We aimed to study the curative effects of botulinum A toxin (BTX-A) on the treatment of post-herpetic neuralgia (PNH).P<0.05 indicated a significant difference and P<0.01 indicated an obvious significant difference.We enrolled 58 PNH patients and treated them with hypodermic injection of BTX-A in Xiangyang No.1 People’s Hospital, Hubei University of Medicine, Hubei, China. We measured and compared the Visual Analog Score (VAS), Neuropathy Pain Scale (NPS), Quality of Life Scale (SF-36) score, PNH seizure severity degree, seizure duration, frequency of attack and the use of painkillers before and after treatment. We used SPSS13 software package for statistical analysis. Values were expressed by mean± standard deviation. P<0.01). The use of painkillers reduced after treatment (P<0.01) and we observed very few adverse reactions associated with BTX-A injection.Attack frequency, attack duration and attack severity were all significantly lower after treatment (The use of BTX-A for treating post-herpetic neuralgia produced very promising results with very few adverse reactions. BTX-A can be considered as a valid approach in the treatment of PNH, especially in patients that do not respond well to painkillers. Herpes zoster and post-herpetic neuralgia (PNH) result from reactivation of the varicella-zoster virus (VZV). Patients usually suffer from painful and itchy rash. The incidence of herpes zoster increases sharply with advancing age, and middle-aged individuals, especially the elderly are more inclined to suffer from this illness.If herpes zoster is not treated in a timely manner, then patient may develop post-herpetic neuralgia (PHN). PHN pain can persist up to 1 to 2 years after resolution of the rash and can be highly debilitating . We inveFifty-eight PNH patients were enrolled in this study. Patients did not respond well to drugs such as carbamazepine and phenytoin sodium. All patients were followed up for 6 months. There were 32 males and 26 females, aged from 34 to 79 yr (average=52.3 yr), and the course of disease was 4 to 15 months (average=9.5 months). Thirty-five patients needed to take painkillers for their PNH attacks. Patients with myasthenia gravis, Eaton-Lambert syndrome, motor neuron disease, allergic constitution, serious organs dysfunction, severe cognitive impairment, mental disorders, asthma history, fever and infectious diseases were excluded from this study. In addition, pregnant women and those who took medication for aggravated transmission disorders of neuromuscular junction, one week prior to this study were also excluded.This study was approved by Ethics Committee of our hospital and all patients signed informed consent forms. All patients were subjected to blood routine, urine routine, liver and kidney function, ECG and EEG tests before the treatment.Before the injection, we measured Visual Analog Score (VAS), Neuropathy Pain scale (NPS) and the Quality of Life Scale (SF-36) score in all patients. PNH seizure severity degree, seizure duration, the frequency of attacks and the use of painkillers were also recorded.Lyophilized crystalline BTX-A was obtained from LanZhou Institute of Biological. Each vial of BTX-A contained 100 U and was preserved at 2 to 8 °C. It was diluted in saline (25 ug/ml) before injection. Five U of BTX-A was injected subcutaneously . Two weeks after the injection, the abovementioned indexes were measured again. Measurements were repeated every month for 6 months through outpatient service or telephone interviews.VAS was used to measure pain severity. 0 represented no pain and 10 represented excruciating pain. 0 point referred to no pain, 1 to 3 indicated mild pain, 4 to 6 showed moderate pain, 7 to 9 indicated severe pain, and 10 showed the most intense pain.Markedly effective: improvement by 50% and over;Effective: improvement of 25% to 49%;Ineffective: improvement below 25%.The onset situation, 3 months prior to treatment was taken as a basic level, and the pain situation was studied. Severity, seizure duration, the frequency of the attack and the use of painkillers were measured. Scale for NPS and SF-36 indexes was as follows:Total effective rate= markedly effective rate+ effective rate.P<0.05 indicated a significant difference.We used SPSS13 software package for statistical analysis. Values were expressed by mean± standard deviation. P<0.01). Compared with 3 months before treatment, the pain severity (VAS score) was significantly lower (P<0.01). After treatment, the seizure duration was significantly shortened (P<0.05), NPS score was significantly reduced (P<0.01), and SF-36 score was significantly improved (P<0.01) (P<0.01) (In 18 (31%) cases BTX-A treatment was effective and in 27 (46.6%) cases BTX-A treatment produced significant results. In 13 patients BTX-A treatment was ineffective (22.4%). Two weeks after treatment, the frequency of pain attack reduced significantly in all patients ((P<0.01) . Compare(P<0.01) .Efficacy duration of BTX-A treatment was ranged from 7 to 10 days, and the peak value was around one month.After BTX-A injection, 4 patients complained about pain around the injection area, but pain disappeared after one week with no treatment.PHN is a neuralgia that persists after a Herpes zoster rash has cleared. Pain often occurs as spontaneous lightning and aggravates when diseased skin touches the clothes. In addition, physical activities, temperature changes and emotional suppression may also deteriorate patients’ condition.Clostridium botulinum that can interfere with neurotransmitters. BTX-A can be used clinically for treating muscle cramps, opisthotonos, brain paralysis, hypermyotonia and strabismus. The VAS score in an 82-year-old PNH patient was lowered from 10 to 1 after BTX-A treatment and the curative effect lasted for 52 days (BTX-A is a type of A toxin secreted by  52 days .P<0.01), which further confirmed the effectiveness of BTX-A treatment for PNH. Pain levels in 29 patients with PNH fell after the injection of BTX-A, and the curative effect lasted for 2 months  BUsing BTX-A for treating PNH generated promising and long lasting results with very few adverse reactions. We believe that BTX-A can be considered as a valid approach in the treatment of PNH, especially in patients that do not respond well to painkillers.Ethical issues  have been completely observed by the authors.


Sickle cell disease (SCD) is a red blood cell disorder that causes many complications including life-long pain. Treatment of pain remains challenging due to a poor understanding of the mechanisms and limitations to characterize and quantify pain. In the present study, we examined simultaneously recording functional MRI (fMRI) and electroencephalogram (EEG) to better understand neural connectivity as a consequence of chronic pain in SCD patients. We performed independent component analysis and seed-based connectivity on fMRI data. Spontaneous power and microstate analysis was performed on EEG-fMRI data. ICA analysis showed that patients lacked activity in the default mode network (DMN) and executive control network compared to controls. EEG-fMRI data revealed that the insula cortex's role in salience increases with age in patients. EEG microstate analysis showed patients had increased activity in pain processing regions. The cerebellum in patients showed a stronger connection to the periaqueductal gray matter (involved in pain inhibition), and negative connections to pain processing areas. These results suggest that patients have reduced activity of DMN and increased activity in pain processing regions during rest. The present findings suggest resting state connectivity differences between patients and controls can be used as novel biomarkers of SCD pain. •Simultaneous EEG-fMRI recordings revealed altered connectivity in sickle cell patients.•Reduced activity observed in default mode network and executive control network.•Patients' salience network strength increases with age; opposite seen in controls.•EEG-fMRI parameters reflect disease severity in sickle cell patients. This diRecent observations suggest that “central sensitization” may underlie chronic pain due to constitutive sensitization of spinal dorsal horn neurons in sickle mice . HoweverFunctional brain imaging studies have suggested that during resting state the brain is active and forms patterns of activity called resting state networks (RSN) . CertainIn our study, we used traditional fMRI methods to assess altered connectivity in RSN. These methods included independent component analysis (ICA) and seed-based analysis . EEG dyn22.1We recruited 15 healthy volunteers, 8 of which were female. The mean age and standard deviation were 28.8 ± 10.7 years, respectively. The healthy subjects' ethnicity included 6 African Americans, 1 Hispanic, 1 Asian, and 7 Caucasian. All subjects met the MR safety criteria and gave their written informed consent. None of the subjects reported any previous neurological or psychiatric disorders, psychoactive medication or history of drug abuse. The study was approved by the Institutional Review Boards of the University of Minnesota.2.2A total of 15 patients with SCD were recruited to participate in the study. There were 7 female patients, and the mean age and standard deviation was 24.5 ± 6.8 years, respectively. There were 2 patients that were under the age of 18 in this study. Patients were asked to rate their pain on the day of the study on a scale of 0 to 10 (with 10 being the worst pain imaginable) and were allowed to take all of their usual medications, including narcotic pain medications. A MR screening form was completed to ensure patients could safely participate in the study. All patients participated in this study with written consent according to a protocol approved by the Institutional Review Board of the University of Minnesota. For the minor participants, written assent was obtained as well as consent from a parent or legal guardian. Patients were also asked if they were willing to share their medical records with the research staff. An additional informed consent was obtained for all patients willing to share their medical records. One patient was not comfortable sharing their medical records.2.3A 64-channel MR-compatible EEG cap was placed on the subject's scalp. One electrode was placed on the subject's back to record cardiac activity for noise removal purposes later on. Electrode impedances were brought below 20 kΩ. The EEG was amplified using MR-compatible amplifiers  and recorded at 1000 Hz. Recordings of EEG were done outside the scanner for all controls and all patients. EEG was recorded both inside and outside of the scanner on the same day of the experiment for 11 patients and 13 controls. For the remaining patients and controls, fMRI was obtained separately from EEG recordings. During outside scanner recordings, the subject was told to sit still and rest with eyes open in a private room. Outside scanner recording lasted 20 min. During inside scanner recording, subjects were asked to have their eyes open and lie still in the scanner and not to fall asleep. 2.4We used a 3 T Siemens Magnetom Trio scanner  with 16 channel head coil for all but one subject. The last subject's data was obtained on a 3 T Siemens Magnetom Prisma scanner  with a 20 channel head coil due to upgrades being conducted at the Center for Magnetic Resonance Research at the University of Minnesota. Individual anatomical MRI data were collected which consisted of 240 contiguous sagittal slices with 1 mm slice thickness  on a 3 T MRI system . Additionally, each subject was instructed to lie quietly in the scanner for two to three functional scans, each lasting 8 min. Whole-brain functional images with blood-oxygen-level dependent (BOLD) contrast were acquired using gradient echo planar imaging sequence .2.5The MR gradient artifact was removed using a principle component analysis (PCA)-based optimal basis set (OBS) algorithm . ECG rec2.6All fMRI data were pre-processed for slice scan time correction, 3-D motion correction and temporal filtering using SPM8 software . All bra2.7A major concern of this study was whether the fMRI data from patients would accurately reflect neurological activity due to the nature of their disease. The BOLD signal measures changes in blood oxygenation. SCD directly affects red blood cells and this could induce changes in BOLD signals that do not reflect neural activity. In order to determine if alterations observed in fMRI reflect true neural activity or abnormalities in blood flow caused by SCD we compared the hemodynamic response function (HRF) of patients and controls. The spontaneous HRF was obtained from resting state data using a previously described method . The raw2.8ICA in the spatial domain was performed using the Group ICA of fMRI toolbox (GIFT) . Detailet-tests for each frequency bin.The “spectral group compare” toolbox in GIFT was used to calculate the power density to evaluate the frequency distribution of the time courses for each RSN. The frequency range was spaced into three equally spaced bins between 0 and 0.25 Hz at 0.8 Hz intervals. Control and patient comparison was done using one-sample 2.9Connectivity was assessed using the CONN functional connectivity toolbox . Functio2.10Spontaneous power fluctuations over different frequency bands were calculated from EEG data. Frequency bands include delta (2–4 Hz), theta (5–7 Hz), alpha (8–12 Hz), beta1 (13–21 Hz), and beta2 (22–30 Hz). The method for obtaining power fluctuations was previously discussed . An averEEG time courses were convolved with the HRF in order to correlate the EEG data to the fMRI results; the time courses for both methods are shown before and after HRF convolution in t-test was used to compare average activation time of each microstate between controls and patients. The average activation time was also used to find correlations with the clinical variables.A ROI analysis was performed on the EEG-fMRI beta1 power results, where a significant cluster was observed in the “patients > controls” contrast image. The z-score of the ROI was obtained from back-projected RSN maps from our previous GIFT analysis. The salience network was chosen for the RSN due to the nature of the group activation for the beta1 band. The z-scores were obtained from both controls and patients, and compared to our clinical variables to find correlations that reflect disease severity. The average activation time of each microstate was calculated for both controls and patients by finding the total times a microstate was dominant and dividing it by the total time points within the EEG recording. A two-sample 33.1We had 15 patients participate in our study with ages ranging from 16 to 38 years. The relevant clinical variables are listed in 3.2The contrast images of RSN1, RSN2, RSN3, RSN6 and RSN9 are shown in The average number of significant voxels was computed for all RSN activation maps for both control and patient groups, shown in 3.3A frequency analysis of the RSN using GIFT is shown in 3.42 = 0.6215, p-value = 0.0008) and ROI2 ; seen in CONN functional connectivity toolbox was used to perform an ROI to voxel group level analysis with the seed placed in the right cerebellum Crus I. This seed location was chosen to further explore the cerebellum's influence on resting state in SCD patients and based on significant differences observed in ROI to ROI maps. The statistically significant clusters that showed negative connectivity in the patient group are shown in 3.52 = 0.5927, p-value = 0.002), shown in 2 = 0.6337, p-value = 0.003), shown in 3.62 = 0.5952, p-value = 0.03). Microstate 8 had a positive correlation between activation time and the number of hospitalizations in the past 2 years . These two microstates were further examined by analyzing contrast images displayed in Group microstate results are shown in 4The multimodal non-invasive imaging utilizing simultaneous EEG and fMRI was feasible in patients with SCD, without causing any discomfort or adverse events due to the procedure. To our knowledge, this is the first multimodal fMRI-EEG study on resting state alterations in patients with SCD. We assessed RSN connectivity using fMRI analysis techniques and EEG-informed fMRI analysis methods. In particular, EEG dynamics enhanced our results by identifying additional pain processing areas active in patients, and detecting enriched temporal information regarding RSN fluctuations due to the high temporal resolution of EEG.4.1Chronic pain has been studied using fMRI and EEG as functional imaging modalities. fMRI studies have indicated that chronic pain patients have altered frequency activity in PFC, thalamus, and DMN . In SCD 4.2The most consistent regions associated with nociception across studies include the primary somatosensory cortex, secondary somatosensory cortex, anterior cingulate cortex, insular cortex, PFC, thalamus, basal ganglia, PAG, and cerebellum . Differe4.3We were able to identify nine RSN in patients and controls using ICA, many of which were similar to a previous study using resting state fMRI with SCD patients . Differe4.3.1The DMN function relates to internal processes including mind-wandering, social cognition, emotional processing, and other stimulus-independent thoughts . The ant4.3.2The right and left ECN involve external processing such as perception, nociception, and decision-making . The rig4.3.3The salience network is involved processing noticeable stimuli, including pain related processing, as well as being known as the switching network, where the salience network chooses to enact either the DMN or ECN based on external input . The sal4.4Frequency analysis of BOLD signals have shown that RSN are characterized by low frequency oscillations (< 0.1 Hz) in healthy patients . The DMNResting state EEG data have revealed that DMN is linked to traditional EEG frequency bands including alpha, delta, beta, and theta . In our 4.5The cerebellum is known to be active during pain processing, but its actual function is not well understood . Recent 4.6One confounding factor in our findings of changes in network connectivity that may influence its specificity to pain is the role of medication. It is possible that medications for pain management are causing the altered connectivity and frequency behavior of RSN. However, we did not restrict patient from using their medications in order to maximize our patient population. Another limitation of our study is the small number of subjects, which lowers our statistical power and limits what conclusions we can draw due to the risk of false positives. However, recruitment is challenging in this patient population due to the irregularity of their symptoms as well as compliance. A national study of pain treatment in SCD involving 31 sties was closed early due to recruitment challenges, where only 38 patients were recruited after 6 months . Another4.7Resting state alterations can lead to biomarkers that can be used to help better understand the neural pathophysiology of sickle pain. The current study identified nine RSN in SCD patients and showed that several of them have altered connectivity and temporal characteristics in the patient population. In particular, the DMN and ECN were shown to have reduced activity, while the salience network had greater connectivity in patients. Utilizing EEG-fMRI techniques enhanced our analysis because the EEG informed fMRI methods were able to describe additional temporal characteristics of the RSN as well as correlate to several clinical variables that are related to disease severity and chronic pain history. Connectivity, spatial and temporal information can all be gathered from EEG-fMRI and may be used to identify biomarkers that reflect SCD intensity to help improve pain treatment techniques.


With the increased use of extracorporeal shock wave lithotripsy (ESWL), the management of urolithiasis has become much convenient for the patients and the health care professionals alike. However, associated with the procedure is the common complaint of pain. No agreed upon pain management strategy has yet been developed for the procedure. We compared the effect of different analgesia drug regiments for pain control.A randomised controlled trial was carried out in Shifa International Hospital from between July 2015 to January 2016. A total of 135 patients were divided into three groups; group A received 30 g lidocaine 2% gel applied locally on corresponding lumber area 30 minutes before the procedure, group B received oral naproxen sodium 550 mg 45 minutes before the procedure, and group C received both oral naproxen and lidocaine gel. Patients were supplemented with intravenous nalbuphine during the procedure. The pain was assessed with 0-10 visual analogue scale. Both pre-procedure and post-procedure pain score was measured.Among 135 patients, 105 (77.8%) were male and 29 (21.5%) were female with mean age of 38.7 ± 1.31 years. There was no difference of mean pain score or need for supplemental intravenous nalbuphine between groups B and C but there was significantly decreased mean pain score and need for supplemental intravenous nalbuphine in groups B and C in comparison with group A.The use of oral naproxen sodium with or without the addition of lidocaine gel during ESWL is a promising option for pain management during the procedure with significant improvement in comparison with lidocaine gel alone. The introduction of extracorporeal shock wave lithotripsy (ESWL) has revolutionized the treatment of urolithiasis due to it being non-invasive in nature, cost effective, and its associated reduced hospitalization time along with lower morbidity -2. The iOpioids are used most commonly for pain relief in ESWL but the associated side effects require patient monitoring and delayed hospital stay -4. In soThere are as yet no guidelines for pain relief during ESWL , 4. In tWe conducted a randomized control trial at the Department of Urology, Shifa International Hospital Islamabad. After institutional review board approval and written informed consent from the patients, we included all the patients who underwent ESWL from July 2015 to January 2016.Patients were included only if they were older than 18 years, had renal stones, and understood the pain scoring system. All those patients who had any of the following were excluded; 1) history of chronic use of analgesia, 2) allergy to any of the used medications, 3) those having ureteric stones, 4) serum creatinine > 1.4, 5) pregnant patients, 6) those having gastric ulcer disease, 7) not willing to participate, 8) having any coagulopathy, and 9) active urinary tract infection.Patients were randomized into one of three groups by lottery method, groups A, B and C. Patients in group A received 20 g lidocaine 2% gel application on the lumbar region corresponding to the entry site of the shockwaves, 30 minutes prior to the procedure, patients in group B received oral naproxen sodium 550 mg 45 minutes prior to the procedure while patients in group C received both locally applied 2% lidocaine gel and oral naproxen sodium 550 mg per oral at the times mentioned previously.We used Modulith SLX lithotripter 4th generation Storz  medical equipment for ESWL. Before entering the procedure room, patients were explained the procedure along with the visual analogue pain scale. Patients were asked to rate their pain on a scale from 0 (no pain) to 10 (maximum pain). During the procedure, pulse, blood pressure, and oxygen saturation were monitored. All patients were assessed by the same physician who was blinded to the patient group assignment. Analgesia was augmented with intravenous nalbuphine on patient demand during the procedure. Patients were monitored for ventilatory depression, decrease in oxygen saturation, nausea, vomiting, drowsiness, and hypersensitivity reactions for one hour after completion of the procedure.Shocks were delivered at low energy levels at the beginning of lithotripsy which was gradually increased to the recommended energy level. The number of shocks varied from 1800 to 4000 during a treatment session. Patients were discharged after completion of the procedure which was the basis of the fulfillment of the discharge criteria and were asked to follow up after one week.Pain score was measured before the start of the procedure and then assessed immediately before giving intravenous nalbuphine in those who needed augmentation of analgesia during the procedure and post procedure in those who completed the procedure without any need for intravenous nalbuphine. The number of shock waves and shock wave pressures at which nalbuphine was given was also noted.Patients were compared for mean age, gender, body mass index (BMI), analgesia requirement, the number of shock waves tolerated without analgesia, the total number of shock waves, peak shock wave pressure, and mean pain score. Data was collected on a specified pro forma, entered and analysed using IBM SPSS version 16.0 . Chi-square test was used to analyse statistical significance of categorical variables. The one-way analysis of variance (ANOVA) (least significant difference or LSD) was used to compare different groups with each other. A p-value of <0.05 was considered statistically significant.A total of 135 patients with mean age of 38.7 ± 1.31 years were included, 105 (77.8%) were male and 29 (21.5%) were females. There were 45 patients in each group. Demographic features of the three groups were comparable as shown in Table Twenty-four (53.3%) patients in group A required intravenous nalbuphine during the procedure compared to 13 28.9%) patients in group B and 14 (31.1%) patients in group C. Higher energy levels were noted for groups B and C at which intravenous analgesia was required as compared to group A . Similarly, a greater number of shock waves was observed at which intravenous analgesia was required in groups B and C as compared to group A  , while there was no significant difference between groups B vs C  (ANOVA) Table . The meaAfter its introduction by Chaussy in 1980, ESWL has become the standard treatment of choice for renal and ureteric stones. It is simple, noninvasive, ambulatory, effective, and associated with minimal comorbidities . The patFactors affecting the analgesia requirement during ESWL are age, gender, the amount of energy used, site and size of the stone, shock wave peak pressure, type of lithotripter, size of the focal zone, and cavitation effects , 7. WithDifferent analgesics including opioids, NSAIDs, local analgesia and different combinations are used via different routes. However, there is as yet no consensus on standard analgesia for pain during ESWL , 4-5. OpLocally applied analgesic creams have a controversial role for pain control. Advantages include their simplicity, non-invasiveness, avoiding the side effects of intramuscular and intravenous analgesics, and their potential use as coupling medium -12. TheiSaita, et al. described the role of intramuscular analgesia with locally applied Luan gel (lidocaine gel 1%) to decrease the discomfort during ESWL and to increase the success rate of ESWL for ureteral and renal stones . Vilar, On the other hand, Acar, et al. in their study of 60 patients compared EMLA with placebo cream before ESWL and patient controlled analgesia with remifentanil during the procedure and described no difference in the dose of remifentanil and pain score between the two groups .The results of our study are consistent with those of Acar, et al. and Eryildirim, et al. We found no significant difference among mean pain score and the need for supplemental intravenous analgesia between groups taking naproxen sodium with and without lidocaine gel. There was also no statistical difference in energy levels and the number of shockwaves at which intravenous analgesia was required between the aforementioned groups.NSAIDs are considered more potent analgesics with fewer side effects as compared to opioids for renal colic . They arWe used naproxen sodium 550 mg per oral 45 minutes before ESWL in our study. Naproxen sodium is one of the most commonly used NSAIDs. It has the lowest risk of vascular events when compared to other NSAIDs . No prevOzkan, et al. compared the effect of lornoxicam (short acting NSAIDs), paracetamol, and tramadol for pre-procedural analgesia. They concluded that lornoxicam is a better analgesic than either paracetamol or tramadol . Iqbal, In our study when we used oral naproxen sodium with or without lidocaine gel, there was a significant reduction in both the mean pain score and the need for supplemental intravenous analgesia as compared to the use of locally applied lidocaine gel alone. There were significantly high energy levels at which intravenous analgesia was required in groups B and C as compared to group A. However, approximately one-third of patients in both oral and mixed group needed rescue intravenous analgesia during the procedure.No patient in our study had any adverse drug reaction thus suggesting that the use of oral naproxen sodium is safe for pain control during ESWL and may be augmented with on demand intravenous analgesia.Due to the recent introduction of ESWL and lack of high-quality data regarding pain management strategies during the procedure, no standardised guidelines have been defined for analgesia use for ESWL.Our study furthered the efforts made by previous investigators in comparing the effect of various analgesia options. A total of three strategies, lidocaine gel alone, oral naproxen alone and a combination of the two, were investigated. The variables being analysed included analgesia requirement, the number of shock waves tolerated without analgesia, the total number of shock waves, peak shock wave pressure, and mean pain score.Our results demonstrated that there was no significant effect of locally applied 2% lignocaine gel on mean pain score and intravenous analgesia requirement during ESWL procedure. However, there was a statistically significant lower pain score and lower supplemental analgesia requirement in patients taking oral naproxen sodium with or without lidocaine gel when compared with locally applied lignocaine gel alone.We, therefore, concluded that oral naproxen sodium with on demand intravenous analgesia is a safe and effective option for ESWL related pain. Further studies need to be conducted to compare its use with that of other pain management strategies such as the use of opioids with regards to their effects on the success rates of ESWL, mean pain score, adverse effects as well as the willingness of the patients to undergo the procedure in case of recurrence using the same pain management strategy.


Sleeping problems are very common in patients with chronic pain. The aim of the study was to investigate the association between different dimensions of chronic pain and sleep quality in chronic pain patients.In this cross-sectional interview-based questionnaire study, patients from 3 different pain treatment centers in Vienna aged 18–65 years, with pain lasting 3 months or longer were asked to participate. The association between the short-form McGill pain questionnaire (SF-MPQ) and sleep quality  was assessed.In this study 121 patients  could be analyzed. Of the patients 38.8% needed more than 30 min for falling asleep, 63.6% reported sleep fragmentation, 30.6% slept less than 5 h and 60.3% reported no recovering effect of sleep. The strongest associations between pain characteristics and sleep quality were found for pain intensity and affective pain aspects. Logistic regression analyses revealed that one point more in the total score of SF-MPQ increased the odds of needing more than 30 min for falling asleep, waking up more than 3 times due to pain, sleeping less than 5 h, and perceiving the sleep as non-recovering, by 6%. Adjusting for physical and psychological quality of life lowered the odds ratios and the association was no longer significant.The results underline the importance of paying attention to sleep quality in patients with chronic pain. The results also indicate that psychological factors might mediate the association between pain and sleep quality. Chronic pain affects approximately 19% of adults in Europe . These pThe association between chronic pain and sleep disorders is bidirectional ; on the Studies on sleep quality in chronic pain patients are scarce in the Austrian population. The aim of the present analysis was to investigate the association between different dimensions of chronic pain, such as pain intensity, sensory dimension, and affective dimension and different dimensions of sleep quality, such as time before falling asleep, sleep fragmentation, sleep duration, and recovering effects of sleep in subjects suffering from chronic pain. Additionally, it was the aim to evaluate how this association changed by controlling for possible confounders, such as sociodemographic factors, pain characteristics, and physical and psychological quality of life.This analysis is part of a larger study with the primary aim to assess the cost of illness in patients which chronic pain in Austria. Patients from three different hospital-based outpatient clinics were included in the study: the outpatient clinic of the Department of Physical Medicine and Rehabilitation of the Medical University of Vienna, the headache clinic of the Department of Neurology of the Medical University of Vienna and the pain clinic of the Orthopedic Hospital Speising in Vienna. Inclusion criteria were: chronic pain (pain lasting for at least 3 months) at any body site, age between 18 and 65 years, sufficient knowledge of the German language, and currently no cancer and no psychiatric diseases. Exclusion criteria were current cancer treatment or current psychiatric inpatient treatment according to the patients’ report.Patients were fully informed about the study and the possibility to participate by the treating doctor during a visit to the clinics. In the headache clinic, patients were additionally recruited via mail and asked to participate in the study. Recruitment of study participants lasted from December 2012 to February 2014. All subjects signed an informed consent form to participate in the study. The local ethics committee of the Medical University of Vienna approved the study (EK-number 1624/2012).Location of chronic pain was assessed with a two-sided homunculus diagram, and subjects were asked to show on this drawing the body site or body sites in which they experienced chronic pain. In total, 14 different body locations could be identified. This approach was also used in publications based on the Austrian Health Interview Survey . Pain chSleep was assessed with a questionnaire used in a previous study . From thAs the covariate, health-related quality of life (HRQOL) was assessed by the use of the short-form 12 health survey (SF-12 questionnaire), and summed scores for the dimensions of physical and psychological quality of life were calculated . FurtherN) and percentages (%) are indicated. To describe the association between pain characteristics and sleep parameters, analyses of variance (ANOVA) was applied. Finally, stepwise logistic regression models were calculated with the four dichotomized sleep parameters as the dependent variables and the total score of SF-MPQ as the independent variable. After an initial crude model, in model I adjustment was made for age, sex, and level of education. In model II additional adjustment for duration of chronic pain and the number of painful body sites was made. Finally, in model III, additional adjustments were made for the summed scores for physical and psychological quality of life according to the SF-12. Results are presented as odds ratios (ORs) and 95% confidence intervals (95% CI).Statistical analyses were calculated with IBM SPSS Statistics V21.0. Descriptive statistics were applied to describe the sample characteristics. For this, either mean and standard deviation (SD), where appropriate or numbers  was remarkably high  showed the highest impact on sleep quality next to pain intensity. This finding underlines the strong effect of psychological factors on the association between pain and sleep. This fact is in line with previous literature, where common mental disorders, such as depression , 24–27 aSleep disturbance experienced by patients with chronic pain is receiving growing attention as an important factor in the quality of life. In our study, when controlling for the physical and psychological dimensions of the quality of life, the association between pain parameters and sleep quality was lowered and not significant any more. This means that at a given level of quality of life we found no significant association between pain dimensions and sleep dimensions. This can also be interpreted that physical and psychological quality of life mediates the association between pain and sleep quality. Quality of life seems to have a central role for patients with chronic pain, which is in line with a previous Austrian study .Despite the observational nature of our study, some possible clinical implementations should be discussed. Our results might support the assumption that sleep and pain have a bidirectional and reciprocal relationship; therefore, clinicians who manage patients with chronic pain should focus on interventions that relieve pain, as well as on assessing and treating sleep disturbance. This is, however often only addressed as a secondary concern . In addrThe present study has some limitations. Firstly, it relies solely on self-reported measures of sleep disturbance; therefore, subjective sleep problems might be overestimated by the patients. Nevertheless, a study by O’Donoghue et al. showed that participants with chronic low back pain demonstrated significantly poorer sleep, irrespective of the kind of sleep evaluation (objective or subjective) . FurtherVarious sleep problems are significantly associated with pain in patients suffering from chronic pain. Physical and psychological dimensions of quality of life notably influence both pain perception and sleep quality and therefore modify the association between pain perception and sleep quality. Because comorbid sleep problems and pain have been related to higher disability, the need to improve sleep quality among patients with chronic pain, and to reduce pain among patients with insomnia, should be an important part of future research.


Chronic postoperative pain after inguinal hernia surgery can affect sexual function. A new short form questionnaire for inguinal hernia pain related sexual dysfunction (SexIHQ) was introduced and applied to a register based cohort of total extra-peritoneal hernioplasty (TEP) operated patients.Sexually active men, 30–60 years old, recorded in the Swedish Hernia Register for a primary inguinal hernia TEP operation were included. Two initial questions of the SexIHQ identify patients with pain at sexual activity. Only these patients proceeded to answer the specific questions on pain-induced impairment of sexual activity, pain frequency and intensity, physical functions (erection and ejaculation), and symptoms of depression. SexIHQ, the Short Form-36 (SF-36), the Inguinal Pain Questionnaire (IPQ) were mailed to participants for long term follow up.p < 0.001). Quality-of-life was reduced in almost all SF-36 domains in patients with pain during sexual activity.In 538 included patients, 44 (8.2%) reported pain during sexual activity at mean 33 months after surgery. Sexual dysfunction was seen in 33 of these patients. A postoperative complication was a risk factor for pain during sexual activity; OR 4.89 (95% CI 1.92–12.43; A short form questionnaire, suitable for large cohorts, was developed to assess sexual dysfunction due to groin pain after inguinal hernia repair in male patients. Sexual dysfunction due to groin pain after hernia surgery by TEP is surprisingly common. Patients should preoperatively be informed of the risk of having pain during sexual activity following groin hernia surgery. Chronic pain as a result of hernia surgery is well-recognized. Knowledge of impairment of sexual function due to pain caused by an inguinal hernia or a postoperative chronic pain condition is, however, limited. Pain affecting sexual function after hernia surgery is believed to be caused by surgical nerve injury, and inflammatory conditions around the mesh or its fixation . It can Pre- and postoperative pain-induced sexual dysfunction related to groin hernias has been reported in one retrospective, three prospective, and one randomized controlled trial (RCT) –5. The pTwo large Danish register-based studies have reported on postoperative complaints. The first assessed 700 patients, of which 72% had been operated on with a Lichtenstein repair. Pain during sexual activity was found in 22%; 6.7% being moderate–severe. A total of 12% had ejaculatory pain  . It was The aim was to introduce a new questionnaire, easy to use for large cohorts of patients, for inguinal hernia-related or postoperative pain-induced sexual dysfunction. The intention was to reduce handling of data by identifying and approaching only patients who have pain at sexual activity and sexual dysfunction related to the groin hernia. The questionnaire was used in a register based study of TEP-operated patients for postoperative assessment of sexual dysfunction.Men aged 30 to 60 operated on for a primary inguinal hernia by TEP between January 2005 and May 2009 were included . Prospecwww.ClinicalTrials.gov (ID: NCT02419950). A written consent was signed by all participating patients in accordance with the Declaration of Helsinki.The trial was approved by the Regional Ethics Review Board at Lund University (634/2008) and registered at No pain during sexual activity (NPS) or Pain during sexual activity (PS). There were no further definition given on these questions in the questionnaire. Only patients with Pain during sexual activity proceeded to the following questions; assessing pain-induced sexual activity impairment, pain frequency and intensity, physical functions (erection and ejaculation) and symptoms of depression. Out-clinic patients provided feedback on content of the questionnaire, which was adapted to include eight questions forming the SexIHQ ; permanent fixation or non-permanent/no fixation, intraoperative complications; operation time (skin to skin); in-hospital or day-care surgery; and postoperative complications within 30 days .Data retrieved in 2010 from the SHR included: age; body mass index (BMI); status according to the American Society of Anesthesiologists (ASA); hernia type; hernia size according to the European Hernia Society classification ; mesh wePain past week was graded on a 7-level scale from No pain to Pain that could not be ignored; prompt medical advice sought. The definition of pain was grades 3–7; pain that could not be ignored, but did not interfere with every day activities and worse. Grade 1–2; No pain and Pain present that could easily be ignored was defined as no pain.IPQ is a validated questionnaire and includes 19 questions regarding different pain modalities , 13. Quewww.hrql.se) at Gothenburg University, was used. The subscales and composite scores  were calculated according to the SF-36 manual , licensed by the HRQL-group  were evaluated using binary logistic regression.The IBM SPSS Statistics Software version 22 was used for all statistical analyses. Continuous variables were analyzed using the Student p < 0.692). The characteristics of the patients are shown in Included patients are reported in a flowchart in p < 0.364). Immediate severe postoperative pain was seen in 0.6% (3 patients), all in the NPS group. Postoperative complications were reported in a total of 6.5%. Within the NPS 6% reported any complication, and in in the PS group 18% (p < 0.005). Postoperative infection was reported in 0.6% (3 patients), all in the NPS group. No reoperation within 30 days was reported.Operative and postoperative data are shown in Results on SexIHQ are reported in p < 0.001). Testicular pain, IPQ 16, was reported in total by 16.3% (83/508), with 13% in the NPS and 49% in the PS groups (p < 0.001). Overall, 7.1% of patients were unsatisfied and regretted having had the operation: 1% of patients in the NPS and 14% in the PS groups (p < 0.001).The IPQ results are reported in All subscales for SF-36 were slightly above the norm in NPS patients, p < 0.001).Risk factor analysis for sexual dysfunction related to pain is presented in This study is based on the Swedish National Hernia Register, introducing the SexIHQ questionnaire specifically addressing impairment of sexual function related to pain after inguinal hernia repair with TEP. Long-term sexual impairment after groin hernia operation was present in one out of twelve patients and did not seem to attenuate over time. Quality-of-life was considerably reduced in afflicted patients.A relatively short questionnaire, specifically investigating genital pain and sexual dysfunction in hernia patients was developed by Aasvang et al. . This prA limitation of this study is the lack of preoperative data. These data are not available in most register-based studies today. Even if all questions focus on the relation between “pain in the groin” and sexual function, it could still be difficult for the patient to differentiate between postoperative groin pain and other conditions as a cause for the impairment of sexual function. In a recently published RCT (Lichtenstein versus the Onstep technique), 28% of patients reported pain during sexual activity preoperatively, but reduced to 11% postoperatively . In anotIncluding patients from a national register has its advantages. All levels of experience and varying techniques used by operating surgeons are included, resulting in high external validity. Three studies on this subject were published from the Danish national hernia register , 4, 7.A register-based questionnaire study of 1,172 patients operated on by TAPP during a 10 year period had a response rate of 68%  and registered at www.ClinicalTrials.gov (ID: NCT02419950). A written consent was signed by all participating patients in accordance with the Declaration of Helsinki.NG has been engaged in all the parts of the study including planning, sending all questionnaires, creating the data platform, analyzing data, performing statistical calculations, preparing tables, figures and the manuscript. PR has been engaged in all the parts of the study, preparing the data base platform, double-checking all statistical calculations, preparing the manuscript, tables and figures, and revising the manuscript. UP been engaged in all the parts of the study, analyzing data and preparing the manuscript. AM, being the principle investigator of the project, has been engaged in all the parts of the study, project planning, applications, data analysis, interpretation of data and preparing the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


P = 3.45 × 10−8; rs880143, P = 3.45 × 10−8; and rs7526880, P = 4.92 × 10−8), which maps to the RP11-634B7.4 gene, a novel antisense gene to three olfactory receptor genes. Olfactory receptor genes, upstream effectors of the MAPK signaling cascade, might be novel target genes for pain in HNSCC patients. Future experimental validation to explore biological mechanisms will be key to defining the role of the intronic variants and non-coding RNA for pain in patients with HNSCC.Pain is often one of the first signs of squamous cell carcinoma of the head and neck (HNSCC). Pain at diagnosis is an important prognostic marker for the development of chronic pain, and importantly, for the overall survival time. To identify variants influencing severe pre-treatment pain in 1,368 patients newly diagnosed with HNSCC, we conducted a genome-wide association study based on 730,525 tagging SNPs. The patients were all previously untreated for cancer. About 15% of the patients had severe pre-treatment pain, defined as pain score ≥7 (0 = “no pain” and 10 = “worst pain”). We identified 3 common genetic variants in high linkage disequilibrium for severe pre-treatment pain, representing one genomic region at 1q44 (rs3862188,  Head and neck cancer is the sixth most common malignancy worldwide. Squamous cell cancer of the head and neck (HNSCC), the most common head and neck cancer, includes cancers of the oral cavity (including the gums and tongue), pharynx, and larynx. In the US, more than 61,760 men and women are expected to be diagnosed with HNSCC in 2016Pain is often one of the first signs of HNSCC, with up to 50% of newly diagnosed patients presenting with painPain is an increasing clinical challenge, especially among cancer patients since traditional therapies are only partially effective. Furthermore, substantial inter-individual variability is observed in pain sensitivity and analgesic response4Patients with HNSCC n = 1,384) and information on pre-treatment pain were ascertained at the MD Anderson Cancer Center Head and Neck Surgery Clinic. All patients were self-reported Caucasians. A majority of the patients were male 78.4%). The patients also reported comorbidities, including hypertension (40.8%), heart disease (17.2%), lung disease (10.7%), diabetes (9.8%), stroke (4%) and liver disease (3.2%). TNM classification  is the single most important prognostic factor and treatment determinant in HNSCC, which includes information on the primary tumor, lymph node involvement and distant metastasis84 and in8.4%. TheFrom that group of 1,384 patients, we randomly selected individuals and assigned them to the discovery (~70%) and replication (~30%) phases of the GWAS by conditioning on identical percentages of males and females and similar distributions of age at diagnosis in the two phases. We excluded 16 individuals due to missing genotypes. The discovery phase had 958 total individuals, with 148 cases  and 810 controls . The replication phase had 410 total individuals, with 58 cases  and 352 controls . Based on the identity-by-state distances, no hidden population substructures were detected and all patients were identified to have Western European ancestry. After applying standard quality control processes, we had 714,494 tagging single nucleotide polymorphisms (SNPs) available for a total of 1,368 HNSCC patients.P values < 0.05 in both phases of the study  for the association between the three SNPs and pre-treatment pain in HNSCC patients were 1.87 , 1.87 (95% CI: 1.50–2.33), and 1.87 (95% CI: 1.49–2.33), respectively. The three SNPs are in high linkage disequilibrium, r2 = 0.99, leading to very similar association results  using the NCBI map viewer (annotation release 105)RP11-634B7.4 gene. This is a novel finding for pre-treatment cancer pain, and to our knowledge, this is the first study to suggest a clinical significance for these SNPs.Pain prior to treatment varies among patients with HNSCC when they present in the clinic. Pain level variability can be due to several factors such as site and stage of disease3RP11-634B7.4 gene has two transcript variants, RP11-634B7.4-001 with 1541 bp and RP11-634B7.4-002 with 722 bp1010OR13G1, OR6F1 and OR14A210RP11-634B7.4 gene, which contains the susceptibility loci for pre-treatment pain in HNSCC patients, can potentially regulate the OR13G1, OR6F1 and OR14A2 genes. A SNP, rs1151640, localized in OR13G1, results in a non-synonymous amino acid substitution 12The The olfactory receptor gene family is the largest gene family in the human genome22MAPK/ERK)1625MAPK1/ERK2 that was potentially associated with pre-treatment pain in head and neck cancer patients® Systems, www.ingenuity.com), as well as a genetic association analysis between the common SNPs within the IPA-derived genes and cancer pain in HNSCC patients. Because of the prior established effects of olfactory receptor genes on MAP kinases, we speculate that these olfactory receptor genes may be upstream regulators of MAPK1/ERK2 in terms of eliciting pain signals associated with HNSCC.Olfactory receptor genes have also been shown to affect pathways that involve mitogen-activated protein kinases -like receptor [NLR] family, pyrin domain containing 3), which is involved in the regulation of inflammationNLRP3 gene encodes a pyrin-like protein, a member of a protein family containing a pyrin domain, nucleotide-binding site domain and a leucine-rich repeat motif31Other genes that map to the region within 1M bases of the three SNPs, rs3862188, rs880143 and rs7526880, include −8 to account for multiple testing. Importantly, we employed a two-stage design, for which two independent data sets were used for the analysis, which helps control the false positive signals34To our knowledge, this is the first report on the possible involvement of olfactory receptors in pre-treatment pain in HNSCC patients. There are limitations to our study. The level of cancer pain experienced prior to treatment varies among patients due to several factors such as the site and stage of disease. Our study did not have any restrictions on the site and stage of disease. Therefore, we further investigated the effect when adjusting for the TNM classification on the SNPs identified in the study using the 890 patients for which such data were available. Importantly, we observed similar association results whether or not we included the TNM classification as covariates. Therefore, we believe the SNPs identified in this study are associated with severe pain irrespective of the TNM classification. Also, our study population only involved self-reported Caucasians. GWASs that incorporate other races or ethnicities can further validate our results. Another limitation of this study is the relatively small sample size, which limited the statistical power for the analysis. We conducted a post hoc power analysis using the software program PS: Power and Sample Size ProgramRP11-634B7.4 gene, a novel antisense gene to three olfactory receptor genes: OR13G1, OR6F1 and OR14A210162425MAPK1/ERK2 as novel target genes for cancer painIn conclusion, chromosome 1:44q may serve as a susceptibility locus for pain prior to treatment in HNSCC patients, with three variants, rs3862188, rs880143 and rs7526880, mapped to the The study population consisted of adult patients with newly diagnosed, histologically confirmed, previously untreated HNSCC. The patients were recruited for the study if they met the following criteria: a) newly diagnosed, untreated, histopathologically confirmed squamous cell carcinoma of the oral cavity, pharynx (excluding nasopharynx), or larynx; b) no previous cancers; c) age of 18 years or older; d) Texas resident; e) no blood transfusions in the past 6 months; and f) not on immunosuppression therapy. The patients were all previously untreated for cancer, which excluded pain associated with cancer treatment and focused on pre-treatment pain. This study was approved by the Institutional Review Board at MD Anderson Cancer Center and all procedures adhered to its guidelines and regulations, in accordance with the Declaration of Helsinki. All participants provided informed consent.The collection of epidemiology and clinical data was conducted by staff interviewers when patients presented at MD Anderson, prior to being seen by clinicians. Specifically, pain “during the past week” was rated using a standardized 11-point numeric scale (0 = “no pain” and 10 = “pain as bad as you can imagine”), a recommended standard for pain assessment in clinical studies of pain35Two hundred nanograms of DNA for each HNSCC patient were extracted from whole blood samples using the Qiagen QIAamp DNA Blood Maxi Kit following the manufacturer’s recommended protocol . High-throughput genotyping of the HNSCC patient samples for both phases was conducted at MD Anderson, using Illumina HumanOmniExpress-12v1 BeadChip , according to Illumina protocolsP value of test for deviation from the Hardy-Weinberg proportion <1 × 10−6. Using the genotype data, we identified and excluded individuals with discordant sex information and duplicates from further analysis. To investigate the cryptic relatedness among individuals, we calculated the genome-wide identity-by-state distances on markers for each pair of individuals45We discarded SNPs based on the following criteriaχ2 test or Fisher’s exact test, where an expected cell count was <5P value < 0.005, with each cluster containing at least one case and one control. We performed a joint analysis that pooled data from both phases. To control for the possible confounding effects from two phases, in additional to sex, age and information of clusters, we included a fixed indicator to represent the phases as a covariate in the analysis and derived joint OR and 95% CI for each SNP and corresponding P value. We assumed an additive genetic model for each SNP when assessing associations. Special consideration was taken when analyzing the sex chromosomes. Only males were included for the association analyses between Y-chromosomal SNPs and the pre-treatment pain status. We conducted the statistical analysis in PLINK. For the association analyses between X-chromosomal SNPs and the pre-treatment pain status, we used the 1 degree-of-freedom χ2 test proposed by Clayton49P value threshold of 5 × 10−8 to account for multiple testing. Manhattan plots for the results from both phases and the joint analysis analysis  were genHow to cite this article: Reyes-Gibby, C. C. et al. Genome-wide association study suggests common variants within RP11-634B7.4 gene influencing severe pre-treatment pain in head and neck cancer patients. Sci. Rep.6, 34206; doi: 10.1038/srep34206 (2016).


Ibuprofen and pregabalin both have independent positive effects on postoperative pain. The aim of the study is researching effect of 800 mg i.v. ibuprofen in addition to preoperative single dose pregabalin on postoperative analgesia and morphine consumption in posterior lumbar interbody fusion surgery. 42 adult ASA I-II physical status patients received 150 mg oral pregabalin 1 hour before surgery. Patients received either 250 ml saline with 800 mg i.v. ibuprofen or saline without ibuprofen 30 minutes prior to the surgery. Postoperative analgesia was obtained by morphine patient controlled analgesia (PCA) and 1 g i.v. paracetamol every six hours. PCA morphine consumption was recorded and postoperative pain was evaluated by Visual Analog Scale (VAS) in postoperative recovery room, at the 1st, 2nd, 4th, 8th, 12th, 24th, 36th, and 48th hours. Postoperative pain was significantly lower in ibuprofen group in recovery room, at the 1st, 2nd, 36th, and 48th hours. Total morphine consumption was lower in ibuprofen group at the 2nd, 4th, 8th, 12th, and 48th hours. Multimodal analgesia with preoperative ibuprofen added to preoperative pregabalin safely decreases postoperative pain and total morphine consumption in patients having posterior lumbar interbody fusion surgery, without increasing incidences of bleeding or other side effects. Acute postoperative pain remains to be a major problem, and inadequate or excessive treatment can cause side effects, including increased risk of myocardial ischemia or infarction, thromboembolic and pulmonary complications, persistent postoperative pain incidence, alterations in immune system, impaired rehabilitation, increased hospital stay or readmissions to the hospital, impaired quality of life, and excessive sedation due to opioid use . There aPatients having lumbar spinal fusion or laminectomy surgeries often complain about severe postoperative pain and postoperative rehabilitation process can be effected negatively , 4. ManyAlthough pregabalin was approved as antiepileptic and for chronic pain, because of its antinociceptive properties it is also used for perioperative pain management. Clinical studies related to perioperative pain indicate that it has effects on reducing acute neuropathic pain and decreasing opioid dose . AdminisThere are positive results related to preventive use of NSAIDs before lumbar surgery , 11. TheWe aimed to examine the effects of adding i.v. ibuprofen to preoperative single dose pregabalin on postoperative pain levels, morphine consumption, and side effects in surgical situations where postoperative pain is severe such as posterior interbody fusion surgery.ACTRN12616000591459). We followed the Consolidated Standards of Reporting Trials (CONSORT) guidelines for reporting randomized trials and provided a CONSORT flow diagram (We included consecutive 42 elective lumbar stabilization patients between 18 and 65 years of age and with ASA (American Society of Anesthesiologists) I-II physical status. All participants were informed both verbally and in writing about details of the study before it started and informed consent was obtained from all participants. Approval from Baskent University Clinical Studies Ethical Committee was obtained . The study was registered to the Australian New Zealand Clinical Trial Registry  device were excluded.2), and noninvasive blood pressure (NIBP) was implemented. Anesthesia induction was obtained with 0.02 mg/kg i.v. midazolam, 2 microgram/kg fentanyl, 2 mg/kg propofol, and 0.6 mg/kg rocuronium. Following endotracheal intubation patients were placed under prone position for operation and surgery was performed under inhalational anesthesia with 1-2% sevoflurane in 40%/60% O2/N2O. Type of operation, operated lumbar area, duration of the operation, intravenous fluids given during surgery, amount of hemorrhage, and amount of blood transfusion were recorded. Patients were transported to the postanesthesia care unit (PACU) after surgery following extubation.Demographic data of the patients were recorded. Patients were divided randomly into two groups by computer program to have 21 patients in each group. All patients in both groups were given 150 mg pregabalin capsule  with a little water 1 hour prior to the surgery. Patients in Group PI  received 800 mg i.v. ibuprofen  30 minutes before surgery in 250 ml saline infused over 30 minutes. Patients in Group P  received 250 ml saline without ibuprofen. Patients were blinded to the study group. After patients were admitted to the operating room standard monitorization with electrocardiography (ECG), peripheral oxygen saturation  device. Intravenous 1 g paracetamol was administered every six hours, first dose to be administered upon arrival to the ward. Postoperative pain was recorded at 0, 1, 2, 4, 8, 12, 24, 36, 48 hours during resting as VAS value . Pain level during ambulation at the 24th hour and patient satisfaction at the 48th hour were also evaluated by using VAS. Presence of side effects such as sedation, nausea, vomiting, dizziness, and visual disturbances was evaluated at the 1st, 2nd, 4th, 8th, 12th, 24th, 36th, and 48th hours . All of these postoperative evaluations were done by a researcher blinded to the patients' groups. Morphine consumption in the PCA was recorded simultaneously with VAS assessments.To determine number of patients for the study 80% power and the difference of 1.5 units in VAS measurements were used. It was calculated that it would be appropriate to take 21 individuals in each group . The difference of 1.5 units in VAS was determined by pilot study and clinical experience.t-test or for nonnormal variables nonparametric two-independent sample Mann–Whitney U test was used. Repeated measurements were analysed by nonparametric k-related samples Friedman test with Chi-square test. All analyses were computed by using SPSS 15.0 statistical package program. P < 0.05 was accepted as significant.For testing categorical parameters between two groups, cross-tab analysis was used with Chi-square test, and for normally distributed continuous variables two independent groups' P < 0.001, P = 0.002, and P = 0.047, resp.). Also at the 36th and 48th hours even though VAS scores were very low they were significantly lower in Group PI (P = 0.05). Morphine consumption in Group P was significantly higher at the postoperative 2nd, 4th, 8th, 12th, and 48th hours   . There wThere was no significant difference between groups regarding sedation, nausea, vomiting, dizziness, and visual disturbances .According to the results of this study preoperative single dose i.v. ibuprofen in addition to preemptive pregabalin significantly reduced pain levels in the first two postoperative hours and reduced morphine consumption especially in the first 12 hours. In a study with a total of 206 orthopedic or abdominal surgery patients, postoperative pain levels and morphine consumption were reported to be lower in patients who received 800 mg i.v. ibuprofen every 6 hours . Again iTotal morphine consumption continued to be significantly lower during the first 12 hours. Results of this study show preoperative use of drugs that have different mechanisms of action and multimodal analgesia, reducing postoperative pain and morphine consumption . DecreasDespite its popularity in the last two decades, there are increasing concerns about studies for preventive analgesia. Preventive analgesia is demonstrated when postoperative pain or analgesic use reduced beyond the duration of the target drug, which is defined as 5.5 half-lives of the target drug . When weAlthough there are reports about pregabalin reducing postoperative pain if used preoperatively, its exact mechanism of action is not clear. Even though gabapentinoids bind to alpha2kappa subunit of presynaptic voltage gated calcium channels, because this subunit's upregulation after injury takes several days, this is not thought to be the mechanism responsible for acute postoperative analgesia . There aIn our study even though the amount of hemorrhage appears to be higher in ibuprofen group, there was not a statistically significant increase in hemorrhage; also there was not an increase in the need for blood transfusion. Ibuprofen, like other NSAIDs, is known to inhibit thromboxane in a dose related manner . From thThere are some limitations to this study. Since we wanted to evaluate preoperative effect of ibuprofen we decided to administer a single dose but postoperative analgesia levels could be higher if postoperative doses were added. Future studies should evaluate incidence of gastrointestinal and renal complications in postoperative period as a result of proposed treatment. In addition, the study would be more significant if a third group with ibuprofen given at the end of the operation was implemented and we could evaluate whether the effect of ibuprofen is preventive or not.In conclusion, addition of preoperative single dose of i.v. ibuprofen to preoperative single dose of oral pregabalin in posterior lumbar interbody fusion surgery patients provided significant analgesic effect in early postoperative period and also significantly reduced postoperative morphine consumption without increasing incidence of side effects. Higher quality of analgesia can be achieved with the recommended doses of 800 mg every 6 hours, but probably increase in incidence of side effects would also be inevitable.


Endometriosis is a chronic gynecological disease that is characterized by the presence of endometrial tissue outside the uterine cavity. The main symptoms include dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. These symptoms impair the lives of most of the women suffering from the disease. Surgical resection of endometriotic lesions is an effective means of treating dysmenorrhea, but the risk of recurrence is high. Western medicine has limited use for treating it due to side effects and ineffectiveness. The purpose of this study is to verify the effectiveness and safety of acupuncture.Guanyuan (CV4), Sanyinjiao (SP6), Taichong (LR3), Zhaohai (KI6) and Qichong (ST30) while the control group will receive acupuncture at non-acupoints. The trial will include three menstrual cycles of treatment and three menstrual cycles of follow-up. The primary outcome is pelvic pain that will be assessed by means of a 10-cm visual analog scale (VAS). At each stage, we will evaluate the safety of the acupuncture treatment.This trial will be carried out in four parts. A total of 106 eligible patients with pelvic pain related to endometriosis will be randomly assigned into two groups, in a 1:1 ratio, as the treatment group or the control group. The participants assigned to the treatment group will be treated with acupuncture treatment at The study will compare the effectiveness and safety of acupuncture with comfort needles on pelvic pain related to endometriosis in the hope of providing significant evidence for using acupuncture on pelvic pain related to endometriosis.NCT03125304. Registered on 30 April 2017.ClinicalTrials.gov, ID: The online version of this article (10.1186/s13063-018-2684-6) contains supplementary material, which is available to authorized users. Endometriosis is a chronic gynecological disease characterized by endometrial tissue being present outside the uterine cavity. It occurs in approximately 10% of adolescent girls and women of reproductive age .The pathogenesis of pain associated with endometriosis is not clear but may be related to inflammation from endometrial lesions, peripheral and central sensitization . Surgicazang-fu organs and meridians [Qi in the uterus. Acupuncture can improve blood and Qi circulation, depending on the conduction of meridian acupoints and the function of the central and peripheral nervous system. When the flow of Qi and blood is unobstructed, pain can lessen [Acupuncture, an important component of traditional Chinese medicine, plays a crucial role in disease treatment. Acupuncture is also a popular means of analgesia in traditional Chinese medicine. The analgesic principle of acupuncture is based on the holistic theory of eridians . Traditin lessen . Some syn lessen –10.One systematic review supports acupuncture for pain relief in endometriosis. However, the evidence for the effectiveness of acupuncture is limited because only a single study was included in this review . FourteeThe purpose of the present study is to demonstrate the efficacy in pain relief and safety of acupuncture in patients with pelvic pain related to endometriosis.This randomized trial will be conducted in four centers: the Second Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, the Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, the Qionghai Hospital of Traditional Chinese Medicine and the Ganzhou Maternal and Child Health Care. A total of 106 patients diagnosed with pelvic pain related to endometriosis will be enrolled in this trial : (1) symptomatic endometriosis detected by laparoscopy or laparotomy or (2) ovarian endometrioma detected by ultrasound or magnetic resonance imaging with pelvic painPatients willing to receive acupuncture for pain reliefPelvic pain score equal to or above 4 cm on the Visual Analog Scale (VAS)Regular menstrual cycleSigned informed consentPelvic ultrasound demonstrates that the endometrial cyst measures more than 5 cm in diameter and surgery is indicatedImaging examination suspects pelvic genital malignancyCancer antigen-125 level > 200 IU/LPelvic infectious diseaseOther severe disorders in the heart, lung, liver, kidney, or mental disorders causing inability to cooperate in the studyPatients who have received any other treatment for endometriosis that may affect the observation of the curative effects of acupuncture over 3 monthsPregnancy or breastfeedingRefusal to be randomizedThis study has two phases. The first phase will include 3 months of acupuncture treatment, and the second phase will include 3 months of follow-up without treatment. Patients will be randomly assigned to one of two groups in a 1:1 ratio, either the treatment group or the control group. Then, acupuncture treatment will start and last for 3 months following by 3 months of follow-up.The whole acupuncture treatment will be carried out by two experienced acupuncturists who have received a license from the Ministry of Health of China and have practiced clinically for more than 5 years. Every acupuncture session will be once a day, three times a week and last for 30 min and only start from 7 days before the expected menstrual onset. During the menstrual period, they will receive acupuncture every day when they have endometriosis-associated pelvic pain.Sanyinjiao (SP6), Zhaohai (KI6), Taichong (LR3), Qichong (ST30) and at Guanyuan (CV4) for a total of nine needles see (Table De Qi) once every 10 min.The design of the treatment group is guided by the theory of Traditional Chinese Medicine. Disposable, sterile, stainless-steel needles, 0.30 × 40 mm, will be inserted into the acupoints on the abdomen and legs for 15 to 35 mm. The participants assigned to the treatment group will receive acupuncture at bilateral The control group will receive acupuncture at non-acupoints. Disposable, sterile, stainless-steel needles will be inserted superficially to a depth of < 5 mm on each shoulder and upper arm, without any stimulation.The primary outcome is pelvic pain that include dysmenorrhea, intermenstrual pain and dyspareunia. They will be assessed on a VAS scale . On the The Endometriosis Health Profile − 30 (EHP-30)  will be Physical functioning will be assessed by the Multidimensional Pain Inventory (MPI) . This quEmotional functioning will be evaluated by the Beck Depression Inventory (BDI)  and ProfThe Patient Global Impression of Change (PGIC)  will be Pain diaries will be used to record the specific time and frequency of pain attacks, the duration of pain, the changes of intensity, the start time of pain relief and any medication used for patients. Pain diaries will be assessed at the baseline period, the first, second and third menstrual cycles and at follow-up.The goal of follow-up is to evaluate the long-term efficacy of acupuncture on pain relief. The follow-up assessments will be performed after treatment and will last for 3 months. During the follow-up period, patients will continue to maintain pain diaries and complete the questionnaires. They can submit the relevant information to researchers via email or short message service. Researchers will also pay close attention to changes in patient illness.One hundred and six eligible patients will be randomly assigned to either the treatment group or the control group in a 1:1 ratio after all baseline assessments. The random allocation sequence was generated by a computer. A researcher who does not participate in treatment, data collection and evaluation will provide the random number and group assignment to each center. The randomization is blinded and allocation is hidden. Owing to the unique nature of the acupuncture operation, it is impossible for the acupuncturists to be blinded. However, patients, the data collector and the statistician will be blinded.This trial will use a clinical-superiority design that aims to verify that the curative effect of acupuncture is better than that of comfort needles. The primary outcome measure is proposed to be the VAS. The minimal important difference (MID) for improvement on the VAS was found to be − 3.9 cm and/or − 49% . AccordiN represents size per group, Z1-α is Type I error, Z1-β is Type II error, δ is expected SD of the population being sampled, δ0 is tolerable error in distance from mean value and S2 is SD. So it requires each group to contain no less than 44 patients. With an estimated 20% dropout rate, we plan to recruit 53 patients for each group, for a total of 106 patients.where P < 0.05.Data will be summarized with counts for categorical variables present as mean and SD for normally distributed variables, or median (interquartile) for the variables not normally distributed. Missing data will be imputed according to the last-observation-carried-forward (LOCF)  principlAll clinical data will be recorded in the case report form. Researchers must fill in the case report form. Any corrections will be explained in the appended notes signed and dated by the physicians. Supervisors will check each case report form to make sure that the trial data are recorded in a timely manner, accurately and completely. Data input will be done separately by two data collectors with computers. The data manager will examine the data in the database to confirm that it is consistent with the data in the case report form and run a database consistency check.Possible adverse events due to acupuncture, such as discomfort, sweating, hematoma, fainting, severe pain, and metal allergy symptoms, will be recorded by the researcher.De Qi in the treatment group, patients will have a feeling of burning, numbness, swelling and pain. These are normal physiological reactions [Qi and blood [This trial is a randomized, multi-center, placebo-controlled clinical trial and aims to demonstrate the efficacy of acupuncture as pain relief in patients with pelvic pain related to endometriosis. When acupuncturists twirl, lift and thrust needles to obtain eactions . It is and blood , to achiIn addition, our study also includes an assessment of quality of life, and this is a strength of the present study. Increasing numbers of studies have shown that most patients with pelvic pain related to endometriosis have depression and anxiety, which influence their quality of life , 26.This trial is currently in the recruitment phase.Additional file 1:Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 Checklist: recommended items to address in a clinical trial protocol and related documents. (DOC 111 kb)


Background: Selective dorsal rhizotomy (SDR) has been used to treat children with spastic cerebral palsy (CP) for over three decades. However, little is known about the outcomes of childhood SDR in adults. Objectives: 1) To study the effects of childhood SDR on the quality of life and ambulatory function in adult life. 2) To determine late side effects of SDR in adults.  Methods: Adults (> 17.9 years) who underwent SDR in childhood (2 - 17.9 years) between 1987 and 2013 were surveyed in 2015. Patients completed a survey, including questions on demographic information, quality of life, health, surgical outcomes, motor function, manual ability, pain, braces/orthotics, post-SDR treatment, living situation, education level, work status, and side effects of SDR. Results: In our study population of 294 patients (18.0 - 37.4 years), patients received SDR during the ages of 2.0 - 17.9 years and were followed up 2.2 to 28.3 years after surgery. Eighty-four percent had spastic diplegia, 12% had spastic quadriplegia, and 4% had spastic triplegia. The majority (88%) of patients reported improved post-SDR quality of life and 1% considered the surgery detrimental. Most (83%) would recommend the procedure to others and 3% would not. However, patients who would not recommend SDR to others ambulated with a walker or were not ambulatory at all prior to SDR. The majority (83%) of patients improved (30%) or remained stable (53%) in ambulation. Twenty-nine percent of patients reported pain, mostly in the back and lower limbs, with a mean pain level of 4.4 ± 2.4 on the Numeric Pain Rating Scale (NPRS). Decreased sensation in small areas of the lower limbs was reported by 8% of patients, though this did not affect daily life. Scoliosis was diagnosed in 28%, with 40% of these patients pursuing treatment. Whether scoliosis was related to SDR is not clear, though scoliosis is known to occur in patients with CP and also in the general population. Only 4% of patients underwent spinal fusion. Orthopedic surgeries were pursued by 59% of patients. The most common orthopedic surgeries were hamstring lengthenings (31%), Achilles tendon lengthenings (18%), adductor lengthenings (16%), and derotational osteotomies (16%). Twenty-four percent of all patients later underwent hip surgery and 8% had surgeries on their knees. Conclusion: Results of this study indicate that the beneficial effects of childhood SDR extend to adulthood quality of life and ambulatory function without late side effects of surgery. In the United States, selective dorsal rhizotomy (SDR) has been utilized to treat cerebral palsy (CP) spasticity over the past three decades -3. SDR iThis quality of life survey study was approved by the Institutional Review Board of Washington University School of Medicine . Informed consent was obtained from patients directly or from guardians when patients were unable to provide consent. The subjects for this study were adults (age > 17.9 years) who underwent SDR in childhood (ages: 2 - 17.9 years) between 1987 and 1989 at University of Virginia Hospital or between 1990 and 2013 at St. Louis Children’s Hospital. SDR was performed through multilevel lumbosacral laminectomy in 54 patients and single level laminectomy in 240 patients . ContactThe survey included questions on demographic information, quality of life, health, surgical outcomes, motor function, manual ability, pain issues, braces/orthotics, post-SDR treatment, living situation, education level, work status, and side effects of SDR. Demographic information encompassed date of birth, living situation, highest education level, and current employment status. Participants were asked if they experienced urinary incontinence, loss of sensation, and increased muscle weakness with age. Patients experiencing sensation loss were further questioned to see if the loss of sensation was complete or partial and if it caused problems with daily life. Respondents were also queried about any additional spine problems, particularly scoliosis, and if they took any steps to treat these problems.The Diener Satisfaction with Life Scale (SWLS) was used to assess quality of life and subjective well-being by rating five statements on a scale from 1 (strongly disagree) to 7 (strongly agree). Summary scores on the Diener SWLS are interpreted as followed: (31-35) extremely satisfied with life, (26-30) very satisfied, (21-25) slightly satisfied, (20) neutral, (15-19) slightly dissatisfied, (10-14) very dissatisfied, and (5-9) extremely dissatisfied. Reliability of this scale has been reported to be greater than 0.80 .Perception of one’s personal health was assessed on a five-point scale from poor to excellent as seen in Question 1 of the SF-36 health survey . OpinionMotor function was assessed using the Gross Motor Function Classification Scale (GMFCS), a commonly used scale for determining gross motor function in children with CP . The scaChanges in ambulation level since surgery were ascertained by comparing preop mobility as gathered from our databases to mobility indicated on the survey via the GMFCS scale questions centered on patient’s walking ability.Upper extremity function was assessed using the Manual Ability Classification Scale (MACS) . Though Patients were asked to report pain experienced within the last week using the Numeric Pain Rating Scale (NPRS). The NPRS is a 0-10 scale with 0 indicating no pain and 10 being the worst pain imaginable. Participants were questioned about the location of the pain. If patients experienced back pain, they were then asked about the location of that back pain and the intensity of back pain using the NPRS. Those experiencing back pain were further queried about whether they received physician care, medications, surgery, physical therapy, or injections for their back pain. Respondents were also asked if they had constant pain in their legs and if this pain was due to muscle/joint problems or nerve pain.The latest contact information was gathered for the 1,047 patients who met the inclusion criteria for this study from the Center for Cerebral Palsy Spasticity at St. Louis Children’s Hospital’s databases. Two hundred and thirty-seven of these patients were unable to be reached, leaving 810 potential participants to be contacted for our survey. Out of the 810 remaining patients, 294 agreed to participate and five refused. No reasons for these refusals were reported, as patients were able to anonymously deny consent to participate in this study. Additionally, due to this anonymity, the exact breakdown of individually self-reported patient responses and caregiver/guardian responses on patients’ behalf was not known. Altogether, the final 294 participant count represented 36% of potential participants who met the study criteria.Selective dorsal rhizotomy had been performed in patients between the ages of 2.0 and 17.9 years (mean age: 7.2 ± 4.2 years). The postoperative follow-up period of this survey ranged from 2.2 and 28.3 years (mean duration: 17.2 ± 6.2 years). The ages of study participants varied from 18.0 to 37.4 years (mean age: 24.4 ± 5.4). Fifty-eight percent of these patients were male. Eighty-four percent of participants were diagnosed with spastic diplegia, 12% with spastic quadriplegia, and 4% with spastic triplegia  have received a high school diploma or equivalent and 31% had an advanced degree. Forty-eight percent were still in school with 84% of this participant group reporting as full-time students. A nearly equivalent percentage of participants (45%) were employed at the time of responding with 40% working full-time and 60% working part-time . Patients also reported physical and recreational daily activities. Sixty percent strengthened muscles at least once a week, 47% regularly stretched hamstrings, and 38% regularly stretched heel cords. Twenty-one percent of participants engaged in recreational sporting activities as well  were classified as Gross Motor Function Classification Scale (GMFCS) Levels I, II, and III with only 13% of patients classified as GMFCS Levels IV and V. Ninety-one percent reported to handle most objects independently and were at either MACS Level of I or II Table . In totaThirty percent of participants have improved their overall level of ambulation since surgery, while 17% saw their ambulation worsen over time. The remaining 53% of respondents reported ambulation in a manner similar to their ambulation level prior to surgery Table . PreoperEighty-eight percent felt that the SDR procedure was beneficial to them, while 1% considered SDR to have been detrimental to their quality of life. Overall, 83% would recommend SDR to other children with CP, 3% would not recommend the procedure, and 14% were unsure , although three patients declined to respond to the Diener Satisfaction with Life scale. Bone problems in the spine, primarily scoliosis, were seen in 28% of all participants with 40% of these patients pursuing some form of treatment. Only 4% of all participants underwent fusion surgery for spinal problems. Follow-up orthopedic surgeries were received by 59% of all patients. The most common orthopedic surgeries were hamstring lengthenings (31%), Achilles tendon lengthenings (18%), adductor lengthenings (16%), and derotational osteotomies (16%). Twenty-four percent of all patients also underwent hip surgery and 8% received surgeries on their knees (Table Three percent of participants had baclofen pumps inserted after SDR and 2% (three quadriplegia patients and two with diplegia) still had baclofen pump implants at the time of the survey. Medication-based anti-spasticity treatments were being taken by 18% of patients  with 12% of the total study population taking oral baclofen Table .Twenty-nine percent of patients reported pain within the past week, mostly located in the back and lower limbs. The mean pain level experienced by patients was 4.4 ± 2.4 and mean back pain score was 4.9 ± 2.6 on the Numeric Pain Rating Scale of 0 - 10 with 0 representing no pain and 10 representing worst pain imaginable. Most patients did not pursue further interventions for back pain, though medications and physical therapy were utilized by 39% and 34% of individuals reporting back pain, respectively. Constant leg pain was reported by 11% of participants. The overwhelming majority (87%) of these patients indicated that this pain was due to muscle and joint problems. Thirteen percent of respondents experiencing leg pain stated that their leg pain was diagnosed as nerve pain  in childhood. However, there are no long-term prospective studies in the CP literature examining the effects of selective dorsal rhizotomy alongside a variety of treatments, including orthopedic surgery, intrathecal baclofen treatment, Botox injection, antispasticity medication, and physical therapy. Lack of sufficient research on long-term outcomes may be attributed to the low prevalence of patients diagnosed with CP in the United States, which is about 1 in 323, resulting in the designation of low priority grant funding for costly long-term CP research . It is uStrengths of our study include the examination of a large patient cohort and of a long-term follow-up period reaching adulthood for participants who received SDR as children. Our study’s 294 adult participant cohort constitutes the largest study population among all long-term SDR studies reported to date. Additionally, the follow-up period extends up to 28 years, including a cohort of 96 patients who fall in the 20 - 28-year follow-up category. Only one previous study has examined a similar long-term follow-up period in a large SDR patient population .The limitations of our study are twofold. First, out of the 810 potential participants who met study criteria, 294 adults (36%) participated. Given that our study utilized a long follow-up period that involved contacting patients many years after their initial surgery, the 36% participation rate in this study was excellent. However, the outcomes of non-participants are still unknown. Second, data was collected from subjective patient self-report through an online survey questionnaire. These responses reflect the perceptions of those who completed the questionnaire and may present response bias in comparison to more objective measurement tools, such as neurological examination or personal interviews. In addition, due to the anonymity of responses, the exact questionnaire completion breakdown of patients to caregivers and guardians, on behalf of patients, is not known.At our center, the primary goal of SDR is to improve patients’ ambulation. Therefore, our data collection was focused on ambulation status before and after SDR. It is significant that 30% of our patients reported improved ambulation since surgery and that 53% reported similar ambulation as before surgery Table . It shouThe remaining 17% experienced worse ambulation since surgery; however, none of the patients in this group ambulated independently or with crutches prior to surgery. This result is consistent with our clinical observations. Patients who ambulate independently or with crutches before and after SDR maintain a high level of ambulation as they age. By contrast, patients who preoperatively ambulate with walkers in only protected environments can lose the ability to ambulate as they age. The decline is caused by increased body weight with growth in the absence of concurrent increased strength.CP spasticity also leads to “early aging” that is typically associated with decreased strength, endurance, and muscle/joint pain . In our We observed 1% of our study population reporting decreased quality of life after SDR and 10% feeling unsure about how SDR impacted their quality of life Table . The reaThough 83% of participants stated they would recommend SDR, 3% (nine patients) would not recommend the procedure  of incontinence in the general CP population . In addiThough 28% of patients reported a scoliosis diagnosis at the time of the survey follow-up, there is not enough evidence in the SDR literature to suggest that scoliosis resulted from surgical intervention . MoreoveEight percent of our patients reported diminished sensation in small areas of the lower extremities, though the sensory changes did not affect daily living. Thirty percent reported weakening muscles with age. However, the weakness is most likely due to muscle underuse rather than SDR. In a previous study, we reported no change in strength two years after SDR, suggesting that weakness could not have been a result of nerve damage from SDR . To dateResults of this study indicate that the beneficial effects of childhood SDR extend to adulthood quality of life and ambulatory function without late side effects of surgery.