Patients were assessed by the visual analogue scale (VAS), pressure pain thresholds (PPTs), Oswestry disability index (ODI), and the physical function (PF) and bodily pain (BP) domains of the 36-item short form health survey (SF-36) before operation and 1 week, 1 month, 3 months, 6 months, and 12 months after operation. The rate and latency of F-wave were obtained before operation and 12 months postoperation. There was no statistical difference in terms of age and sex between both groups. Statistically significant improvements from the patients' data before operation to data obtained 1-month postoperation were observed in VAS, PPTs, ODI, and PF and BP of SF-36 in both groups and kept for 1 year. F-wave rate and latency were improved significantly at 1-year postoperation in both groups. Intergroup differences during follow-ups over a period of 1 year were not found to be significant in all the above assessment between the PRP and steroid groups. No complications were reported. The results showed similar outcome for both transforaminal injections using PRP and steroid in the treatment of lumbar disc herniation, suggesting the possible application of PRP injection as a safer alternative. The trial was registered in the Chinese Clinical Trial Registry (ChiCTR-INR-17011825).Transforaminal steroid injection is extensively used as a treatment in cases of herniated disc, but it is associated with complications. In comparison, platelet-rich plasma (PRP) injection has been used in musculoskeletal disorders and could be another option. This study is aimed at comparing the efficacy and safety aspects between ultrasound-guided transforaminal injections of PRP and steroid in patients who suffer from radicular pain due to lumbar disc herniation. In a randomized controlled trial, ultrasound-guided transforaminal injections of either PRP ( Low back pain is one of the most difficult conditions to manage for doctors, patients, and policymakers. Not only does it limit physical activity, life quality is also greatly reduced alongside additional social and economic burden. The point prevalence of low back pain is 12%, with its one-year prevalence being 38% and the lifetime prevalence being approximately 40% [For over 30 years, epidural steroid injection has been widely used as a treatment for lumbar disc herniation , with itPlatelet-rich plasma (PRP), a biological product from the centrifugation of autologous blood with a high number of platelets in a small volume of plasma, has a positive effect on pain relief in some musculoskeletal diseases, especially osteoarthritis, tendinosis, and ligament tears . PRP conHenceforth, this study is aimed at investigating the efficacy and safety of ultrasound-guided platelet-rich plasma injections compared with steroid injections in treating lumbar disc herniation with radicular pain.ChiCTR-INR-17011825). This investigation was conducted in accordance with the Declaration of Helsinki. 184 patients were assessed for eligibility based on the inclusion and exclusion criteria listed as follows.A prospective, randomized, and controlled study was carried out to compare the treatment of lumbar disc herniation with radicular pain with ultrasound-guided transforaminal steroid or PRP injections. This study was approved by the Ethics Committee of Sun Yat-sen Memorial Hospital, and the trial was registered with the Chinese Clinical Trial Registry (registration number: Inclusion criteria are as follows: (1) aged 20-60 years; (2) low back pain with unilateral lower limb radicular pain, duration of more than 3 months; (3) posterolateral lumbar disc herniation of L4/L5 or L5/S1segment diagnosed by MRI or CT and consistent with the clinical symptoms and signs; (4) degree of pain (VAS) more than 5 and obvious symptoms and clinical signs of nerve root irritation; (5) had received conservative treatment, including physical therapy, manipulation, and nonmorphine treatment; (6) no symptoms of severe nerve damage including motor paralysis, muscle atrophy, and cauda equina syndrome; (7) had no history of spinal surgery.Exclusion criteria are as follows: (1) infection; (2) had received prior injection treatment in the past 3 months, such as nerve root injection and caudal injection; (3) spinal tumors or tuberculosis; (4) multisegmental lumbar disc herniation, spinal deformity, or spinal stenosis; (5) not suitable for local injection; (6) allergic to the drug used in this study; (7) a history of drug abuse or oral anticoagulation; (8) pregnancy; (9) severe diabetes; (10) clinical diagnosis of heart disease, liver and kidney dysfunction, and hematological diseases; (11) abnormal psychological and cognitive disorders.n = 68) and the PRP group . The randomization was performed by the nurse, who did not participate in the process of patient assessment, by opening the numbered sealed opaque envelop. A written informed consent was obtained from each patient before enrollment. During follow-ups over 1 year, 4 patients did not receive allocated intervention and 4 others did not follow through. Thus, only 124 patients were included for data analysis  . The randomization sequence was produced by a statistician, who did not contact with patients, using a random number generator. The other 132 patients who were enrolled were simply randomized at a ratio of 1 : 1 to 2 groups: the steroid group  .The patients who were enrolled to this study underwent physical examination, neurological examination, and laboratory tests. The operation was performed at the operating room in the rehabilitation medicine department of Sun Yat-sen Memorial Hospital.w/v) sodium citrate. The blood sample was then centrifuged at 1600 rpm for 10 minutes at room temperature  under aseptic condition to divide the sample into 3 layers. The lower layers composed of red blood cells were subsequently removed. The remaining sample was transferred into a new centrifuge tube and was centrifuged again at 3200 rpm for 10 minutes at RT. 4 ml was collected from the lower part which contains PRP. 1 ml of this PRP was then sent for quantitative analysis of platelet count.The procedure of PRP preparation was as follows: 18 ml blood sample was drawn from the anterior elbow vein and mixed with 2 ml of 3.8%  Company limited, SONIMAGE HS1 PLUS, Tokyo, Japan) in out-of-plane approach. The patients were prepared in prone position with a pillow under their abdomen. The area of injection was disinfected. The sacral spinous process and the fifth lumbar spinous process transducer were identified when transducer placed longitudinally. The transducer in midline was moved laterally to recognize the lamina, transverse process, and facet joint. Then, the edge of the zygapophyseal joints was obtained when the transducer was moved back. The needle (22 G) was subsequently inserted into the skin using the out-of-plane approach upon determination of injection level to ensure that the needle tip was positioned in the middle of adjacent facet joints. After an inhalation test yielding negative results for cerebrospinal fluid and blood aspiration, the injection was administered  . The detIn the follow-up, some short-acting analgesics were given to patients when they felt obvious pain. The patients would be excluded from this study in follow-up when patients had any one of the following situations: (1) had overloaded pain which affects their life quality; (2) had symptom of motor paralysis, muscle atrophy, or cauda equina syndrome in the follow-up period; (3) transforaminal epidural injection failed to improve pain or function of patients during 3 months postoperation. Treatments including surgery or conservative treatments were given to those excluded patients.The statistics of demographic characteristics, including gender and age, as well as baseline information of patients were collected upon admission of the patients. Baseline information was obtained before operation, which includes visual analogue scale (VAS), pressure pain thresholds (PPTs), the rate and latency of F-wave, Oswestry disability index (ODI), and physical function (PF) and bodily pain (BP) from the 36-item short form health survey (SF-36). Each patient was required to complete the same assessments as the baseline information (except F-wave rate and latency) at 1 week, 1 month, 3 months, 6 months, and 1 year postoperation. F-wave rate and latency were obtained only 1 year postoperation. All assessments were independently performed by two experienced blinded doctors.The visual analogue scale (VAS) was a method to evaluate the degree of pain. A 10 cm line was used as an indicator whereby one end represents no pain, while the other end represents the most severe pain imagined. The patient was asked to indicate the point on the line which could represent the patient's pain level .The pressure pain thresholds (PPTs) were measured by an algometry device  according to the procedure recommended by Fischer . A plastThe rate and latency of F-wave in the affected side were measured by electromyogram. The recording electrode was placed at the muscle belly of abductor halluces of the affected side; the reference electrode was placed at the tendon of abductor halluces; the stimulation electrode was placed at the tibial nerve behind the medial malleolus; the ground wire was placed at the ankle joint between the stimulation electrode and the recording electrode. At stimulation points of the affected side, 20 consecutive stimuli at the frequency of 1 Hz and the width of 0.2 ms were induced, obtaining records of the rate and latency of F-waves at the affected sides.There were 10 items in the Oswestry disability index (ODI), including pain, individual function, and personal comprehensive function. The minimum score for each item is 0 (good state), whereas the highest score is 5 (poor state). The Oswestry disability index referred to the percentage of the sum of score from all 10 items out of 50.The 36-item short form health survey (SF-36) consisted of 36 items, which includes one scale on health transition and 8 domains. The score for each domain ranges from 0  to 100 . The reliability, validity, and application of the Chinese version SF-36 have been proven . In thisα level was 0.05.With a sample size of 60 patients each group, we calculated that the study would have the power of 80% to detect a 0.9 difference at the significant improvement in VAS between groups from baseline to 6 months with the 2 standard deviation of the change in VAS. The mean and standard deviation were based on data from previous literature and our previous study , 18. Besn (%). The Shapiro-Wilk test was used to test the data distribution of the continuous variables. Continuous data before operation with nonnormal distribution was analyzed using the Mann–Whitney U test, whereas the discrete variable was analyzed by the χ2/Fisher exact test. To compare the difference between the steroid group and the PRP group over time, the generalized estimating equation was used to estimate the time × treatment interaction. A negative interaction represents the ability of the generalized estimating equation in indicating the difference between the steroid and PRP groups over time. If the interaction existed, the Mann–Whitney U test can be used to compare the difference between both groups at the same time point. The Friedman test was used to evaluate the difference between different time points within one group, while the post hoc test was used to compare the data between preoperation and postoperation in one group. The Wilcoxon signed-rank test was used for paired sample in one group. The difference is considered statistically significant when bilateral α = 0.05, P < 0.05.Data were analyzed using the SPSS 23.0 software. The continuous variables were expressed by mean ± standard deviation or medians (1st-3rd quartiles) depending on data distribution, while the discrete variable (such as sex) was described as P > 0.05) (P > 0.05)  . Besides > 0.05) .P = 0.887; 580.60 kPa (557.92-601.01) vs. 625.96 kPa (571.53-716.68), P = 0.087; 35.0% (26.4-44.0) vs. 27.0% (20.0-40.0), P = 0.125; 60.0 (45.0-70.0) vs. 75.0 (60.0-90.0), P = 0.284; 41.0 (31.0-51.0) vs. 43.0 (41.0-52.0), P = 0.794, respectively). Statistically significant improvements were observed in terms of VAS, PPTs, ODI, and the PF and BP domains of SF-36 in 1-month postoperation compared to corresponding basal values (Tables P < 0.001). Over the same period of time, PPTs had also significantly improved from 580.60 kPa (557.92-601.01) to 707.60 kPa (612.35-780.18) (P < 0.001), and ODI reduced from 35.0% (26.4-44.0) to 22.0% (14.25-42.5) (P < 0.001). The PF and BP domains of SF-36 had also significantly improved from baseline (60.0 (45.0-70.0) and 41.0 (31.0-51.0), respectively) to 1 month postoperation (88.0 (76.5-95.0), P < 0.001; 52.0 (41.0-62.0), P < 0.001, respectively). In the PRP group, statistically significant differences were also observed between baseline VAS, PPTs, ODI, and PF and BP domains of SF-36 and the same set of data from 3 months, 6 months, and 1 year postoperation (Tables P < 0.001). Significant decrease in F-wave latency was observed in the PRP group, where it decreases from 48.7 ms (46.9-49.7) to 45.2 ms (44.5-46.2) 1 year postoperation (P < 0.001) ; 6.0 (6.0-7.3) vs. 5.0 (5.0-6.0), kPa 557.9-601.01 vkPa 557.9-601.01 v< 0.001) .P = 1.000; 598.74 kPa (535.24-607.81) vs. 598.74 kPa (526.17-694.00), P = 0.683; 27.0% (21.0-43.0) vs. 23.0% (20.0-40.0), P = 0.645; 65.0 (55.0-80.0) vs. 70.0 (60.0-90.0), P = 0.152; 41.0 (41.0-52.0) vs. 47.0 (41.0-61.0), P = 1.000, respectively). Significant improvement was observed from baseline VAS, PPTs, ODI, and PF and BP domains of SF-36 to the same set of data from 1 month postoperation (Tables P < 0.001); PPTs increased from 598.74 kPa (535.24-607.81) to 598.74 kPa (526.17-694.00) (P < 0.001); ODI significantly decreased from 27.0% (21.0-43.0) to 18.0% (12.0-29.0) (P < 0.001), whereas the PF and BP domains of SF-36 all improved statistically from baseline (65.0 (55.0-80.0) and 41.0 (41.0-52.0), respectively) to 1 month postoperation (88.0 (75.0-95.0), P < 0.001; 52.0 (41.0-72.0), P = 0.004, respectively). Statistical differences were found between baseline VAS, PPTs, ODI, and PF and BP domains of SF-36 in the steroid group and data obtained from 3 months, 6 months, and 1 year postoperation (Tables P < 0.001), while the F-wave latency had significantly decreased from 48.9 ms (47.8-50.8) to 45.2 ms (43.6-46.3) 1 year post operation (P < 0.001) ; 6.0 5.0-7.0) vs. 6.0 (5.0-6.0), .0-7.0 vs< 0.001) .During the 1-year follow-up period in this study, both the PRP and steroid groups demonstrated obvious improvements in terms of VAS score , PPTs F, F-wave No complications or adverse effects were reported after the ultrasound-guided transforaminal injection of PRP or steroid during the 1-year follow-up period.This study shows that ultrasound-guided transforaminal injection of both PRP and steroid leads to the significant improvement in the aspects of pain relief, nerve repair, spinal function, and life quality. Furthermore, the outcome after one whole year of follow-up has proven that these improvements stay effective for long term. Besides, no complications or side effects were found during any of the follow-ups.Results from this study are in accordance with a series of clinical studies which have described the effectiveness of epidural PRP injections for treating lumbar disc herniation with radicular pain –21. In aF-wave measurement helps to assess conduction of impulse along the peripheral motor nerve, including most of its proximal segment. This investigation revealed the significant decrease in F-wave latencies and increase of F-wave rate in both the PRP and steroid groups, indicating the nerve repair function of PRP and steroid. Steroid has positive effects on the F-wave in peripheral nerve disorder, such as chronic inflammatory demyelinating polyradiculopathy and Guillain-Barré syndrome. One study reported that local steroid injection could help to decrease the F-wave latency in carpal tunnel syndrome . Althougβ-1 (TGFβ-1), platelet-derived growth factor (PDGF), and insulin-like growth factor-1 (IGF-1), are contained within the α-granules of platelets [α-granules load being secreted within 1 hour [In recent years, PRP has been widely used in treating musculoskeletal diseases due to its anti-inflammatory properties and ability in promoting the processes of endogenous healing by delivering a high concentration of growth factors and cytokines , 26. Thelatelets . Within n 1 hour . Studiesn 1 hour –32. Thern 1 hour , 33.In this investigation, sonography was used to guide transforaminal PRP and steroid injection. The outcomes of nerve root block under the guidance of sonography have proven to be similar to those of injections being guided by either computed tomography scan or X-ray –36. FurtNo major complications and side effects were reported during the 1-year follow-up period in this study. Only one study reported very rare ischemic complications with lumbar epidural steroid injection by the interlaminar route . MeanwhiNonetheless, there is currently a lack of standard procedure in PRP production for PRP therapy although a vast variety of formulations and techniques for PRP production is available. Other than that, the cost-effectiveness of PRP treatment remains controversial. On the one hand, the cost of PRP in Europe is reported to be about twice as much as the cost of steroid treatment ; on the This study was designed to focus on the long-term treatment effect of transforaminal injection of steroid or platelet-rich plasma (PRP) on lumbar disc herniation. Thus, the evaluation time points were mainly set at 1 month, 3 months, 6 months, and 1 year. The limitation of this study was the lack of short-term evaluation time point, including 2 weeks and 3 weeks. It could be further explored in future clinical trial.This study suggests that ultrasound-guided transforaminal PRP injections yield similar effect as transforaminal steroid injections in treating lumbar disc herniation with radicular pain and that it may be a safer alternative in comparison.


This study was conducted to investigate whether the pain catastrophizing scale (PCS) and the central sensitization inventory (CSI) are predictive factors for the reported pain after hip arthroscopy.A total of 37 patients undergoing hip arthroscopy for femoroacetabular impingement syndrome and labral tears were prospectively enrolled. All patients completed the PCS and CSI before hip arthroscopy. Postoperative pain was measured with the numeric rating scale (NRS) weekly the first 12 weeks after surgery by electronic diary.p < 0.01). During 12 weeks follow-up, a significant decrease on the NRS was observed (p < 0.01). Univariate analyses showed that both the CSI and PCS were significantly associated with the NRS during follow-up. Multivariate mixed model analysis showed that only the PCS remained significantly associated with the NRS outcome with a ß of 0.07 .At baseline, univariate analyses showed that both the CSI and PCS were significantly associated with the NRS outcome (Results indicate that both the PCS and CSI are associated with the reported postoperative pain after hip arthroscopy. The PCS and CSI may be useful in daily practice to identify patients that possibly benefit from pain catastrophizing reduction therapy (e.g. counseling) prior to surgery.IV Postoperative pain after hip arthroscopy is usually measured as numeric rating scale (NRS) and is commonly used as outcome after surgery . AlthougOther non-orthopedic factors, such as patient mental health and psychological state, might influence the reported postoperative pain as well , 12, 27.Another non-surgical factor that may be of influence on the reported postoperative pain is pain catastrophizing (PC). If PC is present, the patient has a tendency to magnify the threat value of a pain stimulus and to feel helpless in the presence of pain, also controlling pain-related thoughts can be a problem , 29. PC If factors, such as PC and CS, play a role in postoperative pain there might be a reason for routine pre-operative measuring both scores. The aim of this study is to investigate the role of PC and CS on the reported pain after hip arthroscopy and the hypothesis is that both CS and PC are of influence on the reported pain after hip arthroscopy.All included patients were part of a trial for which the study protocol was approved by the medical ethical committee (NL55669.048.15). Inclusion criteria for our current study were a confirmed diagnosis of Femoroacetabular Impingement Syndrome (FAIS), age between 18 and 65 years and a completed CSI and PCS. FAIS is considered abutment of the proximal femur to the acetabular rim . DiagnosAll patients were operated by a single orthopedic surgeon (D.H) with good hip arthroscopy experience . Procedures were performed in either a general hospital or a private orthopedic clinic. A total of 37 patients completed both the PCS and CSI and were included in our current study. Baseline characteristics are shown in Table Pain was measured using a Numeric Rating Scale (NRS pain) and all patients were asked to complete a Central Sensitization Inventory (CSI) and a Pain Catastrophizing Scale (PCS) before surgery. The NRS was measured pre-operatively at baseline and weekly after surgery until 12 weeks post-operatively (by electronic diary). The outcome ranges between 0 and 10 where 0 means no pain and 10 worst possible pain. The NRS is a validated tool for measuring pain .The CSI is a validated tool that is used to identify patients who have symptoms that may be related to CS . The quePC was measured with the pain catastrophizing scale (PCS). The questionnaire which measures three components of pain catastrophizing being rumination, (e.g. "I can´t stop thinking about how much it hurts"), magnification (e.g. "I´m afraid that something serious might happen") and helplessness (e.g. "There is nothing I can do to reduce the intensity of my pain") . The PCSp value < 0.05 was considered statistically significant. No power analysis was performed since there were no data from previous studies to power on.Baseline and clinical characteristics are described as means with standard deviations (SD) in case of continuous variables and frequencies with accompanying proportions in case of categorical variables. The association of potential risk factors for pain  at baseline and 12 weeks, and during follow-up (weeks) was assessed using linear regression analysis and mixed model analysis for repeated measures, respectively. Initially, univariate analyses were performed to identify potential risk factors. Factors that were significantly associated with the outcome (adjusted significance level of 0.10), were entered in a multivariate model (significance level 0.05). Adjustments for baseline values of the NRS were performed where appropriate. Fixed effects estimates with their 95% confidence intervals are presented (95% CI). A p ≤ 0.01). Multivariate analysis, however, revealed only the PCS as significantly being associated with the NRS with ß-values of 0.09 (p = 0.01) and 0.07 (p = 0.01), respectively   reported a CSI > 40 and three patients (8%) a PCS > 30 points.p < 0.01)  points higher on the NRS than patients with CSI < 40  was significantly associated with pain outcome at baseline, at 12 weeks as well as during 12-week follow-up in patients who had undergone hip arthroscopy. The central sensitization inventory (CSI) was only significantly associated with pain outcome after univariate analyses, and showed that patients with possible central sensitization, based on the cut-off value of 40 points, reported overall 1.5 points higher on the NRS compared to patients with a CSI < 40.These results imply that the PCS was more strongly associated with pain outcome than the CSI. It is however debatable how much clinical significance the PCS has with only a ß of 0.06 meaning that for every point on the PCS patients reported 0.06 point higher on the NRS. The minimal clinical important change of the NRS is on average 1 point or 15% decrease in reported NRS .n = 3), this analysis could not be performed for the PCS.There are some factors that are known to have a negative effect on the outcome after hip arthroscopy. These factors include increasing age, female gender and/or higher BMI , 28. In There is not much literature regarding the CSI and its effect on pain after hip arthroscopy. There are some papers that suggest a correlation between central sensitization and lower outcomes (or chronic pain) after total knee replacement surgery , 30. In A recent study by Dumont et al. shows that patients with FAIS and/or a diagnosis of depression or anxiety have higher levels on the pain catastrophizing scale . In patiPatient understanding and patient selection is important in the goal to achieve satisfying results after hip arthroscopy. The PCS and CSI may be of use in the pre-operative setting for measuring possible pain catastrophizing and identify those patients with high levels of pain catastrophizing or central sensitization. Both the PCS and CSI questionnaires are easy to use in daily practice and can give the orthopedic surgeon extra tools for identifying those patients that may benefit from pain catastrophizing reduction therapy (e.g. counseling) prior to surgery.This study has some limitations: a small sample size, a small variation of the PCS and no results for the group of patients with a PCS > 30. The small sample size may have caused some instability in our results and a larger sample size would be necessary for correction of confounders to identify predictors for the NRS outcome.Results of this study show that both the PCS and the CSI are associated with the NRS reported pain at baseline and 12 weeks and during follow-up after hip arthroscopy. Unfortunately this study has a small sample size and future research is needed to detect if these results hold and whether treating central sensitization or pain catastrophizing might improve indications and outcome after surgery.


The hypermobile type of Ehlers–Danlos syndrome (hEDS) is likely the most common hereditary disorder of connective tissue mainly characterized by joint hypermobility. Patients with hEDS suffer joint pain, in particular low back pain, commonly resistant to drug therapy. The aim of this research was to evaluate a neurocognitive rehabilitation approach based not only on the motion and function recovery but also on the pain management.  In this nonrandomized clinical trial, eighteen hEDS patients  with mean age 21 years (range 13-55) were recruited and evaluated before and after three months of rehabilitation treatment. P = 0.003; McGill , P = 0.03), fatigue , fear of movement , and pain-associated disability .  The outcome scores showed significant statistical results after treatment in reducing pain symptoms (numerical rating scale,  The clinical results observed in our study seem to confirm the role of a specific neurocognitive rehabilitation program in the chronic pain management in the Ehlers–Danlos syndrome; the rehabilitation treatment should be tailored on patient problems and focused not only in the recovery of movement but also on pain perception. Hypermobility Ehlers–Danlos syndrome is a heritable connective tissue disorder recently described among the 13 subtypes of Ehlers–Danlos syndrome  and EDS All patients were consecutively enrolled in the outpatient rehabilitation unit for hypermobility disorders of the Umberto I University Polyclinic Hospital of Rome, after a physiatrist evaluation. Inclusion criteria were as follows: diagnosis of hypermobile EDS according to the 2017 International Classification of Ehlers–Danlos Syndromes [This study referred to TREND guidelines for clinical nonrandomized study.The rehabilitative treatment was performed for one time a week (sixty minutes for each session) for three consecutive months. All the patients continued the daily common activities and ongoing drug therapy. The scope of the treatment has been to reduce and treat the main aspect characterizing the patients: the reduced muscle recruitment, the chronic fatigue, the fear of movement, and the recovery of an adequate motor strategy, in particular of the back spine, but always focused on the patients' feeling of perception of pain and the functional limitations with respect to the principles of the narrative medicine .During the treatment, the neurocognitive approach followed different phases.Felt sense” approach or feeling felt: it is necessary to direct the bodily sensations initially focusing the attention on the healthy parts of the body and then describing the painful typology, localization, and perception in order to confine it on the low back pain region. This first 10- to 15-minute phase was based on the language and narration of lower back pain and its characteristics. For example, the patient was asked to sense the pleasant contact (comfortable warmth) of the therapist's (PT) hands as slight pressure with the palm to the region of the back without pain. Afterward, the PT asked the patient to bind the pleasant and pain-free sensation to the painful area.“The PT used language, through the approach of narrative medicine , 10, askHelping the patient to research physiological and nonpainful strategies to learn the most physiological possible movements and to rebuild a bodily image consistent with reality, using the spatial orientation of limbs, using the touch and the pressure discrimination, in particular along the trunk midline, this part lasted for the remaining 45 minutes of the rehabilitation session.Recognition of the location of the contact, at the trunk level. Modality: the patient sitting , contact with the therapist's hand is employed, using different requests (=tasks) and methods , or with sponges of different consistency. Starting from the area of the shoulder blades then the lumbar and the features of the spine, it considered first with the less painful region and therefore more accessible to contact. The recognition of the contact occurs through complete contact with the physiotherapist's hand or only with the fingertips, as much depending on the proprioceptive discrimination that the patient has to solve; the PT could request and exercised contact with full hand or only with the fingertips. Also, the therapist's hand can lightly touch, fully touch, or exert light pressure . An examRecognition of positions through the lumbopelvic rhythm. Modality: both with the patient seated and on his back, through diaphragmatic breathing, his attention can be directed to the lumbopelvic movement and to small modificationsrequired task was to identify the location, size, and consistency of different sponges placed at the level of the lumbar region. These exercises were executed with eyes closedRecognition of two sponges of different consistency at the pelvis level, through the lumbopelvic rhythm. Modality: the patient was in supine position and lower limbs quite flexed or seated in symmetrical position, feet placed on floor, hips, knees, and ankles flexed at 90°, upper limbs at their sides. The Modality: identification of thicknesses of different heights and of diverse resistance springs placed under the aid. The exercise was executed first with eyes closed and then with eyes open. The exercise was conducted to research the postural symmetry perception of the spine considering the trunk midlineRecognition of the tilting of the pelvis and of the laterolateral and anteroposterior relationship of the trunk. Modality: the patient is seated in symmetrical position, feet placed on the floor, hips, knees, and ankles flexed at 90°, upper limbs at their sides, pelvis placed on a board able to rock in all directions through a gimbal  . ModalitRecognition of the symmetrization of the load. Modality: the patient is in standing position, back resting against a wall, feet parallel, and lower limbs placed on two sets of scales to control the organization of load. Planned laterolateral transferal of load. Subsequently, the same task can be requested, in third grade, with the trunk detached from the wall. Each of these rehabilitative sections lasted about 10-15 minutes. This rehabilitation protocol, which is based on neurocognitive rehabilitation, has taken up some exercises proposed in the treatment of chronic back pain and adapted and customized to hEDS patientsAll patients have been clinically evaluated before and after treatment with different clinical outcome scales: McGill pain questionnaire (MG) , the TamThe McGill pain questionnaire is probably the most well-known and complete tool for the verbal assessment of pain. It provides a subjective measurement of pain intensity as well as clues on qualitative features of the chronic or acute pain experienced by the patients. Results broadly fall into 3 main classes: (1) sensory qualities ; (2) affective qualities ; and (3) intensity of pain. Descriptors are also subdivided into 20 subclasses and arranged in increasing order of pain intensity .TSK is the most widely used questionnaire to assess pain and pain-related fear of movement in subjects with musculoskeletal complaints, and this has been translated into and validated in different languages including Italian . KinesioThe ODI consists of ten questions pertaining to daily activities and covers the following: experiencing general pain, practicing self-care , lifting objects, sitting, standing, walking, sleeping, travelling, engaging in sexual activity if applicable, and participating in social activities. The items are rated on 6-point scales scored in the range of 0–5, with higher scores indicating higher pain-associated disability .NRS is a rapid-to-administrate 11-point numerical scale used to roughly measure any kind of pain with a score ranging from 0 (no pain) to 10 (acute pain) .Moreover, the proportion of patients achieving a higher than a reduction of approximately two points of the NRS pain scores from baseline as minimal clinically important difference (MCID) has been calculated , in assoP < 0.05.Statistical analysis was conducted with the SPSS software package for Windows, version 19.0. The statistical analysis of the continuous variables was conducted calculating median and range (min–max), because these variables were not normally distributed. In order to evaluate the functional scales adopted, we used the Wilcoxon test for paired samples. The significance level was set at Eighteen patients  have been recruited for this study. All the patients have followed the complete period of treatment except for two that have missed one day appointment for personal reasons. All patients referred no changes in daily activities.Results of the functional scales before and after rehabilitative treatment are illustrated in P = 0.003) and McGill  (P = 0.03), a reduction in fatigue by FSS (P = 0.03), a better attitude to move with less fear by Tampa scale (P = 0.003), and, last but not least, an improvement in pain-associated disability by Oswestry disability index (P = 0.03). Considering the MCID for pain, the incidence of a significant score variation was 88.9% while for the ODI scale it was 42%.Patient outcome scores showed significant results after treatment in reducing pain symptoms, fatigue, kinesiophobia, and pain-associated disability as illustrated in Figures Pain is a common symptom referred as complex and disabling in patients with hEDS . A diffeRecently, another hypothesis has been suggested to explain the mechanisms of pain. In particular, an incongruence between sensory input and central motor output  reflecting discrepancies between the motor and sensory cortex may lead to generalized and unfocused pain in some hEDS patients. This phenomenon, hypothesized in other chronic pain conditions, implies defective sensory input coupled with disinhibition of the motor output .More specifically, Di Stefano et al.  have stuThe clinical results observed in our study seem to suggest the role of a specific neurocognitive rehabilitation program in the chronic low back pain management; the rehabilitation treatment should be tailored on patient problems and focused not only in the recovery of movement but also focalize on pain perception. Also, if this is only a pilot study and no electrophysiological evaluation has been done (like for example QST and CPM), it is the first neurocognitive rehabilitation attempt in hEDS and the results are encouraging, not only with respect to the improvement and reduction of chronic LBP in this specific pathology but also—and above all—because an approach based on movement awareness has also allowed to reduce fear linked to the movement itself. In the treatment of chronic pain, neurocognitive rehabilitation has shown good results in the literature and the use of the motor imagery is proving successful –30. hEDScontrol” with regard to the movement parameters  [An organizing relationship of the trunk that rapidly disappears in the patient with chronic pain is the flexibility and fragmentability of the movement itself, with a reduction in the quality and quantity of movement, the maintenance of fixed postures that are not adequate for function. Using the neurocognitive exercise, through the exteroceptive and perceptive inputs, the recovery of movement is obtained through the resolution of a cognitive task . Then, the patient is placed in front of a perceptive task, which therefore requires the integrity of cognitive processes, such as attention and the ability to process tactile, proprioceptive, pressure, kinesthetic information, as well as the ability to interact actively with the contact surface. Unlike the traditional rehabilitation approach, the neurocognitive approach is based on specific rehabilitation settings that could help the patient to extract meaningful information that can lead to conscious recovery improving what that we defined “felt sense.” In fact, the three principles of neurocognitive therapeutic exercises are to assume (i) rehabilitation as a learning process, (ii) the body as a receptor surface, and (iii) the movement as knowledge. Then, each proposed exercise had to be broken down and respect the “tensity) –33. Alsotensity) , 34, 35.tensity) –8.These clinical results seem to confirm the role of a specific neurocognitive rehabilitation program in the chronic pain management in the Ehlers–Danlos syndrome, effective in reducing low back pain and the related disability. An important aspect, contained in our proposed neurocognitive rehabilitation program, is that the rehabilitation treatment should be tailored on patient problems and focused not only in the recovery of movement but also on pain perception for better rehabilitative responses. At last, this study has some limitations such as the lack of a control group, a limited sample size, the evaluation done with only clinical scales, and the absence of a functional evaluation of patients like spine segmental mobility function. Then, our results, although encouraging, should be interpreted with caution. Our data should be integrated with studies applied on a big cohort of patients associated with clinical and neurophysiological evaluation in order to confirm this pilot rehabilitative novel proposal.


To evaluate the impact of diagnostic nerve block and ultrasound findings on therapeutic choices and predict the outcome after concomitant surgery in patients with suspected neuropathy of the infrapatellar branch of the saphenous nerve (IPBSN).p ≤ 0.05).Fifty-five patients following knee surgery with suspicion of IPBSN neuralgia were retrospectively included. Ultrasound reports were assessed for neuroma and postsurgical scarring (yes/no). Responders and non-responders were assigned following anesthetic injection of the IPBSN. The type of procedure  and pain score at initial follow-up were recorded and patients were assigned as positive (full pain relief) or negative  to therapeutic nerve treatment. Factors associated with a relevant visual analog scale (VAS) reduction were assessed using uni- and multivariate logistic regression models and chi-square for quantitative and qualitative variables (p = 0.002) and the absence of knee joint instability (p = 0.029) predicted a positive response of the diagnostic nerve block . In the follow-up after therapeutic nerve treatment, all patients with full pain relief showed neuromas or entrapment of the IPBSN. Patients negatively responding to therapeutic nerve treatment more frequently showed an additional knee joint instability (25% vs. 4%).Responders (37/55) more often had an entrapment or an evident neuroma of the IPBSN (97% vs. 6%). A positive Hoffmann-Tinel sign (Selective denervation for neuropathic knee pain is beneficial in selected patients with significant VAS reduction after diagnostic nerve block. Non-responders following diagnostic nerve block but sonographic evidence of IPBSN pathologies need to be evaluated for other causes such as knee joint instability.Sonographic diagnosis of neuroma or entrapment of the IPBSN is frequently seen in patients with anteromedial knee pain and leads to a good response to diagnostic nerve block following knee surgery.• The vast majority of patients with clinical signs of IPBSN neuropathy and response to a diagnostic nerve block sustained full pain relief following therapeutic nerve treatment.• Patients not responding to therapeutic IPBSN treatment have to be evaluated for other causes of anteromedial knee pain such as knee joint instability.•  The infrapatellar branch of the saphenous nerve (IPBSN) is a purely sensory nerve which innervates the anteromedial skin of the knee and the anterolateral aspect of the proximal lower limb, as well as the anterior inferior joint capsule , 2. The The IPBSN is target to iatrogenic injuries during knee procedures, such as medial arthroscopic approaches, total knee arthroplasty (TKA), and tendon harvest for anterior cruciate ligament reconstruction. The nerve may be most at risk for damage from the medial retractors that are placed during total knee surgery and a retractor that levers out against the medial tibia, so the nerve may be under tension and a stretch neurapraxia can result.The incidence of infrapatellar saphenous neuralgia can be found in up to 55–84% of patients after TKA –5. HowevLesions to this nerve may result in sensorial loss at its innervation territory or painful neuromas at the nerve transection site. Painful neuropathies can also be caused by nerve compression arising from scar adhesions, causing painful entrapment of nerve branches via fibrosis. Physicians have little awareness of its occurrence, resulting in delayed diagnosis as is appropriate therapeutic care. In cases of neuropathic pain, peripheral nociceptors are in a state of continual excitability that induces chemical and anatomical changes in the cortical centers. Factors such as sex, age, genetic susceptibility, and psychosocial context might influence this central process leading to chronic pain . TherapeAs clinical symptoms of IPBSN neuropathy may be non-specific and overlap with other varying causes following knee surgery, we hypothesized that sonographic abnormalities of the IPBSN and response to a diagnostic nerve block correlate with the clinical outcome following nerve treatment.Therefore, the purpose of this study was to assess the impact of diagnostic IPBSN block results with ultrasound imaging findings on clinical outcomes after concomitant surgery.The institutional review board of the local ethics committee approved this fully anonymized retrospective study. All patients at least 18 years old with anteromedial knee pain following open and arthroscopic knee surgery, ultrasound and diagnostic nerve block of the IPBSN, and a clinical follow-up between December 2018 and January 2020 were retrieved from the hospital archive from an IPBSN nerve cohort. Included patients were suspected to have neuroma-specific neuropathic pain, including spontaneous pain, electrical spikes, burning pain, allodynia, and hyperalgesia to touch, pressure, or movement. Clinical examination showed a shooting electrical pain when tapping the injured nerve (positive Hoffman-Tinel sign).In patients with TKA, instability was defined as abnormal and excessive displacement of the articular elements, which has led to clinical failure of the arthroplasty and is known to be one of the most common causes of aseptic failure following TKA . InstabiAll diagnostic ultrasound examinations and perineural injections were performed by three radiologists with musculoskeletal subspecialty training. All diagnostic examinations and procedures were performed with a 14-MHz linear-array transducer on LOGIQ S8 XDclear . Patients were examined in the supine position with the knee slightly flexed. Ultrasound of the IPBSN and its branches from proximal to distal followed a standardized assessment protocol to identify any structural and perineural abnormality.First, the transducer was placed transversally at the mid-medial thigh to locate the saphenous nerve in the distal adductor canal. The canal is bordered by the sartorius muscle superficially, the vastus medialis muscle laterally, and the adductor longus muscle deeply , 13. TheNeuromas were classified as a terminal neuroma or neuroma-in-continuity according to the Seddon and Sunderland classification  as a forScar-tethered nerves as defined by Elliot and Sierakowski might cause nerve distortion by shearing, resulting in bursts of pain . In pati2), which was traced within the hyperechoic epineural rim of the nerve with the transducer perpendicular to the nerve.Additionally, the nerve size of the IPBSN was measured using diameter (mm) and cross-sectional area  or associated paresthesia in the nerve distribution aided in selecting an injection site. Standard sterile techniques were used. Local anesthesia was administered subcutaneously with 1% lidocaine through a 22- or 25-gauge needle, depending on the nerve location depth. In six cases of perineural therapeutic injection, circumferential infiltration around the outer epineurium of the nerve was performed under ultrasound guidance with 1% lidocaine in combination with a water-soluble steroid, dexamethasone (4 mg/mL), in volumes ranging from 1.0 to 5.0 mL.Pain relief was recorded following a four-step scale using the visual analog scale  before and 40 min following diagnostic nerve block: excellent (completely resolved pain according to an absolute VAS reduction to 0 or 1 point or a VAS decrease of > 75%), good (pain decrease of 50–74%), fair (pain decrease of 25–49%), poor (pain decrease of < 25% or increased pain). Patients with excellent and good responses to a diagnostic nerve block were assigned to the responder group, and patients with fair and poor responses were assigned to the non-responder group.A retrospective review of the electronic medical records for patient demographic data, history with details of previous and revision knee surgery, interventional pain procedures (IPP), and follow-up symptomatic relief  as well as post-procedure complications was performed. Following therapeutic nerve treatment, all patients were assigned into two groups according to their pain relief: positive (full pain relief) and negative .Precise treatment strategy to surgical or interventional procedures of the IPBSN was determined on a case-by-case basis, depending on the presence of structural abnormalities identified with ultrasound and pain reduction after diagnostic nerve block.Surgical intervention on the IPBSN was directed at transection of the nerve proximal to the site of the IPBSN pathology, with implantation of the proximal nerve stump into the adjacent vastus medialis muscle where it was secured with epineural/perineural suture.Three main IPP, namely peripheral nerve block (PNB), neural therapy, and cryoneurablation, were applied. PNB had been administered as a single injection in this study. Local anesthetics alone in a volume of 1 to 4 mL were used or in conjunction with water-soluble corticosteroids if the goal was longer relief, particularly in the context of neuromas or entrapment neuropathies , 18. Neup ≤ 0.05 was considered statistically significant. All variables with a p value ≤ 0.05 were integrated into a multivariate step-by-step forward logistic regression model. Statistical analysis was conducted by using SPSS Statistical Software Package (IBM).Descriptive data are expressed either as the mean with standard deviation (SD) or n with percentages. Univariate analysis using t-tests for interval-scaled continuous variables and chi-square tests for nominal or ordinal variables was applied to compare responders with non-responders to diagnostic treatment and to compare positively versus negatively reacting patients to therapeutic nerve treatment; A total of 59 patients met the inclusion criteria. Of these, four were excluded: two were lost to follow-up and in two patients elective neurectomy had been postponed due to COVID-19. The final cohort included 55 patients (33 women and 22 men) with a mean age of 57.1 ± 13.1 years . The mean time interval between initial surgery and patient symptoms was 6.4 ± 4.9 months. Of those, 34 patients (62%) presented with local allodynia and positive Hoffmann-Tinel sign. Sixty-seven percent (37/55) responded positively to the diagnostic nerve block, while 33% (18/55) did not respond. Responders and non-responders did not differ with respect to demographics or previous surgical procedures. In contrast, non-responders showed a higher rate of joint instability (44 vs. 11%) or intraarticular pathologies including arthrofibrosis or osteoarthritis (56% vs. 19%). Detailed information for both groups is summarized in Table 2), in patients with entrapment 1.4 ± 0.5 mm  and with neuromas was 3.4 ± 1.3 mm .Mean caliber of the unremarkable IPBSN was 1.1 ± 0.2 mm  and more likely had an entrapment or a neuroma of the IPBSN (97% vs. 6%) compared to non-responders. The mean pre-interventional VAS score of all patients was 6.4  and post-interventional 2.2 : while this pain did not differ prior to the examination, it was significantly smaller in the responder group afterwards (VAS 0.9 vs. 5.0).p = 0.002) and the absence of knee joint instability (p = 0.029) were the only criteria to predict positive results of a diagnostic nerve block. The other factors did not reach statistical significance. Table In a stepwise logistic regression model of the univariately significant variables (except sonographic IPBSN pathology and pain), positive Hoffmann-Tinel signs p = 0.00 and the A summary of all therapeutic treatment options is illustrated in Fig. Of the 40 patients who received a therapeutic nerve treatment , 28 (70%) sustained full, seven (17.5%) partial, and five (12.5%) no pain relief after treatment .For the univariate analysis, patients with negative or partial pain relief were grouped together and compared with those with full pain relief Table . All patp < 0.001) and absence of knee joint instability (p = 0.050) were the only ones to predict positive results of nerve treatment. Figure In a stepwise logistic regression model of the univariately significant variables, the result of sonographic examination . In the vast majority of responders (28/34), neurectomy and/or IPP yielded durable pain relief and functional recovery. Analogous to our diagnostics, the surgical treatment did not vary significantly for compression or axonotmetic injury.Our consecutive series of patients evaluated for neuropathy of the IPBSN highlight several critical components of clinical care. First, thorough patient evaluation is mandatory to make the diagnosis as accurate as possible because many of these patients have suffered numerous treatments and surgeries and subjecting them to an additional surgery without sincere expectation of success is probably not in their best interest. The critical step to diagnosis in our study was nerve block using local anesthetic agents as a diagnostic maneuver to confirm clinical suspicion of neuropathic pain rather than interpreting sonographic findings alone. Diagnostic nerve block with an absolute VAS reduction to 1 or 0 points or a VAS decrease of > 50% is feasible to differentiate responders from non-responders (When evaluating patients, it is not essential to distinguish between neuropathic pain due to compression neuropathy caused by scar-tethering or direct injury with neuroma-in-continuity formation bearing in mind the distinct possibility of an associated double crush phenomenon , 22.Despite thorough preoperative evaluation and positive diagnostic nerve block that suggested neuropathy of the IPBSN, one responder did not improve with surgery and continued to have neuropathic pain and functional impairment. Identifying the appropriate nerve involved in pain generation is critical, especially considering overlap of nerve dermatomes and frequent plexus formation between cutaneous nerves . TerminaThe five patients that failed surgery with only partial response of up to 50% all had complex medical situations with a history of multiple previous interventions at the knee; however, in many of the patients that successfully responded to surgery, other intra- and extraarticular pathologies and instability were absent. Even though an 82.3% success rate in pain relief is impressive for any therapeutic maneuver in patients with long-standing anteromedial knee pain, the results of this study are consistent with previous published work, stating that 20–30% of neuromas will be refractory to treatment, regardless of type of surgery performed , 26.Six non-responders with clinical suspicion of infrapatellar saphenous neuralgia failed IPP: two patients showed partial and four patients no pain relief, stating that other causes of anteromedial knee pain have to be evaluated.We recommend using additional selection criteria to stratify responders from non-responders: Hoffmann-Tinel sign in the topography of IPBSN, evident neuroma or scar-tethering on sonography, and evaluation of potential knee joint instability.The following limitations have to be considered, including a verification bias as patients who were selected to undergo surgery based on the positive diagnostic nerve block result more likely received surgery than those who tested negative. Furthermore, sonography is limited by patient habitus, with degradation of image quality and anatomic detail in obese individuals. Pain evaluation was made using VAS scores alone, which is a subjective outcome measure. The effectiveness of all procedures performed in our unit is evaluated with VAS scores, a relatively reliable, simple, and sufficient way to ascertain the patients` response to a procedure. Finally, although the effect of treatment in the responder group was monitored for more than 2 months, that might not have been a sufficient length of time to determine the long-term effects of the neurectomy or IPP.Selective denervation for neuropathic postoperative knee pain is beneficial in selected patients with significant VAS reduction after diagnostic nerve block. Non-responders following diagnostic nerve block but sonographic evidence of IPBSN pathologies need to be evaluated for other causes such as knee joint instability.


ObjectiveUltrasound-guided platelet-rich plasma (PRP) injections, as well as needle tenotomy, are becoming increasingly popular in the treatment of epicondylitis. Whether ultrasound (US) findings predict the clinical benefit of these techniques is unclear at the moment. This study aimed to investigate the relationship between the presence of tendon tear assessed by US and the therapeutic response of the PRP injection following needle microtenotomy in patients with epicondylitis.MethodologyThis is a retrospective observational study. Twenty-six patients with chronic (>three months) lateral epicondylitis recalcitrant to conservative treatment or corticosteroid injection. Patients underwent US-guided microtenotomy followed by PRP injection. Data regarding gender, age, US findings at baseline, and numeric pain rating scale (NPRS) scores before and after intervention were collected. Pain improvement rates were calculated at several follow-up time points, namely one, three, six, and 12 months post-intervention. Results are stated as mean ± standard deviation.ResultsAt the time of intervention, the mean age was 47.6±6.5 years, and 57.7% of patients were men. Overall, the mean initial NPRS score was 7.5±1.2, and there were no statistically significant differences in mean initial NPRS scores between the groups with or without tendon tear on the US imaging. The mean improvement rate at one, three, and six months was similar between patients with and without tendon tear. However, a statistically significant difference was observed at 12 months . ConclusionsPatients with tendon tear demonstrated a higher pain improvement rate at 12 months follow-up. This finding could predict the clinical response to this technique, thus allowing a better selection of the candidates. Lateral humeral epicondylitis is a common source of lateral elbow pain, which was first described by Runge in 1873, and is generally accepted as a condition related to repetitive microtrauma . DespiteSeveral therapeutic strategies have been described, namely analgesic drugs, physiotherapy, elbow supports, shockwave therapy, corticosteroid injections, acupuncture, and surgery. However, there is still no generally accepted treatment, and the more is known about its pathophysiology, the more treatments that stimulate tissue regeneration become popular ,7.Percutaneous needle tenotomy, also known as tendon fenestration or barbotage, consists of the fenestration of the tendinopathic tissue with a needle to induce bleeding and the release of growth factors, thus converting a chronic into an acute injury with high healing potential. Similarly, autologous platelet-rich plasma (PRP) injections aim to stimulate the healing process by promoting the release of active cytokines by the platelets when injected into the area of tendinopathy ,8.Despite several authors have been reporting good results with these techniques, either isolated or used in association, in the treatment of tendinopathic conditions -15, littThis retrospective observational study included 26 consecutive patients with chronic (> three months) lateral epicondylitis with no or unsatisfactory improvement after conservative treatment or corticosteroid injection.Clinical diagnosis and the pre-intervention USTwo experienced physicians in musculoskeletal pathology from our center performed the diagnosis, pre-intervention US, and the US-guided microtenotomy followed by PRP injection procedure to all patients. Clinical diagnosis was based on pain at the common extensor origin at the lateral humeral epicondyle, exacerbated by local palpation, forearm supination resistance, active wrist extension, and positive Cozen test. Pre-intervention US was performed with a 6-13MHz high-frequency linear probe .All the patients gave their consent, and the procedures in this study were in agreement with ethical standards and accordance with the 1964 Helsinki Declaration and its later amendments.PRP preparationFor PRP preparation, 20 mL of peripheral blood were collected from all patients, and leukocyte-free PRP was prepared by single spinning at 1500 rpm for eight minutes. The plasma layer was collected under laminar flow, obtaining approximately 4mL of pure PRP, with no external activation.US-guided microtenotomy and PRP injectionAll procedures were performed in the supine position, with the elbow flexed at 120° and the forearm in pronation, following a sterile protocol. Lidocaine (2mL) was initially infiltrated in the subcutaneous tissues superficial to the lateral epicondyle via a 21-gauge needle. After that, 15-20 fenestrations were applied on the tendon by redirecting the needle in different directions, especially over the hypoechogenic tissue, followed by PRP injection in the same areas. All patients were then instructed to rest for 48 hours and avoid weight lifting and manipulation.Data collection and outcomesData regarding gender, age, and US findings at baseline were collected from patients' records. Concerning US findings, patients were grouped according to the existence or absence of intratendinous tear.The primary endpoint was the mean numeric pain rating scale (NPRS) score throughout the follow-up . Secondary endpoints included the mean change in NPRS score from baseline, the improvement rate (%) calculated as a percentage of reduction of NPRS score from baseline and pain intensity classified as no pain (NPRS score = 0), mild (1-2), moderate (3-7) or severe (8-10) pain.Statistical analysisData were presented as mean ± standard deviation (SD) for continuous variables or as frequencies and percentages for categorical variables, as n indicates the number of patients. Normality of distribution for continuous variables was assessed with the Shapiro-Wilk test. Univariate analysis was performed with (i) the Student's t-test or the Mann-Whitney U test for continuous variables, according to the normality assessment, or (ii) the 𝜒2 test or the Fisher's exact test for categorical variables, as appropriate. A p-value <0.05 was considered as the threshold for statistically significant differences. Statistical analysis was carried out with IBM SPSS Statistics version 19.0.0 , and graphs were prepared with ggplot2 package for R using RStudio (version 1.4.1106).Baseline characteristics of the populationA total of 26 patients were included in this study. Table NPRS score throughout follow-upOverall, the mean initial NPRS score was 7.5±1.2 , which is not surprising as epicondylitis is associated with overuse and is more frequently observed on the dominant side. The mean age of the patients studied was 47.6±6.5 years, which was also consistent with the literature . On the We found a significantly higher baseline NPRS score for women . Several authors have reported that men and women differ in their responses to pain, with increased pain sensitivity and more painful diseases commonly reported among women, which is consistent with these findings . HoweverThe presence of tendon tear was observed in 65.4% (n=17) of the population. No relationship has been found between the initial NPRS score and the presence of this ultrasound finding. However, the presence of tear was significantly associated with higher pain relief at 12 months, both regarding the NPRS score, difference from baseline, and improvement rate. As far as we know, only one study has explored the predictive value of US findings in response to needle tenotomy with or without PRP, with no differences being found between the groups with and without tear, regarding the outcomes evaluated .In all time points evaluated, there was a statistically significant reduction in NPRS score greater than three units compared to baseline. As previously proposed, these differences suggest a clinically significant reduction in the level of pain throughout the follow-up period, so this technique can be considered effective for a period of at least 12 months ,25.This study has several limitations, namely the fact that it is retrospective, leading to a limitation in the information that was able to be collected; the small sample size, which may hinder the interpretation of findings and comparability with previous studies. The fact that not all patients had the same follow-up period may also be a limitation in our work. Nevertheless, this aspect was addressed by performing a subset analysis of the patients with data available for the 12-month follow-up.US-guided PRP injection following percutaneous microtenotomy was effective in the majority of the patients with epicondylitis and may be a reasonable option for the treatment of this clinical entity. Patients with tendon tear demonstrated a higher pain improvement rate at 12 months follow-up. This finding could be predictive of the clinical response to this technique, thus allowing a better selection of the candidates. Prospective and larger studies should be considered with the aim of clarifying whether the presence of tears is associated with a better therapeutic response to this technique.


Introduction: Brachial plexus avulsion (BPA) injuries commonly occur secondary to motor vehicle collisions, usually in the young adult population. These injuries are associated with significant morbidity, and up to 90% of patients suffer from deafferentation pain. Neuromodulation procedures can be efficacious in the treatment of refractory neuropathic pain, although the treatment of pain due to BPA can be challenging. Dorsal root entry zone (DREZ) lesioning is a classical and effective neurosurgical technique which has become underutilized in treating refractory root avulsion pain.Methods: A systematic review of the different technical nuances, procedural efficacy, and complication profiles regarding DREZ lesioning for BPA injuries in the literature is included. We also present an institutional case series of 7 patients with BPA injuries who underwent DREZ lesioning.Results: In the literature, 692 patients were identified to have undergone DREZ lesioning for pain related to BPA. In 567 patients, the surgery was successful in reducing pain intensity by over 50% in comparison to baseline (81.9%). Complications included transient motor deficits (11%) and transient sensory deficits (11%). Other complications including permanent disability, cardiovascular complications, infections, or death were rare (<1.9%). In our case series, all but one patient achieved >50% reduction in pain intensity, with the mean pre-operative pain of 7.9 ± 0.63  reduced to 2.1 ± 0.99 at last follow-up (p < 0.01).Conclusion: Both the literature and the current case series demonstrate excellent pain severity reduction following DREZ ablation for deafferentation pain secondary to BPA. Brachial plexus avulsion (BPA) injuries are a common complication secondary to motor vehicle collisions. In one single center study, motor vehicle collisions accounted for 29% of BPA . The mosDorsal root entry zone (DREZ) lesioning is an effective technique in the treatment of chronic neuropathic pain secondary to BPA that is refractory to pharmacological treatment. DREZ lesioning procedures were first described by Sindou for the treatment of pain secondary to Pancoast's syndrome , and mulWhile the procedure was developed and popularized decades ago, it remains underutilized for the treatment of refractory pain, and the literature is limited to class III case series. In the current article, we present a review of the relevant literature, and an institutional case series of seven patients with refractory pain secondary to BPA that were treated with DREZ ablation.This systematic review was conducted according to the Synthesis Without Meta-analysis guidelines. A detailed literature review was conducted through the Embase and MEDLINE databases (1947 to present) with reference scanning using the following search terms:  AND  AND (injury). The references from identified articles were evaluated for the inclusion of additional studies.Only original peer-reviewed clinical studies in humans whose results were published in the English language were considered for inclusion. Due to the relative paucity of the published literature on this procedure, we did not limit our inclusion criteria and thus included all published studies detailing the surgical management of patients diagnosed with BPA and deafferentation pain who were treated with DREZ ablation. DREZ ablation procedures included sharp dissection, laser, radiofrequency, or bipolar coagulation. Outcomes of interest included pain severity score as recorded on the visual analog scale (VAS) or as deemed appropriate in each study. Additional outcome measures included duration of pain relief, and post-operative complications.Articles in languages other than English were excluded, as were gray literature articles. Additionally, the articles that reported the same or part of the same patient cohort at separate time points were excluded. Due to the limited literature base, the included articles were limited to case series and case reports.T-test.A total of 7 patients were treated at the London Health Sciences Centre  for BPA injuries . PatientThe patients are positioned in prone position with the head in a Mayfield clamp. A bilateral C4-T1 laminoplasty is performed using a 3 mm high speed burr and a midline durotomy is performed. The anatomy is often disrupted due to root avulsion and the formation of pseudomeningoceles at the area of interest. The spinal cord may also be rotated, depending on the severity of the avulsion injury. Once the posterolateral sulcus is identified, EMG is used to identify any motor rootlets at 1 mAmp current. A radiofrequency electrode is then used to measure impedance at the identified levels. Normal impedance is estimated at 1200–2000 Ohms, vs. 500–1000 Ohms in injured tissue. Once the injured levels have been confirmed, the probe is tilted at 30–35° from the mid- sagittal plane, and radiofrequency ablation is performed at 75°C for 15–20 s. Lesions are performed at 1–1.5 mm intervals on the side of interest, and the DREZ ablation is extended to 1–2 levels above the highest identified level . The dura is then closed using 6-0 Prolene, and the lamina is reattached using titanium plates and screws.A total of 198 articles were identified through the literature search and underwent title and abstract review and the review process was summarized in a PRISMA chart . After sThe final study list included 31 papers, all of which were case series , 12–36 aThe results of the literature review are summarized in In total, 692 patients underwent DREZ ablation for brachial plexus avulsion. Of these, 567 (81.9%) patients showed a post-operative pain improvement of over 50%, while 125 patients (18.1%) had an improvement of under 50%. Only five studies reported pre- and post-operative VAS pain intensity scores: average pre-operative pain score was 8.5/10, compared to a 3.41/10 post-operative in 62 patients.Radiofrequency lesioning was used in 17 studies; Samii et al. initially used cordotomy electrodes to perform the DREZ lesioning, but later reported switching to radiofrequency electrodes . ThermalMotor, sensory, and non-neurological complications from all studies are summarized in Seven patients with BPA injuries underwent DREZ ablation as described above. Patient characteristics are summarized in (6) = 7.83, p < 0.01]. One patient subjectively reported little to no improvement, although their pain intensity score on VAS was reduced by 60% following surgery.Most patients reported similar pain characteristics including a consistent baseline crushing/burning pain with intermittent electrical pain. Mean pre-operative pain intensity ± standard error on VAS was 7.9 ± 0.63. All but one patient achieved >50% reduction in pain intensity, with an average post-operative pain of 2.1 ± 0.99 on the VAS at the last follow up [tRegarding post-operative complications, several patients reported hemibody paresthesias and transient ataxia, but only one found these sensations to be disabling and required long term rehabilitation. One patient suffered a cerebrospinal fluid leak and her post-operative course was later complicated by wound dehiscence and infection requiring operative revision; however, the patient remained satisfied with her pain improvement.BPA is a devastating injury caused by over-stretching the brachial plexus, which results in pulling the C5-T1 nerve rootlets from their origin in the spinal cord. Almost 90% of patients with BPA suffer from post-traumatic deafferentation pain . Such inThe case series presented here, although limited to seven patients, demonstrates the efficacy of the DREZ ablation procedure in treating neuropathic pain secondary to BPA injuries. All but one patient (85.7%) showed a >50% reduction in pain intensity following DREZ ablation. This aligns with previously published studies, which demonstrate 81.9% of patients achieving overall good post-operative pain control. Pre-operative pain in our series ranged between 7 and 10/10 on the VAS, which closely resembles literature values. This provides an objective measurement of the severity of deafferentation pain and its impact on patients' quality of life.The DREZ aligns with the posterolateral sulcus on the spinal cord and is composed of Lissauer's tract and the dorsal horn . LissaueSeveral theories have been proposed to describe the pathophysiology of chronic pain associated with BPA. As BPA is a preganglionic injury, it affects the function of second-order neurons in the dorsal horn cells, which forms the basis of the deafferentation process. In the event of deafferentation and avulsion injuries, the interneurons located in the dorsal horn exhibit epileptiform-like activity , 42. ThiMRI is considered the best non-invasive diagnostic modality for BPA, but its reliability has been controversial . As a reAs the affected population is generally young and healthy, long-term disability and disease burden becomes significant from an individual and societal level. Notably, up to 90% of patients with true root avulsion suffer from deafferentation pain, and 20% of these patients eventually will require surgical intervention due to intractable pain  , 29. DeaIndeed, prior to developing refractory deafferentation pain, many patients have undergone nerve grafting, suturing, and neurotization in attempt to delay or prevent such pain onset; however, despite early surgical intervention, pain is the primary symptom that has the greatest negative impact on quality-of-life . NeuropaThe pain response to DREZ ablation may be multifactorial. Our literature review demonstrated good overall efficacy of DREZ specifically for BPA injuries. One case series pointed to lower efficacy of DREZ in BPA patients who received surgical amputations in comparison to those who experienced traumatic amputations . In the Several factors were hypothesized to be associated with better outcomes following DREZ ablation, but no consistent trends were highlighted in our literature review. Some evidence suggests that patients with longer duration of deafferentation pain (6 years or more) may experience better pain relief following DREZ ablation compared to patients with shorter duration (3 years or less) . Both PiInterestingly, Samii et al. failed to find a significant correlation between pre-operative pain duration or number of avulsed roots and the response to DREZ ablation . It may Our case series and literature review confirm both the efficacy and relative safety of DREZ ablation for BPA. When combining cases from the literature review, nearly 11% of patients described transient or permanent paresthesia in the ipsilateral lower extremity, likely due to thermal injury to the dorsal columns during surgery. A further 11% of patients experienced transient or permanent motor deficits in the ipsilateral lower extremity, almost all in the form of ataxia. This effect may result from injury to the spinocerebellar tract, or may be secondary to loss of proprioception in the leg that was misclassified as a motor deficit. Other possible complications that may not be specific to DREZ ablation surgery include cardiac complications, surgical wound infection, CSF leak, or postoperative hemorrhage.The most significant limitation of this review lies in the quality of research studies examining the efficacy of DREZ for chronic pain in general, including brachial plexus avulsion injuries. No randomized controlled trials were identified in the literature, and the majority of the studies included in this review are observational and retrospective in nature. Furthermore, while all studies measured pre-operative and post-operative pain intensity, only six studies (including our case series) provided objective VAS scores. Most studies expressed results in percentage change. This significantly limits the ability to compile data from different studies to extrapolate more robust conclusions. Additionally, there is a large variation in the length of follow-up among reported studies, which limits our ability to fully ascertain the long term effects of the procedure. Regardless, this review provides the most comprehensive and up-to-date evidence regarding the efficacy of DREZ ablation surgery for management of BPA.BPA is a devastating injury with lasting neurological sequelae. Deafferentation pain adds to the morbidity of these injuries and tends to be refractory to common neuropathic analgesia regimens. This case series and detailed literature review reinforces that DREZ ablation offers an effective and safe treatment of deafferentation pain secondary to BPA at 1 year post-operatively, despite its underutilization. The current literature lacks consistency in outcome measures, follow-up periods, and use of operative techniques. More structured and detailed studies, in the form of prospective cohort studies, are needed in the future.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.AC and MS contributed to conception and design of the study. AC, MA, and BS performed the literature review. MA performed the statistical analysis. AC and QW wrote the first draft of the manuscript. MS and KM provided supervision and project administration. All authors read and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Were there patient racial and ethnic differences in opioid prescribing by the same primary care physician for episodes of new low back pain, particularly during the first wave of the opioid epidemic when the dangers of opioid use were not as well known?In this cross-sectional study of 274 771 older patients with new low back pain, primary care physicians were more likely to prescribe opioids to White patients than to Asian or Pacific Islander, Black, or Hispanic patients.There may have been unequal treatment of pain by physicians when the morbidity associated with opioid use was less well known. Substantial patient racial and ethnic differences in opioid prescribing have been documented, but how much of these differences were attributable to physicians prescribing opioids differently to patients of racial and ethnic minority groups is unknown, particularly during the first wave of the opioid epidemic when the dangers of opioid prescribing and use were not as well known.To examine associations of patient race and ethnicity with differences in opioid prescribing by the same primary care physician (PCP) for new low back pain episodes among older adults from 2007 to 2014.This cross-sectional study used Medicare data of PCP office visits by Medicare beneficiaries who were 66 years or older with new low back pain.Prescribing of any opioid in the first year of a new low back pain episode (days 1-365) and subsequent long-term use of an opioid (prescribed for ≥180 days in days 366-730).Among the study population of 274 771 patients  with new low back pain, 15 285 (6%) were Asian or Pacific Islander, 16 079 (6%) were Black, 21 289 (8%) were Hispanic, and 222 118 (81%) were White, cared for by 63 494 physicians. In adjusted analysis, on average, 11.5% of the White patients  received an opioid prescription in the first year of new low back pain. The same prescribing physician was 1.5 percentage points  less likely to prescribe an opioid if the patient was Black, 2.7 PP  less likely if the patient was Asian or Pacific Islander, and 1.0 PP  less likely if the patient was Hispanic. The same physician was more likely to prescribe a prescription nonsteroidal anti-inflammatory drug to a patient of a racial or ethnic minority group. White patients with new low back pain were more likely to develop subsequent long-term opioid use than patients of racial and ethnic minority groups .This cross-sectional study found that from 2007 to 2014, primary care physicians prescribed opioids for new low back pain more often to White patients than to patients of racial and ethnic minority groups. These results suggest that there may have been unequal treatment of pain by physicians when less was known about the morbidity associated with opioid use. This cross-sectional study uses a large Medicare data set of older adults with low back pain to examine how race and ethnicity may have been associated with opioid prescribing by primary care physicians during the first wave of the opioid epidemic. These differences have been noted particularly in emergency departments,11 has found a 3- to 4-fold variation across physicians in likelihood of prescribing opioids. Prior findings of racial and ethnic differences in opioid prescribing could have been associated with non-Hispanic White patients being more likely to be cared for by physicians who more frequently prescribe opioids. Whether the same physician prescribed opioids less frequently to patients of racial and ethnic minority groups than to White patients has not been explored. Such prescribing differences may suggest differential treatment or bias by physicians, particularly during what the Centers for Disease Control and Prevention calls the first wave (through 2010) of the opioid epidemic when opioid prescribing was rapidly increasing and the dangers of opioid use were not as well known as they are today.13Other research14 were less likely to prescribe opioids to patients of a racial or ethnic minority group than to White patients for the same outpatient concern, ie, new low back pain.17 This study examined whether physicians were more likely to prescribe a prescription nonsteroidal anti-inflammatory drug  to patients of a racial or ethnic minority group. This study examined whether such prescribing differences, if they existed, varied depending on the number of visits for back pain during the first year after diagnosis, with the number of visits used as a proxy for the level of or duration of pain. This study examined whether within-physician opioid-prescribing differences changed between 2007 to 2010 and 2011 to 2014. This study also examined whether there were racial and ethnic differences in developing subsequent long-term opioid use.The present study used a national sample of older Medicare patients in 2007 to 2014 to examine whether primary care physicians (PCPs), the most frequent prescribers of opioids,STROBE) reporting guideline for cross-sectional studies.The institutional review board of the National Bureau of Economic Research, where the data were housed and analyzed, approved the study and waived informed consent because only deidentified data were used. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology . The second was a binary indicator for prescribing NSAIDs by a particular PCP to a particular patient during a new low back pain episode. The third was a binary indicator for subsequent long-term opioid use, which was defined as being prescribed at least 180 days of opioids by all physicians seen in days 366 to 730 (the year after the new low back pain episode). The sample used for the analysis of subsequent long-term opioid use was limited to those who continued not to have cancer or a hospice claim and remained enrolled in Medicare Parts A, B, and D during the examined time period.19 and year of diagnosis of new low back pain.In addition to race and ethnicity, patient covariates included age , female sex, dual-eligibility for Medicaid, share of months receiving the Part D low-income subsidy, disability as the original reason for Medicare eligibility, Elixhauser comorbidities,20 was followed .In the first specification, a multivariable linear regression of the prescribing of opioids (or NSAIDs) as a function of race and ethnicity was estimated, controlling for the other covariates listed above. Physician fixed effects were included to compare differences in the prescribing of opioids and of NSAIDs to patients of different race and ethnicity by the same physician. The resulting coefficients on race and ethnicity represent the average within-physician opioid prescribing differences by race and ethnicity. Adjusted results by race and ethnicity using marginal standardization  were presented, holding other covariates at their mean values. This study then examined how within-physician racial and ethnic differences in the prescribing of opioids and NSAIDs differed by the number of visits for back pain during a new low back pain episode. To study this, in the second specification, both a categorical variable for number of visits to a particular physician for low back pain  during an episode and the interaction of this variable with the race and ethnicity variable were added. This study then examined whether within-physician opioid-prescribing differences changed between 2007 to 2010 and 2011 to 2014. To study this, in the third specification, the interaction of time period (2011-2014 vs 2007-2010) with race and ethnicity was added. The analysis of the binary outcome of subsequent long-term opioid use also used the first specification. To calculate the percentage of the overall racial and ethnic difference in opioid prescribing for new low back pain attributable to within-physician differences vs between-physician differences, the decomposition method by Chandra and colleaguesAmong the study population of 274 771 older patients  with new low back pain, 15 285 (6%) were Asian or Pacific Islander, 16 079 (6%) were Black, 21 289 (8%) were Hispanic, and 222 118 (81%) were White non-Hispanic, cared for by 63 494 physicians . Women cIn adjusted analyses, a physician was less likely to prescribe opioids to patients of a racial or ethnic minority group than to White patients during an episode of new low back pain . On averConversely, on average, a physician prescribed NSAIDs to 23.8%  of White patients, to 25.0%  of Black patients, a difference of 1.2 PP ; 25.4%  of Asian or Pacific Islander patients, a difference of 1.6 PP ; and 27.6%  of Hispanic patients, a difference of 3.8 PP  . ResultsThe probability of prescribing opioids and NSAIDs increased with the number of visits for back pain during a new low back pain episode A and B. Although the change in the likelihood of prescribing opioids for new low back pain episodes decreased by 1.0 PP  for White patients between 2007 to 2010 and 2011 to 2014, this study did not find a decrease that was statistically significantly different from the decrease among patients of a racial or ethnic minority group . In adjuUsing a nationally representative data set of older Medicare patients, this cross-sectional study found that the same PCP was less likely to prescribe an opioid and more likely to prescribe an NSAID for new low back pain to patients of a racial or ethnic minority group than to White patients. These prescribing differences were larger for patients with more visits for back pain during a given back pain episode. This study failed to find a narrowing of these prescribing differences between 2007 to 2010 and 2011 to 2014. In the year after a new low back pain episode, White patients were more likely than patients of a racial or ethnic minority group to develop subsequent long-term opioid use. Of the overall racial and ethnic difference in opioid prescribing for new low back pain, 60% was attributable to within-physician differences.6 encompass both differences across physicians (some may receive an opioid prescription because they were cared for by a higher opioid-prescribing physician) and differences within physicians. By including physician fixed effects, this study controlled for differential patient sorting by race and ethnicity across physicians. Prior studies may not have been able to do this because commonly used data sets to study opioid prescribing, particularly the National Hospital Ambulatory Medical Care Survey5 and the National Ambulatory Medical Care Survey,6 randomly sample visits from a 4-week and 1-week reporting period, respectively.21 Therefore, studies using these data sets do not have large enough sample sizes per physician to examine prescribing differences by the same physician. In addition, this study found that differential sorting of patients accounted for less than half of the overall racial and ethnic difference in opioid prescribing, meaning that more than half of this difference was attributable to the same physician prescribing opioids differently to patients of a racial or ethnic minority group compared with White patients.To our knowledge, no other study has examined racial and ethnic differences in opioid prescribing by the same physician. Prior findings of differences by race and ethnicity in opioid prescribing22 and the same or a higher prevalence of and level of pain as White patients.9 While the present study’s findings do not exclude the possibility that racial and ethnic differences in preferences for opioid use may drive some of the observed results, if a greater number of visits for low back pain provides a clearer signal to physicians about the severity or persistence of the pain, prescribing differences would be expected to narrow, not increase, with a higher number of visits.A possible reason for the observed differences in opioid prescribing by the same physician is that patients of a racial or ethnic minority group ask for opioid medications less frequently than White patients do. However, research finds that patients of a racial or ethnic minority group have similar expectations of pain relief as White patients23 found that PCPs had lower trust  in non-White than in White patients. Physicians in that study had differences in their level of trust despite there being no racial or ethnic difference in opioid misuse in patients.23 In fact, other research24 suggests that White patients were more likely than patients of other races and ethnicities to have an opioid use disorder.A more worrying possibility for these differences is that physicians may have different levels of trust in patients by race and ethnicity. A survey13 and the morbidity associated with opioids was less known than it is today. For example, in 2011, the Institute of Medicine published the report Relieving Pain in America, in which they wrote that “the majority of people with pain use their prescription drugs properly, are not a source of misuse, and should not be stigmatized or denied access because of the misdeeds or carelessness of others.”25 In light of this sentiment among physicians during this time period—that opioids were safe for most people and that only a few patients might misuse opioids—the prescribing patterns found in this study suggest differential treatment or even bias by physicians when managing patient pain. Finally, although this study describes opioid prescribing differences by race and ethnicity for the same physician, the opioid epidemic has had deleterious effects for people of all races and ethnicities.26 Public policy responses that address current racial and ethnic disparities will be important,29 such as making medication-assisted treatment  more accessible by offering incentives to physicians who serve patients of racial and ethnic minority groups and populations with low income.The time period examined in this study includes the first wave of the opioid epidemic when opioid prescribing was rapidly increasing30 so results that included those with Medicare Advantage may have been quite different. Third, results were based on health claims data only; therefore, details of the case history, such as pain intensity and findings of the physical examination, were not included. Fourth, over-the-counter medications are not included in the data, so the use of these medications  could not be examined. Fifth, although this study focused on an opioid-naive population, opioid prescriptions were not tied to diagnoses, so they may have been prescribed for other reasons. However, differences were also found when examining opioid prescribing within a few months of the new low back pain diagnosis and when examining opioid prescribing for patients with a large number of visits for low back pain. Sixth, the race and ethnicity variable used does not completely identify patients of racial and ethnic minority groups, especially beneficiaries who are Asian or Pacific Islander or Hispanic31; this misidentification would bias the observed differences toward zero. Seventh, the definition of new low back pain used in this study was not externally validated.This study had several limitations. First, this was an observational study and residual confounding is possible. Second, results were limited to the traditional Medicare population with Medicare Part D and may not generalize to other populations, including younger populations, those without Medicare Part D, and those with Medicare Advantage. Those with Medicare Advantage represent one-third of all Medicare beneficiaries and historically have been healthier,This cross-sectional study found that in a large national sample of older adults with Medicare, physicians prescribed opioids less frequently to patients of racial and ethnic minority groups than to White patients during and after the first wave of the opioid epidemic when opioid prescribing was rapidly increasing. Reasons for these differences and implications of these differences on opioid-related morbidity and mortality should be further explored.