A great number of patients that suffer from lateral epicondylitis, commonly called tennis elbow (TE), are not successfully treated, meaning, not getting adequate therapeutic effects and the main origin of the pain not being handled appropriately. The hypothesis of the present study is that the inefficiency of the treatment of the chronic TE may often be due to underdiagnosis of posterior interosseous nerve (PIN) entrapment or and plica syndrome, as the authors believe that those pathologies can often occur simultaneously.A prospective cross sectional study was conducted. A total of 31 patients met the required criteria.Thirteen (40.7%) of the patients had more than one source of the lateral elbow pain. Five patients (15.6%) had all three examined pathologies. Six patients (18.8%) had TE and PIN syndrome. Two patients (6.3%) had TE and plica syndrome.The present study demonstrated concomitant potential sources of lateral elbow pain in patients diagnosed with chronic TE. Our analysis shows how important it is to systematically diagnose patients that present with lateral elbow pain. The clinical characteristics of the three most common causes of chronic lateral elbow pain, meaning, TE, PIN compression, and plicae syndrome were also analyzed. Having adequate knowledge about the clinical aspects of these pathologies can help with a more effective differentiation of the etiology of chronic lateral elbow pain, and with that, a more efficient and cost-effective treatment plan. Lateral epicondylitis, commonly called tennis elbow (TE), is a disorder that is often encountered in clinical practice and is estimated to afflict 1 to 3% of individuals annually , 5. A grTE is characterized by tenderness at the common extensor origin, which is often exacerbated by wrist extension. It is the most frequent type of myotendinosis but also the most commonly diagnosed elbow pathologic condition , 8. OthePIN entrapment may be confused with TE because the clinical symptoms, as well as the location and severity of the pain, are often alike . The mosAnother pathology that may mimic the clinical symptoms of the TE is plica syndrome. The synovial plicae in itself is a controversial structure, with quite scarce literature concerning its morphological aspects, and diagnostic importance. Its presentation and clinical significance may easily be either overestimated or underestimated, mainly due to no clinical consensus being made for the diagnosis of its pathological form . HoweverThe hypothesis of the present study is that the inefficiency of the treatment of chronic TE may often be due to the underdiagnosis of PIN entrapment or and plica syndrome, as the authors believe that those pathologies can often occur simultaneously. It must be noted that patients with a diagnosis of chronic TE might suffer from not only inflammation of the common extensor tendons, but also additional sources of lateral elbow pain. This can therefore lead to an incomplete diagnosis, and, subsequently, unsuccessful treatment. In those cases in which the etiology of the pain comes from numerous causes, the differentiation between these different possible aetiologies of the said pain may be extremely difficult, especially when one has to differentiate between TE, PIN compression, and plica syndrome. Therefore, the goal of the present study was to analyze the co-occurrence of these clinically similar pathologies in 31 patients previously diagnosed with the chronic TE. Having adequate knowledge about the clinical aspects and awareness of the frequency of co-occurrence of these pathologies can help with a more effective differentiation of the etiology of chronic lateral elbow pain, and with that, a more efficient and cost-effective treatment plan.A prospective cross sectional study was conducted to establish the co-occurrence of the TE, PIN syndrome, and plica syndrome in patients with the previous diagnosis of chronic TE. For this purpose, 50 consecutive patients with a diagnosed chronic TE were invited to participate in the study. The examinations of the patients were conducted between September 2021 and December 2022 in Intermed Medical Center, Kraków, Poland.The inclusion criteria were set as follows: (1) unilateral chronic TE (lasting as least 6 months), previously diagnosed and confirmed by a medical records; (2) lateral elbow pain; however, only in the upper extremity with the chronic TE; (3) minimal age of 18 years; (4) declaration in writing of the informed consent to participate in the study and for the publication of the results; (5) no contraindications for the ultrasound (US) examination; (6) no history of nervous system diseases; (7) no history of connective tissue diseases; (8) no significant deformities  in both upper extremities.The exclusion criteria were set as follows: (1) failure to meet any of the inclusion conditions; (2) accompanying neurological or psychiatric disorders or ongoing neurological or psychiatric treatment; (3) pregnancy; (4) patients with a history of trauma to the lateral elbow that may interfere the results; (5) inability to fully visualize and/ or measurement of all of the examined structures; (6) significant artifacts that prevented accurate and precise imaging and/ or measurement of all of the examined structures.Out of the initially gathered group, 19 patients were excluded from the study. Finally, a total of 31 patients met the required criteria.Detailed medical history regarding the upper extremity was collected from all patients. Subsequently, each patient has been physically examined, including the US assessment. Each examination was performed by three independent researchers, of which two are specialists in orthopaedics and/or radiology and deal with the upper extremity in the daily clinical practice. However, none of the measurements results of the researchers could not differ from one another by more than 0.05 mm. Any discrepancies in the examination identified by the reviewers were resolved by consensus or by the fourth reviewer, also an orthopaedic specialist.A detailed interview was conducted with each patient. Furthermore, a physical examination has been performed, and on those bases, a preliminary diagnosis was set. Afterwards, each patient was asked to fill two, subjective, pain-related evaluation forms: (1) Patient-Related Tennis Elbow Evaluation form, validated Polish version (PRTEE) , and (2)The parameters regarding the TE: (1) presence of the oedema; (2) presence of the inflammation assessed via a Doppler analysis; (3) presence of the tendinosis; (4) presence of the uneven bone attachment area; (5) presence of the rupture of the attachments of the extensor carpi radialis brevis (ECRB); and/or extensor digitorum communis (EDC) and/or extensor carpi ulnaris (ECU) and/or extensor digiti minimi (EDM).The parameters regarding the PIN: (1) diameter of the PIN before the supinator canal [mm]; (2) diameter of the PIN in the supinator canal [mm]; (3) diameter of the PIN after the supinator canal [mm]; (4) modeling of the PIN by the arcade of Frohse in a static examination; (5) modeling of the PIN by the arcade of Frohse in a dynamic examination; (6) crossing of the PIN with the recurrent interosseous artery.The parameters regarding the plica: (1) plicas’ maximal thickness [mm]; (2) presence of the oedema; (3) presence of the fibrous changes; (4) presence of the cystic remodeling; (5) presence of the vascularity in Doppler examination; (6) modeling of the plica by bones.The US examinations were performed according to the recommendations by Obuchowicz and Bonczar .p ≤ 0.05. The qualitative variables were compared using the χ2 test of proportions for categorical variables. Wilcoxon signed-rank test was used to establish potential differences between groups. Spearman’s rank correlation coefficient was used to determine possible correlations between the parameters. The statistical analysis has been checked with the CHAMP checklist [Statistical analysis was performed with STATISTICA v13.1 . The frequency and percentages presented qualitative features. The Shapiro–Wilk test was used to assess the normal distribution. Quantitative characteristics were presented by means and standard deviation (SD), as well as by simple percentages. Statistical significance was defined as Eventually, thirty-one patients were examined during this study. Patients were between 33 and 68 years of age, with a mean age of 47.09 (SD 8.48). There were 12 (38.71%) women and 19 (61.29%) men who participated in this research. The mean number of examined sources of the lateral elbow pain  was set to be 1.56 (SD 0.76). The mean PRTEE score was found to be 50.33 (SD 19.69), whilst the mean QuickDASH score was set to be 52.02 (SD 18.22).Thirteen (40.7%) of the patients had more than one source of the lateral elbow pain. Five patients (15.6%) had all three examined pathologies. Six patients (18.8%) had TE and PIN syndrome. Two patients (6.3%) had TE and plica syndrome. Figure The edema occurred in 25 (80.6%) of the symptomatic limbs, whilst only in four 12.9%) of the asymptomatic limbs. The inflammation occurred in 21 (67.7%) of the symptomatic limbs, whilst only in one 3.2%) of the asymptomatic limbs. The tendinosis occurred in 24 (77.4%) of the symptomatic limbs. For detailed results of the TE examination, regarding all the assessed parameters, please see Table 2.9% of t.2% of thThe mean diameter of the PIN before the supinator canal in symptomatic limbs in patients with PIN syndrome was set to be 3.05 mm (SD 0.68), whilst only 1.85 mm SD 0.40) in the asymptomatic limbs of the same patients. The mean diameter of the PIN in the supinator canal in symptomatic limbs in patients with PIN syndrome was set to be 3.08 mm (SD 0.59), whilst only 1.77 mm SD 0.29) in the asymptomatic limbs of the same patients. The PIN was modeled by the arcade of Frohse in a static examination in seven (58.3%) of symptomatic limbs in patients with PIN syndrome. For detailed results of the PIN syndrome examination, regarding all of the assessed parameters, please see Table 9 in the 0 in the The mean plicas’ maximal thickness in symptomatic limbs in patients with plica syndrome was found to be 3.13 mm (SD 1.09). The oedema occurred in 5 (71.4%) of the symptomatic limbs in patients with plica syndrome. The fibrous changes occurred in four (57.1%) symptomatic limbs in patients with plica syndrome. For detailed results of the plica syndrome examination, regarding all of the assessed parameters, please see Table Both PRTEE and QuickDASH scores were found to statistically significantly correlate with the examined number of sources of the lateral elbow pain. For the detailed results of those correlations, please see Table The present study evaluates the co-occurrence of the TE, PIN entrapment, and the plica syndrome in light of the complexity of the origin of lateral elbow pain. Our analysis consisted of 31 patients, with a previous diagnosis of chronic TE. Our results show that almost half of the patients (43.7%) did not suffer from only TE. It must be noted that 15.6% of the patients suffered from TE, PIN compression, and plica syndrome simultaneously. Furthermore, TE and plica syndrome was found in 6.3% of the cases, and TE and PIN compression in 18.8%. In light of the present results, the question that must be addressed by the physicians is whether the patient truly has the unsuccessfully treated chronic TE or is simply treated against an inappropriate source of the pain?Interestingly, the results of the present study show that patients suffering from more than one origin of chronic lateral elbow pain score higher on PRTEE and QuickDASH pain evaluation forms, as the results of both PRTEE and QuickDASH statistically significantly correlated with the number of lateral elbow pain sources. One may postulate that if a patient comes in with chronic lateral elbow pain, and scores exceptionally high on the said evaluation forms, more than one origin of pain may be present. Performing the diagnostic process in a systematic fashion, analogous to what is presented in our study, can increase the probability of diagnosing the patient correctly and subsequently provide appropriate treatment. Our study model and diagnostic approach to chronic lateral elbow pain are easily repeatable, making it a great tool for physicians treating this especially frequent pathology.p = 0.00). Therefore, the presence of these symptoms may indicate the presence of TE. However, a thorough history inquiry and physical examination are needed for an accurate diagnosis. Other mentionable findings that may help with the diagnosis of TE are signs of abnormal thickening of the tendon and capsule and increased signal intensity within the common extensor origin [All of our patients were already diagnosed with chronic TE prior to our own diagnostic approach. We discovered that oedema, inflammation, tendinosis, and uneven bone attachment area occurred more frequently in patients with TE compared to the asymptomatic limbs . Our results further prove that an enlargement of the dimensions of the PIN strongly suggests compression of the said nerve. For refractory cases of PIN syndrome, surgical decompression surgeries are usually performed as the main treatment. These procedures focus on releasing areas of compression of the said nerve. Areas that may be decompressed include releasing fibrous bands non-superficial to the radiocapitellar joint, ligating the leash of Henry , and releasing the arcade of Frohse, amongst others [The radial nerve bifurcates proximal to the arcade of Frohse to divide into the PIN and the sensory branch of the radial nerve. Arcade of Frohse is also said to be the most frequent compression site of PIN , 21. Stut others .p ≤ 0.05). Other significant findings that have been presented in the literature are the occurrence of snapping or clicking during elbow motion, and some local tenderness at the posterolateral aspect of the radiocapitellar joint, and in some cases, in the antero-lateral side [Plica syndrome was also analyzed in our patient group. The synovial plicae, or the synovial fold, is a common anatomical finding that is reported to occur in 86 to 100% of the cases. However, a symptomatic plicae is said to be much less common . HoweverThe present study is not without limitations. This article, to the best of the author's knowledge, is the first in the literature to statistically shed light on the coexistence of these elbow pathologies. Nevertheless, our results are based on 62 elbows and, therefore, should be repeatedly evaluated in further studies by different physicians, ultimately leading to a meta-analysis regarding this issue in the future. Additionally, all evaluated patients were patients from Poland. Therefore, further multinational and multiracial studies should be performed. Furthermore, a receiver operating characteristic analysis regarding the number of sources of lateral elbow pain and the PRTEE and QuickDASH scores should be assessed in further studies with a larger sample. Although the previous study is not without limitations, the authors believe that this study will be the basis for further development of the literature on lateral elbow pain, in effect minimizing the ineffectiveness of its therapy.In conclusion, the present article, to the best of the author’s knowledge, is the first in the literature to statistically shed light on the coexistence of these elbow pathologies. The present study demonstrated how a large proportion of patients that were diagnosed with chronic TE, had also additional sources of lateral elbow pain and, because of it did not obtain therapeutic effects of treatment. Our analysis shows how important it is to systematically diagnose patients that present with lateral elbow pain. In order to increase the probability of diagnosing all of the possible aetiologies of the said pain, every patient should go through a thorough physical examination, an ultrasound assessment of the whole elbow region, and fill out pain evaluation forms. The present study showed how the scores of both PRTEE and QuickDASH statistically significantly correlate with the number of lateral elbow pain sources. The clinical characteristics of the three most common causes of chronic lateral elbow pain, meaning TE, PIN compression, and plicae syndrome were also analyzed. Having adequate knowledge about the clinical aspects of these pathologies can help with a more effective differentiation of the etiology of chronic lateral elbow pain and with that, a more efficient and cost-effective treatment plan.


Background: Osteoarthritis is a debilitating degenerative disease more pronounced in elderly affecting many joints. The first carpometacarpal joint (CMC1) is commonly affected. Pain is the major complaint, which can impact patient’s daily activities. Intra-articular glucocorticoid injection can be considered if conservative measures fail and ultrasound guided injection might be superior to the traditional anatomic landmark-guided technique. Objective: The aim of this study is to evaluate the effectiveness of ultrasound-guided versus landmark-based approach to intra-articular CMC1 injection using the Australian Canadian osteoarthritis hand index (AUSCAN). Methods: Adult patients diagnosed with symptomatic CMC1 osteoarthritis who failed conservative measures were enrolled. In this prospective observational cohort study, utilizing a convenience sample, intra-articular corticosteroid injection was administered either by ultrasound-guided technique or landmark-based approach. Pain, stiffness and function in 10-points scale at baseline, 6 and 12 weeks were collected and analyzed using descriptive analysis. Results: There were 33 patients enrolled. Mean age was 63 years, with females making up the majority of participants . Mean duration of CMC1 pain was 10 months (SD=2.5) up to the point of receiving the injection. Ultrasound guided injection was performed in 60.6% (n=20), while 39.4% (n=13) had the landmark approach. Both groups achieved a statistically and clinically significant level of change in AUSCAN score at week 6 (P≤ 0.05) but with a recurrence of symptoms at week 12 (P ≤ 0.05). At both intervals the AUSCAN scores were better than baseline (P ≤ 0.05). There was no difference between the two groups regarding baseline pain VAS score . No significant differences were identified between two groups in terms of changes from baseline to 6, 12 and between 6 to 12 weeks in pain, stiffness and hand function (P > 0.05). Conclusion: No difference was found between the ultrasound-guided and landmark-based approaches for CMC1 injection on pain score, stiffness, or function.  Osteoarthritis (OA) is a debilitating degenerative disease that affects many joints. The carpometacarpal is one of the commonly affected sites Figure 1). Pain in particular is a major component and this can significantly impact patients’ activities of daily living . Pain inA prospective, observational cohort study was conducted at St James’s hospital in Ireland between January and July 2021. The study employed a convenience sample, comprising patients from the dedicated patient lists of two expert doctors who routinely perform therapeutic injections. Ethical approval was obtained from the St James’ and Tallaght Hospital Joint Ethics Committee. To be included the following inclusion criteria was required of all participants: adults aged ≥18 years) diagnosed with symptomatic first CMC osteoarthritis with Eaton-Littler stage 2 and greater years diData were entered into JASP software and then were analyzed. The efficacy of the two methods were compared based on the pain severity, stiffness, and function of the patient using t-tests and ANOVA. The relation between qualitative variables was assessed using chi-squared tests.There were 33 patients enrolled in this study. The mean age was 63 years (SD = 9.5). There was a higher proportion of females  compared to males. At the time of injection majority  were unemployed, and  were non-smokers. One patient was left-handed (3%) while the rest were right-handed . The mean duration of CMC1 pain was 10 months (SD = 2.5). There was no difference in baseline pain VAS scores between the two groups .Over one third of the participants  did not use a hand splint and, 45.5% (n= 15) had a previous glucocorticoid injection to the joint of interest. The majority of patients  had a right CMC1 glucocorticoid injection. Overall, 60.6% (n= 20) had ultrasound-guided injection and 39.4% (n = 13) had a landmark-based injection. Both groups achieved a statistically significant improvement in AUSCAN score at week 6 (P≤0.05) but with a recurrence of symptoms at week 12 (P ≤0.05), at both intervals the AUSCAN scores were better than baseline (P ≤0.05) . No significant differences were identified between two groups in terms of changes from baseline to 6, 12, and between 6 to 12 weeks in pain, stiffness and hand function. The US-guided injection group and the standard approach group had significant better results in pain score at rest, gripping, lifting, turning, squeezing, and stiffness in 6 weeks’ time as highlighted in Table 1. In the US-guided injection group hand function improved significantly at weeks 6 and 12 (P<0.05) in all aspects assessed apart from carrying a full pot with one hand (P= 0.06). While in the landmark-based approach group significant improvements were captured at week 6 (P <0.05) (Table 1). No injection side reactions or complications were reported during the duration of this study.Osteoarthritis involving the first CMC is a degenerative joint condition for which patients seek intervention to alleviate pain and improve hand function. In this study, 33 participants with symptomatic CMC1 arthritis were prospectively evaluated for response to either ultrasound-guided or landmark-based joint injection. Both cohorts were predominantly female, with a median age of 65 years consistent with baseline demographics of previous studies In addition, a case series of 43 patients with grade 2 or higher Eaton classification were assessed following ultrasound-guided injection to the CMC1 and a strong correlation was found between patients who had persistent pain following glucocorticoid and local anesthesia injection at one week and the progression to surgery, (odd ratio 3.1) Several studies have been done comparing use of ultrasound-guided versus landmark-based approach in small joint or structures In this study, we found that the effect of intra-articular corticosteroid injection is satisfactory but transient for both ultrasound-guided and landmark based CMC1 injectionOur study had limitations, including a small sample size, convenience sample of doctor’s own patients, lack of blinding, and two experts performing the injection in both arms.In a small study of ultrasound versus landmark based CMC1 injection for OA, both techniques provided similar transient pain relief. Ethical approval was obtained from the St James’ and Tallaght Hospital Joint Ethics Committee, Written informed consent was obtained from all individual patients included in the study.The data supporting the study's findings are available from the corresponding author upon a reasonable request.The authors declare that they have no competing interests. No author received funding for this study. SAA: data collection, data analysis, manuscript writing. SM: data collection and manuscript writing. LC and NME: data collection. RC and CJ: manuscript writing/editing. All authors read and approved the final manuscript.


The need for pain management is increasing in pediatrics, but the side effects of overuse or abuse of analgesics can be harmful to children’s health and even life-threatening in severe cases.Patients who underwent resection of Meckel’s diverticulum at the Children’s Hospital of Chongqing Medical University from July 1, 2019, to July 1, 2022, were included in this study. Opioids were administered through patient-controlled analgesia (PCA). Based on the preoperative choices made by the legal guardians, patients were stratified into two groups: PCA Group (PCAG) and Non-PCA Group (NPCAG). Data pertaining to the clinical characteristics and prognoses of these patients were subsequently collected and analyzed to assess the impact of opioid administration.In the study, a total of 126 patients were enrolled, with 72 allocated to the Patient-Controlled Analgesia Group (PCAG) and 54 to the Non-Patient-Controlled Analgesia Group (NPCAG). When compared to the NPCAG, the PCAG exhibited a longer duration of postoperative fasting  and increased utilization of laxatives . However, the PCAG also experienced higher incidences of intestinal stasis and abnormal intestinal dilation . No statistically significant differences were observed in pain assessments at the conclusion of the surgical procedure  or within the first 24 h postoperatively . Additionally, NPCAG patients did not necessitate increased administration of rescue analgesics .The administration of opioids did not demonstrably ameliorate postoperative pain but was associated with a heightened incidence of postoperative gastrointestinal tract dysfunction. The retrospective nature of the current research should be considered and should be clarified further. Current research and scientific literature substantiate that children, including premature infants and neonates, are capable of experiencing pain. Failure to adequately assess and manage pain in this demographic can result in a range of detrimental outcomes –3. As thOpioids, commonly employed for analgesia, are not without drawbacks. Respiratory depression stands as the most acute adverse effect , 6,folloThe paradigm of Enhanced Recovery After Surgery (ERAS) has garnered widespread acceptance, with minimally invasive procedures and expedited recovery increasingly being integrated into clinical practice. However, the dissemination of ERAS in the pediatric population has been relatively sluggish, owing to the specialized needs and considerations inherent to this demographic. Drawing upon empirical data from adult cases and successful pediatric implementations, we posit that ERAS holds potential for improving clinical outcomes in pediatric patients . Our resMeckel’s diverticulum (MD) stands as the most prevalent congenital gastrointestinal anomaly, predominantly manifesting in pediatric patients. Symptomatic cases typically arise between the ages of 2 and 8 years. In pediatric medicine, the surgical excision of symptomatic MD is generally advised, although the removal of incidentally discovered MD continues to be a subject of debate –12.To elucidate the impact of opioid use on intestinal function recovery, we have compiled clinical data from patients who underwent Meckel’s diverticulum resections at our institution over a three-year span for further investigation.In this single-center, retrospective study conducted at Children’s Hospital of Chongqing Medical University, the inclusion criteria encompassed all pediatric patients between the ages of 1 and 18 years who underwent Meckel’s diverticulum resection between July 1, 2019, and July 1, 2022. This included both symptomatic and incidental cases of Meckel’s diverticulum. The patients were excluded if they met any of the following criteria: (1) Postoperative Ventilator Dependency Requiring ICU Admission, referring to those who could not be extubated after surgery and consequently needed transfer to the Intensive Care Unit for further management, including ongoing sedation and mechanical ventilation; (2) Co-Existing Severe Gastrointestinal Diseases Necessitating Concurrent Surgical Intervention, encompassing patients diagnosed with severe gastrointestinal conditions like biliary atresia, necrotizing enterocolitis, or congenital megacolon, who also required simultaneous surgical procedures; (3) Presence of Severe Postoperative Surgical Site Infections, confirmed by literature cited in Reference  ; (4) DiPCA has emerged as the primary modality for postoperative analgesia in pediatric patients owing to its demonstrated efficacy and safety –16. OpioBased on preoperative choices, patients were segregated into two groups: those utilizing Patient-Controlled Analgesia (PCAG) and those opting for no Patient-Controlled Analgesia (NPCAG).A hydromorphone solution was prepared at a concentration of 0.15 mg/kg, totaling a volume of 100 mL, based on the patient’s body weight. Postoperatively, this solution was administered intravenously at a rate of 2 mL/h. For breakthrough pain episodes, the infusion rate could be temporarily increased by 0.5 mL upon activation of the manual switch.Given the heightened risk of respiratory depression associated with opioid use, particularly in pediatric populations, vigilant monitoring is paramount , 17. AneShould pain management prove ineffective in either the PCAG or NPCAG cohorts, rescue protocols were activated: (1) Initial administration of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or acetaminophen. (2) In cases where pain persisted and exhibited no significant relief within 30 min, morphine was employed. (3) Fentanyl was introduced if pain continued to worsen.The primary endpoint of this investigation was the restoration of postoperative gastrointestinal function and the potential for postoperative gastrointestinal tract dysfunction. Secondary endpoints encompassed the efficacy and side effects of opioid analgesics.Clinical data accrued included age, body weight, presence of blood in stools, length of postoperative hospital stay, etiology necessitating surgery, results of diverticulum pathological examinations, Visual Analogue Scale (VAS) scores at surgery conclusion and within 24 h postoperatively, instances of breakthrough pain and interim analgesic use, postoperative pain assessments, duration of postoperative fasting, additional fasting and gastrointestinal decompression requirements post-meal, frequency of laxative administration, and outcomes of postoperative imaging studies, including color ultrasound and X-rays, as well as reoperation rates and opioid-related side effects.2) test or Fisher’s exact test, as appropriate. All tests were two-tailed, and a P-value less than 0.05 was deemed statistically significant.Statistical analyses were executed utilizing the Statistical Package for the Social Sciences (SPSS) software, version 25.0. The Kolmogorov–Smirnov test ascertained data distribution within all groups. Normally distributed data were evaluated using the Student’s t-test and reported as mean ± standard deviation (SD). In contrast, non-normally distributed data were examined using the Mann–Whitney U-test and presented as median along with the interquartile range . Categorical variables were assessed employing either the Chi-squared  admission due to mechanical ventilation dependence, three presented with surgical site infections (SSIs) and organ space infections (OSIs), one patient was discovered to have a Meckel’s diverticulum during laparotomy for multiple traumas, and three had incomplete clinical data. Consequently, 126 patients were included in the clinical study, comprising 97 males and 29 females . Among these, 103 underwent surgery for symptoms attributable to inflamed Meckel’s diverticulum, with bloody stools being the most prevalent symptom observed in 59 patients. Additionally, 18 patients were identified during routine intestinal exploration for appendicitis, and five were diagnosed during surgical interventions for recurrent intussusception. The study cohort was divided into 72 patients in the Patient Analgesic Preference Group (PAPG) and 54 in the No Patient Analgesic Preference Group (NPAPG)  compared to the Non-Patient-Controlled Analgesia Group (NPCAG) (p = 0.044).In cases of postoperative constipation, abdominal distension, or abdominal pain, laxative administration was necessitated. The incidence of requiring more than two laxative doses was significantly higher in the PCAG than in the NPCAG (p = 0.022).The timing for postoperative assessment was contingent on patient recovery, generally occurring 4–5 days post-surgery. Delay or acceleration in this timing was patient-dependent. The postoperative assessment period was significantly protracted in the PCAG compared to the NPCAG (p = 0.035). Based on color ultrasound and X-ray evaluations, 13 patients in the PCAG exhibited postoperative intestinal stasis and abnormal dilation, whereas only 3 patients in the NPCAG exhibited these symptoms (p = 0.037).No statistically significant differences were noted between the two groups in the incidence of postoperative intestinal wall thickening (p = 0.553), slowed intestinal peristalsis (p = 0.354), or minor peritoneal effusion (p = 0.132).All patients were successfully discharged, and analysis revealed no significant variation in postoperative discharge times between the two groups (p = 0.977).Upon regaining full consciousness postoperatively, a single patient in the Non-Patient-Controlled Analgesia Group (NPCAG) experienced mild pain, while the remainder of NPCAG and all patients in the Patient-Controlled Analgesia Group (PCAG) were pain-free. Anesthesiologists conducted Visual Analog Scale (VAS) assessments at random intervals within 24 h post-surgery. Of these, 16 patients in the PCAG (22.2%) and 18 patients in the NPCAG (33.3%) reported mild pain. No statistically significant differences were observed in the prevalence of mild pain immediately post-surgery (p = 0.429) or within the subsequent 24-hour period (p = 0.164) between the two groups.Two patients in the PCAG and four in the NPCAG experienced breakthrough pain postoperatively. All improved following the administration of non-steroidal anti-inflammatory drugs (NSAIDs); statistical significance was not achieved between the groups (p = 0.432).No incidents of respiratory depression were recorded in the PCAG, potentially attributed to the preoperative exclusion of patients with severe conditions necessitating continued ventilatory support. One patient in the PCAG experienced a febrile convulsion during hospitalization; a definitive correlation to analgesic pump side effects was not established.Postoperative pain was not timely assessed in the NPCAG. In the PCAG, pain levels were documented at intervals of 2 h, 6 h, 12 h, and 24 h following PCA utilization. No patients reported moderate or severe pain, while mild pain was reported by 66 patients (91.7%) at 2 h, 65 patients (90.3%) at 6 h, 63 patients (87.5%) at 12 h, and 64 patients (88.9%) at 24 h  is a frequent complication in clinical practice and is influenced by a myriad of factors . The utiThis retrospective study offers partial validation of these observations. Patients in the PCAG demonstrated elevated rates of gastrointestinal dysfunction; however, no significant differences were noted in terms of length of hospital stay or incidence of postoperative bowel obstruction between the two groups. Opioid administration during hospitalization may have contributed to these adverse experiences; hence, routine opioid use is not recommended.In the NPCAG, analgesics were not administered routinely. NSAIDs were only employed when breakthrough pain was reported, effectively alleviating the discomfort. Existing literature suggests that pain can detrimentally impact intestinal perfusion, either directly via nociceptive stimuli , or indiConsequently, the potential role of non-opioid analgesics like intravenous acetaminophen in standard postoperative care warrants further research. It may be judicious to withhold postoperative analgesics altogether, utilizing NSAIDs or opioids solely for cases of breakthrough pain.Extant literature highlights respiratory depression as the most severe complication associated with opioid usage , 6. DespConcurrent with postoperative surveillance, medical staff recorded the pain scores in children belonging to the PCAG. A majority exhibited mild pain, ranging between 87.5 and 91.7%. Regrettably, pain scores were not systematically recorded in the NPCAG, precluding a valid comparative analysis. Moreover, no significant differences in pain experiences were detected between the two cohorts, both immediately following the surgical procedure and during the postoperative assessments by the anesthesiologists. As such, the data suggests that opioid usage does not unequivocally enhance postoperative pain management, warranting further investigation through higher-quality studies.This study is marked by several limitations that concurrently outline avenues for future research. Firstly, the retrospective nature of our investigation inherently invites biases associated with this type of research design. To address this issue, future work should focus on prospective, randomized controlled trials for more accurate elucidation and validation of our observations. Secondly, the lack of systematically recorded pain scores in the NPCAG group restricted our ability to conduct a comprehensive comparative analysis. Subsequent research should ensure that pain scores are consistently recorded across all participant groups. Lastly, our study did not delve into how different doses or types of opioids specifically affect postoperative outcomes, mandating a more detailed examination in future studies. Given these limitations, there is a pressing need for further rigorous investigation into the potential role of non-opioid analgesics like intravenous acetaminophen in standard postoperative care. Additionally, future research should also focus on patient-centered long-term outcomes and quality of life.Our study underscores the imperative of revisiting prevalent opioid-based analgesia in pediatric gastrointestinal surgeries. Notably, opioids did not confer clear benefits in alleviating postoperative pain but increased the risk of Postoperative Gastrointestinal Tract Dysfunction (PGTD). This highlights the urgency to re-evaluate routine opioid administration, advising its reserved use only for breakthrough pain. As we confront a public health crisis around opioid misuse, these findings are timely. For future investigations, the emphasis should be on validating non-opioid alternatives and assessing their impact on long-term patient outcomes.


Although nonsurgical treatment of thumb carpometacarpal (CMC-1) osteoarthritis (OA) provides short-term improvement, the durability of these effects beyond 1 year is unknown. In this study, we investigated patient-reported pain and limitations in activities of daily living (ADL) at >5 years following nonsurgical treatment  for CMC-1 OA. We hypothesized that pain and limitations in ADL would not worsen after 12 months. Secondary outcomes were satisfaction with treatment results and health-related quality of life at >5 years of follow-up and the rate of conversion to surgery.This was a multicenter, prospective cohort study using 2 overlapping samples. The change in the Michigan Hand Outcomes Questionnaire (MHQ) subscales of pain and ADL between 12 months and >5 years was the primary outcome as measured in the first sample (n = 170), which consisted of patients who did not undergo conversion to surgery. Additional measurement time points included baseline and 3 months. We evaluated conversion to surgery in a second sample, which included all patients who responded to the invitation for this follow-up study (n = 217).At a median follow-up of 6.6 years , the score on the MHQ pain subscale did not differ significantly from that at 12 months. The score on the MHQ ADL improved by 4.4 points  compared with 12 months, but this was not clinically relevant. At >5 years, 5% of the patients rated their satisfaction as “poor,” 14% as “moderate,” 26% as “fair,” 39% as “good,” and 16% as “excellent.” The median EuroQol-5 Dimensions-5 Levels (EQ-5D-5L) index score was 0.852 . The rate of conversion to surgery was 22%  at a median follow-up of 7 years .We found positive outcomes at >5 years of follow-up for nonsurgical treatment of CMC-1 OA, with no worsening of pain or of limitations in ADL after 12 months. Our findings support nonsurgical treatment as the first treatment choice and suggest that treatment effects are sustainable.Level II. See Instructions for Authors for a complete description of levels of evidence.Therapeutic  Because of the aging population, the number of patients with CMC-1 OA is expected to increase4. CMC-1 OA often results in pain, limitations in activities of daily living (ADL), reduced quality of life, thenar muscle wasting, and/or thumb deformity2.Osteoarthritis (OA) of the thumb carpometacarpal joint (CMC-1) is a common disorder with a symptomatic prevalence of 7% for females and 2% for males >50 years of age7. Surgery can be considered when nonsurgical treatment fails to sufficiently relieve symptoms9.Most guidelines for the management of CMC-1 OA advise starting with nonsurgical treatment, such as the use of an orthosis, corticosteroid injections, analgesics, exercise therapy, or a combination of these treatments12, the long-term effects are unknown14. Exercise therapy can optimize thumb positioning and improve use in daily life, with a known treatment effect up to 1 year11. Because of the chronic nature of CMC-1 OA, knowledge of the long-term outcomes is needed to provide patients and clinicians with greater insight into the durability of nonoperative management. As treatment focuses on stable thumb positioning and improved use in daily life, we hypothesized that the treatment effects of exercise therapy plus use of an orthosis remain stable from 1 year up to at least 5 years and that this treatment thus offers a sustainable solution. Furthermore, while guidelines advise initial nonsurgical treatment to potentially avoid surgery, the actual long-term conversion to surgery has been poorly described. Few studies have reported on conversion to surgery and typically have had a follow-up of approximately 2 years16. Avoiding surgery is important if possible because of the lengthy associated rehabilitation, costs, and outcome variation; the results are not always to the patients’ satisfaction17.Although short-term effectiveness has been demonstrated for the combination of exercise therapy and orthosis useIn the current study, we investigated pain and limitations in ADL following nonsurgical treatment (consisting of exercise therapy and use of an orthosis) for CMC-1 OA at >5 years and tested the hypothesis that these outcomes would not deteriorate after 12 months in patients who did not convert to surgery. Secondary and exploratory outcomes included satisfaction with treatment results and health-related quality of life at >5 years, and the rate of conversion to surgery following nonsurgical treatment of CMC-1 OA.18. All patients provided informed consent, and the institutional review board approved the study.This was a multicenter, prospective cohort study that followed the guidelines of the STROBE  statement19. On the basis of the combination of the patient’s diagnosis and selected treatment, each patient was assigned a “measurement track,” which includes predefined measurements at predefined time points20. For the current study, patients were invited to complete prospectively distributed questionnaires >5 years after treatment onset.Data were collected during the study period at Xpert Clinics, comprising 8 specialized hand clinics with 18 hand surgeons in The Netherlands. Outcomes up to 12 months were routinely measured using GemsTracker  software (Erasmus and Equipe Zorgbedrijven); details of our data collection were previously publishedAll patients were diagnosed with CMC-1 OA by hand surgeons on the basis of symptoms and physical examination and referred for hand therapy between January 2011 and October 2015. Radiographs are usually made but not routinely recorded. We invited patients to participate in this follow-up study if they had completed the visual analog scale (VAS) for pain at rest, pain during activities, and function, and the Michigan Hand Outcomes Questionnaire (MHQ) at baseline and 3 months as part of their routine outcome assessments.We used 2 overlapping samples in this study, whereby sample 1 was a subset of sample 2. In sample 1, we studied pain and limitations in ADL of patients who did not have surgery. We used sample 2 to evaluate conversion to surgery. For both samples, we included adult patients with complete sociodemographic data at baseline, scores on the MHQ at baseline and 3 months, and data from our follow-up questionnaires at >5 years. Exclusion criteria for both samples were CMC-1 surgery before nonsurgical treatment, posttraumatic CMC-1 OA, a simultaneous intervention for another hand or wrist comorbidity, and a corticosteroid injection <6 weeks before treatment. For sample 1, an additional criterion was that the patient did not undergo conversion to surgery. Information regarding these criteria was extracted from patient records and our data collection system.5. A detailed description of the treatment is presented in Appendix 1. Treatment frequency and duration differed by patient and were determined by the therapist in conjunction with the patient, inherent to the study’s observational nature.Trained hand therapists carried out the treatment at the 8 specialized hand clinics. Treatment was based on the local and Dutch treatment guidelines, generally consisting of the use of a custom-made or prefabricated orthosis, weekly 25-minute therapy sessions including exercises and education to achieve a more stable opposition position, and daily exercisesBaseline demographics, including sex, age, type of work, hand dominance, affected hand, and symptom duration, were retrieved from our database.21. Scores on the MHQ subscales of overall hand function, work performance, aesthetics, and satisfaction with hand function were secondary outcomes22. MHQ scores range from 0 to 100; higher scores indicate better performance for all subscales except pain. We reversed the pain subscale to ease interpretation, and thus higher scores indicate better performance for all subscales. The MHQ pain and ADL subscales have a minimal important change (MIC) of 8 and 6, respectively, for nonsurgically treated CMC-1 OA23.The primary outcome was the change in pain and limitations in ADL between 12 months and >5 years. Pain and limitations in ADL were routinely measured with the MHQ subscales of pain and ADL at baseline, 3 months, and 1 year. For this study, additional MHQ data were collected prospectively at >5 years. The MHQ has high internal consistency, validity, and acceptable reliability24.In addition to the MHQ, other questionnaires were distributed at the >5-year time point. We used the valid and reliable Satisfaction with Treatment Result Questionnaire, which evaluates satisfaction with treatment results on a 5-point Likert scale  and asks whether the patient would undergo the treatment again under similar circumstances26. The EQ-5D-5L had good reliability, validity, and moderate responsiveness in patients with upper-extremity disorders27.The EuroQol-5 Dimensions-5 Levels (EQ-5D-5L) was used to measure health-related quality of life (HRQoL) at >5 years. Scores on the EQ-5D index are anchored at 1  and 0 Data on conversion to surgery within our clinics were extracted from patient records and our database of all patients in sample 2. Additionally, we used a survey to ask patients at >5 years whether they had undergone surgery for their CMC-1 OA.28, alpha = 0.025 (based on a Bonferroni correction for the 2 primary outcomes of pain and ADL), and a power of 0.80 indicated that 49 participants were required. This was well below the achieved sample of 170.A sample size analysis based on our 4 repeated measures, a conventional effect size of 0.25We used linear mixed models with the MHQ subscales of pain and ADL as dependent variables and the time points as a fixed factor for sample 1. We also performed the same analyses for the other MHQ subscales. Assumptions were checked using residual plots and normal probability plots.30.We performed a nonresponder analysis to investigate whether patients with missing values systematically differed from those without missing values, by comparing demographics and primary outcomes at baseline and 3 months between the participants who completed the MHQ at >5 years (defined as responders) and the participants who did not (defined as nonresponders), using t tests and chi-square tests. We performed a similar nonresponder analysis for missing data at 12 months. Additionally, we performed a Little’s test, which assesses the null hypothesis that the data are missing completely at randomWe report descriptive statistics for HRQoL and satisfaction with treatment in sample 1 at >5 years. We report the rate of conversion to surgery and used a Kaplan-Meier survival curve to display the time, in months, at which patients in sample 2 decided to undergo conversion to surgery. All analyses were performed using R .No external funding was received for this study.We invited 552 patients to participate in this study on the basis of their earlier assigned measurement track. We excluded 87 patients without CMC-1 OA, with traumatic CMC-1 OA, hand-related comorbidities, or a corticosteroid injection <6 weeks before treatment initiation . The nonsignificant results of Little’s test (p = 0.175) further suggest that the data were missing completely at randomThe median follow-up duration was 6.6 years . Fig. One hundred and sixty-three participants in sample 1 completed the Satisfaction with Treatment Result Questionnaire at >5 years. Five percent of the respondents rated their satisfaction with the results as “poor,” 14% as “moderate,” 26% as “fair,” 39% as “good,” and 16% as “excellent” , there were additional improvements seen at 12 months and even at >5 years in patients who did not convert to surgery. As we hypothesized, there was no deterioration in terms of pain or ADL limitations, as measured with the MHQ. A possible explanation for the lasting improvements could be that, apart from strengthening the thenar muscles, exercise therapy is aimed at using a new and more stable position of the thumb, thereby reducing joint loading and inflammation. Thus, patients learn how to prevent pain by using this position and to cope with their OA.32. A study by Lane et al. reported EQ-5D index scores of 0.85 and 0.8 at 1 year postoperatively among patients who had surgery for CMC-1 OA, which are similar to, or slightly lower than, the median score in the present study33.The HRQoL was assessed as a standalone cross-sectional outcome at >5 years. Since HRQoL is an underreported part of outcomes in this patient population, this outcome could be valuable for future research11. Gravås et al. reported that 24% of the patients who received occupational therapy in their randomized controlled trial had undergone surgery during a follow-up of 2 years15. In another study, Schloemann et al. reported a conversion-to-surgery rate of 9% with a median follow-up of 1.5 years16. These differences in conversion rates may be due to differences in populations or treatment protocols. Nevertheless, the findings that the conversion rate at approximately 2 years is comparable with the conversion rate at >5 years indicates that few patients undergo surgery once the positive treatment effect has been achieved, which further supports nonsurgical treatment as a first treatment choice.Our finding that only 22% converted to surgery is comparable with rates in other studies with shorter follow-up durations. Tsehaie et al. found a conversion rate of 15% in a study with a mean follow-up of 2.2 years and including a cohort with some of the same patients as in the present studyA limitation of this study is the missing data, which are inherent to the observational nature of this study. However, our nonresponder analyses suggested that the data were missing at random; there was a slight age difference between the responders and nonresponders, which seems clinically irrelevant, and no differences in the MHQ scores between the responders and nonresponders. The nonsignificant results of Little’s test further suggests that the missing data were missing completely at random. Therefore, we are confident that these missing data did not influence our primary findings.16. Predicting conversion to surgery may be improved by also considering the psychological characteristics of patients. A previous study found that patients scheduled for surgical treatment have a worse psychological profile than their nonsurgical counterparts34. Because of the relatively low number of patients who converted to surgery, we could not assess that in our study.Related to the observational design and associated missing data, our ability to estimate the true rate of conversion to surgery may have been limited, as the patients for whom we had data on conversion to surgery may not have been fully representative of the target population. This means that some patients may have sought care elsewhere without our knowledge  or that patients without symptoms who had not undergone surgery did not respond to our survey . However, all patients who did not undergo surgery according to our patient records also responded to the survey regarding additional treatments by indicating that they had not undergone surgery, suggesting that we did not underestimate the conversion rate. Still, this is a limitation, and future studies should address this in their design. Furthermore, insights into factors associated with conversion to surgery may enable faster, well-founded decision-making. Previous studies found that pain improvement, prior surgical experience, surgeons’ attitudes toward CMC-1 OA, previous nonpharmacological treatment, and higher motivation for surgery are influentialAnother limitation is that our patient-reported outcomes only represent patients who did not convert to surgery. This may have introduced selection bias because patients who eventually received surgery most likely had worse outcomes. Therefore, these outcomes only apply to patients who had not undergone surgery by the final follow-up of >5 years. However, since most surgeries occurred within the first year after treatment onset, the findings between 12 months and >5 years seem unaffected by this risk of bias.10. However, this variation is also a strength as it reflects daily clinical practice. To prove causality, a no-treatment arm would have to be included as a control group, since the natural course of CMC-1 OA may be somewhat self-limited regarding pain.Finally, a limitation of our observational design is that we cannot prove causality. However, the results have a higher ecological validity, as our findings reflect daily practice. Similarly, although therapists are trained the same, there may have been variations in the treatment they provided, and treatment frequency. This possible variation is important to acknowledge because it has previously been shown that exercises have a relatively large treatment effect compared with that of orthosis use aloneWe found positive outcomes at >5 years of follow-up after the nonsurgical treatment of CMC-1 OA, with no worsening of pain or limitations in ADL after 12 months, and with only 22% of the participants having converted to surgery at a median follow-up of 7 years. Our findings support nonsurgical treatment as the first treatment choice and indicate that treatment effects are sustainable.jbjs.org (http://links.lww.com/JBJS/H689).Supporting material provided by the authors is posted with the online version of this article as a data supplement at


Chronic postoperative inguinal pain (CPIP) is a common complication after inguinal hernia surgery and occurs in up to 10–14% of cases. CPIP has a significant impact on daily life, work ability and thus compromises quality of life. The aim of this retrospective study was an in-depth analysis of patients undergoing inguinal hernia repair to further refine the prediction of the onset of CPIP reliably.A single center retrospective analysis of patients with who underwent open or minimally invasive inguinal hernia repair from 2016 to 2021 was carried out. Complication rates, detailed analysis of postoperative pain medication and quality of life using the EuraHS Quality of Life questionnaire were assessed.p = 0.016). As additional risk factors for CPIP younger patient age and postoperative complications were identified.Out of 596 consecutive procedures, 344 patients were included in detailed analyses. While patient cohorts were different in terms of age and co-morbidities, and the prevalence of CPIP was 12.2% without differences between the surgical procedures . Postoperative pain was evaluated using a newly developed analgesic score. Patients who developed CPIP later had a significant higher consumption of analgesics at discharge (The prospective use of the analgesic score established here could be helpful to identify patients that are at risk to develop CPIP. These patients could benefit from a structured follow-up to allow early therapeutic intervention to prevent chronification and restore the quality of life. Surgical treatment of inguinal hernia is one of the most frequent general surgical procedures with more than 20 million patients annually. Both, open and minimally-invasive procedures exist, although, apart from the recommendation to use a mesh, there is no standard repair technique . The opeA retrospective single-center analysis of all consecutive patients who underwent inguinal hernia repair at the Department of Surgery at Würzburg University Hospital and gave their informed consent between January 1, 2016, and December 31, 2021, was carried out. The study was approved by the local ethics committee (No. 242/17).Clinical data , need for perioperative pain medication; duration of hospital stay) of patients were retrieved from the local prospectively recorded database. In addition a postoperative survey of all patients using the EuraHS-Quality of life (Qol) questionnaire , 13 was We adopted the CPIP definition according to the current EuraHS guidelines as pain  lasting more than 3 months postoperatively in the EuraHS-Qol questionnaire .Mean postoperative pain is a composite of the pain intensity on the V/NRS and the amount and potency of analgesics taken. To enable the comparison of postoperative pain an analgesic score was established. This was based on the need of postoperative pain medication at the day of discharge. Postoperative analgesic therapy was adjusted based on standard procedures until the patients were pain-free at rest (V/NRS <3). This was documented at discharge. In order to quantify pain postoperatively, the analgesics taken at the timepoint of hospital discharge were defined according to their potency using an ascending point scale based on the WHO analgesics ladder and the dose taken. With this scale an analgesic score could be calculated Fig. . Each su2-test as well as single factor variance and analysis of covariance or as repeated measure ANOVA. In the case of multiple T-tests, a post-hoc test was used by means of Bonferroni correction to detect individual comparisons between the groups without risking an alpha error. Significance was set at p < 0.05. Descriptive analyses included mean (MV), minimum (min) and maximum (max) values or standard deviation (indicated by ±).Statistical analysis was performed using IBM SPSS 28.0 . Differences between groups were calculated using Welch’s test and ChiA total of 596 patients with groin hernia repair were identified in the retrospective evaluation of our prospectively managed database. As presented in Fig. y; range 22–89) than patients who received TAPP  or TEP  (p = 0.001). If TEP was performed, the BMI was significantly lower than with the TAPP or the Lichtenstein (p = 0.035). All three surgical procedures differed significantly in the ASA classification of the operated patients . Patients who underwent Lichtenstein surgery had significantly more malignancies in their history and had a significantly higher rate of anticoagulant medication. In our cohort 27.1% of the Lichtenstein patients took warfarin or non-Vitamin-K-antagonist Oral Anticoagulants compared to 5% in TAPP or TEP , whereas TEP and Lichtenstein surgery showed no significant difference (both 71 min). Patients receiving Lichtenstein surgery stayed significantly longer in the hospital compared to patients who underwent minimally invasive procedures . Patients who underwent Lichtenstein surgery had significantly more postoperative hematomas (p = 0.015) than patients who underwent TEP or TAPP  (Table p = 0.001). They were significantly younger (54. 4 ± 16.0 y vs. 60.3 ± 15.9 y) (p =0.024). There was no significant difference in hernia orifice size between the groups. Also a similar number of patients did regularly consume analgesic medication. : CPIP patients had significantly more postoperative complications like hematoma, surgical site infection or seroma that had to be treated operatively or interventional than patients with no pain . But, there was a significant difference in postoperative complications ≥ 3 according to CDC p = 0.00: CPIP paFurthermore, a subgroup analysis of the expert level of the surgeons was carried out to show the correlation between expert level and CPIP as well as the implanted mesh type . For thep = 0.016) to achieve freedom from pain than patients who did not exhibit CPIP postoperatively. In these patients the mean score was 2.48 ± 0.22 compared to 2.06 ± 0.06 in patients that did not develop CPIP .Using our new analgesic score, patients who eventually developed CPIP consumed significantly more analgesics at the day of discharge  or does not demand more medication. However, the perioperative use of analgesics influences the pain level. V/NRS only measures pain without considering the amount and potency of analgesics used. Based on our data an increased analgesic use can be a possible predictor for the development of CPIP. Patients with CPIP showed a higher consumption of analgesics directly postoperatively. Since early treatment of this postoperative pain could help to reduce the percentage of CPIP , we suggIn the past many different factors have been identified to reduce CPIP. Sophisticated studies suggested that mechanical mesh fixation should be avoided and proper knowledge of inguinal nerves is essential . AnotherAlthough our data show interesting results on the prediction of CPIP based on postoperative analgesic consumption, many questions remain. While probably precise surgical technique and proper nerve management can reduce neuropathic pain, the problem of nociceptive pain remains. Two factors may play a role here: the genetic nature of the metabolism of analgesics and the genetic nature of pain sensitivity as such –34. FurtThe aim of the study was to identify predictors for the development of CPIP in our patients and generate a tool that enables early identification of potential patients with a higher risk for CPIP. In summary, there are several predictors for CPIP. Based on our data, younger patient age and a higher analgesic score have a significant influence. This score might help to improve the identification of possible CPIP patients. However, further prospective studies are necessary to better understand the pathogenesis of CPIP, to confirm these predictors and to establish new therapeutic approaches.


Postoperative analgesia in breast surgery is difficult due to the extensive nature of the surgery and the complex innervation of the breast; general anesthesia can be associated with regional anesthesia techniques to control intra- and post-postoperative pain.This randomized comparative study aimed to compare the efficacy of the erector spinae plane block and the thoracic paravertebral block in radical mastectomy procedures with or without axillary emptying.This prospective randomized comparative study included 82 adult females who were randomly divided into two groups using a computer-generated random number. Both groups, Thoracic Paraverterbal block group and Erector Spinae Plane Block group (41 patients each), received general anesthesia associated with a multilevel single-shot thoracic paravertebral block and a multilevel single-shot erector spinae plane block, respectively.Postoperative pain intensity , patients who needed rescue analgesic, intra- and post-operative opioid consumption, post-operative nausea and vomiting, length of stay, adverse events, chronic pain at 6 months, and the patient’s satisfaction were recorded.p < 0.001) and 6 h (p = 0.012) the Numeric Rating Scale was significantly lower in Thoracic Paraverterbal block group.At 2 h  (first registration 27/04/2020). Breast cancer is the most common cancer among women  and breaApproximately half of women who undergo minor or major breast surgery describe an important postoperative pain  which is not always effectively controlled by standard post-operative therapies .Post-operative analgesia in breast surgery is difficult due to the extensive nature of the surgery and the complex innervation of the breast and poor postoperative pain control may produce a series of acute and chronic complications , 4.Associating general anesthesia (GA) with regional anesthesia techniques, improves pain control, reduce the perioperative need of analgesic drugs, in particular reducing opioid requirements during the perioperative period according with the enhanced recovery programs, diminish postoperative nausea/vomiting (PONV), help in reducing the development of chronic pain, and facilitate early rehabilitation .Although using regional blocks as an adjunct to analgesia existed for many years, they have only recently increased in popularity as a method of postoperative pain management.Pectoralis blocks (PECS 1 and PECS 2), Serratus anterior plane (SAP) block , thoraciChronic pain is a problem that afflicts about half of women undergoing radical mastectomy  and the Proposed mechanisms for decreasing persistent pain include decreasing central sensitization (wind-up) and reducing opioid-induced hyperalgesia .The role of local anesthetics (LA) given for the peripheral nerve block in affecting post-operative nerve impulse activity, in slowing the changes in synaptic neuroplasticity, or in changing the signaling properties of non-neuronal cells has been debated for the past two decades , 13.Furthermore, regional anesthesia may reduce cancer progression by attenuation of the surgical stress response, better analgesia, and reduced opioid usage, and by the direct protective action of local anesthetics on migration of cancer cells .This randomized comparative study, which was carried out on 82 patients who underwent radical mastectomy, aims to compare the efficacy of TPV block with a simpler technique to perform such as the ESP block.Primary aim was comparing the efficacy of TPV block and ESP block on the postoperative pain intensity expressed as Numeric Rate Scale (NRS).This prospective, randomized comparative study was conducted at M. Bufalini Hospital, Cesena, Italy, and Santa Maria delle Grazie Hospital, Ravenna, Italy, from April 2020 to November 2021.It included 82 adult females, aged 18 to 90 years with an American Society of Anesthesiologists (ASA) risk ranging from I to IV, with no contraindications for the execution of TPV and ESP blocks, scheduled for elective modified radical mastectomy (MRM) with or without axillary dissection.The study was approved by the ethics committee of the AUSL  of Romagna (Ref. 2149/2020 I.5/299) and IRST (Istituto Romagnolo Studio Tumori—Institute for Cancer Study of Romagna) and was prospectively registered on Clinicaltrials.gov .The full trial protocol is available from the corresponding author.Patients with allergies and/or contraindications for the administration of drugs used in the study were excluded from the study, as well as patients who presented with chronic opioid use for therapeutic purposes, patients with coagulopathies and/or who used antiaggregant or anticoagulant drugs, with infections and lesions at the puncture site or with a Body Mass Index (BMI) ≥ 40.The primary outcome for this study was NRS pain score 12 h after surgery.NRS pain score at different time point: at the awakening of the patients (time 0) and 2, 6, 24 and 36 post-operative hoursPatients who needed rescue analgesic Intra- and post-operative opioid consumptionPONVLength of stayPatients with adverse events Post-operative chronic pain assessment (6 months)Patients’ satisfaction regarding anesthesiologic procedureThe secondary outcomes were:All patients were admitted to the hospital after having followed an anesthetic visit in pre-hospitalization in the morning on the day of surgery and received premedication with midazolam 3 mg intramuscularly one hour before the surgery, only if requested by the patient.Furthermore during the visit, the patients were instructed on what is meant by NRS scales.In all cases the same six anesthesiologists performed the blocks and the same two surgeons performed the surgery.In the pre-anesthesia holding area, standard monitoring, including non-invasive blood pressure, electrocardiogram, pulse oximetry, and Bispectral Index System  were applied.Both blocks was performed thirty minutes before the surgery with a sterile technique and out of plane approach using hydrolocation with 0.9% saline to help show the position of the needle tip, with the patients placed in the lateral position with the surgical site being uppermost.The ultrasound guidance , with a 16–6 MHz linear probe and 22-G × 50-mm needle  positioned into a longitudinal orientation to obtain a para-sagittal view, was used for both the blocks.TPV Block was performed on two thoracic (T) levels (T2- T3 and T4-T5); ultrasound guidance was used to visualize the superior costo-transverse ligament and the pleura as hyperechoic structures, and the paravertebral space was visualized as a wedge-shaped hypoechoic layer between these structures Fig. .Fig. 1ThAfter local infiltration with 2.0 mL of 2% lignocaine at the site of puncture, the block was performed at two thoracic levels, and for each level 8 mL of 0.75% ropivacaine were injected (120 mg of Ropivacaine), not exceeding the toxic dose.The spread of local anesthetic in the paravertebral space and a concomitant anterior movement of the parietal pleura were observed using real-time image guidance.Ultrasound guided ESP Block was performed, after local infiltration with 2.0 mL of 2% lignocaine at the site of puncture, on two thoracic (T) levels (T2 and T5) using the transverse process, visualized as a hyperechoic structure with acoustic shadowing below, as main ultrasound landmark.When the needle came in contact with the transverse process 12 mL of 0.5% ropivacaine was injected for each level (120 mg of Ropivacaine), not exceeding the toxic dose  was inserted according to the manufacturer’s instruction.All patients in Thoracic Paraverterbal block group (Group TPVB) and Erector Spinae Plane Block group (Group ESPB) received GA with intravenous (IV) bolus of propofol 2 mg kgIV dexamethasone 8 mg was administered before induction of anesthesia.−1 h−1), and the sedation level was monitored using BIS.Anesthesia was maintained by continuous IV infusion of propofol .In patients requiring an axillary lymph node dissection, top-up local infiltration analgesia into the surgical field, to allow the enlargement of the operative field, was performed by the surgeon using 6 mL lignocaine  was treated with boluses of fluid and, if required, ephedrine in doses of 25–50 mg. Bradycardia (HR < 40 beats min or < 20% of baseline) was managed with 0.5 mg atropine.All patients were administered 2 gr of Cefazolin half an hour before the start of surgery.No prophylactic antiemetics were administered.Acetaminophen 1gr IV was administered 30 min before the end of surgery, and then every eight hours.The pain assessment, at rest and related to movement, was carried out, using the NRS scale, at the awakening of the patients (time 0) and 2, 6, 12, 24 and 36 post-operative hours. The assessment was done by an anesthesiologist who had no role in giving the block and in the intraoperative management of the patient but aware of the type of block performed.Wherever pain exceeded 3 according to the NRS scale, or at the explicit request of the patient, 30 mg of Ketorolac was administered IV for a maximum of three times a day.We used morphine 2 mg if, thirty minutes after the administration of Ketorolac, pain persists with NRS > 3.A total of 492 NRS and dose rescue request measurements were performed.The first-line treatment of PONV consisted of IV ondansetron 4 mg twice a day as needed and, if this proved ineffective, second-line therapy consisted of IV metoclopramide 10 mg as needed.The quantity of opioids (morphine) administered post-operatively, requests for rescue doses of NSAIDs, and the presence and number of nausea and vomiting episodes, were all assessed.Patients’ satisfaction was evaluated and recorded 36 h after surgery on a 7‐point Likert scale. .The patients were then discharged when deemed safe according to the Italian version of the Post Anesthesia Discharge Scoring System (PADS). Lastly, the total number of days of hospitalization were also recorded.After six months, patients received a telephone call to ascertain the presence of chronic pain during rest and in motion assessed using the NRS. Patients were also asked to evaluate the pain interference with sleep, work activity, mood tone, and possibility of entertainment.The sample size of the study was calculated based on a retrospective pilot study designed to measure NRS pain score 12 h after surgery in the two groups TPVB vs ESPB (10 patients in each group). We observed a mean NRS of 2.7 vs.0.9 (s.d. = 2.9). Setting the power to 80% and the alpha to 0.05%, the sample size required was 82 patients.Data were reported as mean with standard deviation (s.d.), median with interquartile range (IQR), and number and percentage depending on the underlying distribution.Normality was test with Shapiro–Wilk test.Differences between the two groups were tested with the t-test or Mann–Whitney according to the characteristics and distribution of the variables; for categorical ones, the Fisher’s exact test was used.Eighty-two patients, randomized into two groups using a computer-generated random number (simple randomization method), were included in the study (41 per group), from June 2020 to November 2021, and no patient was excluded for any reason Fig. .Fig. 3CoBoth the groups received GA, the group TPVB (41 patients) was associated with a single-shot TPV block and the Group ESPB (41 patients) was associated with a single-shot ESP block.There were no significant differences between the two groups in age, sex, BMI, and ASA risk Table .Table 1DThirty-three patients underwent only mastectomy, fourteen in Group TPVB 34.1%) and nineteen in Group ESPB (46.3%)  and seventeen in Group ESPB (41.5%); nine patients also underwent axillary dissection, four in Group TPVB (9.76%) and five in Group ESPB (15.2%) (Table % and sevThere were no cases of sympathetic block.Surgery was completed within a time range of 70 to 110 min.p = 0.152). (Table Two patients in Group ESPB (4.88%) and 0 in Group TPVB presented with hypotension p = 0.15. (Table p = 0.152) (Table Thirty-two patients required intra-operative use of fentanyl (100 mcg), thirteen in Group TPVB (31.7%) and nineteen in Group ESPB (46.3%) p = 0.15  and six in Group ESPB 14.6%), with no significant difference between the two groups  and at 2, 6,12, 24 and 36 post-operative hours, was higher than 3 only sixteen times out of a total of 492 measurements (3.25%) .At 2 h mean NRS was 0.78 (± 1.4) in Group TPVB and 1.7 (± 1.5) in Group ESPB, (p = 0.012) (Table At 6 h mean NRS was 0.70 (± 1.0) in Group TPVB and 1.46 (± 1.3) in Group ESPB, p = 0.01 (Table 22) Table .Fig. 5Mep = 0.152) (Table Two episodes of PONV were observed in Group TPVB (4.88%), that resolved spontaneously without the use of antiemetic drugs, and no episode of PONV was seen in Group ESPB p = 0.15 (Table 2There was no significant difference in the length of stay Table .All patients expressed a satisfaction level of 7 with the anesthesiologic procedure (very satisfied).No failures or complications occurred in the execution of both techniques.None of the patients reported any chronic pain at six months from the surgery.In our study the primary end point was to compare the TPV and ESP blocks in the control of post-operative pain after radical mastectomy with or without axillary emptying.As secondary end points, we evaluated the need of rescue analgesia, intra- and post-operative opioid consumption, PONV, length of stay, adverse events, chronic pain after 6 months and patients satisfaction regarding anesthesiologic procedure.We performed both TPV and ESP blocks on two levels. We highlight the importance to “block” the T2 nerve root because from the T2 spinal level originates the inter-costobrachial nerve, which is very important for the axilla innervation.Both the regional blocks reduced the intra- and post-operative opioid consumption, with a comparable duration of analgesic effect and stable hemodynamic profiles.At 2 and 6 postoperative hours, the NRS was significantly lower in Group TPVB than in Group ESPB; however, this difference did not lead to an increased request for rescue doses by patients.The NRS at 12, 24, and 36 postoperative hours did not show significant differences.The number of patients requiring intra-operative opioid administration (100 mcg of Fentanyl) was higher among those in Group ESPB; however, we found no statistically significant differences.No statistically significant data were recorded regarding the PONV episodes and length of stay.We did not observe any adverse events , which is probably related to the great experience of the operators. All patients were absolutely satisfied with the anesthetic procedure and none developed chronic pain 6 months after surgery.Even if not included in our primary and secondary end points, we underline that there were no significant differences in the execution times of the two blocks.Despite the large number of analgesic modalities for postoperative pain management among women undergoing breast surgery, recent reports still highlight a significant post-operative pain burden in this population .Breast surgery is burdened by a high incidence of acute post-operative pain whose inadequate management increases the risk not only of chronic pain but also of in-hospital mortality and functional impairments .The analgesic and anesthetic effect of the TPV block is due to the direct contact of the LA injected into the paravertebral space with the roots of the spinal nerves as well as the spread in the epidural space. Thus, a thoracic paravertebral injection of LA results in ipsilateral somatic and sympathetic nerve blocks including the posterior ramus in multiple contiguous thoracic dermatomes .However, the risk of pneumothorax, the long time to perform the block, and the high level of skills needed make some inexperienced anesthesiologists to avoid the TPV block and use other techniques, such as the ESP block, a novel nerve-blocking technique first proposed by Forero et al. in 2016 .It is generally implemented through deposition of drugs into the fascial plane beneath the erector spinae muscle at the tip of the transverse process of the vertebra, thereby reducing the risk of pneumothorax and significant neurovascular damage.The ESP block allows anesthetic coverage similar to that of the TPV Block. It is considered a peri-paravertebral regional anesthesia technique which is supposed to block the dorsal and ventral rami of the thoracic and abdominal spinal nerves, and thereby block the anterior, posterior, and lateral thoracic and abdominal walls.The mechanism of action of the ESP block is probably related to the spread of the LA into the paravertebral space .This hypothesis is reinforced by the recent discovery that identifies two slits at the medial and lateral ends of the superior costo-transverse ligament (SCTL) that can act as channels to the thoracic paravertebral space .The TPV block is certainly one of the most effective techniques in pain control after radical mastectomy , 21, andSeveral previous studies, though, have documented that ultrasound-guided paravertebral block is an advanced regional anesthetic technique that requires a longer learning curve to manipulate the needle under ultrasonography guidance towards the paravertebral space .Krediet et al. , in theiNevertheless, the complications of TPV block like inadvertent pleural puncture and epidural or intrathecal spread are still a concern even with ultrasound utilization.Ultrasound-guided ESPB, which we preferably perform with an out of plane technique, has been originally described for pain relief in patients with chronic neuropathic pain. However, recent studies found it effective as a postoperative analgesic technique and to reduce the postoperative opioid consumption following breast surgery.Zhang et al.  in theirAgarwal et al.  concludeUnlike our study, they did not find statistically significant differences in postoperative NRS scores at rest and movement at 2 and 6 post-operative hours.The same observations were reported by Moustafa et al. in theirMost of the studies comparing TPV and ESP blocks in breast surgery involved the use of post-operative morphine while none of the patients in our study used post-operative morphine.The use of opioids, intra- and post-operative, in addition to having adverse effects such as nausea, vomiting, and constipation may potentiate the tumor cell survival and angiogenesis, which could lead to metastasis of cancer –31.In our hospital the TPV block has been performed for many years for both mastectomies and quadrantectomies, therefore, its effectiveness has been extensively confirmed even for interventions with awake patients , 21, 32.The limitations of this study were the lack of a control group, the small number of cases performed and that we did not use patient controlled analgesia (PCA) pump, which could help standardize the administration of analgesics in the post-operative period.From the data obtained by our randomized study, we can confirm, as already underlined by the existing literature, that the TPV and ESP blocks used for radical mastectomy were absolutely effective, and very similar in the management of intra- and post-operative pain, in intra- and post-operative opioid consumption and length of stay.It would be desirable to have a randomized trial comparing the TPV, ESP and PECS blocks, the most commonly used regional anesthesia techniques in major breast surgery.


How difficult is it to get patients to do exercises at home?”, “How difficult is it to get patients to do physical activity?”, being frequently uttered by clinicians who find themselves managing patients with musculoskeletal (MSK) pain.Clinicians can encounter many difficulties in motivating their patients to participate actively in the rehabilitation process and encouraging active coping strategies. This can result in a high risks of treatment failure  have previously been shown to be a prognostic factor in MSK pain, with a positive expectation indicating a greater probability of recovering from painful problems  or on the mode of execution , there is a risk of creating nocebo effects that may lead to negative expectations, lack of engagement, tensions, rupture of the therapeutic alliance and drop-out from the rehabilitation pathway  and type of exercise  for many MSK complaints have yet to be identified, and this continues to represent a conundrum for clinicians , considering the status of the participants , their conditions  and the neurophysiological mechanisms of pain . For example, quantitative  and qualitative studies  should investigate patients' and clinicians' perceptions of the elements around exercise prescription and application that potentially induce nocebo effects. Furthermore, future randomized controlled trials should evaluate the efficacy on outcomes such as pain and disability of the same therapeutic exercise  offered with different styles of therapeutic relationship between clinician and patient .Nocebo effects are real and may influence the prescription, practical application, and perceived recovery outcomes from exercise in MSK pain. In this opinion paper, we highlight the importance of considering nocebo effects in clinical and research contexts to manage the complexity of patients with MSK pain. We call on clinicians and researchers to consider not just the exercises that they are using in clinical practice but the context into which they are applied and the effect on expectations they could generate. This context, involving the emotion, relationship, and messaging around exercise, may “make or break” how effective the exercise prescription becomes and should be food for thought for all those in MSK care.GR: Conceptualization, Supervision, Visualization, Writing – original draft, Writing – review & editing. BC: Conceptualization, Writing – original draft, Writing – review & editing.