), OPT/RL (B = 2.117), and NSL/C2' (B = 4.646) than the patients without joint pain after adjusting for confounding variables (P < 0.05).  TMD patients with TMJ pain showed increased forward head posture (FHP) than patients without TMJ pain and TMD-free subjects. No significant difference was observed between the TMD patients without TMJ pain and TMD-free subjects. In the TMD patients with the TMJ pain group, the moderate/severe TMD patients demonstrated increased FHP compared to mild TMD patients. TMD patients with joint pain had greater CVT/RL ( TMD patients with TMJ pain showed increased FHP compared to other groups, and FHP became more significant as TMD severity increased in male patients, indicating the FHP might play an important role in the development of TMJ pain. In the clinical assessment of TMD, the patients' abnormal head and cervical posture might be considered. Temporomandibular disorders (TMDs), with a reporting prevalence between 28% and 88%, are common in young people aged 20 to 40 years and in female . TMD is TMD might be caused by a variety of factors, including trauma, mental pressure, mandibular dysfunction, and malocclusion . Among tBased on the biopsychosocial model, diagnostic criteria for temporomandibular disorders (DC/TMD) enable researchers to understand the relationship between physical and psychological factors and the development of TMD cases, which is a commonly used method for the diagnosis of TMD at present . HoweverAlthough TMD-related pain is not a life-threatening problem, it can affect oral health-related quality of life, and symptoms might transform into a chronic state and be difficult to control . Like maThis study was conducted in accordance with the Helsinki Declaration and approved by the Ethics Committee of the West China Hospital of Stomatology in Sichuan University . After obtaining oral informed consent before the procedure, the participants provided written informed consent when filling the questionnaires. Parents or legal guardians of juvenile patients provided oral informed consent and written informed consent as well.Patients visiting the Department of Orthodontics in the West China Hospital of Stomatology in Sichuan University from August to December in 2021 were consecutively included in this study. The patients were requested to fill out a questionnaire including demographic information and the FAI scale and were asked orally if they had a clinical history related to the exclusion criteria. Then, the lateral cephalograms of the patients performed at the Department of Medical Imaging in our hospital were collected. The inclusion criteria were as follows: (1) patients participating in this study voluntarily; (2) patients visiting our department for the first time; (3) patients filling out the questionnaire clearly; (4) patients aged 12 years or above; and (5) patients with clear cephalogram and in natural head position. The exclusion criteria were as follows: (1) patients with history of orthodontic or orthognathic treatment; (2) patients with head and neck trauma or tumour; (3) patients with congenital deformities of the head and the neck, such as cleft lip; (4) patients with systemic diseases, such as rheumatoid arthritis; (5) patients with severe dental, periodontal, and oral mucosal diseases; (6) patients with psychological disorders; (7) patients with the history of TMD treatment; (8) patients with the history of treatment for cervical; (9) patients with primary headaches; and (10) patients with severe malocclusion and craniofacial abnormalities.The demographic information of the patients included name, age, gender, educational level , residence , and family per capita monthly income .The FAI scale was used to assess the presence and severity of TMD in each patient , 17. As The TMJ pain assessment was performed according to our previously reported method . For TMDThe lateral cephalograms of the patients were performed at the Department of Medical Imaging. The patients were required to maintain the natural head position with the mandible in the maximum intercuspal position, remain still, and not to swallow . The cepTwo blinded researchers performed the cephalometric analysis, and the intra- and interobserver reliability on cephalogram tracing was tested as previous described , 22. No ∗power . Kang [α as 0.05, the estimated minimum sample size was 108 subjects  for this study. Considering that it may be beneficial to analyse the genders separately, a total of 384 subjects were included in this study.The sample size was computed by using Gy). Kang  reportedy). Kang , and we P < 0.05 was considered to have a statistically significant difference. The quantitative data were expressed as mean and standard deviation, and the qualitative data were expressed by quantity and frequency. The Shapiro–Wilk test was used to judge the normality of data distribution. In order to compare the quantitative data of the patients in each group, independent sample t-test and one-way analysis of variance (ANOVA) were used when the data showed a normal distribution, and the Student-Newman-Keuls hoc test was used after ANOVA. The Mann–Whitney U-test or the Kruskal–Wallis H-test was used when the data did not show a normal distribution. In order to compare the qualitative data of the patients in each group, a chi-squared test was used. Spearman correlation analysis was used to correlate the FAI score and head and cervical posture parameters. Correlations were interpreted as follows: weak correlation, r < 0.30 and moderate or strong correlation, r >0.30. Also, the results of correlation analysis were visualized by scatterplots.All statistical analysis was conducted using IBM SPSS Statistics . Multivariate linear regression was used to explore the correlation between TMJ pain in TMD patients and head and cervical posture parameters. The independent variable was TMJ pain, with “TMD patients without TMJ pain” as the reference group. The dependent variables were all head and cervical posture parameters. The other covariables including gender, age, educational level, residence, and family per capita monthly income were adjusted in the regression model.P=0.265). TMD patients without TMJ pain were significantly older than TMD-free patients, with no difference in the age between the TMD patients with TMJ pain and the other groups (P < 0.001). Concerning the educational level, the proportion of senior high school or lower in the TMD patients with TMJ pain was significantly higher than that in the other two groups (P < 0.001). No significant difference in residence and family per capita monthly income was observed among the three groups (P > 0.05). In the FAI survey, the score of FAI in the TMD group with TMJ pain was significantly higher than that in the other two groups (P < 0.001), and the proportion of moderate/severe TMD patients was significantly higher than that in the TMD group without TMJ pain (P < 0.001) , 147 TMD patients without TMJ pain (38.28%), and 68 TMD patients with TMJ pain (17.71%). In terms of demographic characteristics, no significant difference in gender distribution was noted among the three groups (< 0.001) .P=0.033). In all the female patients, the CVT/RL and NSL/C2' of TMD patients with TMJ pain were significantly larger than those of the other two groups (P < 0.05)  .P=0.276). In adult male patients, the CVT/RL, OPT/RL, and NSL/C2' of the TMD patients with TMJ pain were significantly larger than those of the other two groups (P < 0.05). In adult female patients, the CVT/RL and NSL/C2' of the TMD patients with TMJ pain were significantly larger than those of the other two groups (P < 0.05) (P > 0.05)  . MeanwhiP=0.209). Among male, the craniocervical angle of moderate/severe TMD patients with TMJ pain was significantly smaller than that of the mild TMD patients, and the CVT/NSL, CVT/RL, OPT/NSL, and OPT/RL were significantly larger than those of the mild TMD patients (P < 0.05). However, no significant differences in head and neck posture parameters were observed between the two groups in female (P > 0.05).In the TMD patients with TMJ pain, stratified analysis based on the severity of TMD was performed . No signr = 0.162, P=0.018), CVT/RL , and NSL/C2' . For male and female TMD patients, the FAI score was also weakly and positively correlated with several head and cervical posture parameters (P < 0.05)  . The cor < 0.05) .B = 3.099, 95% CI: 1.172∼5.026, and P=0.002), OPT/RL , and NSL/C2'   .The main finding of this study was that there were significant differences in head and cervical posture between the TMD patients with and without TMJ pain, and the patients with TMJ pain have a significant trend of forward head posture (FHP). In the multivariate linear regression analysis, after adjustment for potential confounders, the increased in CVT/RL, OPT/RL, and NSL/C2' were independently associated with the TMJ pain risk. Thus, the null hypothesis was rejected.P=0.05 threshold.The CVT/FH of male patients with TMJ pain and the CVT/RL and NSL/C2' of female patients with TMJ pain were significantly larger than those of the patients in other groups. Cephalometric results showed that the TMD patients with TMJ pain of both genders had a forward inclination of the upper segment of the cervical column and cervical hyperflexion. We then analysed head and cervical posture in adult patients. Adult TMD patients with TMJ pain for both genders also showed increased FHP when compared to TMD-free patients and TMD patients without TMJ pain. After adjusting for potential confounding factors, increased in CVT/RL, OPT/RL, and NSL/C2' remained significant risk factors for TMJ pain in the TMD patients. It demonstrated that the TMD patients with TMJ pain exhibited more pronounced FHP. Also, the increased in the length of the upper segment of the cervical column (C2ap-C4ip) might also be associated with the possibility of presenting TMJ pain. The significance was not statistical, but it was very close to the In this study, the TMD patients with TMJ pain showed a significant FHP compared to the TMD-free patients and the TMD patients without TMJ pain. It is worth noting that there was no significant difference in head and cervical posture between the latter two groups. Therefore, a hypothesis was developed that a close relationship may exist between the FHP and the specific type of TMD with TMJ pain.Previous studies have found that abnormal head and cervical posture was significantly associated with head and neck pain , 27. ThiSimilarly, the FHP was found in patients with back pain, migraine, and chronic headache. Researchers also suggested that excessive stretch of muscles, soft tissues, and capsular ligaments beyond biological limitations from FHP may reduce the threshold of pain sensation in nerve endings and irritate proprioceptors in the joint capsules, which may contribute to these pain symptoms , 41–44.Meanwhile, a severe FHP might not simply be a matter of the presence or absence of TMJ pain. We then further explored the relationship between TMD severity and head and cervical posture in the TMD patients with TMJ pain. Limited by the sample size, we had to combine patients with moderate and severe TMD into one group for statistical analysis, which inevitably overlooked some detailed information. We observed that the FHP appeared to become more significant in male patients with moderate/severe TMD than patients with mild TMD. Similarly, TMD severity in the TMD patients was weakly positively correlated with FHP in correlation analysis for both males and females. This finding suggested a possible “dose effect” could exist between the FHP and the signs and symptoms of TMD, and this requires further investigation based on a large sample size. Few studies have focused on the relationship between the head and cervical posture and TMD severity or the frequency of TMD-related symptoms, and the findings observed in this study in the TMD patients may provide some useful insights for subsequent research studies.TMJ region pain and ear pain are common complaints in TMD patients . To the There are some limitations in this study. First, this study was a cross-sectional study and cannot establish a causal relationship between TMJ pain and head and cervical posture, and longitudinal investigations are necessary in the future. Second, this study only stratified patients based on the presence or absence of TMJ pain and did not quantify pain duration and pain intensity. Third, this study did not strictly distinguish between adults and adolescents. Adolescents at different growth stages may have specific cervical spine morphologies and head and neck posture characteristics due to their growth potential. Since this study included only a small number of adolescent TMD patients, the analysis of adolescent subjects alone may not meet the sample size requirement. It would be meaningful to increase the sample size of adolescents and analyse differences in their head and neck postures in further studies. Fourth, this study only used FAI to assess the severity and prevalence of TMD in patients without further verification of the diagnosis, which may result in grouping error and mislead the final conclusion. The use of DC/TMD could perform an accurate diagnosis of TMD and more detailed clinical subtypes of TMD patients in the follow-up studies.TMD patients with TMJ pain showed abnormal head and cervical posture and increased FHP compared with TMD-free patients and TMD patients without TMJ pain. In male patients experiencing TMJ pain, the FHP appeared to become more significant in moderate/severe TMD patients compared to mild TMD patients. The FHP may play an important role in the development of TMJ pain in TMD. In the clinical treatment for TMD-related TMJ pain, the effect of abnormal head and cervical posture might be considered. Longitudinal investigations are necessary to define the causal relationship between the FHP and TMJ pain in the TMD patients.


Facet joint pain is a common cause of chronic low back pain (CLBP). Radiofrequency (RF) denervation is an effective treatment option.A systematic review and network meta-analysis (NMA) was performed to evaluate and compare the efficacy and effectiveness of different RF denervation treatments in managing facet joint-derived CLBP.The Cochrane Library, Embase, PubMed, and China Biology Medicine were searched to identify eligible randomized controlled trials (RCTs) from January 1966 through December 2021. Interventions included conventional radiofrequency denervation (CRF), pulsed radiofrequency denervation (PRF), pulsed radiofrequency treatment of the dorsal root ganglia (PRF-DRG), radiofrequency facet capsule denervation (RF-FC), and radiofrequency ablation under endoscopic guidance (ERFA). The outcome was the mean change in visual analog scale (VAS) score from baseline. A random-effects NMA was used to compare the pain relief effects of the interventions over the short term (≤6 months) and long term (12 months). The rank of effect estimation for each intervention was computed using the surface under the cumulative ranking curve.A total of 10 RCTs with 715 patients met the inclusion criteria. Moderate evidence indicated that CRF denervation had a greater effect on pain relief than sham control in the short term (standardized mean difference (SMD) −1.58, 95% confidence intervals (CI) −2.98 to −0.18) and the long term . Fair evidence indicated that PRF denervation was more effective than sham control for pain over the long term . Fair evidence showed that ERFA denervation was more effective for pain relief than sham control in the short term  and the long term . Fair evidence showed that RF-FC denervation was more effective for pain relief than sham control in the long term . A fair level of evidence indicated that PRF-DRG denervation was more effective for pain relief than sham control in the short term .RF is an effective option for patients diagnosed with facet joint-derived CLBP.Systematic Review Registration: Identifier: CRD42022298238. Low back pain is a worldwide health care problem with significant social and economic consequences. Most patients can be successfully treated in primary health care, but approximately 10%–15% have persistent pain that transforms into chronic low back pain (CLBP) . Facet jRadiofrequency (RF) denervation, an invasive therapy for CLBP, is a technique that reduces spinal pain by modulating the neurotransmission of nociceptive stimuli. The transmission of nociceptive impulses is blocked by applying an electric current to coagulate the sensory nerves, which deactivates the nerves . A recenA systematic review and network meta-analysis (NMA) was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to evaluate and compare the efficacy and effectiveness of different RF denervation treatments in managing CLBP of facet joint origin.Supplementary material. The third researcher (Jun Zhang) resolved the disagreements.A comprehensive literature search was conducted to include randomized control trials (RCTs) published from all countries. Two experienced researchers (Han Li and Junyan An) comprehensively searched the Cochrane Library, Embase, PubMed, and China Biology Medicine independently by combining the following keywords:  to identify related articles published in English or Chinese between January 1966 and December 2021. Searches were also conducted for previous systematic reviews and cross-references. A detailed search strategy is provided in the The inclusion criteria were as follows: (1) studies: RCTs; (2) participants: adult patients with low back pain lasting more than one month at the time of admission who were diagnosed with facet joint syndrome by a single or double diagnostic block and received at least three months of follow-up; (3) interventions: CRF, pulsed radiofrequency denervation (PRF), pulsed radiofrequency treatment of the dorsal root ganglia (PRF-DRG), radiofrequency facet capsule denervation (RF-FC), and radiofrequency ablation under endoscopic guidance (ERFA); and (4) outcome measures: the primary outcome measure was pain relief, and the outcome indicator was the visual analog scale (VAS). VAS represented 0 with no pain and 10 with the worst pain imaginable. The outcomes of 6 months or fewer of management were considered short-term, and 12 months was considered long-term. For RCTs with more than one follow-up, each follow-up period for VAS was categorized as short-term (≤6 months) and long-term (12 months) in this NMA.The exclusion criteria were as follows: (1) studies in which the subject had an acute cause of low back pain, including fracture, osteoporosis, and malignancy; (2) letters, conference abstracts, and commentaries; (3) different studies recruiting the same participants; and (4) studies from which we could not extract the essential data.Two independent researchers (Han Li and Junyan An) extracted data from the included articles in a standardized data collection form, and a third researcher (Weijian Kong) validated the data extraction. Extracted data included (1) basic information: first author, region of study, study scale, study characteristic, and follow-up; (2) participants: gender distribution, age distribution, number of chronic low back pain patients, and duration of symptoms at enrollment; (3) therapy: protocol and target of interventions; and (4) outcomes: pain relief (the change in mean score on the VAS from baseline).RCTs meeting the inclusion criteria were evaluated with version 2 of the Cochrane tool for assessing risk of bias in randomized trial  and Interventional Pain Management Techniques Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) criteria . RCTs wiSupplementary material  (The change in the mean VAS score from baseline extracted as the primary outcome was reported as the standardized mean difference (SMD) with 95% confidence interval (CI). The Higgins IataCorp) –10. IndiOur search yielded 8,771 records according to the predefined search strategy, of which 1,650 records were duplicates. A total of 7,078 studies were excluded after browsing the abstract. The full texts of 43 RCTs were retrieved for a detailed evaluation. Finally, we identified 10 RCTs for the NMA. The PRISMA flowchart is shown in Supplementary material summarizes the details and the risk of bias of the included RCTs.The study sample size for 10 RCTs ranged from 30 to 150 patients –20. OverThe purpose of this systematic review and network meta-analysis (NMA) was to evaluate the effectiveness of different radiofrequency (RF) denervation procedures for the management of chronic low back pain (CLBP) based on information provided by randomized controlled trials (RCTs). We included 10 RCTs with five interventions: conventional radiofrequency denervation (CRF), pulsed radiofrequency denervation (PRF), pulsed radiofrequency treatment of the dorsal root ganglia (PRF-DRG), radiofrequency facet capsule denervation (RF-FC), and radiofrequency ablation under endoscopic guidance (ERFA). Of these, 60% were considered to have a low risk of bias. The reviewed RCTs provided evidence of fair to moderate quality, suggesting that CRF, ERFA, and PRF-DRG denervation could offer greater pain relief for short-term follow-up than sham surgery, whereas PRF, CRF, ERFA, and RF-FC could offer greater pain relief for long-term follow-up.In 2021, Janapala et al.  publisheFirst, the low total number of patients included in the NMA resulted in a low overall completeness of the evidence. From a clinical point of view, the overall low number of patients is understandable due to the potential damage to patients from x-ray exposure with this invasive technique. However, this methodological shortcoming inevitably leads to a lower quality of evidence.Second, while PRF-DRG denervation showed favorable outcomes in the short term, the result was measured from a single RCT , reflectThird, of the 10 RCTs included in the NMA, only four reported indicators of pain and disorder-specific disability. In this systematic review, we did not include “disorder-specific disability”, “treatment-related costs”, or “ability to work” as required criteria. This was partly because these indicators are not always relevant in patients with CLBP and partly due to the limitations of the trial design of the included RCTs.Fourth, we did not draw definitive conclusions about the risks of RF denervation due to the small size of the RCTs included in the NMA and the lack of assessment of adverse events.Fifth, the follow-up time varied from three months to three years. Three RCTs had a follow-up of less than one year, resulting in missing long-term outcomes. Although two RCTs were performed with up to three years of follow-up, no data were extracted due to the inevitably large proportion of missed visits at the two- and three-year follow-ups. Nevertheless, longer follow-up periods are necessary to demonstrate the effectiveness of RF denervation.Sixth, the lack of RCTs with low bias was a major limitation of this systematic review, although it is encountered in many other systematic reviews. In addition, in most of the RCTs included in the NMA, it was not clearly reported whether cointerventions or similar interventions were avoided. Methodologically sound RCTs with adequate sample sizes performed to assess the effectiveness of RF denervation are still rare.Finally, we attempted to minimize the potential of publication bias through an extensive database search (through December 2021). Although the funnel plot showed no significant publication bias for the included RCTs, it was not possible to assess the impact of potential publication bias on the results.In this systematic review, we analyzed current RCTs regarding different RF treatments in managing CLBP of facet joint origin. The evidence suggested that CRF, ERFA, and PRF-DRG denervation could offer greater pain relief for short-term follow-up than sham surgery, whereas PRF, CRF, ERFA, and RF-FC could offer greater pain relief for long-term follow-up. We concluded that RF is an effective option for patients diagnosed with facet joint-derived CLBP. However, high-quality RCTs with larger patient samples and long-term follow-up results are needed.


The following parameters were evaluated: (1) gliding between tissues; (2) lateral femoral pain during loading; (3) maximum gait speed; (4) stride time variability and step time asymmetry as measures of gait cycle variability; (5) double stance ratio and single stance ratio for assessment of stance phase, (6) jerk; and (7) Locomotor rehabilitation index as a measure of force changes during gait. The gliding coefficient was significantly correlated with lateral femoral pain (r = 0.517), jerk root mean square (r = −0.433), and initial contact-loading response jerk (r = −0.459). The jerk of the force change value during gait was also effective in understanding the characteristics of the gait in the initial contact-loading response in patients with trochanteric fractures. Additionally, gliding is related not only to impairments such as pain but also to disabilities such as those affecting gait.Trochanteric fractures lead to severe functional deficits and gait disorders compared to femoral neck fractures. This study aims to investigate gait parameters related to gliding between tissues (gliding) after trochanteric fracture (TF) surgery. This study implemented a cross-sectional design and was conducted amongst patients who underwent TF surgery ( The global incidence of hip fractures is estimated to increase by 6.3 million every year until 2050 . PostopeGait velocity is a simple, highly valid, and reproducible variable and is assessed for some gait disorders in clinical settings ,9. HowevThe use of inertial sensors with high portability, validity, and reliability has made it possible to measure gait easily . InertiaWe hypothesized that gliding between the VL and subcutaneous tissue is associated with gait disorders during the LR phase of gait motion. The purpose of this study was to investigate the relationship between gliding in the VL and subcutaneous tissue and the parameters as measured by inertial sensors.n = 19, female: n = 75, mean age: 82.9 ± 6.7 years). The patients underwent open reduction and internal fixation (gamma nails). A survey was conducted at approximately three postoperative weeks. The study duration was from June 2019 to December 2020, and the inclusion criterion was pain in the mid portion of the lateral thigh. The exclusion criteria were: (1) patients who had difficulty walking more than 10 m without assistance; (2) patients who could not report their pain accurately due to severe dementia; (3) patients with hemiplegia due to stroke; (4) patients whose gait speed was more than 1 m/s; and (5) patients who could not provide consent to participate in the study. Ninety-four patients with TF participated in this study from two hospitals , and all the patients provided written informed consent.The following parameters were evaluated: (1) gliding between tissues; (2) lateral femoral pain during loading; (3) maximum gait speed; (4) stride time variability (STV)  and stepAn inertial sensor  and the tablet  were used for gait assessment. The inertial sensor was placed on a flat surface and calibrated. For various gait analyses, such as asymmetry, an inertial sensor was attached to the third lumbar vertebra . The ineInitial data was analyzed with stable accelerometer waveform data during steady walking over five steps. Based on IC and toe-off of the left and right sides of the gait cycle, we calculated the percentage of single-leg and double-support phases on the affected side in one gait cycle. The STV , STA 1414, and jThis equation determines the immediate magnitude of vectors by calculating the square root of the sum of each axis when squared, which condensed the three-axis value. To quantify the change in force during gait, the average RMS value of the jerk composite vector during one gait cycle was calculated as jerk RMS  Figure . AdditioThe locomotor rehabilitation index is a method that can determine the similarity between self-selected walking speed and optimal walking speed . First, Then, the locomotor rehabilitation index is calculated from the ratio of the self-selected walking speed to the theoretical optimal walking speed multiplied by 100, according to Equation (3) .(3)LocoLateral femoral pain during the stance phase of the gait was assessed using the numerical rating scale (NRS).Gliding between tissues was applied according to previous studies ,22 as fop < 0.05. The sample size was estimated for a power of 0.8 and an effect size of 0.6. The sample size was determined by GPower 3 Software (version 3.1.9.4) using the T test for correlation. Eighteen participants were deemed adequate (with one extra to account for possible data attrition).Measured data were compared to normal values using the Kolmogorov-Smirnov test. The Pearson product-moment correlation coefficient and Spearman’s rank correlation coefficient were used to examine the correlation between the gliding coefficient, lateral femoral pain, and gait parameters. All statistical analyses were performed using IBM SPSS Statistics for Windows . Statistical significance was set at n = 1, female: n = 17, mean age: 84.9 ± 7.0 years, Height: 149.4 ± 7.0 cm, lower limb length: 70.0 ± 5.2 cm, and postoperative: 34.1 ± 15.3 days) (n = 7), (2) 15 patients with severe dementia, (3) 17 patients without lateral femoral pain on loading, (4) 24 patients who had difficulty with gait for more than 10 m, (5) 11 patients having hemiplegia due to stroke, and (6) Patients having gait speed more than 1 m/s (n = 2). No postoperative problems such as excessive sliding of the lag screw or cut-out were observed in any of the patients.Of the 94 participants, 18 participants met the inclusion criteria and were included in the study  . ReasonsThe results of measurement data are shown in The purpose of this study was to clarify the relationship between the gliding of the lateral thigh following trochanteric fractures and gait parameters. The results showed that gliding had a moderate negative correlation with the jerk RMS and IC-LR jerk. The jerk RMS is strongly correlated with IC-LR jerk. In other words, the change in the force applied to the trunk in the LR phase is considered to be small in cases with low gliding. Additionally, jerk is a parameter that is related to gait velocity but is not associated with lateral femoral pain. Therefore, gliding is related to lateral femoral pain and jerk during gait but not directly to lateral femoral pain and gait. Moreover, gliding was found to be an important parameter that could affect lateral femoral pain and gait velocity. In other words, the jerk of the trunk during gait was low when gliding decreased.This study did not find any postoperative problems such as excessive sliding or cut-out of the lag screw. Therefore, biomechanical parameters such as leg length difference that affect gait were not affected. In our previous study, we reported that lateral femoral pain after trochanteric fracture was associated with gliding  and thatIn previous studies, jerk was considered an index to quantitatively evaluate the quality of motion, such as smoothness and bradykinesia. However, jerk can also be understood as an instantaneous change in force . In partThe jerk of the force change value during gait is also effective in understanding the characteristics of the gait in the IC-LR phases in patients with trochanteric fractures. Additionally, it was found that decreased gliding after trochanteric fracture was not only related to lateral femoral pain but also to loading during gait. Furthermore, our results show that the difficulty in loading during the gait affected the gait speed.The participants of this study were patients with trochanteric fractures and a gait speed of less than 1 m/s. Therefore, the results for participants with a gait speed of more than 1 m/s are not clear. Due to the cross-sectional nature of the study, the causal relationship between gliding and jerk or gait speed is not understood. In the future, it will be necessary to clarify the relationship of gliding between tissues, jerk, and gait ability through intervention studies.The jerk of the force change value during gait is effective in understanding the characteristics of gait in the IC-LR phases among patients with trochanteric fractures. The importance of focusing on jerk RMS and IC-LR jerk were indicated for the improvement of the locomotor rehabilitation index. Additionally, gliding is related not only to impairments such as pain, but also to disabilities such as gait. Therefore, gliding has become an important target for physical therapy interventions.


We tested the hypothesis that reduced skin innervation in fibromyalgia syndrome is associated with specific CNS changes. This prospective case–control study included 43 women diagnosed with fibromyalgia syndrome and 40 healthy controls. We further compared the fibromyalgia subgroups with reduced (n = 21) and normal (n = 22) skin innervation. Brains were analysed for cortical volume, for white matter integrity, and for functional connectivity. Compared to controls, cortical thickness was decreased in regions of the frontal, temporal and parietal cortex in the fibromyalgia group as a whole, and decreased in the bilateral pericalcarine cortices in the fibromyalgia subgroup with reduced skin innervation. Diffusion tensor imaging revealed a significant increase in fractional anisotropy in the corona radiata, the corpus callosum, cingulum and fornix in patients with fibromyalgia compared to healthy controls and decreased FA in parts of the internal capsule and thalamic radiation in the subgroup with reduced skin innervation. Using resting-state fMRI, the fibromyalgia group as a whole showed functional hypoconnectivity between the right midfrontal gyrus and the posterior cerebellum and the right crus cerebellum, respectively. The subgroup with reduced skin innervation showed hyperconnectivity between the inferior frontal gyrus, the angular gyrus and the posterior parietal gyrus. Our results suggest that the subgroup of fibromyalgia patients with pronounced pathology in the peripheral nervous system shows alterations in morphology, structural and functional connectivity also at the level of the encephalon. We propose considering these subgroups when conducting clinical trials.  Abnormalities in pain processing regions in the CNS, neurotransmitter levels, the autonomic nervous system, and in small fibers of the peripheral nervous system are frequent findings associated with FMS, but their causal connection to the manifestation and course of its symptoms is still unclear. Altered pain processing at the level of the CNS is regarded as a major pathophysiological factor3. However, structural lesions and functional deficits were also observed at the level of the PNS, where specifically small fiber pathology is a robust finding in a substantial group of patients fulfilling the established diagnostic criteria of FMS4. These findings of structural and functional alterations in FMS at both CNS and PNS level were reproducible: CNS structural measurements, like voxel-based-morphometry or cortical reconstruction, have revealed atrophy of the grey matter in the left prefrontal cortex and the posterior cingulate cortex6. Diffusion tensor imaging (DTI) has shown changes in white matter integrity, e.g. in the corpus callosum7, and functional magnetic resonance imaging (fMRI) has identified hyperactivity in many regions related to pain processing8, such as the left prefrontal cortex and in the posterior cingulate cortex, the insular cortex and the cerebellum. Functional connectivity was increased in the default mode network (DMN) and pain related areas, such as the insular cortex11. In the PNS, we and other groups described a decrease in intraepidermal nerve fiber density (IENFD)17, which was related to symptom severity4.The fibromyalgia syndrome (FMS) is a chronic pain disorder with a prevalence of approximately 2% in the general population3. Whether CNS and PNS abnormalities coexist in the same patients, or whether CNS and PNS pathology define two non-overlapping subgroups in FMS has never been studied and presents a particular methodological challenge. For FMS, we addressed this challenge in the following manner: We established robust differences between two cohorts of FMS patients using objective and validated criteria of injury at the PNS level . We hypothesized that structural or functional remodeling of the brain would occur differentially in these two subgroups on a global or regional level. We tested this hypothesis in these two FMS subgroups versus case matched healthy controls using MRI methods to measure brain morphometry, structural and functional connectivity.The relative importance of CNS and PNS abnormalities for FMS pathophysiology has been a matter of debate. A continuum between peripherally driven pain at one end and centrally driven pain at the other end has been suggested4. Forty healthy female age and sex matched controls were recruited via public announcements. All patients had been diagnosed with FMS and examined by a rheumatologist and a neurologist, fulfilled the diagnostic criteria for FMS according to the guidelines released by the American College of Rheumatology18, and had been comprehensively examined in our hospital for possible differential diagnoses . Specifically, patients must have had widespread pain for more than three months that could not be explained by other diseases, have a Widespread Pain Index (WPI) ≥ 7 and the Symptom Severity Score ≥ 518.Forty-three female patients with FMS were recruited at the Department of Neurology, University Hospital Würzburg, who also had taken part in a previous study investigating small fiber pathology in FMSAll patients were off their pain medication for 3 days before the examination. None of the patients and controls had been taking anticonvulsants, antihistamines, muscle relaxants or benzodiazepines within the 4 weeks before the examination. All participants in the study gave there written informed consent according to Declaration of Helsinki. The study was approved by the Ethics Committee of the University of Würzburg Medical Faculty (63/18). The exclusion criteria for patients and controls were other current autoimmune or inflammatory diseases that can cause pain, such as rheumatoid arthritis, systemic lupus erythematosus, or chronic inflammatory bowel disease, as well as neurological, cardiovascular, psychiatric diseases, such as major depression, in the past and at present, any contraindication for MRI like cardiac pacemakers, cochlear implants, vascular stents or metal splinters in the body, a history of drug abuse, a history of head trauma requiring medical attention or brains with significant structural abnormalities.4 who had either normal IENFD at the lower leg  and at the upper thigh  or a non-length dependent abnormal IENFD, which means the IENFD was below the lower limits at both biopsy sites, were re-recruited, i.e. were contacted by H.-C. A. and invited to a follow-up appointment for MRI imaging. The first group was termed “noPNS”, the second group “PNS”. These cut-off values were determined based on skin biopsies of these two regions of 120 healthy women  in our department. The cut-off values represent the lower limit of the standard deviation of the IENFD results of all the healthy controls investigated in our laboratory.Patients from the previous study4. To evaluate pain severity, two pain scores were used  and Neuropathic Pain Symptom Inventory (NPSI)). In order to assess the depressiveness of the patients, the “Allgemeine Depressionskala” (ADS) was used, which is a German version of the Center for Epidemiological Studies—Depression scale questionnaire19. To evaluate catastrophizing, the Pain Catastrophizing Scale (PCS)20, which is a self-report measure, consisting of 13 items scored from 0 to 4, resulting in a total possible score of 52, was assessed. To test the anxiety level, the State-Trait Anxiety Inventory (STAI) was used21, which is a commonly used measure of trait and state anxiety. In order to assess the influence of the disease on daily experience, the Fibromyalgia Impact Questionnaire (FIQ)22 was used. Also, the Symptom Severity Scale (SSS) was used to query other FMS-associated symptoms18. It measures three key symptoms during the past week: Fatigue, unrefreshed wakening and cognitive impairment. The O’Leary-Sant Symptom and Problem Index assesses the impairment by bladder dysfunction23 and was selected, as FMS patients frequently report abdominal pain and problems with urination. Data collected in the context of the clinical diagnostics, such as the conduction studies of the sural nerve and the blood values, for example HbA1c and vitamin D, were also analyzed.Results of the questionnaire and clinical examination data of the FMS patients have already been publishedMagnetic resonance imaging was performed on a Siemens MAGNETOM Prisma fit Scanner , operating at 3 T, equipped with a 64-channel head coil at the Department of Neuroradiology, University Hospital Würzburg. For each participant we included a structural T1-weighted (T1w) sequence, diffusion weighted imaging (DWI), fieldmap data and resting-state functional MRI (rs-fMRI) series. The T1w gradient echo MPRAGE sequence (repetition time (TR) 2400 ms, echo time (TE) 3.17 ms, flip angle (FA) 8°, inversion recovery (IR) 1000 ms) contained 176 sagittal slices with an isotropic voxel size of 1 × 1 × 1 mm. The visual examination of the T1w-structural images revealed no gross morphological abnormalities for any patient or subject. DWI was obtained using multiband echo-planar imaging (EPI) with the following parameters: TR = 3100 ms, TE = 89 ms, FA = 90°, isotropic voxel size of 2 × 2 × 2 mm. Diffusion data were collected with reversed phase-encode blips, resulting in pairs of b0-images with distortions in opposite directions for further susceptibility induced distortion correction. Resting state fMRI data was acquired using a T2*-weighted multiband EPI sequence with TR = 1610 ms, TE = 30 ms, FA = 70°, isotropic voxel size of 2 × 2 × 2 mm, 69 slices. During the 9-min resting state fMRI acquisition period with 300 volumes the subjects were told to lie still and remain awake with their eyes open. Participants’ motion was minimized using tight foam pads around the head, their physiology was monitored.25. Parcellations were classified according to the Desikan-Killiany Atlas26. The exact listing of all ROIs used can be found under supplementary material 3. In addition to the exploratory whole-brain approach, hypothesis-driven group comparisons were also performed with volumes of cortical regions that had been shown in a meta-analysis to be specifically affected in FMS5 . Since the factor age has been shown to be associated with differences in white and grey matter volume27, we decided to include this factor as a covariate. We also included the pain intensity score of the GCPS as a covariate.Cortical reconstruction and volumetric segmentation was performed with the FreeSurfer image analysis suite v6.0.0  using the 3D T1w data. The technical details of these procedures are described in prior publicationshttps://www.fmrib.ox.ac.uk)28 was used for DTI data analysis and preprocessing. Our diffusion data, recorded in reversed phase-encode blips, were preprocessed using the FSL tools “topup”29, “eddy (correction)”, “BET”30, and “FNIRT”. FA images and eigenvalue images were created by fitting a tensor model to the preprocessed diffusion data using the FSL FDT toolbox . For ROI specific evaluation of the FA data we created a mask with the ICBM-DTI-81 white-matter labels atlas  in the same space and calculated the average FA value of all voxels in 48 ROIs. The exact listing of all tracts used as ROIs can be found under supplementary material 32, the corpus callosum7, the cingulum and the white matter adjacent to the insula ).The Oxford Centre for Functional Magnetic Resonance Imaging of the Brain software library  and the CONN Toolbox v18  running in Matlab R2019a . The reason for changing from FSL to the Conn Toolbox run in SPM was the extensive ROI to ROI analysis provided by this toolbox. Functional data were realigned, slice-time corrected, spatially normalized to the Montreal Neurological Institute (MNI) space, and spatially smoothed with a FWHM Gaussian kernel of 8 mm. We collected fieldmaps and undistorted the EPI images using the Fieldmap Toolbox (SPM). Motion parameters from realignment were evaluated, and a motion artefact threshold  was employed for exclusion. Participant motion parameters were included as first-level covariates. No participants displayed gross movements to require total exclusion. Slices with motion parameters outside of the threshold were discarded. After denoising, quality control measurements (mean motion and max motion) were correlated and plotted with the functional connectivity values to control for influences (QC-FC correlations). To remove blood-oxygen-level-dependent (BOLD) signal from the cerebral white matter and ventricles, each participant’s T1-weighted MPRAGE image was automatically segmented into grey matter, white matter, cerebrospinal fluid, normalized and transformed to MNI space using the Computational Anatomy Toolbox  running in SPM12. BOLD data were bandpass filtered (0.008–0.09 Hz) to reduce low-frequency drift and noise effects. We then generated seed-to-seed connectivity maps for each individual using 164 seeds. These seeds are provided in the CONN software35. The exact classification of all seeds and the MNI coordinates of all network hubs are documented in supplementary material 36, the frontoparietal network37, the default mode network10 and the somatosensory network38). Pain intensity (GCPS) and ADS (depression) scores were included as second-level covariates. The influence of the IENFD data on the FC-values was analyzed using a linear regression model. False discovery rate (FDR) correction was applied at the cluster level (p < 0.05).Resting state functional data were spatially preprocessed using SPM12  and Cohen’s d. The correlation analyses were performed with a Pearson correlation (after controlling for the distribution of the data), 1000 samples of bootstrapping and a significance level of 0.01. All post-hoc group comparisons were corrected for multiple comparisons using the false discovery rate algorithm39.Data were analyzed with IBM SPSS Statistics for Windows, Version 25.0  and JASP (JASP Team (2021) . We tested the clinical data for normal distribution with a Shapiro–Wilk test and then, depending on the result, examined for group differences with a two-tailed t-test or a Mann–Whitney-U test. Data are given as mean ± SD or median/range unless otherwise specified. We used the Levene test with a significance threshold of 0.05 to check the data for equivalence of variance. The confidence interval was set at 95%. ROI group means of the structural, DTI and functional connectivity data were compared using an ANCOVA after controlling for interactions between the covariate and fixed factor and Tukey-tests for post-hoc comparisons. For the ANCOVA, effect sizes are displayed as ώThe raw, skull stripped, data used to analyze the following results can be obtained upon request from the corresponding author. The processing and statistical analysis of the data was done using established neuroimaging software, as described in the methods. The STROBE Statement-Checklist was used for the quality control of our case–control study.The patient group  and the healthy control group  did not differ in age and BMI. The subgroups noPNS  and PNS (decreased IENFD) differed in BMI, with a higher BMI in the PNS subgroup Tables , 2.Table4. In patients with reduced distal and proximal IENFD (PNS group), FMS symptoms were more severe (p = 0.02) and quality of life was lower compared to FMS patients with normal distal and proximal IENFD (p = 0.01) as reflected by the values of the GCPS pain intensity and the FIQ questionnaire , PNS patients n = 21) and noPNS patients (n = 22). Cortical volume differed between the FMS and control groups in 10 cortical regions , in the posterior cingulate cortex , and trendwise in the left rostral midfrontal cortex  compared to the control group. The subgroup comparison PNS versus noPNS showed no differences in these regions , posterior cingulate cortex , left rostral midfrontal cortex ).Following a meta-analysis that analyzed FMS data from voxel-based morphometryIn the ROI-based analysis comparing patients and controls, a significant increase in FA was found in 14 out of 48 ROIs in FMS patients (after FDR-correction). This was evident in corticospinal pathways such as the corona radiata, but also in regions of the limbic systems such as the fornix and cingulum. A detailed list of these regions with the respective FA values can be found in Table The Pearson correlation analysis, a-priori restricted to the 14 regions that revealed differences in the group comparison, showed a negative association with the anxiety questionnaire (STAI-S) and the FA of the fornix , the posterior thalamic radiation  and the right posterior corona radiata . This means that higher anxiety scores were associated with lowered FA in the respective areas.2 = 0.13), in the body of the corpus callosum , in the genu of the corpus callosum , and in the posterior thalamic radiation . No significant differences were found in the anterior limb of the left  and right  internal capsule and the splenium of the corpus callosum .White matter tracts that had already shown changes in patients with FMS in the literature are the corpus callosum, the thalamus, the cingulate, and the insular cortex connecting tracts . Our data indicated also an increased FA in the FMS group compared to controls in the cingulum . No subgroup differences were seen in the cingulum , body of the corpus callosum , genu of the corpus callosum , splenium of the corpus callosum , and the anterior limb of the left  and right  internal capsule.Subgroup comparison between PNS and noPNS showed an increased FA of the posterior thalamic radiation in the noPNS subgroup  and to the right crus cerebelli 1 (p-FDR = 0.048) in FMS patients. Seed-to-seed analysis between the subgroups noPNS and PNS showed one FDR-corrected cluster of the PNS subgroup compared to the noPNS subgroup  with hyperconnectivity between the left and right inferior frontal gyrus (IFG) and the right angular gyrus  and posterior parietal cortex  respectively  and compared these subgroups with each other. While the structural and functional differences in MRI studies of FM patients have been described in the literature, so far no study has investigated the possible interaction between the peripheral nervous system and the brain of FMS patients.We show that in FMS (1) cortical volume is decreased in the left and right frontal/temporal cortices and the left insula, (2) FA is generally increased in corticospinal tracts and regions of the limbic system and (3) functional connectivity is reduced between the right midfrontal gyrus and the posterior cerebellum as well as the right crus cerebelli.Comparison of the noPNS and PNS subgroups showed (1) lower volumes in the bilateral pericalcarine cortex in the PNS group, (2) lower FA in the left posterior limb of internal capsule and in the posterior thalamic radiation in the PNS group and (3) a hyperconnectivity cluster between the bilateral inferior frontal gyri, the angular gyrus and the posterior parietal cortex in the PNS group. In summary, the noPNS group showed greater deviations from healthy controls in structural MRI measures than the PNS group.40. These regions also appear to change their cortical thickness as the disease progresses41. Decreased gray matter in the left fusiform and prefrontal cortex was also found in FMS patients in another voxel morphometry-based meta-analysis42. In our hypothesis-driven analysis restricted to regions that showed lower cortex volumes in a meta-analysis of structural FMS data , we were able to reproduce the results of the meta-analysis5. However, in our subgroup comparisons, these regions showed no significant differences. The prefrontal cortex is a known site of pain modulation. Indeed, a dual role has been described including antinociceptive effects by modulating sensory afferent influx, as well as the furthering of chronic pain via corticostriatal projections. Interestingly, decline of prefrontal cortex volume in chronic pain can be reversed with successful biopsychosocial therapy, be it cognitive behavioral therapy, exercise or transcranial magnetic stimulation43.Our results on the cortical volume are for the most part  in line with the results of a meta-analysis which pooled structural and functional MRI studies comparing FMS patients to healthy controls44. This hypoconnectivity was also demonstrated in another study using resting state fMRI45 and was associated with decreased resiliency towards pain46. However, the pericalcarine cortex is also involved in other pain disorders, for example, its volume changes during acute migraine attacks and normalizes in post-ictal phases47. Our results do not allow us to determine whether the pericalcarine cortices decrease in volume during the course of the disease in the PNS group or whether the difference exists at the onset of the disease. Longitudinal studies are needed to explore the role of the pericalcarine cortex in pain development.Our subgroup comparison of cortex volume data showed a bilateral decrease in the volume of the pericalcarine cortex in the PNS group. Interestingly, in our results, the pericalcarine cortex is the only region that shows larger volumes in the FMS patients compared to the healthy controls. Thus, the noPNS group has a greater change in pericalcarine volume compared to the healthy controls. The pericalcarine cortex is part of the visual cortex. In our literature research, this region has not yet been associated with FMS symptoms. A magnetoencephalography study showed that the visual cortex in FMS patients has decreased connectivity to other brain regions33. Except for the anterior limbs of the internal capsule, we were able to reproduce these results in our hypotheses driven analyses. Regarding our subgroups analyses, two regions showed a significant decrease of FA in the PNS group compared with the noPNS group . Increased FA of these regions has already been found in studies with FMS patients or other chronic pain disorders and was associated with pain severity48. It has also been shown in FMS patients that white matter pathways with increased FA after a prolonged period of increased activity49, in this case in pain processing regions, show decreased FA again after pain chronification and show lower values than healthy controls33. Longitudinal study designs are needed to clarify the extent to which FA changes over the course of chronic pain disorders and the influences of a reduction or increase in FA on symptoms.Regarding FA, a marker for the integrity of the white matter, our whole brain analysis showed an increase in FA in the corona radiata and regions of the limbic system (e.g. fornix and cingulate cortex) in the FMS group compared to controls. The previous results of diffusion imaging in FMS patients are not consistent, and the results here vary widely. Regions that frequently showed changes in FA in the literature were the corpus callosum, the cingulum, the thalamus, and the anterior limb of the internal capsule adjacent to the insular cortex50 we could not reproduce alterations in these hubs with our data. The reason for this could be the lack of control for depression or pain intensity in other studies or different methods of analysis. The cluster found in our subgroup analysis has not been described in the FMS literature before. All involved regions  are involved in attention and evaluation of external and internal stimuli. Overactivation of the angular gyrus in fMRI has been associated with a stronger negative evaluation of pain51, while the inferior frontal gyrus seems to be involved in the regulation of emotions52. The posterior parietal gyrus with its connections to the somatosensory cortex appears to have an important role in the spatial perception of pain stimuli53.Regarding functional connectivity, even after limiting the regions of interest included in the analysis to network hubs already published in the FMS literature 54. For example, it has already been suggested that a lower activity of the prefrontal cortex, a well-known pain modulation area, could lead to a failure in the elimination of subcortically driven fear behaviors, thereby resulting in pain chronification55. It is currently unclear whether these processes are adaptive, maladaptive or cause some of the symptoms. In order to better understand the pathophysiology of FMS, it is therefore important to first understand the role of brain neuroplasticity in chronic pain, as a brain signature of pain appears to be found across various pain syndromes56. Neuroimaging studies with multiple pain syndromes as comparison groups are needed here before finding brain regions specific to FMS that could potentially trigger some of the symptomatology.Most of our findings have been described in other publications about chronic pain imaging57. This emphasizes the need for longitudinal studies.Our study has some limitations. Because our study was designed as a cross-sectional study, the question of the reasons for and the effects of our detected group differences cannot be answered. By including individual pain intensity as a covariate in our group statistics, we attempted to account for a possible influence of pain intensity on our MRI results. However, because none of the MRI modalities showed a significant association with IENFD scores after FDR correction, we cannot rule out the possibility that subgroup differences were driven by other factors not captured in our clinical examinations. Furthermore, even structural MRI markers, such as cortical volume, are subject to temporal variations, depending, for example, on acute stimulus severity4, only 2% of normal controls had reduced IENFD at the lower and upper leg, so that it is highly unlikely that a large number of our present controls would have had this finding.The healthy controls in our study did not receive a skin biopsy, so we cannot rule out that some persons with reduced IENFD might have been in this group. However, in our previous studyWhile structural and functional MRI changes in FMS patients have already been investigated, our study first demonstrated differences between FMS subgroups with and without peripheral nerve involvement. The study design obviously does not allow any conclusions to be drawn about the reasons for and effects of these subgroup differences. While most clinical trials on FMS therapy included only patients diagnosed according to current diagnostic criteria, one has to consider that FMS is a heterogeneous condition with potentially different underlying pathophysiological processes within subgroups. These subgroups might respond differentially to specific treatments. Psychiatric comorbidities, such as depression and anxiety, also affect the brain structure in FMS and thus influence the results in MRI imaging. We therefore advocate that future studies should take into account the different subgroups of patients both on the basis of small nerve fiber pathology, symptom severity, and psychiatric comorbidities.Supplementary Information.


Background: Preoperative patient education is an effective intervention of the healthcare team, which has been used to promote patient recovery and well-being.Aim: The aim of this study was to investigate the effect of a nursing preoperative educational intervention on the anxiety and pain of patients undergoing spinal decompression surgery.Methods: In this pilot randomized controlled study, patients (n=40) undergoing spinal decompression surgery, were randomized into an intervention group  and a control group (n=17). The preoperative educational intervention included an oral briefing and a leaflet with perioperative care information as well as post-discharge care. Participants completed the Amsterdam Preoperative Anxiety and Information Scale (APAIS), the subscale “State” of the State and Trait Anxiety Inventory (STAI-S), the Numerical Rating Scale, and a questionnaire about demographic characteristics, the day before surgery (T0) and the first post-operation day (T1). Data analysis was conducted using SPSS 22.0. The statistical significance level was set at p<0.05.surgery. Additionally, in both groups after surgery, high state anxiety scores on the STAI-S scale were associated with high pain levels. There were no statistically significant group differences with regard to scores of STAI-S before and after surgery.Results. A significant reduction was found in pain intensity before and after surgery in both groups. Pain levels, after surgery, were significantly lower in the intervention group compared to pain levels in the control group . In both groups, high state anxiety scores on the STAI-S scale before surgery were confirmed by high anxiety scores in APAISConclusions. Nursing preoperative educational intervention in patients undergoing spinal decompression surgery had a positive impact on reducing the intensity of pain after surgery. These results indicated that nurses and health care providers should integrate patient education and health literacy into their daily clinical practice. Spinal decompression surgery is commonly offered to patients with intervertebral disc herniation and lumbar stenosis when conservative management of symptoms is not effective. These pathological conditions have a high prevalence  and negaNurses often use educational interventions to reduce patients’ anxiety ,5, focusDuring the pandemic, time constraints and severe nursing staff restrictions in Greece resulted in limited preoperative educational briefings between patients and healthcare professionals which were generally limited to the surgical procedure itself. Thus, patients who received standard or usual care were informed by the surgeon and signed the consent form. The consent form is a legal requirement before surgery, conducted exclusively by the surgeon, emphasizes information about the surgical procedure, the outcomes, and the potential complications, and ensures patients’ consent for the surgery . On the The aim of this study was to investigate the effect of a systematic preoperative educational intervention on the levels of stress and pain experienced by patients who underwent spinal decompression surgery.Study designThis pilot study was a randomized controlled pilot study, which includes an intervention group (IG) and a control group (CG) with pre-intervention and post-intervention measurements.Sample and procedureThe sample of this pilot study consisted of 40 patients in total, suffering from intervertebral disc herniation or lumbar stenosis. Patients were admitted to the neurosurgery clinic in a tertiary hospital in Athens, Greece, to undergo microdiscectomy or laminectomy during the time period from November 2020 to October 2021. Patients were randomly allocated to either the CG (17 patients) or the IG (23 patients) based on the admission date and received an individualized educational intervention. Patients admitted on an odd date were allocated to the CG, while patients admitted on an even date were allocated to the IG. None of the participants knew which group they belonged to. The inclusion criteria were: age > 18 years, impending spinal decompression surgery (microdiscectomy or laminectomy), ability to speak and understand the Greek language, and provision of consent to participate in the study.Prior to the surgery, participants were informed about the study and signed the consent form for their participation. One day before surgery (T0) all participants completed the questionnaire Figure .Patients of the CG after completion of the questionnaire (T0) received standard care from the healthcare providers and did not receive educational intervention from the researcher. In the afternoon of the first postoperative day (T1) (24-30 hours after the surgery) they completed again the same questionnaire, except for the Amsterdam Preoperative Anxiety and Information (APAIS) since it measures patients' anxiety and needs for information in the preoperative period.Patients in the IG, immediately after the completion of the questionnaire (T0), received the educational intervention which included oral conversation and provision of information lasting about 30-45 minutes concerning preoperative, intraoperative, and postoperative nursing care. A leaflet containing the same information was given to patients as well. In the afternoon of the first postoperative day (T1), patients completed the same questionnaire again, except for the APAIS scale.Educational interventionPreoperative education is a nursing intervention that clinical nurses and other team members apply in order to enhance patient self-efficacy. The design and preparation of the current preoperative educational intervention were based on the current trends , the content of the intervention included post-operation management and appropriate follow-up) .An oral briefing was made by the primary researcher, who is a nurse with long clinical experience in the neurosurgery clinic and the nursing care of these patients. The educational intervention was based on the leaflet which was created for the purposes of this study and was given to patients. The leaflet and therefore the oral briefing consisted of four sections aiming to increase patients’ health literacy. The first section consisted of information about intervertebral disc herniation and lumbar stenosis. The second concerned the patient’s preoperative preparation . The third section included informing the patient about the care and procedures in the intraoperative phase . Finally, the fourth section concerned the patient’s postoperative care during hospitalization as well care following hospital discharge .The leaflet was designed by the primary researcher and finalized with the contribution of the entire research team, based on their long clinical experience and the available literature. During the preparation of the educational material, the researcher took into account questions, queries, and remarks related to the specific surgery that are formulated by the patients who are being treated in the unit where she works. The first version of the material was then given for evaluation to an academic with knowledge of providing nursing care for patients undergoing spine surgery, to a clinical nurse with many years (> 15 years) of experience in the nursing care of patients undergoing spine surgery, and to 2 patients who were not included in the present sample. Then, following the comments, corrections, and modifications acknowledged by the specialists and the patients, the educational material took its final form and was printed out. The printed educational material contains images, is comprehensible to readers, and is written in a language that is simple and easy for them to understand.MeasuresThe questionnaires used in the present study were the following. A questionnaire regarding demographic data was constructed for the study .The State and Trait Anxiety Inventory (STAI-S) scale measures state (adaptive response to a situation) and trait anxiety  . Only thThe APAIS measures patients' anxiety and need for information during the preoperative period . The 6 iThe Numeric Rating Scale (NRS) was used to assess pain. A value of 0 represents “no pain at all” and a value of 10 represents “the worst pain there can be.” Values ranging from 1 to 3 reflect mild pain, 4 to 6 reflect moderate pain and 7 to 10 reflect severe pain .Ethical considerationsThis study was approved by the Scientific Committee of the Nikaia’s Hospital in Athens, Greece (Ref No: 53563/25-11-2020). Written informed consent was obtained by all participants. Helsinki declaration principles were abided by in this study. Permissions were obtained for the use of STAI and APAIS scales by their developers.Statistical analysisStatistical analysis of the study’s variables was performed using Statistical Package for Social Sciences (SPSS) version 22.0 . Shapiro-Wilk's test was employed to examine whether quantitative variables followed a normal distribution, due to our small sample size. T-test was used to examine the presence or absence of relationships between a quantitative variable and a dichotomous variable. Pearson’s correlation coefficients were used to examine the relationship between two quantitative variables. In order to examine the questionnaires’ reliability, Cronbach’s α value was calculated. Cronbach’s α value for the STAI questionnaire was 0.938 and for the APAIS questionnaire was 0.771. These values are considered satisfactory (APAIS) to very good (STAI). The level of statistical significance was set to p<0.05.Our sample consisted of 40 patients, 23 of them, 13 men and 10 women, were allocated to the IG. The rest 17 (seven men and 10 women) were allocated to the CG. There were no significant differences in demographic and clinical characteristics between the two groups . Additionally, after surgery, high scores on the STAI-S scale were associated with high pain levels as demonstrated by NRS scale values, in both groups .After performing Kendall’s tau test Table , it was Using the t-test procedure, a significant reduction was found in pain intensity (NRS scores) before and after surgery in both groups Table . High paanesthesia and APAISsurgery)  Table .This study investigated the effect of preoperative educational intervention on the stress and pain experienced by patients undergoing spinal decompression surgery and demonstrated that educating patients preoperatively can reduce the pain they experience postoperatively.The most important finding of this pilot study was that preoperative educational intervention significantly reduced postoperative pain in patients who underwent spinal decompression surgery compared to patients who did not receive preoperative education. This finding is consistent with the randomized study of Lee et al. in patients who underwent spine surgery  and anotIn the present study, a reduction in postoperative pain intensity was found in both groups. In the IG, the reduction of pain is probably attributed to the intervention and postoperative analgesia. In the group that received the usual preparation for surgery without education, the reduction in postoperative pain may be related to postoperative analgesia alone. However, the statistically significant difference found in postoperative pain between the two groups strongly indicates the positive effect of preoperative education in the IG group. It would be interesting in future studies to control for the type and amount of postoperative analgesia, as these were not identified in the context of the present pilot study.The results suggest that in both groups, high postoperative state anxiety was associated with high postoperative pain intensity. The relationship between anxiety and pain is also confirmed by another study where a positive significant correlation between anxiety and pain was found in patients after total knee or hip arthroplasty and they concluded that the most important prognostic factor for postoperative anxiety is preoperative anxiety . A previThe present study found no statistically significant group differences in stress reduction (STAI-S), before and after surgery. This finding may be attributed to the small study sample in both groups. Consistent with our findings, several studies do not reveal a significant influence of the educational intervention on the level of anxiety of patients undergoing spine surgery , thyroidbefore), in both groups, was associated with increased anxiety for the surgery (APAISsurgery); as it is stated in a previous study that the correlation of the APAIS scale with the STAI-S scale is an important indicator of the validity of the APAIS scale [The current pilot study suggests that increased state anxiety before surgery (STAI-SIS scale .Limitations and strengths of the studyThe present research is a pilot study with a small sample size in both the IG and the CG. Data collection was performed during the SARS-CoV-2 pandemic, a time period where only emergency surgeries were conducted, a fact that led to severe difficulty in acquiring a larger sample as well as marked delays in questionnaires’ distribution and collection. A larger and more representative sample may have yielded more insight regarding relationships between variables’ correlations and may have led to more concrete results. Another limitation is the origin of the sample from only one hospital, a fact that limits the sample’s representativeness and generalizability. A multi-center study could have yielded more reliable results thus allowing for their generalization. One more limitation was the fact that data were collected only on the first post-operative day, due to the patients’ very short length of hospital stay. Follow-up measurements could have strengthened our results.Despite the above limitations, the homogeneous delivery of the intervention which was conducted exclusively by the primary researcher, as well as the fact that the sample of patients underwent similar, in extent and severity, surgical procedures constitute strengths that add to the rigor of our study.In conclusion, the results of this pilot randomized intervention study add new evidence of the effectiveness of the preoperative educational intervention as a strategy to reduce the intensity of pain experienced postoperatively by patients undergoing spine decompression surgery. Patient education and health literacy promotion, are an integral part of nursing care and its implementation could be facilitated by the development of education protocols for procedures performed, such as preparation for surgery, or clinical examination. The results of the current as well as similar studies which show the effectiveness of preoperative education may increase awareness of nurses and health care professionals about the importance of integration of documented educational interventions in daily clinical practice.


Robot-assisted minimally invasive esophagectomy (RAMIE) shows promising results regarding postoperative complications in patients with esophageal cancer. To date, no data are available regarding postoperative analgesic consumption. The aim of this work is to evaluate analgesic consumption after esophagectomy.n = 51) were compared with the hybrid technique  and open abdominothoracic esophagectomy (OTE) (n = 164). Data were collected retrospectively. The primary endpoint was the overall postoperative morphine consumption, which represents a reliable indirect measurement of pain. Pain levels recorded on the first, third, and fifth postoperative days were assessed as secondary endpoints.A total of 274 Ivor Lewis esophageal resections performed sequentially from January 2012 to December 2020 were evaluated. RAMIE cases (p = 0.016). The overall postoperative opioid consumption for patients who underwent RAMIE was significantly lower  compared with the open  and hybrid  groups. Patients who underwent RAMIE reported lower pain scores compared with the open group on the fifth postoperative day, both at rest (p = 0.004) and while performing activities (p < 0.001).A total of 274 patients were included. The postoperative opioid consumption rate for patients who underwent RAMIE /kg body weight (bw)/day) was significantly lower than in the open group (0.19, 0.33, 0.58 mg MME/kg bw/day, This study shows that patients who underwent RAMIE experienced similar postoperative pain while requiring significantly lower amounts of opioids compared with patients who underwent open and hybrid surgery. Further studies are required to verify the results. The advanced magnified 3D overview, enhanced maneuverability of surgical tools in constrained space, seven degrees of freedom of movement, and reduced-access trauma have helped overcome prior limitations of laparoscopic minimal invasive procedures.15 The single previous randomized study  asserted lower rates of complications and postoperative pain. 16 The availability of data on robot-assisted esophageal surgery is limited, and the need for new randomized research is compounded by the growing desire for robotic treatment among patients.Since the onset of using robotics in esophageal surgery, several cohort studies have indicated that robotic techniques are a viable alternative to the current conventional standard of open procedures, both in terms of safety and oncological outcomes.This study examined the primary endpoint of morphine consumption as a proxy for the hypothetical level of pain that patients would have experienced in the absence of analgesics. This endpoint is more informative than pain scores in a retrospective analysis because patients receive a pain-adjusted regime of analgesics.Reduced operation trauma and excellent postoperative pain management can help patients avoid pain, which is a critical component of contemporary surgery. Therefore, in addition to cumulative morphine dose and pain scores, this study assessed complication rates, blood loss, and postoperative hospital and intensive care stay.The study was an investigator-driven and investigator-initiated, single-center, retrospective clinical trial of 274 patients who had an Ivor Lewis esophageal resection performed at the Muenster University Hospital . Between 1 January 2012 and 31 October 2020, patients were treated with one of three different surgical techniques for oncological esophageal resection. The procedures carried out were robotic-assisted minimal invasive esophagectomy (RAMIE) , hybrid esophagectomy (HYBRID) (laparoscopic gastric mobilization and open right thoracotomy), and complete open esophagectomy (OTE). The medical records of the patient sample were evaluated for postoperative pain and opioid usage, retrospectively. Datasets were complete for all included patients.19 Additional approval was obtained from the combined ethics committee of the University of Muenster  and the Medical Association of Westphalia-Lippe (Reference Number: 2021-051-f-S). Written general consent for scientific use of medical data was obtained from all treated patients. The study was registered in the German Clinical Trial Register (Reference Number DRKS00027859).This study was conducted according to guidelines laid out in the Declaration of Helsinki with Good Clinical Practice (GCP), and the STROCSS 2019 Guideline.20 or intraoperative termination following diagnostic laparoscopy were excluded. After introduction of the RAMIE approach, the first 16 surgery instances were also excluded owing to the operating surgeon’s primary learning curve with structured proctoring.11 Two surgeons, who since 2008 have specialized in the field of upper gastrointestinal (GI) surgery, performed all the procedures studied. All robotic-assisted procedures were performed by one of these two surgeons. The learning curves of the open and hybrid technologies occurred prior to 2012 and accordingly have not been accounted for.The study included all patients aged ≥ 18 years with a histological diagnosis of thoracic or abdominal esophagus carcinoma, which was surgically resectable at the time of diagnosis or (if performed) post-neoadjuvant therapy. The sample includes all patients treated via Ivor Lewis esophagectomy with the above-mentioned techniques, fulfilling these criteria at the Muenster University Hospital between 1 January 2012 and 31 October 2020. Patients who demonstrated either a cervical esophageal carcinoma, a carcinoma of the gastroesophageal junction, classified as Siewert III,22The diagnostic workup of all cases consisted of a physical and nutritional assessment, an endoscopy including biopsy, an endoscopic ultrasound, and a computer tomography scan for cancer staging. The indication for surgery and, if required, neoadjuvant therapy was provided by a multidisciplinary cancer board at the Muenster University Hospital . All neoadjuvant treatment was performed following the German Cancer Society (DKG) guidelines for esophageal adenocarcinoma and squamous cell carcinoma. During the study period, neoadjuvant chemotherapy or chemoradiotherapy was conducted following the FLOT  or CROSS (carboplatin/paclitaxel) schemes.23In all three groups, postoperative pain management was based on epidural anesthesia in combination with a pain-adjusted regime of opioid and non-opioid analgesics administered orally or intravenously.25 During the observation period of this trial, no major changes in the treatment algorithms  of the acute pain service have occurred at our center.Patients scheduled for Ivor Lewis esophagectomy have an epidural catheter placed at the level of the seventh to ninth vertebrae. All catheters were placed before surgery in awake patients by experienced anesthesiologists. On the intensive care unit and the general wards, the quality of the epidural anesthesia is controlled daily by an experienced acute pain service specialist. Ineffective epidural catheters were removed as early as possible or were placed again if needed.Evaluation and changes of pain medication were conducted by a specialized anesthesiologic team in consultation with the surgeons. Prior to patients being discharged, all opioid analgesics were discontinued. Owing to regulatory standards, pain therapy with morphine is largely restricted to in-patient hospital use. If postoperative pain persists, the patients’ hospital stay is subsequently prolonged. The subjective sensation of pain was examined multiple times each day using a numerical rating scale. For this study, the median of these values per day and patient were evaluated.27All dissected tumors were evaluated by a specialized gastrointestinal pathologist according to a standardized protocol. The resection margins were examined intraoperatively using frozen section techniques and postoperatively using histological analysis. According to the most recent UICC classification, additional tumor extension, presence, localization, and number of lymph nodes were documented.Intraoperatively, chest tubes and a sponge-coated nasogastric tube connected with a negative pressure of −125 mmHg were placed in all cases. All patients were monitored in the ICU after surgery for at least one night. If there were no complications, the patient was transferred to the general ward. All patients underwent a routine check on the fifth day post-surgery for anastomotic insufficiency by conducting an esophagogastroduodenoscopy. In the case of regular findings, the nasogastric tube was removed, and an esophagogram was performed. The oral diet was started with liquid followed by soft food, each for 3 days. Physiotherapy in all groups was started at the intensive care unit 1 day after surgery and includes chairing on the first postoperative day and walking on the second postoperative day.Chest drains were removed after exclusion of a chylothorax and a drainage output of less than 200 ml per day.The protocols for the intensive care unit stay and further postoperative management underwent no major changes since 2012. The same assessment can be made for the diet regime, mobilization through physiotherapy, respiratory training, and blood management. There was no standardized Enhanced Recovery After Surgery (ERAS) program in any group.28 The abdominal stage was conducted via conventional laparoscopy. The thoracic stage was executed by using a da Vinci Surgical System .The RAMIE technique is a two-stage transthoracic esophagectomy.The abdominal phase of the hybrid esophagectomy was performed laparoscopically, as with the RAMIE method. An anterolateral thoracotomy on the right side was performed during the thoracic stage. A median laparotomy was followed by an anterolateral thoracotomy in the traditional open esophagectomy.All three surgical methods are based on the exact same technique for reconstruction of the esophagus. In all three groups in the abdominal stage, a bendable endoscopic linear cutter with a length of 45 mm is used in the preparation of the gastric tube. The anastomotic technique in the thoracic stage varied only in the surgical access route . In all techniques, a plate is sutured into the esophageal settlement margin via a purse-string suture. The gastric tube is anastomosed using a 29 mm CDH circular stapler  in end-to-side technique. The lateral part of the gastric tube with the attached tumor-bearing specimen is detached using the bendable endoscopic linear cutter (45 mm). Usually, for this step, two staple loaders (with a staple depth of 1.8–3 mm) are needed.29The primary endpoint was the postoperative opioid usage in morphine milligram equivalents, measured either cumulatively, or normalized by patient weight and length of stay. The postoperative pain levels, measured on days 1, 3, and 5 during movement and rest, were documented using a numerical rating scale (NRS), which were treated as secondary endpoints. Morphine consumption is justified as a primary endpoint because this is a retrospective study in which patients received a pain-adjusted regime of analgesics. Therefore, if analgesic consumption differs across groups, subsequent pain levels are not comparable. In contrast, opioid consumption is a more reliable proxy for the level of pain, which patients would have experienced in the hypothetical absence of a pain management regime. Furthermore, minimizing opioid consumption while maintaining patient comfort is a desirable clinical goal to reduce opioid-related side effects.30 using the modified Clavien–Dindo classification.31Additional secondary endpoints were the length of postoperative hospitalization stay, duration of ICU stay, postoperative complications, occurrence of pneumonia and anastomotic leakage, scale of blood loss, overall operation time, survival rate, and resection tumor margins. Postoperative complications were assessed following the Esophagectomy Complication Consensus Group (ECCG)Z-test to compare two proportions, a Kaplan–Meier estimator, and log-rank test to perform survival analyses. All reported p values were two-sided. Multiplicity adjustments for pairwise comparisons across the three groups were made through a Holm correction. The significance level for the adjusted p values was set to p = 0.050.Statistical analysis was performed using the program R version 4.0.3 . Categorical variables were summarized by counts and proportions. Quantitative variables were summarized by their mean and standard deviation if normally distributed, and otherwise by quartiles. Statistical significance was determined using Fisher's combination test to assess the independence of two categorical variables, pairwise Mann–Whitney tests to compare two non-normally distributed quantitative variables, a two-sample Between January 2012 and October 2020, 375 patients underwent surgery for resectable esophageal cancer. Of these, 274 patients were treated by the Ivor Lewis technique and eligible for inclusion. A total of 51 patients were treated via RAMIE, 59 via HYBRID, and 164 via open surgery. In five cases, metastatic spread was found intraoperatively . These cases were included in further analysis. There were no statistically significant differences in demographic and clinical characteristics among the three patient population groups at the beginning of the study (Table p = 0.038) and OTE  approaches  versus OTE 4.85, 8.59, 14.63 mg/kg (p < 0.001)], and, although less significantly, so did the analysis adjusted by body weight and length of stay .Patients treated by RAMIE postoperatively received significantly lower amounts of opioid analgesics  compared with those treated with HYBRID . The same results could also be evaluated at rest on the third postoperative day (p = 0.005). On the fifth postoperative day, pain levels while active and at rest were lower in the RAMIE group compared with OTE procedures . All other pairwise comparisons between pain levels on the first, third, and fifth postoperative days were not statistically significant  and hybrid (22.0%) surgery than in the OTE comparison group (37.2%), although these differences were not statistically significant. The severity of complications, recorded via Clavien–Dindo classification, was lower in the RAMIE  and HYBRID  than in the OTE  group, but these differences were not statistically significant. The prevalence of severe complications (CD ≥ 3b) was lower in the RAMIE (13.7%) and HYBRID (11.9%) than in the OTE group (21.3%), but these differences were not statistically significant (Table 3.5% and p < 0.001) and open  groups. However, the duration of intensive care stay was significantly lower among patients undergoing RAMIE  compared with the HYBRID  and OTE  groups. The duration of postoperative hospital stay was significantly lower in the RAMIE group  than in the OTE  group, but similar to that of the HYBRID group .The operative time was significantly higher in the robotic  compared with hybrid . No significant difference was found in between RAMIE and HYBRID (p = 0.14). Conversions occurred in neither RAMIE nor the laparoscopic part of the hybrid technique  and hybrid operations  was lower than in open procedures   than in the HYBRID (15.3%) and OTE group (7.3%). However, these differences were not statistically significant. Survival rates did not differ across the three groups.p = 0.038; RAMIE versus OTE p < 0.001). We found a significant difference regarding the per day amount of morphine consumption, when comparing RAMIE with open surgery techniques. Between RAMIE and HYBRID techniques, a significant difference can only be evaluated in the total morphine consumption and not for per day consumption, as stated. However, there is no significant difference between the duration of hospital stay for these groups, which allows comparability of the total amount of morphine consumption. Distortions of the reported morphine equivalent doses due to different lengths of epidural anesthesia were ruled out as no significant difference was observed.32Patients who underwent robotic surgery consumed significantly fewer opioid analgesics to achieve a sufficient analgesia than the other two groups  and while active (p = 0.009). In patients who underwent robotic-assisted operation, lower pain scores were found in the analysis on the fifth postoperative day compared with the OTE group both at rest (p = 0.004) and during movement (p < 0.001). However, these differences in postoperative pain intensity were only small and are possibly not clinically relevant. Nevertheless, this study clearly highlights that patients undergoing invasive and long-lasting laparoscopic robot-assisted abdominal procedures (like esophagectomy) still might be better treated with epidural catheters instead of single shot regional analgesia [such as transversus abdominis plain (TAP) blocks] or even no regional analgesia combined with opioids and non-opioids. However, our data are retrospective, and this finding should be therefore interpreted with caution. This is in contrast to a recently published statement regarding the future of epidural analgesia in laparoscopic abdominal surgery.36 From our point of view, it is premature to abandon general epidural analgesia in patients undergoing laparoscopic abdominal procedures; instead, the effectiveness and safety of epidural analgesia  should be studied specifically in patients undergoing long-lasting, invasive laparoscopic abdominal procedures in the future.Effective postoperative pain control is relevant for the patient without causing severe opioid-related adverse events, because a fast decrease of postoperative pain intensity is associated with a reduced risk of postoperative chronic pain.Apart from postoperative pain intensity, the observed difference in opioid consumption between open, hybrid, or robot-assisted esophagectomy was large and is clinically relevant owing to the decreased risk for opioid-related adverse events. The lower postoperative opioid analgesic consumption in patients who underwent RAMIE may be partly explained by a lower operative trauma associated with the robotic surgical technique. Owing to the retrospective study design, a detailed evaluation of adverse effects caused by opioid therapy was not possible with our data. However, low opioid consumption must be considered as a surrogate parameter for lower nociceptive activation. Further prospective studies are needed to address these findings.p < 0.001; HYBRID versus OTE p = 0.001). Even though considerably lower blood loss was measured with RAMIE, there was no significant advantage in the comparison with the HYBRID group.Both RAMIE and HYBRID patient groups lost significantly less blood during surgery than those operated on openly .Severe postoperative complications (MCDC ≥ 3b) occurred less often in RAMIE (13.7%) and HYBRID (11.9%) than in OTE (21.3%) groups, although no statistically significant difference was proven. Similar findings were established for differences in reoperation rate  as described in the wider literature.43 This retrospective evaluation established typical clinical symptoms and the start of antibiotic therapy (MCDC 2) as the critical diagnostic criterion for pneumonia since confirmation by microbiological sputum examination was frequently omitted in clinically clear cases. This resulted in an overall higher rate of this complication.Patient recovery depended highly on mobilization and respiratory training. Possible complications, especially respiratory complications like pneumonia, can occur when mobilization is restricted owing to pain.p < 0.001) and OTE groups . Although a decrease in operation time can be expected in the future owing to the long learning curve of about 70 patients in RAMIE,44 data from established centers show an advantage of open surgery here.16On analysis, there was a significant increase in operating time with robotic surgery  compared with both the HYBRID , and similar to the HYBRID group . This fits in with the findings of lower postoperative analgesic consumption, as both interdependent factors suggest a faster reconvalescence.45The length of postoperative hospital stay for patients undergoing RAMIE  was significantly lower compared with the OTE group .Since there is no strict separation of the intensive care and observation ward, patients stay longer during routine observation and in the case of complications. Therefore, the length of stay recorded at this unit is overall high.p = 0.059; ICU p = 0.005).In a comparison of the HYBRID with the OTE group, patients undergoing hybrid techniques showed lower values for the postoperative length of stay as well as for the intensive care unit stay, although only the second difference was statistically significant , which started in January 2021 and compares full robotic to full laparoscopic approach in a randomized multicenter design study.We acknowledge certain limitations to this study. The single-center design might influence the generalizability and transferability of the results. Even so, the collected data and analyses are consistent to other published findings. Owing to the nonrandomized study design, it cannot be ruled out that patients' pain perception may be affected by the placebo effect leading to a reduced analgesic consumption. Additionally, a similar bias can be assumed for the treatment team as expectations on pain intensity may vary depending on the surgical approach. The data used in this study are routine data collected several times a day and not study-specific data. Therefore, it cannot be assumed that the patient was influenced either intentionally or unintentionally.16 This number is expected to increase with further scientific proof of the feasibility of the approach. The strength of this evaluation is based on the large-scale sample size of 274 patients, all of them with complete datasets.Since the procedures examined in this study were performed by only two different surgeons, there are few confounders that could have altered the results. However, owing to limits in documentation, these differences in technical nuances of the operation and postoperative patient management within the framework of the hospital standards may have affected the outcome. As with most retrospective studies, time period bias cannot be excluded in this clinical trial. The results should be verified by reproduction as a randomized controlled approach, although a randomization is inherently difficult, as a non-neglectable number of patients already requested robotic intervention in the ROBOT trial.Patients undergoing esophagectomy benefit from robotic surgery as compared with hybrid or open techniques owing to a significant lower need for analgesics to treat postoperative pain. In addition, patients who underwent RAMIE had significantly less intraoperative blood loss. Despite longer operation times, patients who underwent RAMIE experienced a shorter stay in the intensive care unit and accelerated postoperative recovery. Further studies, preferably randomized trials, should be conducted to further verify the shown benefits of the RAMIE approach.