Objectives. To evaluate the comparative analgesia effectiveness and safety of postoperative continuous femoral nerve block (CFNB) with patient controlled intravenous analgesia (PCIA) and their impact on knee function and chronic postoperative pain. Methods. Participants were randomly allocated to receive postoperative continuous femoral nerve block (group CFNB) or intravenous patient controlled analgesia (group PCIA). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores for knee and incidence of chronic postoperative pain at 3, 6, and 12 months postoperatively were compared. postoperative pain and salvage medication at rest or during mobilization 24 hours, 48 hours, and 7 days postoperatively were also recorded. Results. After discharge from the hospital and rehabilitation of joint function, patients in group CFNB reported significantly improved knee flexion and less incidence of chronic postoperative pain at 3 months and 6 months postoperatively (P < 0.05). Analgesic rescue medications were significantly reduced in patients receiving CFNB . Conclusion. With standardized rehabilitation therapy, continuous femoral nerve block analgesia reduced the incidence of chronic postoperative pain, improved motility of replaced joints, and reduced the dosages of rescue analgesic medications, suggesting a recovery-enhancing effect of peripheral nerve block analgesia. Major knee surgeries have been practiced widely to cure joint dysfunction, deformity, and pain . HoweverTo maximize the analgesic efficacy and minimize its side effects, a multimodal analgesic regimen was recommended for patients who underwent knee surgery. Among a variety of analgesic techniques, peripheral nerve block analgesia has emerged as a cornerstone within this regimen, which has been recommended by the American Association of Hip and Knee Surgeons for postoperative pain management .Knee is innervated primarily by femoral nerve, then by sciatic nerve, and very partially by obturator nerve (from anterior divisions of lumbar plexus); therefore, peripheral nerve block often targets femoral nerve. Femoral nerve block (FNB) is the most common type of peripheral nerve block for analgesia after major knee surgeries . A set oApart from pain, joint function is also a major concern after major knee surgery. All of these patients should undergo a process of rehabilitation, during which course, a considerable portion of patients still complained of articular pain at rest or in motion –8. Few sThis study was approved by the Institutional Review Board of the First Affiliated Hospital of Chongqing Medical University. The protocol design was in accordance with Consolidated Standards of Reporting Trials (CONSORT) statement . All potBased on the treatment efficacy in a pilot study, a 10% difference between the treatment (CFNB) and control (PCIA) groups in the incidence of moderate-to-severe pain in motion 3 months after the surgery was used to estimate the sample size required in this study. Statistical power of 80% at the 0.05 significance level required 140 subjects in each group, assuming a 15% dropout rate. A total of 280 patients were randomly allocated in a 1 : 1 ratio to either the CFNB group or the PCIA group. Statistics Analysis System software (SAS) proc plan procedure was used to generate the random number. A sealed opaque envelope, which contained the group allocation, was prepared for each patient. The envelope was not opened until the patient was enrolled in the study.All participants were informed with the two methods of patient controlled analgesia and the tool of evaluating pain ; antibiotics were used for prophylaxis preoperatively, intraoperatively, and postoperatively. The protocol of prophylaxis for thromboembolism in patients receiving continuous femoral nerve block was initiated 12 hours postoperatively with subcutaneous injection of low molecular weight heparin (LMWH), 8 hours before the femoral catheter was estimated to be extracted; the use of LMWH was paused. Patients receiving intravenous patient controlled analgesia received LMWH from 12 hours postoperatively till the hospital discharged all participants.2, and invasive arterial blood pressure monitoring; HR was maintained at 60–100 beats/minute, SpO2 at 98–100%, and mean arterial pressure (MAP) at 65–80 mmHg. Fluid therapy was administered at 5–10 mL/kg/h; vasodilators, vasoconstrictors, and diuretics were used when necessary. The anesthetics used were midazolam 0.1~0.15 mg/kg (but etomidate 0.15~0.2 mg/kg for the patients over 65 years old), propofol 2.0~2.5 mg/kg, sufentanil citrate 0.3~1.0 μg/kg, and vecuronium 0.08~0.12 mg/kg for anesthesia induction. The maintenance of anesthesia was with inhalation of 1%~3% sevoflurane and continuous intravenous infusion of remifentanil 7~8 μg/kg/h and propofol 25~75 μg/kg/min with microperfusion pump. Anesthetic depth was monitored with Narcotrend index  to maintain a Narcotrend index between 40 and 50. In order to reduce the bleeding during the total knee arthroplasty (TKA), pneumatic tourniquet was used for operation with the pressure of 45 Kpa and pneumatic tourniquet time was recorded. All surgical procedures included selecting medial patella incision, using the medial-quadriceps-tendon-patellar approaches, fixing artificial knee joint with bone cement, washing the articular wound with hydrogen peroxide, iodine solution, and saline, taking out soft tissue and bone debris, and assembling drainage before closing. Upon closure of the wound, 5–10 μg sufentanil was intravenously injected, and loading dose of PCA was injected. Participants were assessed as fulfilling the discharge criteria of being discharged from postanesthetic care unit (PACU), if Steward score was larger than 4 and VAS for pain was less than 4 [All of the participants received general anesthesia with intravenous and inhalational anesthetics. They were monitored with electrocardiogram (ECG), heart rate (HR), SpOThe femoral nerve block was performed before the induction of anesthesia on the leg to be operated on. All procedures were performed by one group of senior anesthesiologists. All of the patients were placed in supine position with their legs extended. After sterile preparation, puncture site was identified using ultrasound guidance . 2% lidocaine was used for topical anesthesia; then an insulated needle   was connected to the nerve stimulator . The parameters were as follows: stimulating intensity of 1 mA at a rate of 2 Hz. The needle was advanced at 30°~45° angle to the skin, until quadriceps femoral muscle twitches were elicited. Its position was accepted if contractions were still elicited when an output was equal to 0.3 mA. Then, the patients were given 10 mL 2% lidocaine and 10 mL 1% ropivacaine as an initial dose. The catheter remained in place for 10~15 cm. When catheter insertion was difficult, 0.9% saline solution was injected through the cannula to ease the catheter placement. To confirm the correct position of the catheter, the cutaneous sensation in the area of the femoral nerve was assessed using a cold test . 30 minuA strict rescue regimen of analgesia was adopted. During the implantation of patient controlled analgesia, a three-stage rescue “ladder” was adopted: the anesthesiologists decided on, first, the alternation of the PCA pump parameters with inspection of the catheter, second, the use of intravenous nonopioid rescue analgesics, and, finally, the use of opioid rescue medication  when nonopioid rescue medications were deemed as ineffective  30 minutes after the intravenous injection. For patients receiving intravenous patient controlled analgesia, the alternation of the parameters of PCA pumps was considered first and then a salvage intravenous injection of tramadol within the daily dose limitation (400 mg daily); then pethidine  was used when nonopioid rescue medications were deemed as ineffective  30 minutes after the intravenous injection; see All participants included in this study received the preventive use of antiemetic as an intravenous injection of 4 mg ondansetron. During the hospital stay, one team specializing in providing acute pain service (APS) to the participants inspected the ward every 4 hours to assess the adverse events.Incomplete Analgesia. See rescue regimen of analgesia.Nausea and Vomiting. Intramuscular injection of 10 mg metoclopramide or intravenous injection of 4 mg ondansetron, 0.1 mg/kg of ondansetron was the maximal dose.Oversedation. Reduce the background infusion by 0.1–0.5 mL/h in PCIA group and 0.5–2 mL/h in CFNB group, with an intravenous injection of 0.4–0.8 mg naloxone.Respiratory Depression. Reduce the background infusion by 0.1–0.5 mL/h in PCIA group and 0.5–2 mL/h in CFNB group, with an intravenous injection of 0.4–0.8 mg naloxone; extract the catheters of PCIA and CFNB pump if necessary, with mask ventilation with 3–10 L/min, mechanical ventilation with endotracheal intubation if necessary, and cardiopulmonary resuscitation if necessary.Catheter Loss of CFNB. Extract the catheter and switch to PCIA.Local Hematoma of CFNB Catheter. Compress with a sand bag and switch to PCIA.Local Infection of CFNB Catheter. Extract the catheter and switch to PCIA.Topic Pain of CFNB Catheter. Fix the catheter with suitable suture, with the topical use of diclofenac sodium ointment.Fall. A Bromage scale was used to assess the muscle strength of the lower limb. It is a four-point scale, with 1 meaning no motor block, 2 meaning unable to raise the legs, 3 meaning unable to bend the knee, and 4 meaning unable to bend the knee. Three/four grade is an indication of motor block and it is advised to switch from CFNB to PCIA. Escort and surveillance of the patients are mandatory when knee joint exercise was carried out.Prophylaxis of Thromboembolic Events. The protocol of prophylaxis for thromboembolism in patients receiving continuous femoral nerve block was initiated 12 hours postoperatively with subcutaneous injection of low molecular weight heparin (LMWH). Eight hours before the femoral catheter was estimated to be extracted, the use of LMWH was paused. Patients receiving intravenous patient controlled analgesia received LMWH from 12 hours postoperatively; the injection of LMWH was practiced till the hospital discharged all participants. On day 3 and day 7 postoperatively, all patients were monitored with lower vascular ultrasound to assess the thromboembolic events.On day of surgery, all participants were advised to start a deep breathing exercise and an active ankle range of motion (ROM) exercise at the tolerance of the patients, on postoperative day 1, lower-limb isometric exercise , passive ROM training of Patella, and active ROM exercise of hip of at least 2 hours per day. From postoperative day 2 to day 3, continuous passive motion (CPM) of knee begins at 0 degree to 45 degrees, reaching 60 degrees in the first week, gradually reaching 90 degrees in 3 weeks; the duration of exercise was at least 2 hours per day. From postoperative day 4 to week 2, participants were advised to start CPM of knee of at least 1 hour per day and, simultaneously, active-assisted ROM of knee as tolerated of at least 2 hours per day. From postoperative week 3 to week 6, participants were advised to start isotonic and isometric muscle strengthening training of at least 4 hours per day, especially the quadriceps and straight leg raising exercise. From postoperative week 7 to week 12, weight-bearing of at least 2 hours per day was begun in this period, according the patient's situation with different ambulatory aids, for example, walker, crutches, and cane. Between postoperative week 13 and week 20, participants were advised to start resisted strength training of at least 1 hour per day, ROM exercise of at least 2 hours per day, and weight-bearing without aids of at least 2 hours per day.Chronic postoperative pain (CPOP) was diagnosed according to the definition of International Association of Study on Pain (IASP) . This stBolus frequency, rescue frequency, mean doses of rescue medications, and adverse events related to patient controlled analgesia were recorded. Baseline characteristics were categorized into preoperative  and intraoperative  categories. Degrees of flexion of the knee were assessed by calibrating the angle of the extended line of the femur and the tibias by an independent orthopedic doctor.t-test, Wilcoxon rank test, or Kruskal-Wallis test was used to compare results for continuous variables. Chi-square test was used to compare results for categorical variables. Fisher's exact test was used for categorical variables when the number of events was less than 5. Both intention-to-treat analysis  and per-protocol set analysis  were used in this study. Statistical difference was assumed when P value <0.05.All analyses were performed using the SAS 9.2 software package. The level of statistical significance was set at 0.05. Data were expressed as mean± standard deviation (SD) for continuous variables and total number (percent frequency) for categorical variables. A group N = 140) and a PCIA group in which intravenous patient controlled analgesia was used (N = 140); 13 participants in the CFNB group and 17 in the PCIA group were excluded from the PPS analysis for short-term outcome because of personal reasons or rescue protocol violation. Thirty-nine participants were lost to follow-up 3 months postoperatively and were not included in the PPS analysis of long-term follow-up. The principle of per-protocol analysis was followed in the analysis of preoperative characteristics. The two groups were comparable in baseline characteristics ; surgical time and anesthetic were also similar in the two groups ; CPOP was still observed in PCIA group at 6 months with the reported rate of 52.4%, while that of CFNB group was 33.0% (P = 0.004). At 12 months postoperatively, the incidence of CPOP in both groups was minimal and no statistical difference was found (P = 0.224). ITT analysis still found a significantly reduced incidence of CPOP in CFNB group compared with PCIA group . At 6 months postoperatively, this rate in group CFNB dropped to 22.9% while that of group PCIA decreased to 36.3% (P < 0.05). At 12 months postoperatively, this rate decreased to 1.4% in CFNB group and to 4.3% in PCIA group (P = 0.214). In ITT analysis, no statistical difference was found between the two groups  or at rest (P = 0.031). Chronic postoperative pain was assessed at 3 months, 6 months, and 12 months postoperatively; patients in CFNB group reported a significantly lower level of pain intensity at 3 months in motion (P = 0.025) or at rest (P < 0.0001) and at 6 months (P = 0.011 for pain in motion and P < 0.0001 for pain at rest) postoperatively but not at 12 months postoperatively . During the PCA period, two types of rescue analgesic medications (parecoxib and tramadol) were consumed less in CFNB group . In the non-PCA period, all analgesic medications  were consumed less in CFNB group   ; the sam, resp.) .P = 0.015). The incidence of other adverse events varied from 0 to 4.06% . Nerve-block-catheter-related adverse events, such as catheter thrombosis, catheter dropout, local hematoma, and local infection, were not observed in CFNB group. During the non-PCA period, the incidence of incomplete analgesia was slightly higher in PCIA group   .The prominent finding of this study was that continuous femoral nerve block postoperatively could effectively reduce the incidence of postoperative chronic pain and improve joint function during short-term and long-term follow-up. The use of CFNB was also associated with less analgesic medications for rescue, indicating the advantage of peripheral nerve block over intravenous patient controlled analgesia in controlling acute perioperative pain and the development of chronic postoperative pain. In this study, we observed less severity of pain and slightly improved degree of flexion on 7 days postoperatively, suggesting a rehabilitation-enhancing effect than continuously intravenous infusion of analgesics, which reinforced the evidence from other randomized controlled trials that femoral nerve block could bring good quality of postoperative analgesia compared to systemic analgesics or epidural analgesia and thus fasten the recovery process and allow patients to be more mobile after total knee arthroplasty , 14.Different volumes and concentrations of local anesthetics could impact the analgesic efficacy and motor block of peripheral continuous nerve block analgesia; most of the previous studies adopted the concentrations from 0.2% to 0.3% of ropivacaine –17. To aOne feature of this study was that a strict analgesic rescue protocol was designed to minimize the number of patients with incomplete analgesia, with the transition analgesia from PCA period to non-PCA period. During the non-PCA period, participants in CFNB group required less analgesic medications after cessation of patient controlled analgesia; less incidence of incomplete analgesia was also observed in CFNB group, suggesting a more efficacious role of peripheral nerve block in ameliorating the transition of acute surgical pain to persistent pain during hospital recovery , 25.As the primary outcome for this study, less incidence of chronic postoperative pain was found at 3 and 6 months postoperatively but not at 12 months; the same trend was observed for WOMAC scores for knee –28. WOMASeveral limits existed in this study. First, we found a statistically significant yet not clinically important increase in the degree of flexion 7 days postoperatively, which weakened the power of this study; second, we observed the chronic pain and WOMAC by subjective interviews without direct calibration of joint movement; NRS for pain was recorded regardless of the use of analgesics; third, blindness was not possible for the participants and anesthesiologists for the CFNB group.In conclusion, after rigorous analgesic rescue protocol, CFNB revealed advantage over intravenous patient controlled analgesia in reducing the dosage of rescue medications and improving short-term and long-term joint function, reducing incidence of chronic postoperative pain.


Background. The aim of this report was to evaluate the clinical profile and previous management of patients with uncontrolled neuropathic pain who were referred to pain clinics. Methods. We included adult patients with uncontrolled pain who had a score of ≥4 in the DN4 questionnaire. In addition to sociodemographic and clinical data, we evaluated pain levels using a visual analog scale as well as anxiety, depression, sleep, disability, and treatment satisfaction employing validated tools. Results. A total of 755 patients were included in the study. The patients were predominantly referred to pain clinics by traumatologists (34.3%) and primary care physicians (16.7%). The most common diagnoses were radiculopathy (43%) and pain of oncological origin (14.3%). The major cause for uncontrolled pain was suboptimal treatment (88%). Fifty-three percent of the patients were depressed, 43% had clinical anxiety, 50% rated their overall health as bad or very bad, and 45% noted that their disease was severely or extremely interfering with their daily activities. Conclusions. Our results showed that uncontrolled neuropathic pain is a common phenomenon among the specialties that address these clinical entities and, regardless of its etiology, uncontrolled pain is associated with a dramatic impact on patient well-being. Neuropathic pain is defined as pain that originates from a lesion or disease that affects the somatosensory pathways within the peripheral or central nervous system . NeuropaManaging neuropathic pain requires an interdisciplinary approach in which pharmacological treatment is fundamental , 16. DesAlthough there is consensus that many patients with neuropathic pain do not respond adequately or are unable to tolerate existing treatments , 20, epiThis report was an observational, multicenter, and prospective study performed by 161 investigators from pain clinics throughout Spain between February 2009 and February 2010. The study was approved by the Ethics Committee of the Hospital General Universitario de Valencia (Spain). Written informed consent was obtained from every subject. The study was conducted in accordance with the principles of the Declaration of Helsinki. In this report, we presented the baseline  data of the study.For inclusion in the study, the patients had to fulfill the following criteria: age 18 years or older; referral to a pain clinic because of uncontrolled pain; and a score of equal to or greater than 4 in the DN4 questionnaire. The patients were excluded from the study if they were unable to understand the study objectives or complete the self-administered questionnaires.At baseline, the following information was recorded: sociodemographic data, type of specialist referring the patient, diagnostic confirmation of neuropathic pain, confirmation of the presence of uncontrolled pain as assessed by the investigator, etiology and duration of pain, causes for uncontrolled pain, pain intensity as measured using a 0 to 100 mm visual analog scale (VAS), and signs and symptoms of neuropathic pain. We also recorded pharmacological and nonpharmacological treatment for neuropathic pain. Additionally, the Spanish validated versions of the following questionnaires and scales were completed: DN4 questionnaire, Hospital and Anxiety Depression Scale (HADS), the Medical Outcomes Study Sleep (MOS Sleep) Scale, the World Health Organization Disability Assessment Schedule (WHO-DAS II), and the Treatment Satisfaction with Medicines Questionnaire (SATMED-Q).The neuropathic pain diagnostic questionnaire DN4 consists of 10 items that describe different pain characteristics. A score of at least 4 of 10 possible points is considered acceptable to identify neuropathic pain with 83% sensitivity and 90% specificity –24.The HADS, which is a self-administered instrument, consists of 14 items: 7 items that refer to depression symptoms and 7 items that refer to anxiety symptoms , 26. EacThe MOS Sleep Scale, a self-administered questionnaire, evaluates the key aspects of sleep , 28 and The WHO-DAS II comprises 12 items that evaluate an individual's level of functioning and disability in six areas: understanding and communicating, getting around, self-care, getting along with people, life activities, and participation in society –31. The The SATMED-Q, a self-administered questionnaire, consists of 17 items that evaluate six dimensions: treatment effectiveness, convenience of use, impact on daily activities, medical care, global satisfaction, and undesirable side-effects , 33. TheThe analysis was essentially descriptive using the means and standard deviations for quantitative variables and using the absolute and relative frequencies for qualitative variables. The patients were categorized as having clinical anxiety or depression if they had a score equal or greater than 11 in the anxiety or depression subscales of the HAD.We included 755 patients in the study. We excluded 27 (3.6%) patients who did not meet the selection criteria, thereby leaving 728 evaluable patients.The patients had a mean age of 57 years, were predominantly women (61%), and exhibited obesity in a high proportion (20%) . More thThe patients had severe pain with a mean score of 75 using the VAS; the duration of pain was generally 2,6 years and was longer for those patients who were referred to pain clinics from the departments of rheumatology, neurosurgery, and neurology . The majThe major cause for uncontrolled pain, as assessed by the pain clinic investigators, was attributed to suboptimal treatment (88%) because of the use of ineffective drugs or subtherapeutic doses . The useThe patients were receiving a mean of 3 drugs; one-third of the patients, regardless of the referral specialty, were receiving 4 or more drugs . The mosPatients with uncontrolled pain showed low satisfaction with their treatment with a global satisfaction score of 44 of 100. Treatment effectiveness and the impact of medicine on their everyday life were the areas exhibiting lower satisfaction, with mean scores of 32 and 30, respectively .The number of drugs that the patients were receiving was higher among the patients with central neuropathic pain (3.7), plexopathy (3.5), radiculopathy (3.3), and complex regional pain syndrome (3.2) and was lower among those with diabetic neuropathy (2.3) . The useMore than half of the patients were diagnosed with depression, and 43% of the patients were diagnosed with anxiety . Sleep wThe proportion of disability among patients with uncontrolled pain was high, with approximately 50% of the patients rating their overall health as bad or very bad and 45% noting that their disease was severely or extremely interfering with their life . The difOur results indicate that uncontrolled neuropathic pain is a problem that extends into multiple specialties that address the issue of chronic pain. Uncontrolled neuropathic pain appears to affect patients with clinical entities that are a subsidiary of traumatological care, in which radiculopathy is the most common cause. Other common causes of uncontrolled pain are pain of oncological origin and trigeminal neuralgia. Regardless of the cause and the specialist managing the patient with uncontrolled pain, we observed the following. The impact of the disease is high in terms of disrupting the patients' psychological well-being and disability; the major cause of uncontrolled pain is receiving suboptimal treatment; and the patients are generally dissatisfied with the treatment received.Traumatologists were by far the primary referral specialists of uncontrolled pain 34%), and radiculopathy was the most common cause (43%) of uncontrolled pain. These findings are consistent with the most common causes of chronic pain in the general population. Thus, according to the survey of pain in Europe, the most frequent location of chronic pain was back pain (42%) and the more frequent cause of pain was herniated or deteriorated discs (15%) and traumatic injuries (12%) %, and ra. AlthougThe fact that neuropathic pain may be associated with the presence of anxiety and depressive symptoms and sleep disturbances is well known –40. HoweThe investigators from the pain clinics determined that the main reason for uncontrolled pain was because the patients were receiving suboptimal treatment; that is, the patients received either ineffective drugs or subtherapeutic doses of the drugs. For instance, NSAIDs were used to treat more than 40% of the patients, and carbamazepine and oxcarbazepine, the first-line treatments for trigeminal neuralgia , were onThe major limitation in our study was the definition of uncontrolled pain that was entirely based on the subjective evaluation of the investigators from the pain clinics. We accepted this subjective evaluation because there is no standard definition of refractory neuropathic pain . RecentlOverall, our results showed that uncontrolled neuropathic pain is a common phenomenon among the specialties that address these clinical entities, and regardless of its etiology, uncontrolled neuropathic pain is associated with a dramatic impact on patient well-being. A definite need exists for improving the management of neuropathic pain in all of these specialties, which should not be limited to the improvement of pain but also should be extended to the management of psychological symptoms and possibly to the improvement of the doctor-patient relationship.


Laparoscopic cholecystectomy (LC) has become the treatment of choice for gallbladder lesions, but it is not a pain-free procedure. This study explored the pain relief provided by combined wound and intraperitoneal local anesthetic use for patients who are undergoing LC.Two-hundred and twenty consecutive patients undergoing LC were categorized into 1 of the following 4 groups: local wound anesthetic after LC either with an intraperitoneal local anesthetic (W + P) (group 1) or without an intraperitoneal local anesthetic (W + NP) (group 2), or no local wound anesthetic after LC either with intraperitoneal local anesthetic (NW + P) (group 3) or without an intraperitoneal local anesthetic (NW + NP) (group 4). A visual analog scale (VAS) was used to assess postoperative pain. The amount of analgesic used and the duration of hospital stay were also recorded.The VAS was significantly lower immediately after LC for the W + P group than for the NW + NP group . Patients in the W + P group received a lower total amount of meperidine during their hospital stay. They also had the shortest hospital stay after LC, compared to the patients in the other groups.Combined wound and intraperitoneal local anesthetic use after LC significantly decreased the immediate postoperative pain and may explain the reduced use of meperidine and earlier discharge of patients so treated. Since 1987, laparoscopic cholecystectomy (LC) has become the standard procedure for the treatment of gallbladder lesions. Increased experience with this technique has altered some of the previous contraindications for LC such as patients with end-stage renal disease, liver cirrhosis, and severe cardiovascular disease . A majorBetween 2009 and 2011, 220 consecutive patients who underwent LC (performed by author C. N. Yeh) at the Department of Surgery in the Chang Gung Memorial Hospital  were included in this prospective case-controlled study. The study participants were adult patients who had been referred for elective LC to treat gallbladder lesions. The study was approved by the local institutional review board of the Chang Gung Memorial Hospital (No. 95-0147B). Patients provided written, informed consent authorizing group allocation and use of anesthetics for pain relief.Each of the consecutive 220 patients was liberally rather than randomly allocated into 1 of 4 groups. The groups included patients who received a local wound anesthetic at the end of LC either with an intraperitoneal local anesthetic  or without an intraperitoneal local anesthetic  and patients who received no local wound anesthetic at the end of LC either with an intraperitoneal local anesthetic  or without an intraperitoneal local anesthetic  , an anesthesiologist, administered general anesthesia to all 220 patients by using the same protocol. Before the start of the cholecystectomy, the LC patients in the W + P group and in the NW + P group received 5 mg/kg of 1.0% levoropivacaine in 200 mL of 0.9% normal saline as an intraperitoneal infusion into the operative field . Levoropivacaine was administered in 2 separate 100-mL infusions while the patient lay in the Trendelenburg position. The first infusion was administered in the right subdiaphragmatic region and the second infusion was administered in the left subdiaphragmatic region. Patients in the W + NP and NW + NP groups received 200 mL of 0.9% normal saline as the intraperitoneal infusion of the operative field before the start of surgery. All infusion fluid was drained after the completion of the LC. The LC patients in the W + P group and in the W + NP group received a total of 20 mL of 1.0% levoropivacaine at the port sites immediately after wound closure . Patients in the NW + P and NW + NP groups received a total of 20 mL of 0.9% normal saline at the port sites immediately after wound closure . At the end of surgery, local anesthesia or normal saline was applied to the skin, subcutis, fascia, and parietal peritoneum through the port sites.A visual analog scale (VAS) with a 10-cm vertical score ranged from “no pain” to “worst possible pain”. The VAS was used to assess postoperative pain when the patient awoke in the operating room (approximately 1 h after surgery), at 6 h after surgery, and at 24 h after surgery. The pain score was recorded by 1 of 4 authors  who were blinded to the patient groups. Acetaminophen was used for pain relief in the postoperative period. Meperidine was further used as rescue pain relief if acetaminophen did not work well. Pain intensity was estimated by using the VAS and the amount of analgesics used. Biochemical data, operative time, hospital stay, and perioperative complications were recorded.post hoc test for comparing between subgroups. Ordinal scale data were compared with the Kruskal-Wallis test between groups and a post hoc test was used for comparing between subgroups. Pearson’s chi square tests and Fisher’s exact tests were used for nominal variables. All statistical analyses were performed by SPSS software (version 10.00) . Values of p < 0.05 were considered statistically significant.All data are presented as the percentage of patients or the mean with the 95% confidence interval or median with interquartile ranges. Numerical data were compared by using analysis of variance (ANOVA) tests between groups. The Scheffe’s test was used as the Tables Table Because LC has become the treatment of choice for many gallbladder diseases, postoperative analgesia for LC pain has been evaluated in several prospective studies. Pain after LC is less intense and lasts a shorter time, compared to pain after open cholecystectomy -6. This 2) at body temperature, applying intrapleural morphine [Postoperative pain control is directed at early mobilization, recovery, and discharge. However, pain can play a major role in metabolic and endocrine responses and can impair postoperative pulmonary function. Various methods have been proposed to control LC postoperative pain such as the use of local anesthesia , intrapemorphine , and themorphine .2, maintenance of high abdominal pressure, irritation of the phrenic nerve, and application of cold CO2[Several factors have been extensively studied that may moderate pain after laparoscopic surgery such as the use of local anesthesia at the incision sites, intraperitoneal anesthesia, intraoperative irrigation and suction, the number of operative ports, application of pneumoperitoneum, and maintaining pneumoperitoneum pressure. Several mechanisms of postlaparoscopic pain generation have also been proposed such as ruptured blood vessels resulting from the rapid distension of the peritoneum, traumatic nerve traction, release of inflammatory molecules, trauma to the abdominal wall, trauma occurring with the removal of the gallbladder from the abdomen, pneumoperitoneum created by utilizing CO cold CO2. Because cold CO2. A numbeEarly studies focused primarily on gynecological procedures ,23. HoweSeveral trials assessing the use of intraperitoneal local anesthetics have yielded conflicting results. The use of intraperitoneal local anesthesia reduces shoulder tip pain. Its value when used in combination with a local anesthetic has been assessed previously ; howeverThis case–control study is aimed at studying the benefits of combined local anesthetic  and intraperitoneal local anesthetic infusions (before LC) for reducing LC postoperative pain. As demonstrated in this study, LC is not a pain-free procedure. Pain remains a prevalent complaint after LC during the early postoperative period. This study clearly showed that pain peaks within the first few hours after the operation, but diminishes greatly by the next day, as demonstrated by the distribution of pain scores and requirement for parenteral analgesics. Incisional pain is reportedly more intense than visceral pain and dominates during the first 48 hours immediately following LC . TherefoLevoropivacaine is a new long-acting local anesthetic that was developed after evidence of severe bupivacaine-related toxicity emerged. Levoropivacaine contains only the left-isomer of the active chemical, and based on its three-dimensional structure, it has less toxic potential for the central nervous system and heart . SeveralAlthough our results may support the use of combined wound and intraperitoneal anesthetics for LC patients significantly decreased immediate postoperative pain, there are several limitations inherent in this study. First, this was a prospective case controlled study, and the selection of patients would not be randomized. Although all of the data were collected prospectively and the characteristics of four groups were similar and homogeneous, the selective and recall bias could not be prevented completely. Another obvious limitation of this study is that it was not double-blinded. Hence, biases of the patient’s and surgeon’s attitudes are likely to arise, especially for evaluation of intensity of pain. The advantages of the combined pain relief procedures observed in unblinded patients may lead patients to be more motivated to see the benefit after received “combined pain relief” procedure. Unblinded surgeons may also contribute to the better postoperative recovery as surgeons may take more aggressive attitudes to early discharge after operation. To overcome these limitations, our results should be confirmed by further prospective randomized controlled trials.In conclusion, the use of combined wound and intraperitoneal anesthetics for LC patients significantly decreased immediate postoperative pain. This short-term benefit may explain the decreased use of immediate parenteral analgesics and earlier discharge.The authors declare that they have no competing interests.C-N Y and C-Y T participated equally in data collection and helped to draft the manuscript. C-T C, S-Y W, Y-Y L, F-J H, Y-Y J, and M-F C reviewed the manuscript and provided suggestions. C-C L conducted anesthesia. C-N Y supervised paper editing and the study design. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/14/28/prepub


To study the efficacy of peritubal infiltration in postoperative pain following percutaneous nephrolithotomy in general PCNL patients and PCNL patients with supracostal renal access.A total of 105 PCNL patients were randomized into two groups, 53 patients receiving peritubal analgesic infiltration (study group) and 52 patients as the control group. Of these patients, supracostal access was performed in 22 patients of study group and 23 patients of control group. The study group received peritubal injection with 10mL of bupivacain. Postoperative pain as the primary outcome was assessed by using visual analogue scale at 1, 4, 12, 24 and 48 hours postoperatively. The secondary outcomes were the total postoperative morphine usage in 24 hours and time of the first analgesic demand.The average VAS pain at 1 and 4 hours after the operation in the study group were significant lower in the control group (P≤0.001 and 0.026). Doses of morphine usage for controlling postoperative pain and the first analgesic demand were significantly lower and longer in study group. Among patients submitted to supracostal access, the average VAS pain at 1 hour after operation in the study group was lower (P=0.018). Doses of morphine usage for controlling postoperative pain also was lower in the study group (P=0.012).The peritubal local anesthetic infiltration is effective in alleviating immediate postoperative pain after percutaneous nephrolithotomy even with supracostal access. Traditionally, opioid analgesics such as meperidine and morphine are used in postoperative pain management. High doses of these drugs lead to higher rates of side effects including postoperative nausea and vomiting, drowsiness, respiratory depression, ileus, urinary retention and constipation , 3–6. SeWe studied the efficacy of peritubal infiltration of 0.25% bupivacaine in postoperative pain following percutaneous nephrolithotomy with percutaneous nephrostomy tube. We also studied the efficacy of this technique in patients with supracostal renal access.A total of 105 patients who underwent single tract PCNL with postoperative nephrostomy tube placement were recruited. The patients were randomized into two groups: 53 patients received peritubal analgesic infiltration (study group) and 52 patients were included in the control group. Twenty-two patients of study group and 23 patients of control group received supracostal access. Exclusion criteria included patients with a history of local analgesic allergy, patients who underwent a second nephroscopy, patients who required more than one puncture, and patients who had excessive intra-operative bleeding.After general anesthesia was administered, an open-end 6 F ureteral catheter was placed transurethrally into the ureter in supine position. Under fluoroscopic guidance in prone position, contrast media was injected via ureteral catheter. Renal access was created by the biplane technique of standard PCNL. For the supracostal access the needle puncture was performed through the diaphragm and retroperitoneum in full inspiration, whereas the needle was passed through the kidney during deep inspiration. After the tip of the needle was located in the collecting system, working and safety guide wires were inserted followed by tract dilatation with telescopic metal dilators sizes 8F to 30F with 30F Amplatz sheath. Stone was disintegrated with ultrasonic and/or pneumatic lithotripsy. The nephrostomy tube size 20F was routinely inserted in all cases.In the patients of the study group, the 23-gauge, 90mm spinal needle was inserted up to the renal capsule under fluoroscopic guidance along the nephrostomy tube at 6 and 12 o'clock positions ; then 0.25% bupivacaine was infiltrated into the nephrostomy tract, including renal capsule, muscle, subcutaneous tissue and skin, 10mL in each position . The conDemographic and clinical characteristics of the patients were recorded at the time of enrollment. Postoperative pain as the primary outcome was assessed by an independent observer blinded to the infiltration using a 0–10 point visual analogue scale for pain (VAS pain) where 0 on the scale meant no pain and 10 meant very severe pain. VAS pain was recorded at 1, 4, 12, 24 and 48 hours postoperatively. The secondary outcomes were the total postoperative morphine usage in 24 hours, time of the first analgesic demand and adverse effects.Statistical analysis was performed using SPSS® version 13. Continuous variables were compared using t-test for two independent samples. Categorical variables were compared using Chi-square analysis. P-value<0.05 was considered to be statistically significant.All patients provided written informed consent. The ethical approval was obtained from the Institutional Review Board for human research project of Faculty of Medicine, Chiang Mai University.Profiles of patients were not clinically significant different between the two groups . PostopeSupracostal access was performed in 55 patients, 22 patients in study group and 23 patients in control group. Profiles of patients are shown in Postoperative pain is an important issue following the surgery. This affects the postoperative quality of life especially in recovery period with patient's anxiety and several negative aspects such as delayed mobilization, increased postoperative complications and prolonged hospitalization –6. RecenPercutaneous nephrolithotomy (PCNL) is accepted to be the minimally invasive procedure for large renal and ureteral calculi with less morbidity and mortality compared to open surgery. Even in minimally invasive nature, PCNL still causes significant postoperative pain especially in standard PCNL with nephrostomy tube. The purpose of nephrostomy tube placement following PCNL is for the tamponade of the bleeding along the tract, adequate drainage and maintenance of tract for a second nephroscope , 9. A siPatients with small bored nephrostomy tube have less postoperative pain score and less narcotic requirement , 7. TubeOpioid analgesics are traditionally used for controlling postoperative pain, but these drugs usually have side effects. The usage of multimodal or a combination of lower doses of opioid analgesics with non-opioid analgesics could avoid these side effects. Several studies demonstrated the efficacy of acetaminophen with and without opioid in management of postoperative pain , 18, 19.The benefit of local anesthesia was demonstrated in previous studies of general surgery, gynecology and anesthesia such as cesarean sections, hysterectomy, thyroid surgery, mastectomy, total-hip arthroplasty and cervical spine surgery, where marcaine was used as anesthesia agent –23. FromJonnavithola et al. studied the randomized control of peritubal infiltration of bupivacaine of renal capsule and demonstrated the effectiveness of this technique. The technique consisted of the use of a 23 gauge spinal needle (10cm in length) along nephrostomy tube at 6 and 12 o'clock and each infiltrated 10mL of 0.25% bupivacaine. The pain free period and mean total consumption of tramadol following operation of controlled group and blocked group were 4.6±5.4 hours and 105±85 mg and 14.7±9.6 hours and 31±44 mg, respectively. The mean AUC-UAS was 39.2 hours in control group and 18.9 hours in infiltration group . The aim of the study was to evaluate visual analog score (VAS), peak expiratory flow rate (PEF) and blood gas analysis. The time of first analgesic demand, total analgesic need and VAS at 6 hours were significantly lower, and PEF at 2 and 6 hours were significantly higher in patients with combinded ropivacaine infiltration and parenteral analgesic. Combination treatment for postoperative pain control lead to better pain management, which resulted in better patient's ventilation .Parikh et al. reported a prospective randomized study of the efficacy of 0.25% bupivacaine peritubal infiltration in 60 PCNL patients; 30 patients were included in the treated group (0.25% bupivacaine infiltration) and 30 in the controlled group . Exclusive criteria of the study were multiple punctures, supracostal puncture, stone size larger than 2.5cm, duration of procedure more than 3 hours and excessive intraoperative bleeding. Visual analogue scale (VAS) and dynamic visual analogue scale (DVAS) were lower in bupivacaine injected patients in early and late postoperative times. Mean of first tramadol demand was significantly shorter in normal saline infiltration patients (1.96hours VS 4.4hours). Total tramadol consumption was higher in normal saline patients (276.8mg VS 119.3mg) .Our patient recruitment criteria included all single tract PCNL patients with postoperative nephrostomy tube placement including supracostal puncture without considering operative time and stone size, which is different from previous studies. Our study confirms the benefit and safety of peritubal analgesic infiltration in controlling postoperative pain (lower VAS number), lower use of morphine and longer time of first analgesic requirement. These results were also observed in the subgroup analysis of supracostal access, which should have more pain after this operation.Peritubal local anesthetic infiltration with 0.25% bupivacaine resulted in beneficial effects in alleviating immediate postoperative pain after percutaneous nephrolithotomy even with supracostal access. This effect resulted in lower early postoperative pain (lower VAS score), lower number of morphine usage and longer time of first analgesic requirement.


Study Design. Quasiexperimental study. Objective. To investigate whether radiofrequency treatment can preclude the need for spinal surgery in both the short term and long term. Background. Radiofrequency is commonly used to treat lumbosacral radicular pain. Only few studies have evaluated its effects on surgical indications. Methods. We conducted a quasiexperimental study of 43 patients who had been scheduled for spinal surgery. Radiofrequency was indicated for 25 patients. The primary endpoint was the decision of the patient to reject spinal surgery 1 month and 1 year after treatment . The primary endpoint was the decision of the patient to reject spinal surgery 1 month and 1 year after treatment. In addition, we also evaluated adverse effects, ODI, NRS. Results. We observed after treatment with radiofrequency 80% of patients rejected spinal surgery in the short term and 76% in the long term. We conclude that radiofrequency is a useful treatment strategy that can achieve very similar outcomes to spinal surgery. Patients also reported a very high level of satisfaction (84% satisfied/very satisfied). We also found that optimization of the electrical parameters of the radiofrequency improved the outcome of this technique. Lumbar-radicular pain is a condition commonly encountered in pain units, and it represents one of the main reasons why patients request a consultation . ConservRadiofrequency is the most widely used one of these procedures, due to its low complication rate (<1%), its ease of application, and the low associated costs . The twoNumerous studies have demonstrated the short- and long-term effectiveness of both procedures. However, a common concern of patients considering radiofrequency is whether this treatment will allow them to avoid surgery. A review of the literature reveals only one study that analyzed the impact of these procedures on surgery (a retrospective study on only 12 patients: ). Thus, n = 43), and who had previously undergone conservative pharmacological treatment and physiotherapy without success. Lumbar fusion had been indicated for 40% of the patients and laminectomy with discectomy for the remaining 60%. The study team was not involved at any stage in determining the surgical indication for these patients. The following exclusion criteria were applied: clinical/radiological discordance, large hernia, extrusion-migration and stenosis with bilateral claudication. The radiofrequency procedure was fully explained to all participating patients and their signed informed consent was obtained in all cases.We used a quasiexperimental before-and-after study design. The participants were all patients that had been scheduled for spinal surgery by the Department of Neurosurgery at the University Hospital “Puerta del Mar” as of May 1, 2011 ; and Visit 4 . A total of 42 patients (1 failed to attend) underwent a clinical examination and an imaging test during the initial screening visit, which resulted in the exclusion of 13 patients based on the exclusion criteria defined in the study. In addition, three patients refused to undergo the procedure. Thus, the final number of patients included in the study was 26 (61.9%), with a mean age of 51 years  and 57.7% of them being male.NRS  is a rating scale of pain intensity in which the patients rate their pain on a scale of 0 (no pain) to 10 “worst pain imaginable.” Accordingly, pain intensity was classified as mild (1–4), moderate (5-6), or severe (7–10).Oswestry Disability Index (ODI) is a questionnaire designed to determine the degree to which pain interferes with the performance of daily activities. The questionnaire consists of 10 items that are rated on a scale of 0–5 (minimum to maximum impairment). On completing the test, the points are added, divided by 50, and multiplied by 100 to obtain the percentage disability. The higher the ODI score, the greater the interference of pain.The following variables were evaluated during the visits before treatment (1) and those 1 month (3) and 1 year (4) after undergoing the procedure.patient satisfaction scale: as measured using a 4-point verbal rating scale where 0 = “very dissatisfied,” 1 = “dissatisfied,” 2 = “neutral,” 3 = “satisfied,” and 4 = “very satisfied,”analgesic drug consumption: in which the patient's intake of analgesic medication was measured at the baseline, before treatment, and again at Visit 4 to determine the effect of treatment on analgesic drug consumption,adverse effects diary.On Visits 3 and 4, the patients were asked to decide, depending on their clinical improvement, whether they would remain on the waiting list for surgery or reject undergoing surgery on their spine. In addition, on Visit 4 the number of patients who refused surgery on Visit 3 but ended up undergoing spinal surgery in the Neurosurgery Department between Visits 3 and 4 was recorded. The resulting data allowed us to determine how many of the patients treated with radiofrequency avoided spinal surgery in the short term (1 month) and long term (1 year), which is the main variable.The following variables were also evaluated at Visit 4:The breakdown of the spinal injuries suffered by the patients was L3-L4, 1 patient; L4-L5, 8 patients; L5-S1, 10 patients. Two patients presented a combined lesion at L4-L5 and L5-S1, while in one 3-facet involvement was observed and in another, canal stenosis with bilateral involvement of L5 due to listhesis of L4 over L5 was also described .n = 13), L5 (n = 11), and/or L4 (n = 8). As reflected, in some cases, treatment targeted two roots that were causing pain. The optimal location was determined using contrast radiography and with electrical sensory (50 Hz) and motor (2 Hz) stimulation. Strict localization criteria were used, with an average sensory stimulation of 0.21 V  and an average impedance of 457.89 ohms  , CRF of lumbar medial branch 12%), or a combination of both techniques (12%). All procedures were performed under fluoroscopic guidance following radiation safety standards. The treatment procedures involving the dorsal root ganglion targeted the following roots: S1  with temperature control was used in all procedures.t-test was used to compare pain intensity before and after the intervention and to analyze the ODI scores.We performed a descriptive analysis of the data, calculating frequencies or measures of central tendency and the dispersion in function of the type of variable analyzed. A paired Student's Of the 42 patients scheduled for spinal surgery, 26 (61.9%) were selected for inclusion in the study in the screening visit. One of these patients could not tolerate the prone position required to perform the procedure and thus, this patient was dropped out of the study. The mean age of the 25 patients selected was 50.64 years (SD 15.92) and 56% were male. The mean baseline Visual Analogue Scale (VAS) was 7.64  and the mean ODI score was 51.08% .At Visit 1 (1 month after treatment), 20 (80%) of the 25 patients studied refused to undergo the spinal surgery scheduled, representing a total decrease of 46.51% in the number of patients requiring spinal surgery initially. In the evaluation performed 1 year after radiofrequency, we found that only one of the patients treated who had opted out of surgery at the 1-month evaluation subsequently required a surgical intervention. This patient reported recurring back pain but no recurrence of radicular pain. Thus, 1 year after radiofrequency treatment, 19 of the 25 patients did not require surgery and as such, 76% of the patients treated with the minimally invasive technique (radiofrequency) had a favorable long-term outcome and avoided surgery . Indeed,p < 0.01) in pain intensity, with an average NRS score of 2.64 . This difference persisted 1 year after treatment  , whereas one month after radiofrequency treatment we observed a significant decrease (14–4.34) . When th14–4.34) .p < 0.01). Moreover, this difference relative to the pretreatment score was maintained at 1 year after treatment , reflecting moderate impairment. One month after radiofrequency treatment (Visit 3), the mean ODI score for this same group was 15.28% , which differed significantly from the pretreatment score , yet by Visit 4 (1 year after treatment), 68% of patients had decreased their consumption of analgesics with respect to the baseline levels and almost 35% achieved a complete cessation of medication.No adverse effects were observed after radiofrequency treatment, although a few patients reported mild pain at the puncture site in the days following the treatment. This discomfort was resolved spontaneously without any need for further treatment.Lower back pain (with or without radiculopathy) is increasingly prevalent and indeed, it is the most common noncancer related pain pathology reported in pain units and in many cases, it is chronic in nature , 8. SurgCurrently, two electrical procedures are commonly used to treat radicular and/or lower back pain: conventional radiofrequency of the medial branch for facet pain and pulsed radiofrequency of the dorsal root ganglion for radicular syndrome , 10.Many studies have demonstrated the analgesic efficacy of these procedures. Van Kleef et al. reported the use of CRF has been attributed a level of evidence of 1B to treat lumbar facet syndrome , while pIn our research, we found that 80% and 76% of patients who underwent radiofrequency treatment decided to refuse scheduled spinal surgery 1 month and 1 year after treatment, respectively. Moreover, treated patients reported a higher level of satisfaction (84% satisfied or very satisfied) and a decrease in the consumption of analgesics. Also, the low complication rate and a low cost should be noted. Together with the observed decrease in the number of surgical procedures performed in patients with lumbar radicular pain resistant to other treatments, these findings suggest that radiofrequency could be a useful alternative to surgery in certain circumstances. a mechanical and an inflammatory component. The former is generated by direct compression of the nerve root by the hernia, while in the case of the latter, proinflammatory products of both the nucleus pulposus of the intervertebral disc and impaired venous and lymphatic drainage promote inflammation of the nerve root. Various studies have shown that pulsed radiofrequency can induce alterations in membrane and intracellular structures, thereby modifying action potential transmission and the perception of pain [It should be emphasized that the pathophysiology of radicular pain due to hernia involves of pain . HoweverAnother factor that appears to have been important in our study was the precise location of the needle relative to the dorsal root ganglion; thereby the mean sensory stimulation obtained was 0.21 V (DT = 0.082), ruling out the presence for motor stimulation twice the sensory stimulus achieved. The sensory stimulus that produces a positive response is inversely proportional to the distance from the tip of the needle. Thus, if we maintain a positive stimulus at a low voltage, we can bring the tip of the needle closer to the dorsal ganglion and achieve a more effective electromagnetic field for pulsed radiofrequency .The impact of sensory stimulation has been recently analyzed, reporting no significant difference between the values of sensory stimulation and the effectiveness of the technique . HoweverSome limitations of our study should be borne in mind, such as the small sample size and the lack of a control group. The latter was not possible as the patients included were already scheduled for surgery.In summary, radiofrequency using precise parameters for electrical localization and applying specific inclusion criteria could produce very satisfactory outcomes in patients over both the short term and long term, in some cases avoiding the need for surgery. Indeed, we think it is necessary to take radiofrequency into account before scheduling a surgery. Thus, there are indications for radiofrequency as well as for surgery.However, further controlled studies with larger sample sizes will be necessary to better determine the efficacy of these treatments , 17.


Objectives. The objective of this narrative review was to examine the usage of ketamine as a postoperative analgesic agent across a wide variety of surgeries. Design. A literature search was performed using the phrases “ketamine” and “postoperative pain.” The authors analyzed the studies that involved testing ketamine's effectiveness at controlling postoperative pain. Effectiveness was assessed through various outcomes such as the amount of opiate consumption, visual analog scale (VAS) pain scores, and persistent postoperative pain at long-term follow-up. Results. While many different administration protocols were evaluated, delivering ketamine both as a pre- or perioperative bolus and postoperative infusion for up to 48 hours appeared to be the most effective. These effects are dose-dependent. However, a number of studies analyzed showed no benefit in using ketamine versus placebo for controlling postoperative pain. While ketamine is a safe and well-tolerated drug, it does have adverse effects, and there are concerns for possible neurotoxicity and effects on memory. Conclusions. In a number of limited situations, ketamine has shown some efficacy in controlling postoperative pain and decreasing opioid consumption. More randomized controlled trials are necessary to determine the surgical procedures and administrations  that ketamine is best suited for. Postoperative pain is one of the most undesirable experiences for a patient undergoing surgery. Deliberate action should be taken to prophylactically treat the pain. If postoperative pain does develop, it should be managed early and aggressively, because severe pain not only induces a delay in discharge and poorer patient satisfaction, but also can create a hyperalgesic condition known as persistent postoperative pain (PPP). This strains not only the patient, but also the healthcare system as a whole. Recent studies show that PPP has an incidence as high as 40%. Furthermore, 18.3% of patients report that this pain is moderate to severe .Recently, interest has focused on the use of N-methyl-D-aspartate (NMDA) receptor antagonists for the management of postoperative pain. In particular, ketamine has been thrust into the limelight both as a standalone drug and as an adjuvant to other analgesics  . KetaminKetamine was first described in the literature in 1965 . VariousThis review will describe the pharmacology of ketamine, examine its usage as a postoperative analgesic, and discuss its adverse effects and safety profile.13H16ClNO and a molecular mass of 237.725 g/mol. It is composed of a chlorophenyl ring structure that is bonded to a cyclohexanone ring. Ketamine has a chiral center at the carbon-2 atom of its cyclohexanone ring and therefore it exists as the optical stereoisomers S(+) and R(−)ketamine. Ketamine was previously only available as a racemic mixture but now comes in its two stereoisomer varieties. S(+)ketamine binds NMDA receptors with affinity that is four times greater than that of R(−)ketamine. While the duration of S(+)ketamine is shorter than that of R(−)ketamine, S(+)ketamine has been shown to have an analgesic potency twice as great as the racemic mixture and four times as great as R(−)ketamine [The word “ketamine” is a portmanteau of the words “ketone” and “amine,” speaking of its chemical structure. It is a hydrochloride salt, available in both powdered and aqueous forms, with the molecular formula Cketamine .The diverse effects and multifaceted mechanisms of action of ketamine have given it the title “nightmare of the pharmacologist” . As therKetamine causes the central effect of anesthesia when it interacts with NMDA receptors in the brain. Brain concentrations of ketamine were directly related to analgesia using an ischemic pain model. Pain activation in the secondary somatosensory cortex, insula, thalamus, and anterior cingulate cortex was all decreased. Functional magnetic resonance imaging (fMRI) studies demonstrated that both pain and ketamine changed brain connectivity in areas involved in endogenous pain modulation. The studies showed that ketamine was responsible for a decrease in connectivity in the brain regions responsible for pain sensing and affective processing , 27.μ preferentially in rats [κ-opioid receptor as the site of analgesia [μ- and δ-opioid receptors is responsible for the central antinociceptive effects of ketamine [The analgesic effects of ketamine do not end with NMDA receptors. It has been shown to interact with opioid receptors  in rats . Studiesnalgesia . Howevernalgesia . Other snalgesia . A 2014 ketamine .μ-receptor activation by opioids leads to a sustained increase in glutamate synaptic effectiveness at the level of NMDA receptors. Although the mechanisms that allow ketamine to be an analgesic and opiate-sparing agent after opiate exposure remain poorly understood; an important concept that is worth mentioning is being studied in rat models. Rat studies in brain ischemia have found a role of postsynaptic density (PSD), proteins, specifically PSD-95, in potentiating NMDA function and signaling to nitric oxide synthase resulting in chronic and neuropathic pain. Studies show that ketamine may decrease injury-triggered increases in interactions between the NMDA receptor, postsynaptic density protein 95 (PSD95), and protein kinases, thereby reducing nitric oxide-related neuronal injury [Studies show that prevention of opioid tolerance may be another mechanism of pain prevention by ketamine. It has been reported that l injury . This col injury , 35.Many other receptors have been shown to play role in ketamine analgesia; however, their mechanisms remain unclear. Once thought to be an opioid receptor, the sigma-receptor has been implicated as a binding site for ketamine. The role of sigma receptors is uncertain; they may modify other receptors such as NMDA receptors.Needless to say, the effects of ketamine on the human body, both within the realm of analgesia and without, are incredibly complex. Further study is encouraged to fully elucidate the effects of this multifaceted drug on the body's various receptors.A 2013 study by Jha et al.  Table 1Table 1 eEghbal et al.  examinedA 2014 meta-analysis by Cho et al.  reports Nitta et al.  tested tμg/kg/min perioperatively and a group receiving both 1 μg/kg/min perioperatively and 1 μg/kg/min postoperatively. The patients in the control group required first analgesic demand dose earlier than the ketamine groups. Total morphine consumption, visual analog scale (VAS) pain scores, and rates of nausea and vomiting were significantly lower in the group receiving both peri- and postoperative ketamine versus the control group.Hadi et al.  used lowμg/kg/min infusion following a bolus dose of 0.5 mg/kg resulted in patients requiring significantly less fentanyl in the postoperative period with no increase in adverse effects [Kim et al.  report s effects .Pestieau et al.  evaluateμg/kg/minute) intraoperative ketamine on postoperative pain after total knee replacement surgery. The control group received a placebo. There was a prolonged time to first analgesic request in the ketamine group and a reduction in cumulative morphine consumption at 1, 3, 6, 12, and 24 hours after surgery. VAS scores were also significantly lower in the group receiving ketamine instead of placebo.Cengiz et al.  performeA study performed by Guará Sobrinho et al.  assessedD'Alonzo et al.  tested aNesher et al.'s 2008 study  examinedAbdolahi et al.  utilizedThomas et al.  studied Bilgen et al.'s 2012 study  utilizedμg/kg/min IV ketamine infusion for 12 hours thereafter. Usage of ketamine reduced morphine requirements at the 4–8, 8–12, and 12–24-hour time points. The patients in the ketamine group showed reduced pain sensitivity at the T-10 dermatome, suggesting an antihyperalgesic effect. At three years after surgery, patients reported no differences in residual pain or dysesthetic symptoms.Suppa et al.  performeμg/kg/min infusion thereafter for 48 hours; the second ketamine group received a 0.5 mg/kg bolus perioperatively and a 2 μg/kg/min infusion only for the duration of the surgical procedure. All of the patients were given morphine PCA. The authors found that cumulative morphine consumption was significantly lower in the group receiving the 48-hour infusion when compared to the shorter infusion and control groups. VAS scores were measured postoperatively and were significantly lower in the ketamine groups when compared to the control group. As an added effect, while all patients in the study received hydroxyzine preoperatively, the 48-hour infusion group experienced significantly less nausea than the control group . It is worth nothing that there were no side effects of the ketamine, psychotomimetic, or otherwise.Zakine et al.  performeKatz et al.  analyzedde Kock et al.  studied A 2011 review by Laskowski et al.  found a A second review by Elia and Tramèr  shows siSubramaniam et al.'s 2004 systematic review , includiMcCartney et al.  performeKetamine has been reported to be a safe and well-tolerated drug , 58. DesThe most common concerns about ketamine as an analgesic agent are related to its mind-altering effects. Katalinic's team addressed these concerns and their review showed that most of the research conducted using subanesthetic doses of ketamine has shown transient increases in the following psychiatric symptoms: positive and negative symptoms of schizophrenia, dissociative symptoms, and manic symptoms. Fortuitously, these symptoms are only present at times of administration and usually disappear within 60 minutes of administration . Quiet, Other psychotomimetic effects of ketamine use include feelings of intoxication, increased confusion, lowered inhibition, and perceptual disturbances. In addition, research shows that chronic use of ketamine may impair several memory systems including episodic and working memory. Nonetheless, these effects have been restricted to time of administration and are transient in nature. Additionally, implications of these effects have not been found to be dependent on dose or route of administration .No severe physical symptoms have been reported with the use of low-dose ketamine; however, studies have reported benign effects of lightheadedness, headache, nausea, diplopia, drowsiness, and dizziness. These effects, unlike the psychotomimetic effects, tend to be dose-dependent. They are also limited to time of administration and a short time thereafter .Ketamine can also induce various CNS side effects . One systematic review found incidences of these CNS effects were 18%, 10%, 9%, and 0.7% with IV PCA, IV infusion, IV single dose, and epidural groups, respectively. No significant increase in these effects was seen compared to patients who did not receive ketamine .Almost 200 cases of ketamine-induced uropathy have been reported in the literature, mostly in the context of chronic abuse, but five within medical analgesic use . Case seHepatotoxicity has been reported at anesthetic doses (≥1 mg/kg) and patients receiving low-dose continuous infusion. Noppers et al. present data on the occurrence of ketamine-induced liver injury during repeated administrations of S(+)ketamine for the treatment of chronic pain. Six patients received 2 continuous intravenous 100-hour S(+)ketamine infusions, 10–20 mg/h, separated by 16 days. Three of these patients developed hepatotoxicity evident through elevated transaminases. Ketamine infusion was promptly terminated and the liver enzymes slowly returned to reference values within 2 months, suggesting an increased risk for development of ketamine-induced liver injury when the infusion is prolonged and/or repeated within a short time frame . Trials It has been described in the literature that ketamine use can lead to neuronal cell apoptosis. This is triggered by the direct blockade of NMDA receptors. The effect was demonstrated in rats at repeated doses of 20 mg/kg . HoweverChang et al.  reportedIn a study conducted to evaluate the safety and efficacy of ketamine for the treatment of refractory status epilepticus, it was found that the drug's administration caused possible adverse events in 5 out of 60 study patients. These included a life-threatening severe acidosis, a syndrome similar to propofol-related infusion syndrome, supraventricular tachycardia, and atrial fibrillation .Ketamine is not FDA-approved for epidural use as it carries a risk of neurotoxicity. Furthermore, there is no safety or efficacy data on the neuraxial administration of ketamine. Because of this, the epidural and/or intrathecal administration of ketamine are discouraged outside of the preclinical research setting. Spinal neurotoxicity after continuous intrathecal ketamine infusion of 5 mg/day over 3 weeks has been reported . HoweverPotential dependence through chronic or repetitive ketamine use is concerning. Studies of recreation ketamine-using populations report cravings for the drug, physiological tolerance, and possible withdrawal symptoms on drug cessation. Physiological tolerance is of particular relevance as it has been suggested for individuals having undergone repeated procedures requiring anesthesia with ketamine . ToleranAlthough it was first used purely as an anesthetic, ketamine is making a certain resurgence in the management of postoperative pain. Many of the aforementioned studies have demonstrated significant effectiveness in controlling postoperative pain, increasing time to first analgesic request, and decreasing overall opioids required, as well as demonstrating fewer of the opioid-related side effects like PONV. These effects have been demonstrated across many realms of surgery, including otolaryngology, abdominal surgery, orthopedic surgery, spinal surgery, and gynecological surgery. While all of the exact mechanisms have not been entirely agreed upon, the primary effect of the drug is related to its NMDA receptor antagonism. An intravenous bolus given prior to incision followed by a continuous infusion appears to be the most effective modality for postoperative pain control. If the infusion is given over a protracted time course (48 h) for more invasive and routinely painful procedures, patients can have a decreased risk of developing persistent postoperative pain in months that follow. This infusion can also be combined with PCA for excellent control of acute postoperative pain. Ketamine may not provide a clear benefit for patients undergoing smaller procedures, as analgesia with low dosages of opioids, NSAIDs, and local anesthetic infiltration can usually provide adequate pain relief. The often feared psychotomimetic effects can be blunted by administering general anesthesia or the less effective benzodiazepine. While animal models show some degree of neurotoxicity in high-dose applications and possible induction of neuronal apoptosis, these effects have not been demonstrated and are not of concern at the dosages and durations employed for postoperative analgesia. The other conclusion that can be drawn from the aforementioned studies is that although ketamine was effective in many of the trials, other trials showed that it provided no benefit when compared to a placebo. While ketamine holds a place in the prevention and treatment of postoperative pain, more large, high-quality controlled studies are necessary in order to determine which procedures it is best suited for and at what dosages and frequencies it should be administered.


Objective: To evaluate the ability of lidocaine local injection to relieve postoperative pain in cesarean delivery. Materials and methods: This double blinded clinical trial was conducted in a university on 100 women underwent elective cesarean section during March 2012 till March 2013. Patients were divided to two groups with random block method (n = 50 in each group). First group received 4mg/kg lidocaine 2% and its volume was titrated to 30 cc with distilled water. Second group received 30 cc of normal saline. Injections were done in different layers of abdominal wall. Visual analogue scale (VAS) was applied to record 12 hours severity of pain in all patients. Data were analyzed by SPSS software using one way ANOVA parametric test.Results: VAS average was 4/13 in lidocaine group and 4/81 in placebo group. The need for analgesic use was 300 mg in lidocaine and 346 mg in normal saline patients and the difference was significant (p < 0.000).Conclusion: Local use of lidocaine 2% in cesarean incision reduced post operative pain and need to use analgesic agents. Cesarean section is the most common major surgery which is performed for women in the United States currently, and it is estimated that more than 1.3 million cesareans performed annually. Postoperative pain relief is an important consideration issue as in clinic. Although different methods have been described for proper pain relief, it is not sufficient and satisfactory in some patients . Due to Several studies have been conducted to evaluate the efficacy of different post-partum pain management protocols for cesarean section . On the Local analgesics usage during surgery has fewer side effects in compare with opioids or neuro-axial method . ConsideAfter ethics committee approval, we randomly (random block method) assigned 100 consecutive patients undergoing elective cesarean section to one of the two equal groups. Surgeon and nurse who evaluated pain were blinded about the injected solution. Primigravid women, with the weight between 50 and 80 kg, and minimum education level about high school were selected and patients with comorbidity, contraindication for spinal anesthesia and drug abuse were excluded and also surgeries which lasted more than one hour. Group A: First group received 4mg/kg from lidocaine 2% (solution volume was titrated to 30 cc with distilled water) and it was divided into three parts and the first two parts were injected in abdominal muscle and subcutaneous layer. Third part was infiltrated on peritoneum.Group B: second group received 30 cc of normal saline, and then this was injected in different layer of abdominal wall. Third part of it was infiltrated on peritoneum. Visual Analog Scale for Pain was described for all patients before operation and they were asked to estimate their post operative pain between zero and 10. VAS was recorded for 12 hours after surgery as below: every one hour in the first 4 hour after surgery, and every 4 hour for the rest of the time. If the patient complained from pain, a 100 mg diclofenac suppository was administered and time was recorded. Cesarean section technique: All operations were performed by a single surgeon. The surgery technique and postoperative protocol were same. Cesarean section was performed with transverse lower segment incision and anesthesia method was spinal in all cases. Statistical analysis: comparison between groups was performed using student’s t-test or one way ANOVA parametric test. Descriptive analysis were computed for all variables. P value less than 0.05 was considered significant statistically.Demographic variables were matched in two groups. Patients mean age was 24 ± 4 years and their weight was 61 ± 4 kg. Mean duration for removing urinary catheters and walking after surgery was 18 ± 2 hours in both groups. There was no adverse event or side effect in patients. Mean VAS had no difference between groups at the first hour which might result from remaining effect of spinal anesthesia. Mean VAS was 4.13 and 4.81 in lidocaine and normal saline patients, respectively. VAS in lidocaine group was significantly higher at the second, third, fourth and overall 12 hour score (p < 0.000). Mean suppository usage varied between groups (p < 0.00). Mean dosage of analgesic needed for pain relief after CS was 300 mg in lidocaine group and 346 mg in normal saline (p < 0.00). Mean pain score of VAS had a normal distribution in both groups which is compared between groups in a 12 hours period in VAS in lidocaine group was significantly higher at the second, third, fourth and overall 12 hour score (p < 0.00). Mean suppository usage varied between groups (p < 0.00). The mean interval between the completion of the operation and need to use diclofenac suppository between two groups are compared in The mean interval between the completions of the operation and need to use diclofenac suppository was significantly less in lidocaine group (p = 0.016). Turkey post HOC test confirmed that diclofenac suppository usage at first hour showed no difference in groups.This study showed that Lidocaine 2% injection in cesarean section incision results in reduction in post operative pain and analgesic usage without any important side effect. th hours and opioids usage was lesser in marcaine group in regard to placebo (Different studies approved our results. Moradi and colleagues  showed t placebo . Beaussi placebo . There are few evidence which are opposed the idea about the efficacy of local analgesic in post operative pain control. In a study by Abbas et al extra peritoneal bupivacaine usage in laparoscopic herniorrhaphy did not lead to reduction in analgesic dosage and pain . This diPost operative pain control has a great impact on patient satisfactory and well being which has a great impact on the quality of maternal and neonatal care. Lidocaine 2% injection in cesarean section incision results in reduction in post operative pain and analgesic usage without any important side effect.


Chronic mechanical low back pain is common among different age groups and genders. Different manual therapy techniques combined with exercise therapy and electrotherapy modalities play an important role in its management. Our objective was to compare the effects of McKenzie extension exercisesprogram (EEP) versus Mulligan Sustained Natural Apophyseal Glides (SNAGs) for chronic mechanical low back pain (CMLBP).st July to 31st December 2014.This randomized control trial (RCT) was conducted at Riphah Physical Rehabilitation Centre, Pakistan Railways General Hospital Rawalpindi, from 1The inclusion criteria was patients of both gender and age range 30-70 years with minimum 4 weeks history of CMLBP. A total of 37 patients were screened out as per inclusion criteria and randomly placed into two groups. Twenty patients in group A were treated with Mulligan SNAGs and 17 patients in group B with McKenzie EEP for four weeks at two session per week and single session per day. Visual Analogue Scale (VAS), Oswestry Disability Scale (ODI) and lumber Range of Motion (ROM) were used as an assessment tools and were measured at baseline and at the completion 4 weeks intervention. The data was analyzed with SPSS to draw the statistical and clinical significance of both interventions.At the completion of 4 weeks intervention the pre and post statistical analysis revealed that clinically the McKenzie EEP improved pain (mean 9.12 to 1.46) and disability (73.82 to 6.24) slightly more than Mulligan SNAGs , while the Mulligan SNAGs improved lumbar ROM more effectively than McKenzie EEP in all directions including flexion, extension, side bending and rotation. Statistically there was no significant difference between the effects of two interventions in managing pain and disability, and improving Lumber ROM.McKenzie EEP is clinically slightly more effective in the management of pain and disability as compared with Mulligan SNAGs, while Mulligan SNAGs are more effective in the improvement of lumbar ROM as compared with Mechanize EEP in the management of CMLBP. Low back pain (LBP) is one of the most common ailments affecting human being. Epidemiological studies showed that 70 to 80% of all people have LBP at some time in their life.2The management of low back pain consists of different intervention strategies. These include surgery, drug therapy, and non medical intervention. Most of the systematic reviews focus on the effectiveness of a single intervention and describe the effectiveness on different types of LBP.3Various types of exercises have been used in the management of low back pain. For example, William’s flexion exercise, and McKenzie extension exercise are used in the treatment of low back pain.8One of most important technique of mobilization with movement (MWM) is SNAGs, which involve the application of accessory passive glide to lumber vertebra, while patient simultaneously perform active movement.st July to 31st December 2014. The inclusion criteria were patients of both gender and age range 30-70 years with minimum 4 weeks history of CMLBP, while patients with acute and sub acute low back pain and trauma were excluded from the study. A total of 37 patients in which there were 20 male and 17 female patients were screened out as per inclusion criteria and randomly placed into two groups.This randomized control trial (RCT) was conducted at Riphah Physical Rehabilitation Centre, Pakistan Railways General Hospital Rawalpindi, from 1Twenty patients in group A were treated with Mulligan SNAGs in sitting, standing and prone position by applying anterocranial glide in the direction of treatment plane over the spinous or transverse process at 6 to 8 repetitions per sessions, and 17 patients in group B were treated with McKenzie active EEP in prone position with repeated movements along with standard protocols. Both groups were treated for four weeks at two session per week and single session per day and total 8 sessions. Treatment was applied at different lumber levels from L1 to L5. Both groups were given electrotherapy treatment such as hot pack and Transcutaneous Electrical Nerve Stimulation TENS.The self reported Visual Analogue Scale (VAS), Oswestry Disability Scale (ODI) and lumber Range of Motion (ROM) were used as an assessment tools and were measured at baseline and at the mid intervention (2 weeks) and completion of 4 weeks intervention. The lumber ROM for flexion and extension was measured by inclinometer, side bending with finger – tip to floor method, and rotation with help of measuring tape. The data was analyzed with SPSS version 20 to draw the statistical and clinical significance of both interventions.The mean age of participants in group A was 50.25 ± 9.56 and in group B was 49.12 ± 12.47. Statistically there was no significant difference between the mean ages of participants in both the groups (P=0.762), as shown in The pre and post interventional analysis revealed that clinically the patients in group B treated with McKenzie EEP improved pain slight more (mean pain from 9.12±0.48 to 1.46±1.73) as compared with the patients in group A treated with mulligan SNAGS (mean pain from 8.85±0.87 to 2.55±2.65), while statistically both the interventions were equally effective in both group for pain as assessed by VAS. as shown in The pre and post interventional analysis revealed that clinically the patients in group B treated with McKenzie EEP improved function slightly more (mean ODI from 73.82±7.81 to 6.24±5.89) as compared with the patients in group A treated with mulligan SNAGS (mean ODI from 73.75±0.7.58 to 7.05±5.83), while statistically both the interventions were equally effective in both group for the management of disability as assessed by ODI.The pre and post interventional analysis showed that clinically the patients in group A treated with Mulligan SNAGs improved lumber flexion ROM more (mean flexion from 4.00±2.902 to 56.25±3.93) as compared with the group of patients treated with McKenzie EEP (mean lumbar flexion from 4.88±3.05 to 37.94±13.35), while statistically both the interventions were equally effective in both group for the improvement of lumbar flexion as measured by inclinometer.The pre and post interventional analysis showed that clinically the patients in group A treated with Mulligan SNAGs improved lumber extension ROM more (mean extension from 3.80±1.542 to 31.80±3.286)as compared with the group of patients treated with McKenzie EEP (mean extension 3.12±1.764 to 18.76+4.726), while statistically both the interventions were equally effective in both group for the improvement of lumbar extension as measured by inclinometer.The pre and post interventional analysis showed that clinically the patients in group A treated with Mulligan SNAGs improved lumber side bending ROM more (mean side bending from 3.50±1.670 to 19.15±1.496) as compared with the group of patients treated with McKenzie EEP (mean side bending from 3.65±1.935 to 13.536±3.625), while statistically both the interventions were equally effective in both group for the improvement of lumbar side bending as measured by inclinometer.The pre and post interventional analysis showed that clinically the patients in group A treated with Mulligan SNAGs improved lumber rotation ROM more (mean rotation from 5.00±1.5 to 16.30±2.105) as compared with the group of patients treated with McKenzie EEP (mean rotation from 3.00±1.3 to 10.41±2.12), while statistically both the interventions were equally effective in both group for the improvement of lumbar rotation as measured by inclinometer.The results of this study showed that both techniques were statistically effective, but clinically have slight difference in the management of pain, disability and ROM in patients with chronic low back pain. Furthermore at the completion of four weeks intervention the pre and post statistical analysis revealed that clinically the McKenzie EEP improved pain and disability slightly more than Mulligan SNAGs, while the Mulligan SNAGs improved lumbar ROM more effectively than McKenzie EEP in all directions including flexion, extension, side bending and rotation.The result of our study showed that there is reduction in pain through McKenzie approach and long term increase in ROM through Mulligan SNAGs. In 2013 Shum GL et al. conducted a study on patient with lumber pain and decreased ROM, after the application of postero-anterior mobilization technique on lumbar spine there was immediate reduction in pain and decrease in stiffness.Descarreaux M and colleagues in 2004 conducted a study on spinal manipulation, in which they proved that spinal manipulation is effective for the treatment of LBP. Also they suggested that care after spinal manipulation is beneficial for patient to maintain subjective post intensive treatment disability levels.According to a recent study done by Dunning J et al. in 2015, flexion-distraction manipulation technique is an effective treatment technique for pain and disability in patient with lumber stenosis.13A study conducted by Nagrale AV and colleagues has demonstrated that slump stretching and home exercises along with lumbar spine mobilization and stabilization exercises are more effective for rate and magnitude of recovery of self reported disability, pain and fear-avoidance behaviour compared to treatment without slump stretching.14Another recent study in 2014 done by Mbada CE and colleagues demonstrated that health related quality of life in patients with long term mechanical low back pain decreases pain with severity. Also the addition of dynamic back extensors endurance exercises to McKenzie treatment protocol cause greater difference in health quality of life.15McKenzie Extension Exercise Program is clinically slightly more effective in the management of pain and disability as compared with Mulligan SNAGs, while Mulligan SNAGs are more effective in the improvement of lumbar ROM as compared with Mechanize Extension Exercise Program in the management of Chronic Mechanical Low Back Pain. Our recommendations are to conduct further studies with large sample size and long duration of intervention for the investigation of long term effects of both interventions in chronic mechanical and other types of low back pain.