Total knee arthroplasty (TKA) can improve the postoperative quality of life in patients with severe knee osteoarthritis. Although occupational therapy (OT) using a coping list may be useful for post-TKA patients, its use has not been documented. This study aimed to explore the effectiveness of OT using coping skills. Five post-TKA patients underwent OT using coping skills. The Canadian Occupational Performance Measure (COPM), numerical rating scale (NRS), Hospital Anxiety and Depression Scale (HADS), EQ-5D (EuroQol-5-dimension)-5-level (5L), EQ-5D Visual Analogue Scale (VAS), modified fall efficacy scale (MFES), Pain Disability Assessment Scale (PDAS), and coping skills were measured at the start and end of the study. Significant improvements were observed in COPM, NRS, HADS, EQ-5D-5L, and PDAS scores (p <0.05). No significant improvements were found in the EQ-5D VAS and MFES scores. All evaluations showed a large effect size (r ≤ 0.5). The total number of coping skills also increased. This report suggests that OT with coping strategies is effective for pain, psychological factors, quality of life, and activities of daily living. Incorporating coping skills in OT may be useful in postoperative TKA pain management. However, larger studies are needed to validate this. Chronic pain is defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” . The ecoKnee osteoarthritis (OA) is a disease that typically presents as joint pain, and total knee arthroplasty (TKA) has been shown to improve postoperative QOL . HoweverIn recent years, cognitive behavioral therapy (CBT) has been shown to be an effective intervention for pain and psychological disturbances, in patients with chronic pain . StudiesMaterials and methodsStudy DesignThis study was a case series that assessed each evaluation index , at the start and end of OT.Ethical ConsiderationsAll patients provided written informed consent to participate in the study. The study design was approved by the ethics review board of Fukuoka Rehabilitation Hospital (FRH-2020-R015).ParticipantsPatients who underwent TKA from July 2020 to July 2021 at the institution were included in the study  that would interfere with the completion of the questionnaire, as well as refusal to participate in post-surgical rehabilitation. Additional exclusion criteria were postoperative complications , other significant medical diseases interfering with postoperative rehabilitation, previous TKA , and TKA performed for causes other than degenerative diseases . The screening was performed by an orthopedic surgeon prior to surgery. The TKA surgeries were performed by four surgeons.Postoperative RehabilitationSurgeries were performed under general anesthesia in all patients. All patients received nonsteroidal anti-inflammatory drugs (NSAIDs)  for two weeks, postoperatively. All patients followed the same physical therapy protocol after surgery. All patients began physical therapy on postoperative day 1, including knee range-of-motion exercises (flexion-extension) and stretching. Approximately 3 weeks post-operation, walking using a walker was started. Approximately 5 weeks postoperatively, walking with a cane or without assistance was possible, and the patient was discharged from the hospital. All physical therapy interventions lasted 40 min/day.InterventionOverview of Occupational Therapy PracticeThe American Occupational Therapy Association explained that, in OT for pain, one must “implement a self-management approach focusing on participating in daily life” , “set individual occupational therapy goals,” and start “activation of behavior,” and perform “home exercise”  .It has been shown that interventions for OT education, OT goal setting using COPM, and behavioral activation using an activity diary are also effective in Japan . HoweverThe treatment time was two sessions twenty minutes each (20 min × 2 units of 40 min). Movement practice was performed step by step, in consultation with the physical therapist, according to the movement form.Interview Using COPMThe first interview was conducted using COPM, and emphasis was placed on creating an environment in which the interviewer could easily form sympathetic and supportive relationships with the patient while listening to them narrate details of their current pain and anxiety. Further, we listened to the background of the patient’s life before surgery  and determined the necessary activities they needed to fulfill after discharge. We proposed a coping list for the necessary activities needed upon discharge, for the achievement of goals , and for pain management. The coping list included those who had an agreement on introduction and research and those who had an intention to acquire coping skills. At the time of the first interview, measurements of numerical rating scale (NRS), Hospital Anxiety and Depression Scale (HADS), modified fall efficacy scale (MFES), Pain Disability Assessment Scale (PDAS), EuroQol-5-dimension-5-level (EQ-5D-5L), and EQ-5D visual analogue scale (VAS) were performed simultaneously.Acquisition of Coping SkillsIn the early stage of the OT practice, an interview using a coping list was conducted, in combination with OT centered on motion practice , to promote an understanding of its use. We conducted a review to note additional coping skills for patients who could provide specific coping mechanisms. In addition, for patients who lacked specific coping skills, coping skills based on the patient’s hobbies and tastes, which stemmed from coping skills that had already been brought up , presenting a collection of coping tips, listening to the conditions of the previous day, and acquiring coping skills from pain-free movements and the activities performed during that time, were urged upon. After being given specific coping skills, the patients were recommended to increase the number of coping skills, themselves, for better self-management.OT Self-managementAfter progressing to self-management, we reviewed the content that was tackled at the time of the intervention. During the intervention, in addition to ADL practice, instrumental ADLs , and outdoor walking practice were carried out, step by step, toward discharge. Finally, an interview using COPM was conducted at the time of the final intervention, an intervention in the form of coping skills was reviewed, and the OT was completed.At this time, NRS, HADS, MFSE, PDAS, EQ-5D-5L, and EQ-5D VAS were also measured.OutcomesCanadian Occupational Performance MeasureOT sessions were performed using the COPM . Using CCoping SkillsRegarding coping skills, a coping list Figure  was usedPainAn NRS was used to evaluate pain . The 11-Anxiety and DepressionThe HADS was used to evaluate anxiety and depression . The HADSelf-efficacy for Daily LifeThe MFES was used to evaluate self-efficacy in daily life ,16. The Disability for PainThe PDAS was used to evaluate life disorders associated with pain . The PDAQOLQOL was measured by the EQ-5D-5L questionnaire, which contains five questions with five responses for each question, and the total score is converted into the final EQ-5D value, ranging from 0.000 to 1.000; higher scores indicate a better QOL . The EQ-Data analysisStatistical analyses were performed using JMP software version 14.2.0 (SAS Institute Co.), Ltd, and descriptive statistics were used to describe the demographic data. Descriptive analyses were performed using mean, standard deviation, and frequencies. Pre-OT and post-OT data were compared in terms of outcomes  using the Mann-Whitney U test with JUMP 14.2.0 . The effect size (r) to describe the magnitude of the treatment effect was as follows: small, 0.10 to < 0.30; medium, 0.30 to < 0.50; and large, ≥ 0.50 .Results/findingsThe values of each evaluation index at the start and end of the OT are shown in Table In addition, the total number of coping skills that were effective for each patient increased Table . All parProgress of OT among patientsThe progress of patients in terms of coping skills is listed below.Case A: Anxiety was noted for pain and climbing stairs. After acquiring coping skills, he was able to manage pain and climb stairs and was discharged from the hospital after acquiring a total of 28 effective coping skills and saying, “I have no particular anxiety.”Case B: The patient was anxious about pain. After acquiring coping skills, pain management became possible. The patient said, “I’m glad that I felt like doing this in various situations,” and was discharged from the hospital after acquiring a total of 23 effective coping skills.Case C: Anxiety about pain was noted. After the introduction, it was difficult to improve effective coping skills; therefore, in the first week of the intervention, we deepened our understanding of their use, mainly through interviews. Effective coping skills were mentioned on the 5th day. After that, the patient acquired a total of 21 effective coping skills, said, “I am looking forward to my future life,” and was discharged from the hospital.Case D: Pain and anxiety in life after discharge were noted. After acquiring coping skills, the patient reported subsidence in pain, acquired 11 effective coping skills, and was discharged from the hospital.Case E: The patient became inactive due to anxiety caused by pain and admitted that he wanted to be anesthetized to feel better, even for a day. Through the interviews, we encouraged the acquisition of coping skills through empathic and supportive relationships. After the introduction, he acquired 13 effective coping skills and said “I think I can live at home,” and was discharged from the hospital.Occupational therapy practice using coping skillsIn this case series, improvements in COPM, NRS, HADS, and EQ-5D-5L were observed in five post-TKA patients, by OT practice using a coping list. To the best of our knowledge, this is the first case series combining coping lists and OT practice, after TKA. In a study, Riddle et al. reported that the practice of incorporating coping skills was found to improve pain, living function, and catastrophic pain in post-TKA patients, after two months . FurtherIn another cohort study, Riddle et al. presented a practical protocol based on previous studies, incorporating coping skills after TKA . This stHowever, this intervention did not result in a significant improvement in MFES. It has been reported that higher levels of self-efficacy in acquiring coping skills result in a greater effect; thus, MFES plays an important role in coping with pain . Our resClinical applicationAccording to a survey conducted among elderly people with long-term pain, patients felt that they did not understand the pain, they were not interested in their own pain, and they gave up on the situation of pain . TherefoLimitations and prospects of this researchSince this study was a case series , the results cannot be generalized. In addition, the long-term effects are unknown because of the limitations of the OT practiced by the first author and the verification of short-term effects alone. Furthermore, because physical therapy and drug therapy are used in combination, the confounding effects of these cannot be completely eliminated.This report suggests that OT with coping skills is effective for pain, psychological factors, quality of life, and living function. Incorporating coping skills in OT may be useful in post-TKA/TKR pain management. However, larger studies are needed to validate this. Furthermore, because physical therapy and drug therapy are used in combination, the confounding effects of these cannot be completely eliminated.


Chronic pain and functional impairment interfere with the quality of life of subjects suffering from temporomandibular joint (TMJ) disorders. Intra-articular (IA) hyaluronic acid (HA) injections have been shown to alleviate pain and improve mandibular mobility in patients with TMJ osteoarthritis (OA).The primary aim of the study was to identify the prognostic factors of patient satisfaction for a single IA injection of a mannitol-modified crosslinked HA (HANOX-M-XL) in patients with TMJ-OA. The second goal was to obtain clinical data on effectiveness, safety and mandibular mobility throughout a six-month follow-up period.This was an observational single-arm prospective trial with a six-month follow-up. Inclusion criteria: patients with TMJ-OA which is not relieved by analgesics and/or non-steroidal-anti-inflammatory drugs and/or orthotics, with radiological evidence of TMJ-OA. All patients received a single IA injection of 1 ml HANOX-M-XL in the target TMJ. The primary endpoint was patient satisfaction on day 180. The main secondary outcome measures were pain variation on a 11-point numeric scale (0–11) between the date of injection and month six, the variation over time of the Maximum Inter-Incisal Opening Distance (MIIOD) and the patient’s assessment of effectiveness. Predictive factors of success or failure were also studied. All adverse events were recorded.p < 0.0001) and the MIIOD increased from 29 ± 7 to 35 ± 5 mm (p < 0.01). On day 180, all patients were satisfied with the treatment, with 34 patients (94%) rating it as highly effective or effective. Tolerability was good in all but one patient. In the multivariate analysis, patient satisfaction on day 180 was highly correlated with the pain while chewing score, pain on palpation score and the decrease of pain over time  but not with MIIOD, gender, age, bruxism, articular noise and symptom duration. Previous viscosupplementation was also related to higher satisfaction (p = 0.01).36 subjects , covering a total of 52 injected TMJs, were included. Between baseline and endpoint, the average pain while chewing decreased dramatically from 6.9 ± 1.2 to 2.9 ± 1.3  decrease in pain and improvement in mandibular mobility, with no safety concerns.The online version contains supplementary material available at 10.1186/s12891-022-05352-3. Temporomandibular disorders are the most common cause of pain of non-dental origin in the orofacial region, affecting 21.5 to 51.8% of adults . We looked for the predictive factors of response or non-response, first in univariate then in multivariate analysis, by integrating all of the factors with a The main analysis was intended to be carried out in the per protocol (PP) population using only patients for whom all of the data on day 0 and day 180 were available, then confirmed in the intend-to-treat (ITT) population by processing missing data with the Last Observation Carried Forward (LOCF) method. Mann-Whitney or chi-square tests were used, as appropriate, to assess the association of quantitative or qualitative factors with patient satisfaction. The regression coefficients of the multivariate models (ANCOVA and mixed model) were considered significant if they were less than 5%. Statistics were achieved using XLstats software© .Thirty-six patients  were included in the trial. There was no drop-out, so the statistical analysis was performed on the total patient sample. The average age (range) was 55.3 years (range 27 to 72 years). Fifty-two TMJs were injected, since 20 patients suffered from a single TMJ disorder and 16 suffered bilateral TMJ involvement. The mean (range) symptom duration was 98 months (2–480). Most of the patients were taking analgesics and/or NSAIDS and wore an occlusal splint. Detailed characteristics of the patients at baseline are given in Table N = 13) were very satisfied, 61% (N = 22) were satisfied and 1 subject was hardly satisfied. Pain while chewing decreased significantly from 6.9 (1.2) to 3.4 (1.3) and pain on palpation from 7.7 (1.1) to 3.8 (1.3) , The MIOOD increased significantly from 29 (7) mm to 36 (6) mm (=0.005). A decrease in analgesics or NSAIDs consumption was reported by 61.3% of the patients.Ninety days after the injection of HANOX-M-XL, 36% of patients (+ 2.0 mm). All patients were satisfied with the treatment (22 satisfied and 14 very satisfied) and 81% of analgesics/NSAIDs users had decreased their drug consumption. The reduction in pain killers was > 50% in half of those patients. No complications or side effects were observed in any patient but one, who experienced local pain during injection due to a technical problem. Outcomes in month three and month six are given in Table Between D90 and D180, pain continued to decrease, reaching 2.9 1.3) and 3.2 (1.4) on D180 for pain while chewing and on palpation respectively (p versus baseline < 0.0001). On D180, MIOOD was not significantly different to that measured on D90 , as well as chewing pain, pain on palpation and the decrease of pain over time . Unsurprisingly, patient satisfaction was also highly related to the patient’s assessment of effectiveness on D90 and D180 (p < 0.0001). Previous viscosupplementation was significantly related to higher satisfaction (p = 0.01), as well as the decrease in pain killer use (p = 0.012). There was a trend for higher satisfaction in patients using an occlusal splint (p = 0.12) and achieving buccal rehabilitation (p = 0.07) and in those with shorter symptom duration (p = 0.13), but the difference did not attain statistical significance, likely because the sample size was too small.In the univariate analysis, patient satisfaction on day 180 was highly correlated with satisfaction on day 90 (p = 0.63), MIIOD on D0 (p = 0.68) and D180 (p = 0.46), MIIOD variation over time (p = 0.64), gender (p = 0.54), age (p = 0.19), previous corticosteroid injection (p = 0.46), baseline pain killers use (p = 0.65), bruxism (p = 0.46) or articular noise (p = 0.39).Inversely, satisfaction on both D90 and D180 was not correlated with pain on D0 , advanced age, a smaller MIIOD and a high level of baseline pain did not significantly reduce the rate of success of the HANOX-M-XL injection. In our study, we did not find any differences in outcome in patients treated for unilateral or bilateral TMJ OA, unlike Guarda-Nardini et al. , who fouHowever, in the absence of a control group, the present pilot study does not allow to formally assert that HANOX-M-XL acts better than a placebo. Although this study was open-label, and not intended to prove the effectiveness of HANOX-M-XL injections for TMJ OA, it is interesting to note that all of the enrolled patients benefited from the treatment, as shown by the percentage of satisfied patients, that reached 100% by month 6. A placebo effect cannot be formally excluded, at least in some patients. However, the percentage of satisfied patients exceeded the expected proportion of placebo responders –24. FurtHowever, our study suffers from several limitations. The sample size was small, which likely explains the lack of statistically significant correlations between patient satisfaction and symptom duration, the use of an occlusal splint and buccal rehabilitation. The fact that IA injections were performed without the help of imaging guidance can be considered an important limitation. However, the high rate of responders during months three and six strongly suggests that the TMJs were injected with accuracy. Lastly, we did not collect precise data on the radiological features and therefore cannot explore the relationship between treatment effectiveness and the anatomical severity of OA. Anyway our study confirms the positive data on the effect of HA in TMJ pathologies obtained using different protocols. Kopp et al. first reported in 1985 and 1987 the short- and long-term therapeutic outcomes of HA injections after arthrocentesis of the TMJ, and compared their effects with that of IA injections of corticosteroids . Guarda-In conclusion, despite no response predictors being formally identified, this open-label trial gave relevant information on the use of HANOX-M-XL in patients suffering from symptomatic TMJ OA. Six months after a single 1 ml injection in the TMJ, all patients experienced a decrease in pain and an improvement of jaw mobility. All were satisfied with the treatment and 39% said they were highly satisfied with the therapy despite a long history of pain. A single IA injection of HANOX-M-XL might be a new therapeutic option to relieve pain and improve function in patients suffering from TMJ pain of degenerative origin, with no safety concerns. Further controlled studies with larger sample sizes are needed to confirm these promising results.Additional file 1.


Background and objective: There is no report of the rate of opioid prescription at the time of hospital discharge, which may be associated with various patient and procedure-related factors. This study examined the prevalence and factors associated with prescribing opioids for head/neck pain after elective craniotomy for tumor resection/vascular repair. Methods: We performed a retrospective cohort study on adults undergoing elective craniotomy for tumor resection/vascular repair at a large quaternary-care hospital. We used univariable and multivariable analysis to examine the prevalence and factors  associated with prescribing opioids at the time of hospital discharge. We also examined the factors associated with discharge oral morphine equivalent use. Results: The study sample comprised 273 patients with a median age of 54 years , 173 females (63%), 174 (63.7%) tumor resections, and 99 (36.2%) vascular repairs. The majority  received opioids postoperatively. The opiate prescription rates were 72% (n = 196/273) at hospital discharge, 23% (19/83) at neurosurgical clinical visits within 30 days of the procedure, and 2.4% (2/83) after 30 days from the procedure. The median oral morphine equivalent (OME) at discharge use was 300 . Patients were discharged with a median supply of 5 days . On multivariable analysis, opioid prescription at hospital discharge was associated with pre-existent chronic pain  and time from surgery to hospital discharge , discharged at 12 days and later ). There was a linear relationship between the first 24 h OME (p < 0.001), daily OME (p < 0.001), hospital OME (p < 0.001), and discharge OME. Conclusions: This single-center study finds that at the time of hospital discharge, opioids are prescribed for head/neck pain in as many as seven out of ten patients after elective craniotomy. A history of chronic pain and time from surgery to discharge may be associated with opiate prescriptions. Discharge OME may be associated with first 24-h, daily OME, and hospital OME use. Findings need further evaluation in a large multicenter sample. The findings are important to consider as there is growing interest in an early discharge after elective craniotomy.  According to the Centers for Disease Control, it is estimated that national opioid prescription in the US has tripled since 1999, and the economic cost of prescription opioid misuse exceeds 78 billion dollars annually  while 67Pain from craniotomy surgeries is commonly managed intraoperatively with fentanyl, remifentanil, or sufentanil infusions, intravenous fentanyl, morphine hydromorphone, and acetaminophen, as well as with the use of scalp blocks and infiltration of a local anesthetic at the craniotomy incision site. Even though it has been historically reported that post-craniotomy pain may be less severe compared to that after non-craniotomy procedures , severalTo bridge this knowledge gap, we undertook a study to examine the prevalence and factors associated with opioid prescriptions in patients at the time of hospital discharge. We attempted to examine the continued prescription of opioids at the neurosurgical clinic follow-up. We studied this in a cohort of patients undergoing craniotomy for tumor resection/vascular repair. The specific aims of this study were (1) to examine the prevalence of opioid prescription at the time of hospital discharge and neurosurgical clinical follow-up within 30 days of the neurosurgical procedure and after 30 days of the neurosurgical procedure and (2) to examine the association between perioperative factors associated with the rate of opioid prescriptions. Knowledge gained from this study may increase awareness of opiate prescriptions amongst healthcare providers routinely caring for patients undergoing craniotomy, which in turn may inform responsible and appropriate discharge opioid prescription practices.This is a single-center, retrospective observational study conducted at Harborview Medical Center in Seattle, Washington, a comprehensive stroke, and Level I trauma center.We included patients 18 years of age and older who underwent elective craniotomy by a single neurosurgeon (Author LS) at Harborview Medical Center between January 2015 and December 2019. We included craniotomy for tumor resections and vascular repair . Exclusion criteria included non-intracranial surgeries, emergency surgeries, more than one neurosurgical procedure during the same surgical encounter, expired patients, and patients with pain not located in the head/neck region.All post-craniotomy patients were admitted to an intensive care unit, regardless of extubation status. None of the patients received scalp nerve blocks perioperatively. The pain was assessed by bedside nursing staff with the Critical-care Pain Observation Tool (CPOT) in intubated patients and by a numerical scale (range 0–10) in communicative patients.Patient information and specific data are collected from the electronic health record (EHR) and refined via a departmental database, Perioperative & Pain Initiatives in Quality Safety Outcome (PPIQSO).We categorized the variables of interest into three groups:(a) Preoperative: age, sex, race category (White/non-White), ethnicity (Hispanic or Latino/Non-Hispanic/Non-Latino), Language category (English-speaking/Non-English speaking), insurance , history of chronic pain, pre-admission use of opiates, and oral morphine equivalent (OME), history of any depression/anxiety disorder, and a history of substance abuse.(b) Intraoperative: type of procedure (tumor/vascular), location , surgical duration, use of remifentanil infusion, fentanyl infusion, lidocaine infusion, methadone, hydromorphone, ketamine infusion, and non-opioid analgesic such as intravenous acetaminophen.(c) Post-operative: first 24 h post-op OME, first 24 h post-op maximum pain scores, maximum pain score during the hospital stays, daily OME from postoperative day one to postoperative day 30, total hospital OME, hospital OME/per day of stay in the hospital, and hospital length of stay.(d) Follow-up: timing of visits in days since the original neurosurgical procedure and opiate prescriptions.Opiates at discharge, OME at discharge, and Opiates prescribed at follow-up . Total discharge OME and discharge OME per day is inferred from the number and dose of tablets and the administration frequency in the prescription. The OME conversion was as follows: oral morphine: conversion factor 1, oral controlled release Morphine: 1, oral codeine: 0.15, oral hydromorphone: 4, oral hydrocodone: 1, oral oxycodone: 1.5, oral oxymorphone: 3, oral meperidine: 0.1, oral levorphanol: 15, oral tramadol: 0.25, oral tapentadol: 0.3, transdermal fentanyl: (mcg/h): 2.4, oral methadone (1–20 mg/day): 4, oral methadone (21–40 mg/day): 8, oral methadone (41–60 mg/day): 10, oral methadone (>61–80 mg/day): 12, sublingual buprenorphine: 30.The descriptive analysis described the study sample characteristics. After normality testing using the Shapiro–Wilk test, continuous variables such as age, body mass index (BMI), 24 h OME, hospital OME, OME at discharge, and hospital length of stay were expressed as median . Categorical variables were expressed as counts and percentages.p-value of <0.05 indicates statistical significance. STATA 15 . Patients spent a median of 2 days  in the ICU and a median of 6 days  in the hospital. Eighty-three patients followed up in the neurosurgical clinic after the original neurosurgical procedure. The median time to follow-up time after the procedure at the neurosurgery clinic was 16 days [IQR 13–54], with the longest follow-up at 206 days. The median pain scores were 8.n = 170/196, 87%) and hydromorphone . Others had tramadol (n = 3), methadone, morphine, and fentanyl (n = 1). The average total discharge OME was 45 . Patients were discharged with a median supply of 5 days . We found a linear relationship between days of discharge opioid supplied and 24 h postoperative OME use (One hundred ninety-six (72%) were prescribed opioids at hospital discharge. Opioids commonly prescribed included oxycodone (n = 19), while the rate of opioid prescription after 30 days from the neurosurgical procedure was 2.4% (n = 2).Amongst the 83 patients that followed up in the neurosurgical clinic at our institution, the opioid prescription rate during the first visit before 30 days of the neurosurgical procedure was 23% (p = 0.03) and time from surgery to hospital discharge. Compared to patients discharged within days 1–4 postoperatively, patients discharged between days 5–12 , and at 12 days and later  were less likely to be prescribed opioids at the time of discharge. The Homer-Lemeshow test (p = 0.27) indicated that the model adequately described the data. We found no association between discharge opioid prescription rate and total hospital OME .n = 196), the average total discharge OME was 300 . The median first 24 h OME use was 58 . The median daily OME was 23 . The median total hospital OME was 178 . There was a statistically significant correlation between discharge OME and (a) first 24 h OME (Amongst those discharged on opioid medications (p = 0.47) and discharge time after surgery There were no statistically significant differences in the discharge OME and history of chronic pain (509 ± 6 vs. 408 ± 113, We examined the opioid burden and the prescription of opiates for head and neck pain at the time of hospital discharge after elective craniotomy for tumor resection/vascular procedures. The main findings of the study are described and discussed below.Our study finds that seven out of ten patients are prescribed opioids at the time of their discharge from the hospital. Those with a history of pre-operative chronic pain were more likely to be prescribed opioids at discharge. In contrast, those with more extended hospital LOS were less likely to be prescribed opioids at discharge. Practitioners were more likely to prescribe patients with pre-existent chronic pain opioid pain medications on discharge since the presence and severity of pre-existing pain may correlate with the intensity of acute postoperative pain . Given tWith regard to the amount of opioid pain medications with which patients were discharged among those who were prescribed any after their craniotomy procedure, we found a statistically significant linear relationship between discharge OME and the first 24 h OME, daily OME, and total hospital OME. This may explain one of the reasons providers may base the amount of discharge OME to be prescribed. Though rich in risk factors for postoperative pain and the development of chronic pain, literature is scarce on factors associated with the amount of opioid medications patients are discharged with.One observation that was not expected is the association between hospital length of stay and the rate of opioid prescription. The highest risk for opiate prescription in patients discharged within the first four days of their craniotomy, and its decrease with longer hospital length of stay suggest an association between pain scores and hospital OME, both of which decrease over time as the patient is observed after craniotomy. This would also be congruent with current studies, which showed that severe pain is commonly experienced within the first 48 h after surgery , presumaFindings from our study suggest that hospital discharge opioid prescription was not associated with age, sex, prior opioid use, surgical location and approach, and history of depression and/or anxiety, which were thought to predispose patients to postoperative pain and opioid use ,13,20,28At this time, opioid-free craniotomy care remains elusive ,29,30, yThis study puts into perspective the use of opioids after elective craniotomy and highlights possible reasons for prescribing opioids at the time of discharge. The findings of hospital LOS being an important factor raises concerns since there is growing interest in early discharge from the hospital after craniotomy ,32. SuppLimitations are typical of a single-center retrospective study in that the data used for this study was not collected for research purposes, the sample size and power analysis were not performed a priori, and the follow-up data is missing more than half of the original sample size. If a patient received opioid-based patient-controlled analgesia during their postoperative period, there were institutional limitations regarding the accuracy of the recorded dosage. In addition, we could not assess if patients self-administered the opioids they were prescribed at discharge. We did not study the impact of patient positioning or tumor grading  on the rBeing a retrospective study, findings are hypothesis-generating, and conclusions cannot be generalized to other institutions; however, the results from our research warrant a multicenter investigation in a larger cohort of craniotomy patients.Opioids are commonly prescribed intra- and postoperatively after craniotomy. Most patients, as many as 7 in 10, may be prescribed opioids at the time of hospital discharge, though only 4 out of 100 patients are prescribed opioids 30 days after craniotomy.


There is no approved drug for fibromyalgia syndrome (FMS) in Europe. In the German S3 guideline, amitriptyline, duloxetine, and pregabalin are recommended for temporary use. The aim of this study was to cross-sectionally investigate the current practice of medication in FMS patients in Germany. We systematically interviewed 156 patients with FMS, while they were participating in a larger study. The patients had been stratified into subgroups with and without a decrease in intraepidermal nerve fiber density. The drugs most commonly used to treat FMS pain were nonsteroidal anti-inflammatory drugs (NSAIDs) , metamizole (22.4%), and amitriptyline (12.8%). The most frequent analgesic treatment regimen was “on demand” (53.9%), during pain attacks, while 35.1% of the drugs were administered daily and the remaining in other regimens. Median pain relief as self-rated by the patients on a numerical rating scale (0–10) was 2 points for NSAIDS, 2 for metamizole, and 1 for amitriptyline. Drugs that were discontinued due to lack of efficacy rather than side effects were acetaminophen, flupirtine, and selective serotonin reuptake inhibitors. Reduction in pain severity was best achieved by NSAIDs and metamizole. Our hypothesis that a decrease in intraepidermal nerve fiber density might represent a neuropathic subtype of FMS, which would be associated with better effectiveness of drugs targeting neuropathic pain, could not be confirmed in this cohort. Many FMS patients take “on-demand” medication that is not in line with current guidelines. More randomized clinical trials are needed to assess drug effects in FMS subgroups. Fibromyalgia syndrome (FMS) is a chronic pain disorder associated with fatigue, sleep, memory, and mood disturbances, defined by a widespread pain index (WPI) and the symptom severity scale, symptom persistence over 3 months, and exclusion of all other diseases that might cause pain . The etiSystematic reviews of randomized clinical trials have shown that serotonin–norepinephrine reuptake inhibitors (SNRIs) , pregabaNo drug is licensed specifically for FMS in Europe, while the United States Food and Drug Administration approved pregabalin, duloxetine, and milnacipran for this indication . In EuroWe have prospectively recruited and comprehensively investigated a large cohort of patients with FMS . Here, wPatients were recruited for a larger study on FMS and small fiber pathology at the Department of Neurology, University Hospital Würzburg, Germany, between 2014 and 2019. A flowchart of the inclusion process is shown in Having determined IENFD in skin biopsies of the lower and upper leg, we had identified patients at the two opposite ends of the spectrum, which resulted in a group with pathologic IENFD in both the distal and the proximal biopsy and a group with normal IENFD in both biopsies . Here, wTo evaluate pain relief by the drugs, we used a numeric rating scale . This scale was used for all analyses regarding the effectiveness of individual drugs in relieving pain. The remaining pain questionnaires were only used to obtain a more comprehensive clinical characteristic but were not related to the effectiveness of the medications. To evaluate persistent pain severity, we used the Graded Chronic Pain Scale (GCPS), which reflects two dimensions of chronic pain: pain intensity and pain-related disability . To asseWe categorized diclofenac, ibuprofen, and acetylsalicylic acid as nonsteroidal anti-inflammatory drugs (NSAIDs); etoricoxib and nimesulide as cyclooxygenase-2 (COX-2) inhibitors; tilidine and tramadol as weak opioids; oxycodone, tapentadol, and fentanyl as strong opioids; tolperisone as a muscle relaxant; fluoxetine and sertraline as selective serotonin reuptake inhibitors (SSRI); and duloxetine as serotonin–norepinephrine reuptake inhibitors (SNRI). Some patients reported guaifenesin treatment explicitly against FMS symptoms; hence, we also included this mucus diluent in our analysis.t-test for group comparisons. For nonnormally distributed data, the group comparison was performed by the Mann–Whitney U test. The crosstabs were tested for significance using the chi-square test. Correlation analysis was performed by the two-sided Spearman–Rho test. The confidence interval was 0.95, and the significance threshold was p < 0.05. In order to compare the effectiveness of the pain medication between the small nerve fiber groups, only medication classes that were taken by more than 15 patients were included for sufficient statistical power.For statistical analysis, the program IBM SPSS Statistics for Windows version 25.0  was used. Data were converted into the dichotomic multiple answer system of SPSS and evaluated using crosstabs. the Shapiro–Wilk test was performed to check for normal distribution of the data. For normally distributed data , we used a two-sided One hundred and fifty-six patients  were included in our analysis. The median age was 50.6 years (range 21.5–74.7). The sum scores of the patients' symptom questionnaires and the proportion of frequent FMS comorbidities are displayed in the Supplementary The most frequently taken class of drugs was NSAIDs with 41.0% of all patients, followed by metamizole with 22.4% and amitriptyline with 12.8% . OpioidsOnly 29.6% of the patients had drug therapy according to the German S3 guideline. However, 78.8% of the patients had already tried at least one of the drugs recommended in the guideline in the past and had discontinued it due to side effects or lack of efficacy. Amitriptyline  was the most frequently discontinued drug in the past, followed by NSAIDs (35.1%) and pregabalin (19.2%). Current therapy was the first medical treatment attempt for only 9.1% of the patients. Most often, previous drugs had been discontinued due to lack of effect . The median duration of the current drug therapy up to study enrollment was 3 years (range from 1 month–30 years).n > 15 patients. These were NSAIDs with a median pain reduction of 2 points (range 0–5), SNRIs with a median of 1 point (range 0–3), amitriptyline with 1 point (range 0–4), and metamizole with 2 points (range 0–8)  .n = 36) and with entirely normal skin innervation (n = 42). In the overall response and also analyzing the frequently taken drugs NSAIDs or metamizole, we did not find intergroup differences in treatment response  or guaifenesin (r = -2.0) was negatively correlated with the IENFD in the distal leg. Interestingly, the use of strong opioids was associated with higher scores in the “O ´Leary/Sant voiding and pain indices.” To validate this correlation, we conducted a direct group comparison. In this direct comparison of the questionnaire results between patients taking opioids (n = 12) and those not taking any (n = 146), we found one difference, namely, higher scores (p=0.02) in the “O ´Leary/Sant voiding and pain indices,” which asks about urinary problems. Since these correlation analyses had an exploratory purpose to enable us to test hypotheses from them later in large cohort studies, we did not apply the Bonferroni correction. These data should therefore be regarded as pilot results and warrant replication.We found several correlations between the intake of distinct drugs and clinical parameters . Intake Only 29.6% of FMS patients took recommended medication according to the German FMS guideline . In the D (5.9%); drugs are listed in As shown in In this cross-sectional study of 156 patients with FMS, we found that NSAIDs and metamizole on demand were the most frequently used drugs. Drugs with proven efficacy in randomized controlled trials (RCTs) and with recommendations in national and international guidelines  were onlAmong the few studies worldwide that have investigated the current use of drugs in FMS, one explicitly deals with opioids. A study from the United States of America (USA) examined the intake of opioids by FMS patients from 2011 to 2017 . In 2011Two population-based studies focused on the choice of drug against FMS symptoms , 26. BotOur cohort is smaller compared to the previously mentioned studies, but similar in patients' characteristics. Here, as well, the average age is approximately 50 years, and on average, about 80% of the patients are women. However, the number of other pain disorders was lower in our cohort compared to others . This maThe reason for the low number of patients taking the drugs according to the guidelines (29.6%) remains unclear. One obvious reason may be that duloxetine and pregabalin are off-label for FMS in Germany. Other reasons may be lack of information in the group of the treating physicians or that physicians decided to discontinue an ineffective drug therapy after consulting the guidelines, which recommend initial nondrug therapy. Another reason may be a lack of adherence by patients. Often the term “antidepressants” is misunderstood and patients feel stigmatized by taking such a drug. Many patients also report side effects, such as weight gain or fatigue, which can lead to severe loss of quality of life. We show in our results that this varies greatly depending on the medication taken. This may lead to patients preferring complementary medicine to classical medicine. Since there are no drugs specifically approved for FMS in Europe, a standardized therapy is more difficult. Well-planned RCTs or register studies might lead to additional safety and possibly to the licensing of helpful drugs in Europe.Although the German guidelines explicitly do not recommend the use of opioids in FMS , 7.7% ofOur study has a number of limitations. For certain classes of drugs, the number of patients was low, so the conclusions in these cases are limited. This is a cross-sectional study; therefore, the recall of medication effects may be biased. We did not query the compliance of the patients, which could have been influential on the results. Patients were asked to distinguish between multiple medications individually; however, overlapping effects may have occurred. In addition, the different drugs were taken over different periods of time; we could not control this parameter with our data. Previously published small RCTs do not show a superiority of NSAIDs over the placebo effect ; howeverIn conclusion, FMS patients in Germany take many different medications for their pain, which are not officially recommended for the treatment of FMS. However, these lead to moderate therapeutic success. These substances, such as NSAIDs and metamizole, should be tested in randomized controlled clinical studies in FMS. To assess possible differences in therapeutic response between the subgroups with and without small nerve fiber pathology, studies with larger cohorts are needed. Physicians treating FMS patients should also pay attention to the recommended dose ranges with regard to the tolerability of the medication. Limitations of the study were the small number of patients in the subgroups, the cross-sectional design that did not allow for conclusions about placebo effects or overlapping effects with multiple medications, and a lack of control for patients' medication adherence.


The upper limit of the 95% CI for the differences  was within the predefined noninferiority margin of 2. Total doses of rescue analgesics  and satisfaction scores  vs. 4.0 , p = 0.227) were similar. Thus, the ESPB combined with ICNB may be an efficacious option after VATS.This monocentric, single-blinded, randomized controlled noninferiority trial investigated the analgesic efficacy of erector spinae plane block (ESPB) combined with intercostal nerve block (ICNB) compared to that of thoracic paravertebral block (PVB) with ICNB in 52 patients undergoing video-assisted thoracic surgery (VATS). The endpoints included the difference in visual analog scale (VAS) scores for pain  in the postanesthetic care unit (PACU) and 24 and 48 h postoperatively between the ESPB and PVB groups. The secondary endpoints included patient satisfaction  and total analgesic requirement in morphine milligram equivalents (MME). Median VAS scores were not significantly different between the groups  vs. 2.0 ,  Although it is less invasive and damaging to tissue, video-assisted thoracic surgery (VATS) still causes moderate to severe postoperative pain . PostopeWe hypothesized that the ESPB would not be less effective than the PVB for attenuating pain when combined with ICNB after VATS. The primary outcome of this monocentric, single-blinded, randomized controlled noninferiority trial was the median difference in postoperative pain scores between the groups. The secondary outcomes were the cumulative postoperative analgesic consumption  and patient satisfaction scores.https://cris.nih.go.kr . We enrolled 52 patients with American Society of Anesthesiologists physical status I, II, or III, aged 19–80 years, who had undergone VATS between June 2021 and January 2022. Patients were excluded from the study for cognitive impairment, anticoagulant administration, coagulopathy, antiplatelet drug administration within 48 h, double antiplatelet therapy, surgical site infection, refusal of procedure, allergic reaction to local anesthetic, requiring therapeutic anticoagulant therapy after surgery, or pregnancy. Patients with comorbid diseases were excluded according to the judgment of the anesthesiologist . Patients were randomly and evenly assigned to either the PVB with ICNB group or the ESPB with ICNB group by a computer-generated randomization table. Blinding of the group designation was maintained for the patients and attending anesthesiologists, except one practitioner (J.-H.P.) who performed the PVB or ESPB.The study trial was approved by the Institutional Review Board of Yonsei University Wonju College of Medicine, Wonju, Korea, and the participants are listed at ® (tramadol 37.5 mg/acetaminophen 325 mg), and transdermal fentanyl patch.Anesthesia was induced by a bolus of propofol 1.5–2 mg/kg) and remifentanil (1 mcg/kg). Rocuronium (0.6 mg/kg) was used for tracheal intubation. The remifentanil infusion rate was adjusted by the attending anesthesiologist according to the overall hemodynamic data and the suggested intensity of surgical stimuli. The fraction of inhaled anesthetics was administered under BIS guidance. The surgeon performed the ICNB and placed a chest tube during the surgery. At the end of the surgery, the ESPB or PVB was performed in the lateral position. One anesthesiologist (J.-H.P.) performed the PVB and ESPB. The same experienced surgeon (C.S.B.) performed the ICNB. The intravenous patient-controlled analgesia (PCA) was used at the discretion of the anesthesiologist, and the dose was recorded in terms of morphine milligram equivalents (MME). The patients were extubated and transported to the postanesthetic care unit (PACU). The standard analgesic algorithm in PACU was intravenous nonopioid analgesics for visual analog scale pain scores of 4–6 [ mg/kg anAfter surgery, each patient was placed in the lateral decubitus position, and skin preparation was performed. The patient was palpated at the T5 level, and the linear transducer was positioned in a vertical plane approximately 2.5 cm lateral to the palpated spinous process, obtaining a sagittal plane of the transverse process, superior costovertebral ligament, intertransverse ligaments, desired paravertebral space, pleura, and lung tissue. The paravertebral space was bordered by the vertebral body, intervertebral foramen, parietal pleura, and costovertebral ligament. A 21-gauge, 10 cm echogenic needle  was placed in the paravertebral space using an in-plane approach to confirm that there was no blood aspiration. A small amount of local anesthetic was then injected into the test dose in real time to reduce the anterior displacement of the pleura and spine. Ropivacaine  was injected with aspiration every 5 cc to prevent intravascular injection.At the T5 level, the linear transducer was moved slowly from the midline to the lateral, and the transducer was moved approximately 3 cm until a transverse projection was observed. It was distinguishable from the ribs at that level: the transverse process is shallow and wide, whereas the ribs are deep and thin. The trapezius, rhomboid, and erector spinae muscles were then identified. An echogenic needle was inserted from the head to the foot, using an in-plane approach, and advanced toward the transverse process through the trapezius, rhomboid, and erector spinae muscles under ultrasound guidance. A small amount of local anesthetic was administered when the needle tip was located below the erector spinae muscle. The correct position of the needle was verified by visually confirming that the erector spinae muscle was separated from the transverse process. Ropivacaine  was injected with aspiration every 5 cc to prevent intravascular injection.At the end of the surgical procedure, a total of 10 cc of ropivacaine (2 cc per space) was injected into the intercostal space until swelling of the intercostal nerve at the T4–T8 levels occurred.The primary endpoint of the present study was to assess the analgesic efficacy of ESPB compared with that of PVB when combined with ICNB by measuring the median differences between the groups in the VAS of pain at the PACU, as well as 24 and 48 h after surgery. The secondary endpoints were to investigate the total amount of analgesics administered to the patients in MME and the satisfaction score of patients using a five-point rating scale.The standard deviation for PVB with ICNB in the pilot study was 2.29, and no significant difference was observed in the variance between the ESPB and PVB in a previous study . The sigt-test and are reported as the mean ± standard deviation (SD). For pain scores assessed at three timepoints, a post hoc Bonferroni correction was applied to adjust for multiple comparisons.All statistical analyses were performed using the IBM SPSS statistical software package . Distribution of continuous variables was assessed using the Shapiro–Wilk test. Intergroup comparisons of the non-normally distributed variables were performed using the Mann–Whitney U test and are reported as the median (interquartile range). Intergroup comparisons of other variables that showed a normal distribution were tested using an independent In total, 52 patients were screened, and all of them were enrolled and assigned to the two groups. There was no dropout among the enrolled patients. Hence, all 52 patients were included in the final analysis.The patient characteristics and types and durations of the surgeries were similar between the groups .p = 0.767), the number of rescue analgesic events , and satisfaction scores  vs. 4.0 , p = 0.227) were not significantly different between the two groups  scores for each timepoint were not significantly different between the ESPB and PVB groups. The higher limit of the 95% CI for this difference  was within the predefined noninferiority margin of 2 (delta). The total doses of rescue analgesics (110.24 ± 103.64 vs. 118.40 ± 93.52 MME, o groups . There wo groups . The numThe hemodynamic data, including heart rate and mean arterial blood pressure during surgery, were also similar between the groups .The results of the present trial suggest that ESPB was not inferior in analgesic efficacy to PVB when combined with ICNB for attenuating surgery-related pain. Moreover, this combination block was similar in terms of patient satisfaction, analgesic requirement, and the frequency of hemodynamic perturbations. In addition, although the difference was not significant, pleural puncture was absent in the ESPB-ICNB group but present in two cases in the PVB-ICNB group.VATS is a minimally invasive procedure that results in minimal tissue trauma. Nevertheless, it also causes significant and intense acute pain, which may lead to post-thoracotomy pain syndrome . The scoTEB has long been the standard procedure for pain control after thoracotomy. However, side effects such as hypotension, bradycardia, and pruritus are common, and analgesic failure often occurs because of an incorrect target position. In addition, catastrophic side effects, such as epidural hematoma, require close attention . A previESPB involves the injection of local anesthetics into the fascial plane between the transverse process and erector spinae muscle . In the Although there is no consensus on the analgesic effect, ESPB has several advantages over PVB. Firstly, it is technically easier to contact the transverse process than it is to fix a needle tip in the relatively narrow paravertebral space. Therefore, high skill is not required for the practitioners, and the difference in efficacy was shown to be little among the practitioners . MoreoveOur study had several limitations. Firstly, the analgesic effect was compared using a subjective index. However, there is no objective indicator that measures the pain index, and several previous trials have used the NRS as an effective tool for evaluating analgesic efficacy ,29. SecoIn conclusion, the present study is the first trial to compare the effects of ESPB and PVB with ICNB. Both groups provided an adequate analgesic effect in VATS. However, compared to PVB, ESPB is easier to implement and has advantages in terms of safety due to no adjacent vulnerable structures. The present study provided evidence that ESPB with ICNB may be an efficacious analgesic option in VATS.


Cancer patients are increasing in number, with an increased lifespan and advances in cancer treatment. Palliative care physicians often encounter difficulties in caring for patients with pain. In addition to cancer-related pain, patients with cancer may suffer from various musculoskeletal diseases, resulting in significant functional limitations of physical activities of daily living. We present three cases illustrating methods to deal with nonspecific mechanical low-back pain in patients with advanced cancer. We provide our therapeutic experiences, focusing on the usefulness of radiofrequency treatment in palliative care in patients with cancer. LBP might be an important sign of more serious diseases in some cancer patients, such as spinal metastases. In this situation, the patients might present severe night pain or progressive and non-mechanical pain, which is considered a red flag for spinal metastasis.2Although low-back pain (LBP) is known to be one of the most common health problems with a one-year prevalence estimated at 38%,In contrast, the patients can also experience nonspecific mechanical LBP, which is not associated with cancer itself but with degenerative conditions of the spine. Nevertheless, the intensity of nonspecific LBP in cancer patients might be much more severe, leading to significant deterioration of functional abilities compared with noncancer patients.3 LFS-related pain may present as LBP, which can be radiated to the buttock or leg according to the affected facet joints. The diagnosis of LFS is often challenging for pain physicians due to the low diagnostic accuracy of physical examination based on symptoms and signs and the unpredictability of radiological imaging, including magnetic resonance imaging (MRI) and computed tomography (CT).4Lumbar facet syndrome (LFS) is considered one of the most frequent degenerative spine diseases.5 Instead, lumbar medial branch block (MBB) is widely accepted as a useful diagnostic tool for LFS with moderate to strong strength of recommendation. Radiofrequency (RF) treatment of the medial branch as well as nerve block has been accepted as a successful therapeutic option for LFS.6The degree of radiological facet joint abnormality detected by MRI is poorly correlated with LBP symptoms.In this case series, we encountered three patients with different types of advanced-to-terminal cancers who were referred to our palliative care center for managing LBP. All patients were suspected of having LFS without evident spinal metastasis. We introduce our experience with successful treatment with medial branch RF for LBP in patients with cancer.Written informed consent for publication of this case series was obtained from each patient. We experienced three cases of successful RF treatment for nonspecific mechanical LBP in patients with cancer without definite spinal metastasis. The LBP-related clinical characteristics of the patients are presented in A 46-year-old man visited our palliative pain center because of a recently aggravated LBP. The patient had received palliative chemotherapy for advanced gastric cancer with peritoneal metastasis for 19 months. However, radiological examinations such as CT revealed progressive disease, and end-of-life care was planned. The patient complained of severe and aching acute LBP with the worst intensity of 9 on the 11-point numeric rating scale (NRS). LBP was refractory even with a gradual increase in the dose of analgesics, including transdermal non-steroidal anti-inflammatory drugs (NSAIDs), transdermal fentanyl 100 μg/h, intravenous morphine 25 mg/day, and intranasal fentanyl spray 200 μg/day. The maximum opioid dose was equivalent to an oral morphine dose of 375 mg/day.He had previously received celiac plexus neurolysis with 99% dehydrated alcohol due to cancer-related abdominal visceral pain six months before presentation, and the abdominal pain relieved. The patient was referred to our palliative care pain center. Although he could not describe his pain because of severe debility, he presented definite direct tenderness on both the L4/5 and L5/S1 lumbar facets on physical examination. The patient was suspected of having LFS, and we first considered MBB at L3, L4, and L5 bilaterally for diagnostic and therapeutic procedures.6 Upon the procedure, the affected facet joints were rechecked by palpation using fluoroscopy. The correct final needle position, which was the junction of the superior articular and transverse processes, was confirmed using oblique, anteroposterior, and lateral fluoroscopic images. A total of 0.5 mL of 0.2% ropivacaine was injected at each site after confirming negative blood aspiration and appropriate contrast dye dispersion. After two repeated MBBs, the patient reported a 50% pain reduction (from 9 to 4 of the NRS).The procedure was performed under fluoroscopic guidance after a previously accepted standard technique.A 70-year-old man visited our outpatient palliative care pain center because of acute LBP that had developed a month prior. The patient had previously received pylorus-preserving pancreaticoduodenectomy (PPPD) for pancreatic head cancer 24 months prior, and adjuvant concurrent chemoradiation therapy was administered. The LBP with an average NRS of 8/10 persisted despite taking oral opioids  and several pain interventions, such as trigger point injections. The patient's LBP negatively affected his quality of life. He had difficulty sleeping because he could not lie down in the supine position for several minutes.He did not complain of abdominal discomfort even though the CT scan revealed cancer infiltration in the proximity of the superior mesenteric artery and multiple retroperitoneal lymph node metastases with peritoneal seeding. Physical examination revealed severe tenderness on palpation of the L3/4 and L4/5 lumbar facet joints. MBB at bilateral L2, L3, and L4 was performed, and the patient experienced pain reduction by 80% (from 8 to 4 of the NRS) after two repeated blocks.A 65-year-old woman, diagnosed with common bile duct cancer with lung metastasis, was referred to our outpatient palliative care pain center because of LBP radiating to the right buttock area. She underwent PPPD and adjuvant chemotherapy for 34 months. CT findings revealed cancer infiltration in the mesenteric root and hematogenous lung metastasis. She reported that her pain had increased, especially in the supine position; therefore, she had to sleep while lying in a chair.Although the patient was taking oral medications equivalent to an oral morphine dose of 285 mg/day, the pain persisted. After confirming severe tenderness on the right L5/S1 facet joint using fluoroscopy, diagnostic MBB at the right L4 and L5 was performed. After two repeated MBBs, she reported a pain reduction of 50% (from 6 to 3 of the worst pain NRS).All patients were considered to have a positive response to diagnostic MBBs, and RF treatment was performed by an experienced pain physician. The RF procedures were performed using an RF generator  using a thermocouple electrode needle. The target facet joints and segmental medial branches were visualized using fluoroscopy in the oblique view. A 22-gauge 10-cm RF needle with a 5-mm active tip  was advanced adjacent to the medial branches.Upon placement of the needle, the appropriate impedance was verified to be in the range of 300–600 Ω. Then, sensory stimulation was tested at 0.5–0.6 V with 50 Hz to ensure appropriate paresthesia and concordant pain. Motor stimulation at 1.0–1.2 V with 2 Hz was tested to detect muscle contraction in the multifidus muscle. The anteroposterior and lateral views of the appropriate RF needle placements to the medial branches with the dispersion of contrast dye are shown in In Cases 1 and 3, pulsed RF treatment was delivered at 42°C and 45 V for 180 seconds, with a pulse frequency of 2 Hz and a pulse width of 20 ms for each site. In Case 2, a combined conventional and pulsed RF procedure was performed. Conventional RF was applied to the right L3 and left L4, where the most painful concordant LBP occurred. Before the lesioning, 0.5–1 mL of 2% lidocaine was injected for anesthesia.The tip temperature was set at 80°C with a lesion time of 180 seconds at each location. At the rest of the target site, pulsed RF was performed using the same technique as in Cases 1 and 3. The procedural details for each patient are described in 7 Severe functional limitations of physical activities might be associated with various musculoskeletal dysfunctions, especially in advanced or end-stage cancer patients.9 Although the prevalence of musculoskeletal diseases among cancer patients is still unknown, various musculoskeletal diseases might occur due to the cancer burden itself or anticancer treatment.10Many patients with cancer experience reduced physical activity in daily living during and after cancer treatment. The mechanism of the functional decline in cancer patients is complex and multifactorial and includes cancer-related factors, patients' comorbidities, psychosocial factors, and the consequences of anticancer treatment.11 Lumbar facet joints represent a potential pain generator because the facet joint capsule and surrounding structures are richly imbued with nociceptors.5 With aging, the joints may undergo biomechanical changes such as capsular weakness and morphological changes of the articular surface. Degeneration, inflammation, and repetitive injury of the facet joints are the proposed pathophysiological mechanisms of LFS.12In the current cases, the cause of LBP seems to be LFS. LFS is a common degenerative spine disease that causes LBP, and its prevalence may increase with age.14 Moreover, most cancer patients experience significant weight loss and resultant progressive loss of skeletal muscle mass (sarcopenia).15 Cooley et al reported that severe facet degeneration was associated with altered paraspinal muscle morphology.14There are some possible explanations for the development of LFS, particularly in patients with cancer. First, the acceleration of degenerative changes in the spine and the paraspinal muscles may compromise the proper biomechanics of the spine.10 mild-to-moderate osteoporotic changes of the spine are prevalent in cancer patients, especially in those with solid tumors, which might partly contribute to the deterioration of the biomechanics of the spine.The authors think that sarcopenic changes in the paraspinal muscles might be one of the causes of LFS in these patients. Second, osteoporotic changes in the spine may be another cause of LBP. According to the study results of Gheita et al,6 Instead, diagnostic blocks including intra-articular or MBB with a low-volume injection are the most accepted confirmative diagnostic methods.However, the diagnosis of LFS is challenging. There have been no reliable pathognomonic historical signs or physical examination findings, and radiological imaging is not routinely recommended because of the low diagnostic value for LFS.In the current cases, radiological examinations such as MRI or CT scans were not available because the severe LBP made it difficult for them to lie down in the supine position for several minutes. Fortunately, they could bear the prone position during the diagnostic MBB. The positive response from low-volume MBB (<0.5 mL) helped to determine the cause of LBP in these patients. The role of diagnostic MBB is noteworthy, especially in severely debilitated patients, such as those with advanced cancer.16 Meanwhile, pulsed RF treatment uses short-pulsation low energy to minimize tissue injury.17There are two types of RF treatment: conventional RF and pulsed RF. Conventional RF ablation of the lumbar medial branches is the traditional and standard RF technique for the treatment of LFS. The conventional RF current coagulates the target nerve with controlled heat and causes denervation of the painful facet joint. It proved the short- and long-term effectiveness of LFS treatment.18–20 Pulsed RF has expanded its role in various neuropathic and musculoskeletal pain interventions. In the current case, we successfully treated LBP in an advanced cancer patient with pulsed RF to the lumbar medial branches. The authors believe that these cases demonstrate that RF treatment may be a safe and useful therapeutic option for various painful diseases, especially for patients with cancer in palliative care.Although the exact therapeutic mechanisms of pulsed RF are unclear, temporal blockage of nerve signals, enhancement of the descending inhibitory pathway, and changes in gene expression have been suggested to be associated with short- and long-term therapeutic efficacy.


Despite advances in surgical and anesthesiology techniques, many patientscontinue to experience postoperative pain after lumbar disc surgeries. Theaim of this study was to investigate the effect of preoperative oralmelatonin on the severity of postoperative pain after lumbarlaminectomy/discectomy.In this double blinded randomized controlled clinical trial 80 patientsundergoing an elective mini-open microdiscectomy surgery at Imam Khomeinieducational hospital in Sari, Iran, were selected and randomly assigned intoone of four groups. Patients in group A, B, C, and D received 3, 5 and 10 mgmelatonin or placebo tablets one hour before surgery, respectively. Usingthe visual analogue scale (VAS) the severity of pain, nausea and vomiting,pruritus, and use of narcotics were assessed immediately after surgery andbefore leaving the post-anesthesia care unit, 6, 12 and 24 hourspostoperatively.In all three groups receiving melatonin at all three different doses,postoperative pain was significantly less than the placebo group(P<0.01). There were no statistically significant differences inpostoperative pain level between the three groups receiving melatonin(P>0.05). The amount of opioid received by the patients within 24hours after surgery had statistically significant differences within thegroups . The results of post hoc analysis in terms ofpostoperative pain intensity showed statistically significant differencesbetween the two groups receiving melatonin at a dose of 5 mg and the placebogroup (P=0.04). No serious side effects reported in four groups.The use of oral melatonin with a dose of 5 mg, 1 hour before the surgery asan inexpensive method can effectively reduce pain intensity as well as theamount opioid use after lumbar laminectomy and discectomy. Lumbar discectomy is the most commonly performed surgical procedure for the treatmentof patients with lumbar radiculopathy caused by for lumbosacral disc herniation. DespitePostoperative pain can cause adverse physiological effects such as inadequate depthof breathing and inadequate discharge of respiratory secretions, atelectasis andpulmonary complications, increased heart rate and blood pressure, ileus andprolonged bed rest. Immobility secondary to pain could potentially lead to anincrease in incidence of deep vein thrombosis –5. In adTherefore, utilizing pain reduction pathways with low rate of complications is animportant postoperative goal. Narcotic drugs especially in an injectable form arethe first line pain relief modality and are widely used to relieve acutepostoperative pain following lumbar spine surgery , 7–8. OnOne of the most commonly used drugs for the reduction of acute pain and improvementof analgesic effects after the surgery is melatonin. Melatonin or n-acetylmethoxy-tryptamine is a hormone secreted by the pineal gland in the brain. Melatoninhas important biological effects in the body and plays an important role inadjusting the sleep cycle and awakening process –12. StudThe analgesic effects of melatonin on the improvement and enhancement of morphineantinociceptive have been shown in various animal studies –17.WhilTherefore, given that melatonin is a safe drug, more clinical trials are required toevaluate the analgesic effects of melatonin and compare its different doses forunderstanding the most effective and appropriate dosage for administration –16. In aThis study was a parallel, double blinded randomized controlled clinical that wascarried out between April 2016 and January 2017. After obtaining approval from theEthics Committee of the University and informed consent from patients, 80 patientswho were undergoing open lumbar spine laminectomy and discectomy at one or twolevels at Imam Khomeini Educational Hospital in Sari, Iran, were recruited. Theywere classified by the American Society Anesthesiology (ASA) as class I and II ofanesthesia and were admitted to a teaching hospital in an urban area of Iran.Inclusion criteria were age 35–70 years, confirmation of the diagnosis usingphysical examination, computed tomography (CT) scan and magnetic resonance imaging(MRI) and undergoing an elective discectomy surgery. Exclusion criteria wereunwillingness at any time to continue participation in this study, emergencydiscectomy surgery, involvement of more than two lumbar discs, opiate drug use up to12 hours before the intervention, alcohol or drug abuse and occurrence of anyunusual complications during the surgery. Also, patients with the history of priorspinal surgery and known allergy to the drugs used in the study were excluded.Eligible patients were randomly assigned into four equal sized groups, using simplerandomization technique, as A, B, C and D. For ensuring allocation concealment, thesequentially numbered, opaque, sealed envelope technique was used by a nurse who wasunaware of the study groups. Before the surgery, the patients were provided withadequate explanations and education on how to report pain severity, nausea, vomitingand itchiness after the surgery using the Visual Analog Scale (VAS).®, USA), respectively.Groups C and D received one 10mg tablet of melatonin and placebo (which was the sameshape of melatonin) one hour before their surgery, respectively. In the operatingroom, all patients were placed under general anesthesia using a similar anestheticprotocol including midazolam (0.1mg/kg), fentanyl (2µ/kg), neodonal (5mg/kg), atracorium (0.5 mg/kg), 50% N2O, isoflore MAC 0.6–1 and morphine0.1mg/kg and atracurium based on the patient need 0.01 mg/kg. All surgeries wereperformed by one surgeon via a same approach.One hour prior to surgery an anesthesiology nurse helped administer group A and B one3mg and 5mg melatonin tablet  1 g every 8hours. Patients did not received any antiemetic prophylaxis. At the beginning of thestudy, weight and height of the patients in kg and cm were measured, respectively.Body mass index (BMI) of the patients was also calculated using standard methods.This information was documented in the relevant sheet with specifications such asage, level of education, duration of surgery, duration of anesthesia, lumbar disclevel involved, patient's first request to receive pain medication aftersurgery and the amount of opioid used within 24 hours of the surgery.Sample size: A priori sample size were calculated using GPower3.1 withthe formula for calculation of samples of repeated measures, based on a presumedeffect size of 0.3, a statistical power of 80%, and a type I error of 5%. Theoverall proper sample size was found to be 74 participants. We therefore recruited80 patients to account for any dropouts.Statistical analysis: After data collection, statistical analysis wasperformed using descriptive and inferential statistics via the SPSS v.18 software.Shapiro-Wilk test was used to assess normality of the data. Chi-Square/Fisher exacttest and t-test were used for qualitative and quantitative variables, respectively.Repeated Measure Analysis of Variance (ANOVA) or Kruskal-Wallis tests were used toevaluate pain severity, nausea and pruritus, following by a Tukey test as a post hocanalysis. P-value less than 0.05 was considered statistically significant.Data sharing: All relevant data and methodological detail pertaining tothis study are available to any interested researchers upon reasonable request tocorresponding author.In this study, 98 patients were evaluated, of which 80 patients were eligible to beincluded in this study and assigned into the groups. Except for one patient in groupA, all other patients completed the study, and data from all these patients wereanalyzed . The demChanges in pain intensity after the surgery: depicted in Changes in the incidence of postoperative nausea: According to The amount of requested and received opioids within 24 hours of thesurgery: According to Changes in the incidence of pruritus and vomiting after the surgery:None of the patients experienced postoperative pruritus. In terms of the incidenceof vomiting, 2 patients in group A and 1 patient in group B and 2 patients in theplacebo group had postoperative vomiting which were not statistically significant.(P=0.641). We did not observe any statistically significant differences between thegroups in incidence of postoperative vomiting (P=0.524). There were no othercomplications in all four groups.The findings of this study showed that preoperative oral melatonin administrationsignificantly reduced the severity of postoperative pain compared with placebo inpatients undergoing one or two levels lumbar open laminectomy and discectomy.However, no statistically significant dose dependent differences were reportedbetween the three groups receiving melatonin in regards to postoperative painintensity. In addition, postoperative opioid administration in all three melatoningroups was less than the placebo group. However, this difference was statisticallysignificant only between the two groups receiving melatonin at a dose of 5 mg andthe placebo group.A study revealed that using of 10 mg of melatonin before cesarean sectionsignificantly reduces the severity of patients' pain, increases the durationof postoperative analgesia, reduces the need for analgesics after surgery andresumption of physical activity, without any major side effects .Caumo et al. showed that taking 5 mg melatonin tablets one night and 1 hour beforethe surgery in patients undergoing abdominal hysterectomy caused a significantreduction in pain intensity and anxiety in the first 24 hours after the surgerycompared with the control group. In addition, patients receiving melatonin hadsignificantly less need to take morphine in the postoperative period , which wAlso, the positive effect of melatonin 10 mg as a premedication on the pain oftourniquet and the improvement of pain control in patients undergoing electivesurgery has been reported . AnotherThe precise mechanism of the analgesic effect of melatonin has not been accuratelyrecognized. However, possible analgesic effects of melatonin are the role ofβ-endorphins, GABA and opioid receptors  and NitrFollowing early studies on melatonin's analgesic effects, it has been shownthat the circadian rhythm plays a role in the feeling of pain . Animal Another study compared the effect of melatonin and midazolam, as a premedication, inpatients undergoing laparoscopic cholecystectomy using general anesthesia. Patientswere randomly assigned into three groups: (i) patients receiving melatonin tablets 3mg a night before the surgery; (ii) patients receiving midazolam tablets 3.75 mg;(iii) patients receiving placebo tablets. It was shown that in the postoperativeperiod, the anxiety level in all groups was less in the melatonin group than in theplacebo group .In the present study, administration of melatonin tablets with all three doses of 3,5 and 10 mg caused significant changes in the severity of postoperative paincompared with the placebo group. However, in the three groups receiving melatoninwith different doses, no statistically significant differences in the severity ofpostoperative pain were reported. In terms of postoperative opioid use, only thegroup receiving 5mg of melatonin (Group B) reached statistical significantdifference compared to the placebo group. However, the other two groups receivingmelatonin (Group A and C) also received less opioids postoperatively compared withthe placebo group, albeit not statistically significant. In addition, no significantdifferences in the incidence of vomiting and severity of nausea and vomiting betweenthe groups were found. No other side effects in any of the groups were reported.It seems that the use of melatonin at a dose of 5 mg before the surgery is aneffective and safe option for reduction of postoperative pain intensity, amount ofpostoperative opioid consumption and higher patients' satisfaction.Experimental studies on animals showed the antinociceptive effects of melatonin indoses ranging from 0.1 mg/kg to 300 mg/kg . In a stNo major side effects have been reported in regards to administration of melatonin bypatients. Melatonin has been used for over five decades both clinically and invarious research projects and no significant side effects have been reported exceptfor mild side effects such as drowsiness, dizziness, nausea and headache. Morestudies have shown that these effects are somewhat similar to placebo treatment. In addiThere are some limitations in the present study that need to be addressed. Our studyis a single-center clinical trial, and selective bias is possible. Pain score issubjective and several factors can affect the severity of pain. Therefore, thisshould be mentioned as another limitation of present study. In conclusion, our studyshowed that using 5mg of oral melatonin 1 hour before one or two level lumbar spinelaminectomy/discectomy is an inexpensive and safe method to effectively andefficiently reduce postoperative pain intensity and opioid use in thesepatients.


BackgroundSpasticity is a major health problem worldwide. Response to current medical and rehabilitation treatments is often poor. Surgical treatment is available only for a very limited number of patients.AimWe recently reported the application of stereotactic radiosurgery as a treatment option for spasticity and related pain. This paper describes a larger experience using image-guided stereotactic radiosurgery targeting the cervical or lumbar spinal roots to relieve spasticity and pain in four patients.MethodsAll the patients had refractory spasticity and related pain, one patient had additional paroxystic neuralgic pain. The cause of spasticity and pain was a traumatic brain and/or spinal cord injury, brain and/or spinal cord surgery, and stroke. Symptoms affected the right superior limb in one patient, and the inferior limbs in three patients . According to the symptoms, one patient was treated at the cervical level (C7 right sensory root) and three patients at lumbar level . The target was selected on constructive interference in steady-state (CISS) MR, focusing the irradiation on the postganglionic sensory segment of the cervical root or the intra-foraminal dorsolateral sensory portion of the lumbar roots. Appropriate spasticity and pain scales were used to assess the patient’s status after the treatment.ResultsThe treatments were tolerated well. Marked symptomatic relief was found in all the treated patients. Improvements in spasticity and pain scales were observed up to the latest follow-up. After 2 years, the mean reduction of the visual analog scale (VAS) and Modified Ashworth Scale (MAS) was 64.3% and 43.7%, respectively, while the median reduction of MAS score was 50%.ConclusionsExcept for a previous case report, this is the first study describing a novel noninvasive technique based on image-guided radiosurgery to treat severe spasticity and pain due to brain and spinal cord injury. This novel technique appears to be safe and effective and deserves to be studied further. Stereotactic radiosurgery (SRS) has been historically restricted to the treatment of intracranial targets until the introduction of image-guided frameless radiosurgery by John Adler . The CybSDR is a surgical procedure originally developed to treat children with severe spasticity caused by cerebral palsy. SDR has been later applied to the treatment of spasticity in adults, providing symptomatic relief in patients with brain and spinal cord injury -13. DuriSetting and study designData were collected and retrospectively analyzed at the CyberKnife Center, Centro Diagnostico Italiano (CDI), Milan.ParticipantsThe study includes patients undergoing stereotactic spinal root irradiation to relieve spasticity and/or pain.Radiosurgical treatmentPatients were treated with SRS using a CyberKnife VSI . High-resolution thin-slice (0.6 mm) computed tomography (CT) was acquired without and with contrast. The treatment planning was carried out on the CT with co-registered constructive interference in steady-state (CISS) and T1-weighted magnetization-prepared rapid gradient echo (MPRAGE) MRI images using MultiPlan . The treatment planning, including target volume delineation, dose prescription, and optimization of the dose distribution, was executed by an experienced neurosurgeon (PR) and reviewed by a radiation oncologist (GB). An inverse treatment planning algorithm was used to generate steep dose gradients by means of nonisocentric beam delivery with up to 1600 incident beam positions, thereby allowing optimal tumor coverage and minimal dosage to adjacent organs and tissues at risk for late radiation damage.Target and dose selectionThe treating physicians co-registered the CT and MRI datasets and checked the quality of co-registration visually using multiple views and transparency tools of the treatment planning system (TPS)  in the three projections. The selected target  was then identified and drawn. Treatment of cervical roots was performed on the sensory root in the liquoral space between the dorsal ganglion and the root entry zone (postganglionic segment). The target was placed far distal toward the dorsal ganglion to minimize the irradiation of the spinal cord. Treatment of lumbar roots was performed at the intraforaminal level, selecting the dorsolateral sensory portion of the root. Critical volumes, including the spinal cord, thecal sac, kidneys, liver, bowel, and stomach were also delineated to prevent incident beams from passing through them. The prescription dose was 60 Gy in a single fraction for the cervical roots, 35 to 45 Gy for the spinal roots. A lower dose to the lumbar roots was prescribed taking into account the much larger volume of these targets.Patient evaluation and follow-upPatient response to treatment was assessed after 3, 6, 12, and 24 months. Spasticity was measured using the Modified Ashworth Scale (MAS), which ranks from 0  to 4 (rigidity). The pain was measured using the visual analog scale (VAS).Four patients affected by spasticity and pain experienced substantial symptomatic relief after SRS targeting the spinal roots. In three patients, there was a marked reduction of spasticity and related pain. In one patient, there was marked reduction of associated neuropathic pain. After 2 years, the mean reduction of VAS and MAS was 64.3% and 43.7%, respectively. The median reduction of MAS score after 2 years was 50%. Treatment involved one cervical root (C6) in one patient and one or more lumbar roots in three patients. Two patients had one lumbar root treated  and one patient had two lumbar roots treated . A detailed description of each case is provided below. Figures Patient 1A 34-year-old man had a persistent vegetative state  and spastic quadriplegia after brain injury due to a car accident. He was affected by severe leg flexor spasms, temporarily relieved by lidocaine injection over the L2 roots. His family refused to consider invasive procedures such as surgical rhizotomy or placement of baclofen pumps but accepted SRS. Both L2 roots were treated with 45 Gy delivered to the 75% isodose . Treatment volume was 409 mm³ for the right and 400 mm³ for the left root. MAS was 4 before treatment, 3 after 3 months, 2 after 6, 12, and 24 months. Caregivers considered these results as a major improvement. VAS could not be assessed, being the patient unresponsive, but the pain was clearly improved due to relief of flexor spasms.Patient 2A 34-year-old female developed right hemiparesis due to a brain hematoma caused by the bleeding of an arteriovenous malformation. Severe spasticity affecting the right arm and hand could be relieved by botulinum injections over the distribution of the right C7 root but efficacy was lost with time. Due to the refusal of invasive procedures, a selective radiosurgical rhizotomy was proposed and accepted. The right C7 dorsal root was treated with a prescribed dose of 60 Gy, with a mean and maximum dose of 64.2 Gy and 68.18 Gy. The target volume was 57 mm³. The mean and maximum doses delivered to the spinal cord were 1.65 Gy and 7.19 Gy, respectively. Figure Pre-treatment MAS score was 4. MAS score was 2 after 3 months, 1 after 6, 12, and 24 months. VAS score was 7 before treatment, 2 after 3 months, 1 after 6 months, and 3 after 12 and 24 months.Patient 3A 44-year-old man with recurrent hemangioblastomas (von Hippel-Lindau disease) developed spastic tetraparesis following multiple brain and spinal procedures. The right leg was affected by severe spasticity and related pain, not responsive to medical therapy. The patient refused intrathecal baclofen pump. Stereotactic image-guided intraforaminal irradiation was delivered to the dorsolateral portion of the right L4 root, on the basis of electromyography (EMG) findings. The dose delivered was 45 Gy prescribed to the 82% isodose. The mean delivered dose was 50.24 Gy, maximum dose was 54.87 Gy. The target volume was 82 mm³. The treatment was well tolerated, without side effects and complications. Resolution of spasticity and related pain in the right leg was found after 6, 12, 18, and 24 months. Spasticity-related pain disappeared completely within 3 months, going down from 7 to 0 on the VAS score. Spasticity in the right leg was markedly reduced after 6 months, going down from a score of 5 to a score of 1 on the MAS. The MAS score in the contralateral leg improved as well, going down from a score of 4 to a score of 2. VAS and MAS scores remained stable after 12, 18, and 24 months. This case has been extensively described in a detailed case report [Patient 4A 63-year-old male with shooting pain along the left S1 distribution following microsurgical resection of a spinal cord arteriovenous malformation (AVM). VAS score was rated 8. The pain was refractory to medical therapy. He had also spastic paresis of the left leg (MAS score 3). Implant of a spinal cord stimulator was refused. He underwent selective dorsolateral rhizotomy of the left S1 root, receiving 35 Gy prescribed to the 80% isodose. Figure Mean and maximum doses were 39.42 and 43.75 Gy, respectively. The treatment volume was 105 mm³. VAS score went down to 3 after 3 months, 2 after 6 and 12 months, and 4 after 24 months. MAS score went down to 2 after 3 months and remained stable thereafter.Close to 100 million people worldwide suffer the sequelae of severe trauma to the brain or spinal cord, with spasticity and related pain being a common long-term complication in survivors . This paSDR counteracts spasticity by removing the afferent inputs of the reflex arc, brought to the spinal motor neurons by the sensory fibers (Ia) located in the dorsolateral portion of the spinal roots. SDR is a relatively invasive procedure requiring multiple laminectomies to expose the dural sac, which is opened to allow the exposure and section of the involved rootlets. The selection of the rootlets to be sacrificed is guided by intraoperative electrophysiological mapping. Preoperative EMG and botulinum injections are useful to identify the dorsal roots involved in the genesis of spasticity and to predict the clinical efficacy of the procedure. An alternative to SDR, especially in adult patients, is the placement of an intrathecal baclofen pump. The main shortcoming of this procedure is the need to implant hardware and to periodically refill the reservoir: missing baclofen refill appointments can lead to severe and potentially fatal withdrawal syndrome. Also, hardware-related complications are relatively common. The cost and maintenance of the baclofen pump can be an issue in several regions of the world, essentially restricting its use in wealthy countries.Image-guided frameless SRS is a precise, noninvasive, and highly cost-effective procedure and is an emerging treatment for functional central nervous system (CNS) disorders (such as pain and epilepsy). The role of SRS in the treatment of TN is well established . CyberKnImage-guided SRS of selected nerve roots to relieve spasticity and pain is an interesting noninvasive alternative to SDR or to the placement of a baclofen pump. The treatment delivered doses ranging from 35 to 45 Gy to the dorsolateral portion of the lumbar spinal roots, characterized by a relatively large target volume, while the same dose was used to treat the trigeminal nerve (60 Gy) was used to treat the sensory cervical root. Both doses are not strictly ablative and the clinical benefit is likely to be mediated by the non-necrotic effects of radiation. Radiomodulation has been suggested to be related to symptomatic relief in patients undergoing SRS for epilepsy and TN . It’s inImage-guided SRS of the sensory component of spinal nerve roots appears to be a safe procedure due to the small target volume involved, with minimal irradiation of adjacent organs. However, a precise assessment of toxicity related to the treatment requires a prospective study on a much larger cohort of patients. On the basis of the experience treating TN with SRS, the development of hypoesthesia and/or paresthesia can be expected in some patients.The preliminary experience here discussed has shown that SRS of the spinal nerves provided benefits in patients with brain and/or spinal cord injury due to a variety of causes, including stroke, trauma, and surgery. Further work is needed to assess the indications of this technique and define which conditions may benefit most from this treatment. This study is limited by the small number of patients and the relatively heterogeneous origin of spasticity. Further studies are being planned to understand further the indications, benefits, and limits of this novel technique.Stereotactic image-guided SRS of cervical and spinal nerve roots appears to be a safe and effective noninvasive treatment for patients with spasticity and pain caused by brain or spinal cord injury. This technique provides a useful option for the treatment of a wide variety of patients suffering from the long-term sequelae of neurological injury. Further studies to evaluate this novel treatment option are needed.


Adolescents patients presenting with mood disorders, including disruptive mood dysregulation disorder (DMDD), often present with the comorbid disorders such as oppositional defiant disorder (ODD) and attention-deficit hyperactivity disorder (ADHD).1) Evaluate the association between suicide in adolescents and various mood disorders. 2) To study the impact of comorbid conditions in DMDD on suicide ideation and attempt in adolescents.We used 2016-2017 National Inpatient Sample dataset to select patients with mood disorders. Rao Scott adjusted Chi-Square test used to compare the groups with SPSS v26.In this study, 15195 patients were in the DMDD group  and 219205 in the ‘other mood disorders’ group . The odds of SI/SA were two times more in patients with the ‘other type of mood disorder’ . Patients with the primary diagnosis of DMDD sub-classified into four groups (Group 1: DMDD only (n=5160), Group 2: DMDD+ADHD (n=7240), Group 3: DMDD +ODD (n=700), and Group 4: DMDD+ADHD+ODD (n=2095). SI/SA was prevalent in 30.8%, 26.0%, 22.9% and 26.3% in Group 1, 2, 3 and 4 respectively (p: 0.03). SI/SA was more prevalent in females compared to males (31.3% vs. 25.2%). An increase of 1 year in age was associated with a higher SI/SA . The SI/SA odds were 5% more in female patients .The study reveals that the risk of suicide ideation or suicide attempt is almost twice in the adolescent with mood disorders without DMDD compared to the DMDD group.No significant relationships.