Recent information on epidemiology and management of post-herpetic neuralgia (PHN), a painful complication of zoster, is scarce.This study was conducted at the Pain Clinic of the Policlinico Tor Vergata, Rome, Italy, on eighty-five immunocompetent patients with a clinical diagnosis of PHN. At enrollment , the patients were interviewed by physicians to obtain demographic data and information about their zoster clinical history and underwent a blood test for VZV-DNA research. DN4 and SF-12 questionnaires were used to assess the neuropathic nature of pain and the overall health status, respectively. A one-year follow-up was planned for enrolled cases, who were visited at regular intervals of at least 3 months.p = 0.006 vs untreated patients). Only 2.6% of patients treated with antivirals during acute zoster but 18.6% of the untreated ones presented with neuropathic pain at T12 (p =0.007), even though the two groups were similar at T0. VZV-DNA was found in 5 out of the 50 available blood samples. At the last follow-up visit, PCS and MCS scores of the PHN patients were found to be recovered over those of the historical age-matched healthy controls. Undesirable side effects of analgesic therapies were observed in 15.3 to 28.8% of the patients.At T0 all the patients were at least 6 months from the episode of acute zoster and still presented with intense pain . Using antivirals within 72 hours from the rash onset was associated to a significant reduction of pain at T0  contains supplementary material, which is available to authorized users. Post-herpetic neuralgia (PHN) is the most challenging and debilitating complication of herpes zoster (HZ) in immunocompetent hosts. It is characterized by constant or intermittent burning, itching or aching, with paroxysmal or lancinating pain. Other primary characteristic, such as numbness, tingling and allodynia, also contribute to the burden of PHN. Pain intensity at the rash onset, age, rash severity, length of prodromal pain and cranial localization are more frequently reported as predictors of PHN -14]. Se. Se14]. Despite advances in antiviral therapy during acute HZ and the more recent introduction of vaccination against Varicella-zoster virus (VZV) , PHN conThe treatment of PHN is presently based on a well characterized array of drugs and drug associations with proved efficacy, including tricyclic antidepressants, the antiepileptic drug gabapentin, pregabalin and opioids, with some evidence also for topical lidocaine . It remaAcute HZ and consequently PHN particularly afflicts the immunocompromised and elderly patients, a fact that has serious implications for health-care delivery in the context of ageing populations in the developed world and the worldwide spread of HIV disease. Left untreated, PHN can become a severe and debilitating condition affecting all aspects of a patient’s life .The present report focus on the actual impact of diagnosis and management of PHN. In detail, the correlations existing between demographic and clinical characteristics of patients, the possible utility of VZV-DNA research in blood, and the efficacy of treatments for pain relief on the quality of life of PHN patients have been examined.Patients with a clinically diagnosed PHN, with pain over 3 VAS for at least 6 months after the onset of acute zoster, were consecutively enrolled at the Pain Clinic of the Policlinico Tor Vergata, Rome, Italy, and examined and treated between January 1, 2009 and November 15, 2010. The study was submitted to and received approval by the Independent Ethical Committee of the University of Rome “Tor Vergata”.Eighty-five immunocompetent patients with PHN gave written informed consent to be included in the study. They were interviewed by physicians to obtain demographic data , memory of primary VZV infection and HZ history . All data obtained from the interviews were recorded in database files.Participants in the study also were asked to undergo a blood test for VZV DNA research at the time of enrollment. Blood sampling (5 ml whole blood per patient) was performed after an overnight fast. Whole blood samples were collected and DNA was extracted using a QIAamp DNA blood mini kit  according to the manufacturer’s instructions. The eluted DNA was stored at -20°C. Detection and quantification of VZV DNA were performed by using a VZV Q-PCR Alert kit . The cut-off of the method was 56 viral copies/ml and below this level it is able to detect up to 10 copies/ml of virus, if present.Different tools were used to quantify and qualify pain in the enrolled PHN patients. Briefly, the intensity of pain was evaluated using a visual analog scale (VAS) of 10 cm in length that was graduated from “0” to “10,” where “0” represented no pain and “10” the most unbearable pain.The DN4 questionnaire (which stands for Douleur Neuropathique en 4 Questions) was used to estimate the probability of neuropathic pain in our PHN patients. It consists of 10 items subdivided into two parts: sensory descriptors (seven items) and signs relating to the sensory examination (three items). The presence of neuropathic pain was taken to be the dependent variable and needed to reach a score of at least 4 out 10, while non-neuropathic pain presented scores of less than 4 out 10. This questionnaire has been well validated in a number of studies -39]..39].The SF-12 questionnaire was also used in the medical interviews . It is aA one-year follow-up was planned for all the enrolled cases, who were visited at least every 3 months. Patients were subjected to drug therapy according to the protocols currently in use at international level ,43]. Tr. Tr43]. Statistical analysis and data processing were performed using SPSS software – version 20 for Windows™. All two-sided statistical tests were performed with a 5% significance level. Quantitative variables were analysed by descriptive statistics including mean values, standard deviation, median, minimum and maximum. Clinical and demographic characteristics were analysed by Chi-square test and Analysis of variance (ANOVA).The demographic and clinic characteristics of the PHN patients enrolled in the study are listed in Table The information on age, gender, HZ diagnosis and history, the overall health status and the immune status were collected by medical interview and visit at the time of enrollment in the study. Immune status was determined on the basis of the absence of specific conditions or treatments, i.e. active cancer, solid organ transplant, AIDS, chronic corticosteroid use, or other immunosuppressive treatments for autoimmune diseases or other conditions.All the patients, in both gender categories, reported to have had prodromal pain and abnormal sensations in the days (from 1 to 3) preceding the HZ rash onset. The rash localization was thoracic in 37 patients and cranial, cervical or lumbar in 19, 10 and 19 patients, respectively. The intensity of rash was moderate or severe in the 87% of patients and mild in the remaining 13%. Only one half of the patients had received specific antiviral therapy prescription at the time of the HZ episode.Chi-square: p < 0.03).No statistically significant difference between the two gender groups in relation to the different parameters showed in Table i.e. time 0, T0) was reported by the majority of the patients .Intense or very intense pain at the time of enrollment  and 6 months (range: 6-72), respectively ( p = 0.067).The median duration of pain (time from the rash onset), which was equal to 9 months (range 6-150) in the total population sample, was found to be longer for women than men, The measures of the intensity and quality of pain at the time of enrollment and during the follow-up period are reported in Table p = 0.006 versus untreated patients). Further analyses confirmed a significant risk of having greater pain among patients who had not received antiviral therapy (Table p =0.007), even though no difference among the two groups had been observed at the time of enrollment (T0).The use of antiviral therapy , starting within 72 hours from the rash onset, had been capable of inducing a significant reduction of pain (VAS average) at the time of enrollment at the Pain Clinic (T0)  in the patients with PHN at all the times tested (p <0.001), without significant differences among different age groups Table . HoweverThe Physical and Mental Health Composite Scale (PCS and MCS) scores of the patients enrolled in the study were measured by means of the SF-12 questionnaire. As expected, they varied as a function of the patients’ age and were found to be lower in older individuals than in the younger ones Table .Table 4As shown in the Table At the time of enrollment, PCS mean scores of our patients were found to be lower in older patients than in the younger ones, whereas MCS mean scores appeared to be quite similar Table . The effFive out of the 50 available blood samples from the total of 84 PHN patients enrolled in this study were found to be positive for VZV DNA. Among them were 3 males  and 2 females (48 and 75 years-old). Four of them had been affected by thoracic zoster, whereas the fifth was a 48 y-o woman who has presented with trigeminal zoster. The demographic and clinic characteristics of VZV DNA-positive PHN patients are summarized in the Table This study confirms and extends previous observations about the natural history of zoster pain in a cohort of eighty-five consecutive immunocompetent PHN patients, who were followed prospectively after their admission at the Pain Clinic, Policlinico Tor Vergata, Rome, Italy, to receive proper medical therapy for pain relief.At the time of study entry all the PHN patients were at least 6 months from the episode of acute zoster and still presented with intense or very intense pain (VAS >6), whose neuropathic nature was confirmed by the positivity of DN4 questionnaire, with scores greater than 4 in all the patients examined.Our results clearly indicate that patients who still have significant neuropathic pain  6 months after the acute episode of zoster , have a high probability of suffering from chronic pain in the subsequent months/years. This finding is in accordance with data from the international literature, since, on the basis of recently published prospective studies, six months is just emerging as a reliable time-threshold to discriminate, in the context of patients with PHN, between those with a more favorable or poor prognosis . ConsistWe had shown previously that older age, greater acute pain intensity, greater rash extent and longer duration of prodromal pain are independent risk factors in the development of post-herpetic neuralgia, by analyzing the relationship between baseline and 6-month follow-up data in a sample of 219 Italian immunocompetent herpes zoster patients . Even coOur previous studies did not establish female gender as a predictor of post-herpetic neuralgia . SimilarIt is a matter of fact, however, that the median duration of pain before going to the pain clinic, which in the present study was equal to 9 months (range 6-150) in the total population sample, was found to be longer for women than men, i.e. 12 months (range: 6-150) and 6 months (range: 6-72), respectively, approaching the statistical significance and raising the question of gender differences with regard to the PHN.Interestingly, a recent study shows that the incidence of CNS disease caused by alphaherpesvirus  is associated with gender and its influence varies over the lifetime . StartinAlthough current guidelines recommend antiviral treatment within 72 hours from the rash onset in individuals aged over 50 years, with the aim of reducing the incidence and duration of PHN, only around one half of our PHN patients had received appropriate treatment. However, when considering that, as reported recently, 78.4% of zoster patients receive antiviral therapy in Italy , the herQuality of life is dramatically reduced in patients with long-lasting PHN. Consistently, PCS and MCS scores of our patients at the time of enrollment in the study were found to be sharply lower than those of a large Italian population sample of healthy individuals, who were used as an historical age-matched control. As expected, not only the MCS scores but even more the PCS scores of our patients varied as a function of the patients’ age and were found to be lower in older individuals than in the younger ones. Also, it has to be emphasized that treatments used for pain relief seemed to have worked in all the patients enrolled in the study regardless of age groups or gender. This fact outlines the importance of a systematic and specialized approach to the problem of chronic pain in PHN patients. The nature of neuropathic pain in PHN is variable, so that it may be described as continuous or paroxysmal, evoked or spontaneous, burning or lancinating, and be associated with a range of other sensory abnormalities in the skin . This vaFinally, our results do not allow us to confirm a clear relationship between the positivity/persistence of VZV viremia and PHN, since only 5 out of the 50 available blood samples from the PHN patients in the study were found positive for VZV DNA search. Other reports show comparatively higher percentages of VZV DNA-positivity in blood or saliva of patients affected by HZ and/or PHN ,56]. It. It56]. It seems that up to date, in spite of the large body of evidence available in the literature, there is still a need to gain new insights on the mechanism/s underlying PHN pathogenesis, which at present remains not fully elucidated. In detail, whether PHN pathogenesis is due to persistent productive virus infection in ganglia or to neuronal cell damage , is still controversial -67]. Th. Th67]. We report that patients who still have significant neuropathic pain six months after acute zoster present a high probability of suffering from chronic pain in the subsequent months/years. Antiviral therapy used within 72 hours from the rash onset reduces the risk of higher VAS in the follow-up. Current strategies of analgesic therapy are effective to achieve relief of pain in PHN patients, but they are burdened with heavy and undesirable side effects. PHN represents a major public health problem. In spite of the large body of evidence available in the literature, there is still a need to gain new insights on chronic pain, its burden and the efficacy of available treatments.


P < 0.001). With respect to JOABPEQ, significant improvements were observed with regard to the following dimensions: pain-related disorders (P < 0.01), lumbar spine dysfunction (P = 0.031), gait disturbance (P = 0.028), and psychological disorders (P = 0.014). The IMC distance showed an improvement tendency after PGB treatment, albeit with no significance (P = 0.063). Minor adverse events such as dizziness were observed. PGB can be effective for neuropathic leg pain refractory to NSAIDs in LSS patients, resulting in not only pain control but also improving lower back pain-related ADL/QOL scores. We investigated the efficacy of pregabalin (PGB) for neuropathic leg pain in lumbar spinal stenosis (LSS) patients with disturbed activities of daily living (ADL)/quality of life (QOL) in a prospective observational study. Subjects were a total of 104 LSS patients with neuropathic pain (NeP) in leg and neurological intermittent claudication (IMC) refractory to nonsteroidal anti-inflammatory drugs (NSAIDs) for at least a month. NeP was identified using screening tool, Pain DETECT questionnaire. Visual analog scale (VAS) scores and responses to the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) were assessed before and 6 weeks after PGB treatment initiation. Changes in IMC distance and adverse events were also recorded. PGB significantly improved their VAS scores for pain and sleep quality ( Patients with lumbar spinal stenosis (LSS) often experience chronic and refractory pain, and this condition is the most common reason for spinal surgery in patients older than 65 years . The majPatients with LSS exhibit accumulated neuronal damage, which results in chronic pain that is refractory to existing analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) because it originates from the damaged nervous system known as neuropathic pain (NeP), along with nociceptive pain (NocP) . In patiα2δ subunits of Ca2+ channels [Pregabalin -3-(aminomethyl)-5-methylhexanoic acid), is a newer generation gabapentinoid that was originally synthesized as an adjuvant antiepileptic drug over four decades ago. Since 2004, however, it has been commonly used as a first-line drug for NeP in the United States and Europe [channels . The effchannels , 8. HoweOn the basis of the above perspectives, the current study evaluated the effects of PGB on NeP in the legs, ADL, and QOL in patients with LSS.This prospective, observational study was approved by our Institutional Review Board and is registered in the Japanese national clinical trials registry . Informed consent was obtained from all patients before enrollment. In total, 19 certified Japanese orthopaedic surgeons from 13 facilities were involved in this study.PGB-naïve LSS patients with low back and leg pain aged 20–90 years who were diagnosed with chronic NeP using the Pain DETECT questionnaire (PD-Q), which is a patient-oriented and validated screening tool, were included in this study [Patients with conditions that could alter their pain perceptions, such as diabetes mellitus, psychiatric disorders, and chronic regional pain syndrome (CRPS), were excluded, as were patients with a history of previous spine surgeries for LSS, nerve block injection within 2 months before trial registration, peripheral vascular disorder, and malignant tumor within 2 years before trial registration. Patients with a fresh vertebral fracture or spinal tumor identified on MRI were also excluded.Following appropriate NSAID treatment for more than a month, the patients were additionally prescribed PGB without discontinuing or modifying the dose of NSAIDs. Treatment was initiated with a dose of 25 mg/d, which was gradually increased every week to 150 mg/d over 6 weeks, depending on their pain intensity, until a VAS score of <30 was achieved .The primary endpoint was the direct analgesic effect of PGB on leg pain evaluated using VAS, while the secondary endpoints comprised changes in circumstantial aspects of the pain, namely, sleep quality and ADL/QOL. For the evaluation of ADL/QOL, the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) was used, while VAS was used to assess sleep quality. JOABPEQ is an ensured and a validated method for evaluating the degree of LBP-related ADL/QOL and includes the following five dimensions: pain-related disorders (PaD), gait disturbance (GaD), lumbar spine dysfunction (LuD), social life disturbance (SoD), and psychological disorders (PsD) . The min t-tests, Fisher's exact test, and multivariate linear regression analyses. A P value of <0.05 was considered statistically significant.Statistical analyses were performed by a biostatistician using the SAS software ver. 9.2 . Data were analyzed using a combination of unpaired 2-tailedP = 0.67). There were no significant differences in demographic characteristics such as sex, age, and physique (height and weight) between the two sets. LSS pathology showed no significance among the pathologies, spinal nerve compression, cauda equina compression, or both (P = 0.82).P < 0.0001 and 11.5–29.3; P = 0.0006, resp.). The scores were not influenced by the LSS pathology.P < 0.0001), LuD , GaD , and PsD  showed a significant improvement after PGB treatment, while that for SoD showed an improvement tendency with no significance . The scores were not influenced by the LSS pathology.P = 0.063; The IMC distance showed a tendency to increase after the 6-week administration of PGB, although the change was not significant , dizziness , nausea , and edema  experienced PGB-related adverse events , which iP < 0.05). The IMC distance showed a tendency to improve, albeit with no significance. Finally, PGB-related adverse events such as dizziness, ataxia, and somnolentia, which were of mild severity and resolved without any additional treatment, were observed. First we should keep in mind that the current preliminary study has relative control of the patients themselves with a limited observational period, which can contain placebo effect.The current study evaluated the therapeutic effects of PGB in patients with LSS accompanied by neuropathic leg pain and IMC refractory to NSAIDs. PGB significantly improved the VAS scores for leg pain and sleep quality and the JOABPEQ scores for PaD, LuD, GaD, and PsD  defined in a previous study . TherefoTaken together, the effects of PGB on neuropathic leg pain in the LSS patients in the current study were similar to those observed in a previous study including 96 LSS patients , thus coThe current study suggests that PGB not only alleviates NeP but also improves the associated symptoms such as sleep disturbance, mood disorders, and disability; this eventually translates into an improvement in overall health. JOABPEQ is a new outcome measure that enables the evaluation of dysfunction, disabilities, and psychosocial problems caused by a disease on the basis of the Roland-Morris Disability Questionnaire and Short-Form (SF) 36 , 13. AmoThere may be a correlation between the improvement in the JOABPEQ score for PsD and that in the VAS score for sleep quality, because the two factors are clinically related and because PGB itself can alleviate anxiety, depression, and sleep disturbance –18. HoweInterestingly, we observed a significant change in the score for GaD and an insignificant improvement in the IMC distance, even though the two parameters are believed to be closely related. Evidence regarding the effects of PGB on IMC is somewhat controversial. Markman et al. reported that PGB did not increase the walking duration of LSS patients during a treadmill test . HoweverA clinical study based on patient-oriented outcome measures such as the SF-Mc Gill Pain Questionnaire and EuroQol 5D showed the effectiveness of PGB in alleviating painful lumbar radiculopathy . The strPGB-associated adverse events occurred in 12.5% patients, including dizziness, nausea, ataxia, somnolentia, weight gain, and peripheral edema. These are common PGB-related events, and their intensity generally increases with an increase in the PGB dose . The incThe current study has some limitations. First, it was not a randomized controlled, blinded study. Also the current study allowed drop-out data due to unsatisfied data collection under strict control, which should be improved more aggressively. Second, it lacked a strict control; the status of refractory pain before PGB treatment was used as a relative control. This may have led to potential cross-interaction between PGB and preprescribed drugs, although PGB reportedly does not interact with other drugs . FurtherThe major advantages of PGB include its relative reliability, ease of use, and high tolerability . Thus faIn conclusion, the results of this study suggest that PGB can not only control neuropathic leg pain refractory to NSAIDs but also affect lumbar spinal function, gait disturbances, psychological disorders, and sleep quality. There is a possibility that an appropriate diagnosis of NeP and early PGB initiation can significantly decrease medical costs by avoiding prolonged treatment .


Objective. Although intrathecal drug infusion has been commonly adopted for terminal cancer pain relief, its adverse effects have made many clinicians reluctant to employ it for intractable cancer pain. The objective of this study is to compare the efficacy and security of an intrathecal continuous infusion of morphine and ropivacaine versus intrathecal morphine alone for cancer pain. Methods. Thirty-six cancer patients received either a continuous morphine (n = 19) or morphine and ropivacaine (n = 17) infusion using an intrathecal catheter through a subcutaneous port. Numerical Rating Scale (NRS) scores and the Barthel Index were analyzed. Adverse effects and complications on postoperative days 1, 3, 7, and 15 were also analyzed. Results. All patients experienced pain relief. Compared to those who received morphine alone, patients receiving morphine and ropivacaine had significantly lower postoperative morphine requirements and higher Barthel Index scores on the 15th postsurgical day (P < 0.05). Patients receiving morphine and ropivacaine had lower NRS scores than patients receiving morphine alone on postoperative days 1, 3, 7, and 15 (P < 0.05). Negative postsurgical effects were similar in both groups. Conclusions. Morphine and ropivacaine administration through intrathecal access ports is efficacious and safe and significantly improves quality of life. Despite guidelines and recommendations, many patients with cancer still have inadequate pain control . Many paIntrathecal injection of opioids has already been successfully utilized as a front-line treatment for cancer pain refractory to traditional treatment . Intrathμ, δ, and κ opiate receptors [Morphine exerts effects against pain by binding to the eceptors , which seceptors . Voltageeceptors . Ropivaceceptors . Studieseceptors . Despiteeceptors , this trFew studies have utilized an intrathecal continuous injection of ropivacaine with morphine to treat cancer pain . The objThis was a double-blind, random clinical study conducted at our hospital. The institutional ethics committee was used to assign patients and provide advice regarding ethical issues. The study was approved by the institutional review board, which also confirmed informed consent by the patients. This study included thirty-six terminal cancer patients between November 2010 and September 2013 . EligiblAll 36 patients were at the hospital receiving systemic treatment. They were told about the availability of an intrathecal catheter for pain management (with dosages administered by a responsible and capable caregiver) days ahead of the catheter implantation. In addition to verbal instruction, they were presented with the intrathecal catheter and port system and informed of the implantation treatment in written form, particularly with regard to the advantages and potential side effects of intrathecal therapy. They were also advised in writing of complications and related blood tests, particularly coagulation screening, C-reactive protein and white cell count. All instructions were performed before catheter placement. Clindamycin (600 mg) was administered intravenously 2 h before catheter insertion for antibiotic prophylaxis.Intrathecal catheterization combined with implantation of a subcutaneous infusion port  was conducted in the sterile condition in an operating room. The patient was put in the lateral decubitus position and then draped in a sterile fashion. Lumbar puncture was performed at the interspace between L2 and S1 using an 18-gauge Tuohy needle. A 20-gauge intrathecal catheter was introduced through the Tuohy needle. The catheter was then inserted into the subarachnoid space. The catheter location was confirmed by ensuring that aspiration of cerebrospinal fluid was possible. Approximately 15–30 cm of the catheter was introduced intrathecally according to the location of the pain under fluoroscopic guidance. The catheter was moved through the subcutaneous tissue between the lumbar incisions and port pocket and then attached to the port. The port pocket was established through a bone structure . The port was placed into a subcutaneous pocket organized in the chosen area and attached to the fascia. Every patient underwent the procedure with no complications. Access to the port was via percutaneous injection using a special noncoring needle that was connected to a patient-controlled analgesia (PCA) device with a total volume of 100 mL and a rate of 0.5 mL/h. The original intrathecal morphine dosage was obtained from the preoperative morphine injection using an oral-intrathecal ratio of 300 : 1 . The staWe analyzed the demographic statistics  of the patients, cancer categories, location of pain, morphine dosage history, use of oral medications, and pain intensity before implantation of the port as reported using the Numerical Rating Scale (NRS) in which 0 means no pain and 10 means the greatest pain. The NRS score and intrathecal morphine and ropivacaine consumption on postsurgical days 1, 3, 7, and 15 were evaluated. The Barthel Index, a disability scale with scores from 0 (completely dependent) to 100 (completely independent), was used to evaluate the functional status of the patients. Data regarding technical aspects of the procedure  and nonpharmacological methods used to reduce cancer pain were obtained. The day before hospital discharge, the use of extrasystemic opioids and adjuvants was also recorded.t-test and two-way ANOVA were used for data comparisons. P < 0.05 was defined as significant.The data were analyzed using SPSS 17.0 software. The paired-sample Thirty-six patients completed the trial: 17 in group R and 19 in group M. In group M, 11 male and 8 female patients were studied, with an average age of 64.0 years (40–85 years). In group R, 14 male and 3 female patients were studied, with an average age of 62.6 years (49–85 years). In group M, nociceptive pain was present in 11 patients, whereas a mixture of neuropathic-nociceptive pain was present in 8 patients. In group R, nociceptive pain was present in 7 patients, whereas mixed neuropathic-nociceptive pain was present in 10 patients. Physicians were asked to rate the pain characteristics based upon complaints from patients, with nociceptive pain defined as “aching, squeezing, or pressure-like sensations”; neuropathic pain was characterized as “tingling, burning, or electrical” sensations. The mean duration of hospital care was 12 days for patients in group M and 15 days for those in group R.P = 0.688).The doses of preoperative systemic opioids  were summarized as the oral morphine equivalent dose. Additional usage of opioid treatment was also documented to summarize gross opioid usage on a daily basis and presented as the variation in preoperative opioid dosage. The preoperative oral morphine consumption was between 45 and 600 mg/day (mean: 200.8 mg/day) in group M. The preoperative oral analgesic consumption was between 6 and 750 mg/day (mean: 223.7 mg/day) in group R. The mean preoperative doses of oral morphine in groups M and R were similar . However, the mean dose of intrathecal morphine on postoperative day 15 in group R was significantly lower than that in group M (P = 0.005). In group R, the mean doses of intrathecal ropivacaine on postoperative days 1, 3, 7, and 15 were 4.5 mg, 6.10 ± 2.10 mg, 6.96 ± 2.48 mg, and 8.71 ± 6.54 mg per day, respectively. Dose escalation was guided by the clinical response. No patient received oral opioid supplementation for 15 days after the surgery.The daily dosage of intrathecal morphine and ropivacaine was adjusted at a certain time based on the pain degree and the bolus dosage required in the last 24 h. A significant increase was observed in intrathecal morphine administration on postoperative days 3, 7, and 15 in comparison with day 1. In group M, the mean doses of intrathecal morphine on postoperative days 1, 3, 7, and 15 were 0.67 ± 0.48 mg, 1.02 ± 0.64 mg, 1.44 ± 0.86 mg, and 2.36 ± 1.56 mg per day, respectively. In group R, the mean doses on postoperative days 1, 3, 7, and 15 were 0.75 ± 0.66 mg, 0.93 ± 0.80 mg, 1.09 ± 0.99 mg, and 1.23 ± 1.10 mg per day, respectively. The mean doses of intrathecal morphine on postoperative days 1, 3, and 7 in groups M and R were similar (P = 0.069). The average NRS scores on the postoperative days 1, 3, 7, and 15 decreased gradually in both groups M and R . However, the average NRS scores on postoperative days 1, 3, 7, and 15 were statistically lower in group R than in group M   .P = 0.472). However, the Barthel Index score on the 15th postoperative day was higher in group R than in group M (P = 0.017)  .Most intrathecal catheters were implanted at the L2-3 interspace in both group M (72.2%) and group R (61.1%), and most of the catheters reached T10 in both group M (55.6%) and group R (44.4%). Intrathecal morphine and ropivacaine presented few complications or adverse effects. No patient experienced respiratory depression. In group M, one patient experienced transient urinary retention and three experienced nausea and vomiting. In group R, one patient experienced transient urinary retention, one constipation, and one nausea and vomiting. The adverse effects were managed with conservative therapies. Urinary retention was controlled through transient urinary catheterization. No complications of intrathecal drug delivery were noted. No surgical complications were found, and meningitis and infection were not observed. Regional headaches were also not observed. Ropivacaine was added to the opioid injection without any significant dermal numbness or decreased sensation. There were no complications or adverse effects serious enough to require intrathecal port removal or treatment changes.The first study of intrathecal morphine in a cancer patient was performed by Tung et al. in 1980 . The firThe mechanism of action of intrathecal opiates is under debate. As an opiate receptor agonist, morphine blocks the activity of some cells in the substantia gelatinosa of the medullary dorsal horn . As a reδ and C fibers [δ and C fibers [μ, δ, and κ receptors) [The combined intrathecal treatment is useful when insufficient pain reduction is realized with intrathecal monotherapy, especially in neuropathic pain patients. Different pain statuses have various potential mechanisms; as a result, a medication with a particular mechanism tends to only be efficient for one or two specific pain conditions. Thus, combining agents tends to be useful to treat multiple aspects of the pain, generating synergistic efficacy for pain management. Intrathecal morphine targets medullary opioid receptors, whereas intrathecal ropivacaine functions at the dorsal root and the nerve roots to promote pain management. Ropivacaine reversibly blocks sodium influx, thereby hindering pain signal transmission through AC fibers . RopivacC fibers , 14 by dceptors) . Our finThe adverse effects observed in this study were similar to those previously reported. Nausea and vomiting tended to be the most common and were observed in 15.7% (3 of 19) of morphine-only patients and 5.8% (1 of 17) of patients treated with ropivacaine and morphine; these symptoms are frequently reversible with ondansetron. Urinary retention is also relatively common with intrathecal opioids. In our patients, urinary retention often resolved in a few days or weeks, and prolonged bladder dysfunction was not common. Both treatment groups had 1 patient with transient urinary retention. Constipation was not observed, as most patients treated with systemic opioids in this research were treated with a bowel stimulant, a stool softener, or laxatives prior to intrathecal management. Constipation occurred in 1 patient in group R. Somnolence and sedation are rare adverse effects for medullary opioids . We did Because of the above risks and system implantation costs, proper selection of patients prior to subcutaneous intrathecal port transplantation is critical. The following selection criteria are recommended: (1) great pain despite oral narcotic management or unsatisfactory narcotic side effects at the dosage required to manage pain; (2) medication for the underlying disease, for example, radiation tumor treatment or surgical tumor treatment, that has not caused the pain; and (3) neuroablative processes for pain reduction that were refused by patients or deemed as unsatisfactory by physicians. In addition, the outcome with the intrathecal port is greatly determined by the attitude of the patient and family; a peaceful and friendly environment is important. The implantation of intrathecal catheters connected to subcutaneous injection ports was appropriately indicated for patients in this study on the grounds of life expectancy, expense, and drug/dosage requests.Our study had several limitations. First, the effective sample size was small, as the study included only 36 patients. Second, long-term complications, such as formation of granulomas and intrathecal infection, were not assessed because of the short follow-up period. Third, mild negative effects, such as sedation or pruritus, may have been underestimated, as the patients showed pharmacological adverse effects in a passive manner in the present study. Fourth, the preoperative pharmacological adverse effects of systemic opioids were not available. Thus, it is not clear whether opioid-mediated side effects were decreased by the intrathecal treatment.Intrathecal morphine and ropivacaine management in connection with a transplantable subcutaneous port is a safe and efficient approach to provide treatment of intractable cancer pain. The extra intrathecal ropivacaine enhances pain management and increases the quality of life. The usage of intrathecal ropivacaine is therefore deemed to be safe and acceptable. Large-scale prospective random trials are necessary to assess the advantages and safety of intrathecal ropivacaine.


Effective short-term outcomes have been well documented for trigeminal neuralgia (TN) patients treated with Gamma Knife radiosurgery (GKRS) with reported success rates of 70–90 % with median follow-up intervals of 19–75 months. Fewer series, however, have described uniform long-term follow-up data. In this study, we report our long-term institutional outcomes in patients treated with GKRS after a minimum follow-up of 36 months.Thirty-six consecutive patients with medically intractable TN received a median radiation dose of 45 Gy applied with a single 4-mm isocenter to the affected trigeminal nerve. Follow-up data were obtained by clinical examination and telephone questionnaire. Outcome results were categorized based on the Barrow Neurological Institute (BNI) pain scale with BNI I–III considered to be good outcomes and BNI IV–V considered as treatment failure. BNI facial numbness score was used to assess treatment complications.The incidence of early pain relief was high (80.5 %) and relief was noted in an average of 1.6 months after treatment. At minimum follow-up of 3 years, 67 % were pain free (BNI I) and 75 % had good treatment outcome. At a mean last follow-up of 69 months, 32 % were free from any pain and 63 % were free from severe pain. Bothersome posttreatment facial numbness was reported in 11 % of the patients. A statistically significant correlation was found between age and recurrence of any pain with age >70 predicting a more favorable outcome after radiosurgery.The success rate of GKRS for treatment of medically intractable TN declines over time with 32 % reporting ideal outcome and 63 % reporting good outcome. Patients older than age 70 are good candidates for radiosurgery. This data should help in setting realistic expectations for weighing the various available treatment options. Trigeminal neuralgia (TN), also known as tic doloreaux, is a debilitating pain condition characterized by agonizing, paroxysmal, and lancinating pain . First-lAfter institutional review board approval, patient demographic characteristics, clinical presentation, treatment history, and the radiosurgical modality were retrospectively reviewed.Patients were also followed up by a telephone questionnaire that was conducted by a medical resident and a medical student who were not involved in treatment. Patients were questioned about the time to the onset of pain relief, the degree of pain relief, and treatment complications. Based on the Barrow Neurological Institute (BNI) score for TN, we classified pain relief after treatment into five grades. A BNI I score corresponded to complete pain relief without medications; BNI II score, some pain but not requiring medications; BNI III score, some pain but adequately controlled with medications; BNI IV score, some pain not adequately controlled with medication; and BNI V score, severe pain or no pain relief. The BNI facial numbness score was used to assess complications. A BNI I score corresponded to no facial numbness; BNI II score, mild facial numbness, not bothersome; BNI III, facial numbness somewhat bothersome; and BNI IV score, facial numbness, very bothersome.Between September 2002 and June 2010, 81 patients with TN underwent GKRS at our clinic. Indications for GKRS included medically intractable pain refractory to standard medications, refusal of invasive procedures, or failure of previous invasive procedures. Among them, we retrospectively reviewed the medical records of patients with TN undergoing GKRS treatment that had a minimum follow-up of 36 months. Ten patients had died prior to their 36 months follow-up. Fourteen patients were lost to follow-up and were lost to follow-up and on whom we were unable to obtain accurate contact information. Five patients had received GKRS treatment twice and were excluded. Two patients had bilateral disease and were excluded. Eleven patients refused to participate in the survey and adequate follow-up could not be obtained on the remaining 20 patients despite valid phone numbers and multiple attempts. Three patients were retreated but results of GKS retreatment were not included in this analysis. Rather, our report presents the results of single GKS treatment for patients with TN when using a standard treatment algorithm. A total of 36 patients were included in the final analysis with a mean follow-up of 69 months (range 36–246 months). A summary of patient characteristics is provided in Table All patients were treated on the 201-source 60Co Gamma Knife unit, model 4C, manufactured by Elekta instruments . Treatment planning was performed jointly by a radiation oncologist, neurosurgeon, and medical physicist for all cases. After induction of local anesthesia, the Leksell Model G stereotactic coordinate frame was affixed to the head of each patient, and contrast enhanced MR imaging was performed to visualize and target the trigeminal nerve root entry zone. As a planning tool, the Leksell Gamma Plan System (Elekta) was used. A single 4-mm isocenter was placed adjacent to the trigeminal nerve root entry zone. The median peripheral dose was 45 Gy with a range of maximum dose between 80 and 90 Gy delivered to the involved trigeminal nerve root entry zone. A plugging pattern typically blocking 32 sources was used so that the surface of the brainstem was irradiated at no greater than the 20 % isodose line for any patient.Treatment outcomes were assessed by patient self-reports of pain control and medication usage at last follow-up. A pain-free outcome was defined as BNI pain score I and pain relief or good outcome was regarded as maintaining a BNI pain score IIIa or better without requiring further surgery. Treatment failure was defined as pain returning to a BNI level of IV or V, or the patient undergoing an invasive surgical procedure due to uncontrolled pain. A recurrence was defined as a relapse to a previous lower level after attainment of any higher level of pain relief. Patients reported the time interval for a response and pain recurrence after GKRS. The date of treatment failure was considered to be the date at which pain relief became a BNI IV or V score.p value <0.05 was accepted as statistically significant. All statistical calculations were performed using SPSS software, version 13.0 .Time to BNI class IV to V pain relapse was calculated with the Kaplan–Meier method. Log rank tests were performed to determine statistical differences between pain relapse curves. We conducted a univariate analysis of several factors hypothesized to influence or predict successful treatment, using Cox regression analysis: age, gender, side of pain, duration of symptoms, new facial numbness. A The mean time from GKRS to pain improvement was 1.6 months . Of those patient that experienced immediate pain relief (29 or 80.6 %), the majority (27 or 75 %) described an early pain response to treatment within the first 2 months after GKRS, whereas two (5.5 %) patients reported symptoms relief after 2 months. Seven patients (19 %) reported no pain response. The median time to recurrence of any symptoms was 46 months . Of the 29 patients that experienced pain relief, 17 (58.6 %) did not have any pain recurrence (BNI I), while the remaining 12 (41.4 %) had some return of some pain (BNI ≥2). Results of Kaplan–Meier analysis of response time after GKRS are displayed in Fig. At last follow-up, 26 (72.2 %) patients had good treatment outcome  and 10 patients (27.8 %) had treatment failure. The 10 patients with treatment failure included the seven patients who did not have any response to treatment. Kaplan–Meier analysis shows an actuarial rate freedom from severe pain of 63 % at mean last follow-up of 69 months Fig. . The patThe majority of the patients (26 or 72.2 %) did not experience any post-treatment facial numbness. Two patients (16.7 %) reported mild facial numbness that was not bothersome. Very bothersome facial numbness (BNI IV) was reported in a total of four patients (11.1 %) (Table p = 0.02). Patients older than 70 reported significantly better freedom from any pain compared with those less than 70 years of age.Univariate analysis for previously published prognosticators of treatment failure is shown in Table In their large series, Kondziolka et al.  and RégiAllowing for variability in grading systems among studies, our results are similar to previously published results , 16. TheOur series is one of few to include only longer term follow-up of patients undergoing GKS for TN. An increasing body of literature suggests that the beneficial effect of stereotactic radiation on TN diminishes with time. At minimum follow-up of 3 years, 67 % were pain free (BNI I) and 75 % had good treatment outcome. At a mean last follow-up of 69 months, 32 % were free from any pain and 63 % were free from severe pain. Our results are strikingly similar to previously reported long-term analysis of TN pain outcomes. In a small series with minimum follow-up of 3 years, Park et al.  reportedOur incidence of new-onset facial numbness at 11 % was in accordance with previously published incidences. The reported incidence of facial numbness has ranged from 6 to 37 % –18 with However, a statistically significant correlation was found between age and recurrence of any pain with age >70 predicting a more favorable outcome radiosurgery. In their series examining long-term pain outcomes of TN, Han et al.  reportedFinally, although the median peripheral dose of 45 Gy that our institution has adopted is higher than the currently recommended dose (40 Gy) necessary to provide pain relief while avoiding toxicity , 20, we GKRS is a safe, effective, and minimally invasive treatment modality for patients with medically intractable TN or those who are ineligible or refuse open surgery. Our results demonstrate that a single GKS treatment is associated with good outcomes in nearly 60 % of patients in an average follow-up period of approximately 6 years. While most pain recurrence develops within 6 months of treatment, treatment failure may still manifest years later. Our results also suggest that patients >70 presenting with medically intractable TN are good candidates for radiosurgery. The small sample size and retrospective nature of our study design limit the power of our outcome observations. Additionally, although pain intensity and numbness scales are validated tools for the quantification of pain and numbness, they are subjective outcome measures because they are dependent on personal interpretations and variation. The results of this study should, however, help clinicians provide important information to patients so they can have realistic expectations and be able to weigh the risks and benefits relative to the various available treatment options.


Functional constipation in children and adolescents is a common and invalidating condition. In a minority of patients, symptoms persist despite optimal conservative therapy. The aim of this study was to evaluate whether the short-term effects of sacral neuromodulation (SNM) in children and adolescents with constipation are sustained over prolonged period of time.Patients aged 10–20 years, with refractory constipation, fulfilling the Rome III criteria, were included in our study. If SNM test treatment showed >50 % improvement in defecation frequency, a permanent stimulator was implanted. Primary outcome measure was defecation frequency during 3 weeks. Secondary endpoints were abdominal pain and Wexner score. To assess sustainability of treatment effect, a survival analysis was performed. Cross-sectional quality of life was assessed using the EQ-5D VAS score.p < 0.001). During test treatment, abdominal pain and Wexner score decreased from 3.6 to 1.5 and 18.6 to 8.5 (p < 0.001), respectively. Improvement of symptoms sustained during a median follow-up of 22.1 months (12.2–36.8) in 42.9 % of patients. On a scale from 0 to 100, quality of life was 7 points lower than the norm score (mean 70 vs. 77).Thirty girls, mean age 16 (range 10–20), were included. The mean defecation frequency increased from 5.9 (SD 6.5) in 21 days at baseline to 17.4 (SD 11.6) after 3 weeks of test treatment (SNM is a therapeutic option for children with chronic constipation not responding to intensive oral and/or laxative therapy, providing benefits that appear to be sustained over prolonged period of time. Constipation is a common problem in childhood and adolescence, with a prevalence ranging between 0.7 and 29.6 % median 12 %) [2 % [1]. Various modalities have been developed in the treatment of functional constipation, including increase of dietary fiber intake, osmotic and stimulant laxatives, retrograde bowel irrigation, and behavioral therapy, including biofeedback training and pelvic floor physiotherapy , 4. In tA group of patients exists, however, in whom symptoms persist for many years. In these patients, abdominal pain, most likely due to the low defecation frequency, is severely disabled in their daily activities, such as attending school and participation in sports and social events. For these refractory patients, surgical procedures such as antegrade bowel irrigation by means of a Malone stoma, colectomy, or segmental colonic resection may be considered . Such trSacral neuromodulation (SNM) was initially developed as a treatment for urinary incontinence and retention in adults . In thesA prospective cohort study was conducted in a tertiary referral hospital to assess the efficacy of SNM in adolescents with refractory constipation. All patients between 10 and 20 years of age, who were referred to our center for chronic (>1 year) constipation refractory to conservative treatment, were eligible to be included in this study. Informed consent was obtained from all patients and their parents.All patients met the criteria for functional constipation, as defined by the Rome III criteria . DemograThe Wexner score is a composite score ranging from 0 to 30 based on eight domains including frequency, difficulty to evacuate, completeness, painfulness, duration (time in lavatory), successfulness, and need for assistance in defecation, as well as history (duration of symptoms) .Further diagnostic tests included defecography to assess possible outlet obstruction, anal ultrasound, anorectal manometry to exclude Hirschsprung’s disease, colonic transit time measurement using radio-opaque markers, and MRI of the lumbar spine.The operative technique for SNM has been described in detail elsewhere . BrieflyPatients were followed up at 1, 3, 6, 12, and 24 months after implantation of the pacemaker. Prior to each follow-up moment, a 3-week bowel diary was completed, and questionnaires and Wexner constipation scores were recorded. Additional use of laxatives, recurrence of symptoms, or technical failure with or without reoperation was recorded. The primary endpoint was the frequency of defecation as recorded in the 3-week bowel diary. Treatment was considered successful when defecation frequency was at least three times per week.Secondary outcome parameters were change in Wexner constipation score, presence of abdominal pain, pain at defecation, straining, feeling of urge, incomplete evacuation, general comfort, and quality of life. Abdominal pain, pain at defecation, straining, feeling of urge, and incomplete evacuation were assessed using a 5-point scale, ranging from 0 “never,” 1 “rarely,” 2 “sometimes,” 3 “most of the times,” to 4 “always.” Quality of life was assessed by means of the EQ-5D VAS . Recurret test and Wilcoxon signed ranks test. A time-to-event analysis was conducted using Kaplan-Meier survival analysis. Event was defined as a remission to a defecation frequency of less than three times per week, with or without lead or pocket revision. Analyses were conducted using SPSS. A p value of 0.05 was considered statistically significant.Data are presented as mean (SD) or median (range) for continuous variables, and count (percentage) for categorical variables. Changes over time in severity of symptoms were tested for statistical significance using paired Thirty patients with refractory constipation were referred to our center between February 2009 and December 2011. Table All patients were female with a mean age of 16 years (range 10–20) at the time of the test stimulation. Mean duration of complaints was 8.1 years (range 1–18). At the time of presentation in our outpatient clinic, all patients had been treated extensively with various conservative treatments for at least 1 year, under supervision of a referral center. All patients used laxatives, including polyethylene glycol, Metamucil, lactulose, bisacodyl, and magnesium oxide, or a combination of these, with or without retrograde bowel irrigation. Duration of laxative use ranged from 1 to 17 years (mean 5.9 years). One patient had a Malone stoma for antegrade bowel irrigation. All patients had been admitted multiple times to hospital for either oral and/or rectal lavage .Colonic transit time was assessed in 22 of 30 patients and showed a mean colonic transit time of 92.3 h. Fifteen patients had colonic transit times exceeding 62 h Table . Lumbar p < 0.001).At baseline, the mean defecation frequency during a 3-week period was 5.9 (SD 6.5) or 1.96 times per week. During the test phase, the mean defecation frequency increased to 17.4 (SD 11.6) per 3 weeks or 5.8 times per week. During follow-up, the mean defecation frequency remained stable at this level. At each time at follow-up, the defecation frequency was significantly higher when compared to baseline defecation frequency (p < 0.001). The abdominal pain score decreased from mean 3.62 at baseline to 1.53 at 1 year follow-up (p < 0.001). At baseline, two patients reported to have abdominal pain some of the time, while the other patients reported to have abdominal pain most of the time (9) or always (19). At 1 year follow-up, two patients still had abdominal pain most of the time, nine sometimes, seven rarely, and two never. Accompanying symptoms such as pain at defecation, straining, and incomplete evacuation showed a comparable decrease, while the times of feeling of urge increased. The EQ5D VAS score was 69.90 (SD 17.96) at a median follow-up of 12 months, which is lower than the norm score for healthy Dutch females aged 15–19  (Table The mean Wexner score decreased from 18.6 (SD 8.5) at baseline to 8.2 (SD 8.3) during test phase and remained stable during follow-up  compared to sham . IFT, a The extensive diagnostic workup prior to the test period was performed in an attempt to identify possible prognostic factors for success regarding SNM. Unfortunately, the number of patients in this study is too small to draw any conclusions in this regard.The high rate of revisions in this population is the major drawback of this surgical intervention. In accordance with the other pediatric study, in approximately half of the cases, the indication for revision was pain in the area of the implanted stimulator . This isFor fecal incontinence, SNM appeared to be cost-effective , 23. ForA major limitation of our study is its observational, noncomparative nature. Causally attributing the improvement in symptoms that we observed to the SNM therefore critically hinges on the assumption that, in the absence of treatment, no such recovery would have occurred. In a survey conducted among residents of Olmsted County, MN, aged 30–64 years, Talley et al. (1992) studied the onset and disappearance of symptoms consistent with functional gastrointestinal disorders, including constipation. They found that 89 % of the population surveyed had no change in their symptoms during a period of 12–20 months, suggesting a relative stability in this patient population . SimilarIn conclusion, for this group of adolescent patients with severe complaints of constipation resistant to conservative treatment, SNM is an effective treatment with beneficial effect on defecation frequency and abdominal pain.


Objective. The current study aimed to identify and characterize distinct RA subgroups based on their level of EA and AS and compares the difference among the subgroups in mood, disability, and quality of life. Methods. Individuals with chronic pain for at least 3 months were recruited from an academic rheumatoid clinic. Participants were assessed for demographic, psychosocial, and personality measures. A two-step cluster analysis was conducted to identify distinct subgroups of patients. Differences in clinical outcomes were compared using the Multivariate ANOVA based on cluster membership. Results. From a total of 223 participants, three distinct subgroups were formed based on cluster analysis. Cluster 1 (N = 78) included those with low levels of both EA and AS. Cluster 2 (N = 81) consisted of individuals with moderate levels of EA and low levels AS. Cluster 3 (N = 64) included those with moderate levels of EA and high AS. Compared to those in Cluster 1, those in Cluster 3 had significantly higher levels of mood impairment and disability and lower quality of life (p < 0.05). Significantly lower levels of mood impairment were seen in Cluster 1 compared to Cluster 2 (p < 0.05). However, no significant difference in disability or quality of life was seen between the two groups. Conclusions. The three subgroups differed significantly in levels of impairment in mood, disability, and quality of life. However, levels of EA had a greater impact on disability and quality of life than AS.  Rheumatoid arthritis (RA) is an autoimmune disease that causes joint inflammation and leads to bone and cartilage damage . Pain isA variety of psychosocial variables impact coping in chronic pain conditions such as RA , 5. ExpeBoth AS and EA are associated with negatively experiencing internal events but they are distinct constructs . ExperieIt has been reported that pain in patients with RA is related to their daily function . Rice etParticipants were recruited from an academic Rheumatology Outpatient Clinic, at St. Joseph's Health Care, in London, Ontario, over a 20-month period. Inclusion criteria were as follows: diagnosis of RA by a rheumatologist (using the American College of Rheumatology criteria), persistent pain of greater than 3 on the Visual Analogue Scale, thought to be secondary to RA for greater than three months, and age of 18 years or older. Given that this study involved the completion of self-report questionnaires, those with an inability to read and write English were excluded.Patients who met the inclusion criteria and agreed to participate were referred to the research coordinator by their primary physician. The research coordinator provided potential participants with the letter of information and consent form. Patients were made aware that their decision to participate in the study will in no way interfere with their standard care at the hospital. All patients received individualized pharmacotherapy and psychotherapy as seen fit by the multidisciplinary team. Participants who consented to the study were mailed a questionnaire booklet two weeks prior to their scheduled appointment at the clinic. This mailing was followed by a telephone call from a research assistant who answered the participants' questions and instructed the participants to complete the booklet prior to their appointments. Participants were asked to arrive half an hour before their appointment was scheduled to begin. When participants arrived at the clinic, the research assistant collected the first questionnaire booklet consisting of questions regarding demographics  and then each subject was asked to complete the second booklet of questionnaires containing outcome measures related to personality, coping, disability, pain, and quality of life. The research assistant made sure of clarifying all answers left blank by the participant. This study was approved by the University of Western Ontario Health Sciences Review Board.The ASI  is a 16-The AAQ  is a 9-iThe BPI-S  is a widThe DASS-SF  is a 21-The HAQ-disability and pain scales are self-report measures of function in patients with rheumatic diseases. Disability is assessed by eight categories: (1) dressing, (2) arising, (3) eating, (4) walking, (5) hygiene, (6) reach, (7) grip, and (8) common activities. The HAQ has proved to be a very reliable measure and has been found to predict many features of patients' subsequent disease course .The SF-36 is a 36-item self-report measure that assesses eight domains of health related quality of life. These domains include (1) limitations in physical functioning, (2) social limitations due to emotional or physical troubles, (3) role limitations due to physical health problems, (4) role limitations due to emotional health problems, (5) general mental health, (6) bodily pain, (7) vitality, and (8) general health perceptions . The SF-χ2 tests for categorical variables in order to characterize the resulting clusters. A multivariate analysis of covariance was conducted on outcome measures  according to cluster membership with patient demographic factors including age, gender, pain duration, and pain intensity as covariates. Post hoc analyses were conducted with a Tukey correction. SPSS version 23.0  was used for all tests performed, with the significance level set at 0.05, two-tailed.A two-step cluster analysis was performed using SPSS version 23.0  to organize observations into two or more mutually exclusive groups, where members of the groups shared properties in common. Two clustering variables were used in the analysis: AS and EA based on ASI and AAQ scores, respectively. The log-likelihood distance measure was used to compute likelihood distance between clusters with subjects assigned to the cluster leading to the largest likelihood. Number of clusters was not predetermined. The Bayesian information criterion was used to judge adequacy of the final solution. Differences in sample demographic characteristics were compared according to cluster membership using univariate analysis of variance for continuous variables and A total of 441 patients were eligible for inclusion within the study, of which 218 refused to participate, leaving a final sample size of 223 patients in the study. The study population consisted of individuals with a mean age of 57.8 years and was predominantly female (75.7%). Almost half of the individuals were employed (48.9%). Thirteen participants (6%) had a diagnosis of comorbid fibromyalgia in addition to RA. Average pain intensity among the individuals was 3.8 on an 11-point scale (0–10) and average pain duration was 14.3 years. Most were married or in a long-term relationship at the time of the study 75.3%; .N = 78) included those with lowest levels of EA (1 SD below mean) and AS (0.75 below mean). These individuals could be best described as adaptive copers. Cluster 2 (N = 81) or the average copers included those with levels of EA (0.5 SD above mean) and AS (0.5 SD below mean) who were the closest to the group means. Cluster 3 (N = 64) included participants with highest levels of EA (0.75 SD above mean) and AS (1.25 SD above mean); this group represented the dysfunctional copers, see p = 0.02). The remaining demographic variables, age, sex, education, relationship status, pain duration, and average pain intensity, were comparable among the three groups , whereby adaptive copers scored significantly higher on mood and QoL and lower on disability compared to dysfunctional copers. Average copers significantly differed from adaptive copers but not from dysfunctional copers on DASS-SF total, DASS-SF stress, and HAQ Total (p < 0.05). All groups significantly differed from each other on DASS-SF depression and DASS-SF anxiety (p < 0.05), with dysfunctional copers consistently scoring lowest for mood and QoL and highest on disability.As can be seen in To our knowledge, this is the first study to characterize participants with RA into three subgroups based on their AS and EA levels. The difference in mood, disability, and QoL was also examined among the three clusters: (1) adaptive copers, (2) average copers, and (3) dysfunctional copers, with demographic factors and pain measures as covariates. Consistent with our hypotheses, adaptive copers were more likely to have improved mood, disability, and QoL compared to average and dysfunctional copers. The adaptive copers group was also the only group with EA levels below the average. It may be that even moderate levels of EA may result in impaired mood, disability, and QoL. Even though levels of AS were similar between the adaptive and average copers group, the low levels of EA may act as a protective factor. Adaptive copers may be more accepting of negative bodily sensations and instead of avoiding tasks out of fear of pain they may be persistent in completing them. Those that are adaptive copers may also be less likely to have dysregulation of emotional experiences and life-constricting behaviours that lead to greater disability and lower QoL. Kashdan et al.  found anSurprisingly, average copers did not differ significantly from dysfunctional copers on total scores. An explanation for this may be due to the overlap in the level of EA in both subgroups as seen in Conversely, average copers did not significantly differ in outcomes total scores from adaptive copers. Again, this may be explained by the degree of overlap in the levels of AS between the two groups, while the level of EA was significantly higher . The lowHence, average copers may not differ from dysfunctional copers due to the overlap in the level of EA and from adaptive copers due to the overlap in AS. This overlap provides a pseudocontrol condition among the subgroups, allowing the effect of AS or EA to be examined while controlling for the other. Bardeen et al.  demonstrThis study may be limited by its recruitment strategy which involved convenience sampling of individuals at one academic RA center. Additionally, information was not captured on those patients who refused to consent. This may also add to the bias of patient selection in the current study, thereby reducing the generalizability of the results to those individuals seen only in the community. The lack of information regarding comorbid issues and medication use limits the ability to control for these as cofounders. The cross-sectional nature of the study and the lack of a control group preclude conclusions regarding causation. The study's sole reliance on self-report measures may impact biases in reporting. It is also possible that patients responded to some of the items with a degree of bias such as their pain scores which required patients to recall symptoms from the past two weeks. Nonetheless, literature on bias related to pain recall has found that patients are still fairly accurate in recalling pain and pain characteristics even after 10 years; thus, we suspect the two-week recall would not overly bias patient reported pain .Despite these limitations, the current study has important clinical and research implications. Much of the current data on AS and EA represents the chronic pain population; however, this study fills the gap in the effect of AS and EA among individuals with RA. The study demonstrates that the maladaptive effects of AS and EA are not limited to the chronic pain population but that they may also effect outcomes among those with RA. The current study also found that the effects of high EA and AS are not limited to mood but also relate to greater disability and lower QoL among those with RA.Acceptance and commitment therapy has previously been shown to be effective in reducing overt dysfunctional behaviours such as escape avoidance behaviours and AS and encourage the acceptance of an individual's private experience . FurtherIn conclusion, the present study has important implications for the understanding of how, in a seemingly heterogeneous population of RA individuals with chronic pain, different subgroups may exist which predict mood, disability, and QoL. It may be important to identify patients that may be dysfunctional copers during the management of chronic pain among RA patients, since addressing these avoidant behaviours and the ability to experience distressing bodily sensation with patients may prove useful in helping to manage their pain. Acceptance based interventions that target EA by helping to develop more adaptive response styles and tolerance to undesirable experiences may help to improve outcomes among these individuals.


The importance of the removal of spinal implants is known in the presence of infection. However, the benefits and/or risks of the removal of spinal implant for the management of back pain are not clear.In this retrospective study, we aimed to evaluate the beneficial effects of the removal of spinal implants for back pain. Study included 25 patients with thoracolumbar instrumentation.Seventeen (68%) of them were male. Indications for spinal instrumentation were vertebra fracture (n = 9), iatrogenic instability due to multiple segment laminectomy (n = 12), and instrumentation after recurrent disk herniations (n = 4). Mean visual analog score (VAS) before the removal was 8.08. Mean VAS was 3.36 after the removal. Spinal instruments were removed after the observance of the presence of fusion. All patients were prescribed analgesics and muscle relaxants for 3 weeks before removal. Back pain did not decrease in five (20%) patients in total. Four of them had been instrumented due to recurrent lumbar disk herniation. None of the patients reported the complete relief of pain.In conclusion, patients should be cautioned that their back pain might not decrease after a successful removal of their instruments. The application of spinal instrumentation plays a significant role in today’s spine surgery. It is performed for different indications such as vertebra fracture, revision operations, cases of degenerative spondylolisthesis, fusion over multiple levels, scoliosis, stenosis with scoliosis or lateral slip or in cases where iatrogenic instability is created at the time of an operation . The remIn the present study, we aimed to evaluate whether the removal of spinal instruments decreases back pain or not.The present study included a retrospective analysis of patients in whom the posterior instrumentations were removed in Teaching and Research Hospitals of Bozok University and Yuzuncu Yil University. Hospital folders of 40 patients were retrospectively searched for demographic data such as age, gender, previous indication for posterior segmental instrumentation, and visual analog score (VAS) before and after removal of spinal instruments. Ten patients in whom removal had been performed due to infection and instrument-related problems such as malposition and/or breakage of the instruments were excluded from the study. Five patients with inadequate data or those who could not be reached were also excluded from the study; thereby 25 patients were enrolled into the study. Pediatric patients were also excluded from the study. All patients whose instruments were removed had been treated with analgesics and muscle relaxants for 3 weeks before removal. Computed tomography images of spine were obtained in all patients with the aim of the observance of the development of the adequate fusion. Spinal instruments were removed in patients with adequate fusion.Twenty-five patients were included in the study. Seventeen (68%) of them were male and the remaining were female. The mean age was 44.40 . The mean VAS was 8.08 (min. 7.0 - max. 9.0) before removal of instruments. The mean VAS was 3.36 (min. 1 - max. 9.0) after removal. The mean decrease in VAS was 4.72 (min. 0 - max. 7) .Indications for posterior segmental instrumentation were vertebra fracture , iatrogenic instability due to multiple segment laminectomy , and instrumentation after recurrent disk herniations . The mean age was 37.56, 51.50, and 38.50 in groups I, II, and III, respectively. The mean VAS before removal of instruments was 7.8, 7.9, and 9.0 in groups I, II, and III, respectively. The mean VAS was 2.11, 3.08, and 7.0 in groups I, II, and III, respectively after removal of instruments. The mean decrease in VAS was 5.7, 4.83, and 2.0 in groups I, II, and III, respectively. ANOVA showed statistically significant differences between groups in terms of age, VAS before removal, VAS after removal, and decrease in VAS  .Patients were divided into three groups according to the indications of posterior spinal segmental instrumentation: vertebra fracture (group I), iatrogenic instability due to multiple segment laminectomy (group II), and instrumentation after recurrent disk herniations (group III). There was a statistically significant difference in group I and group II in terms of age (P = 0.01). However, there was no significant difference between other groups in terms of age. Statistically significant differences were observed between groups I - III and groups II - III in terms of VAS before removal . When groups were compared in terms of VAS after removal of instruments, a statistically significant difference was observed between groups I - III and groups II - III . A statistically significant difference was detected only between groups I and III in terms of decrease in VAS (P = 0.018) .t-tests, one-way ANOVA, Mann-Whitney U tests or Kruskal-Wallis tests as appropriate. Statistical analyses were performed using the statistical package SPSS, version 15.0 ; a value of P < 0.05 was used to define statistical significance.Quantitative variables were expressed as mean ± standard deviation (SD) or median with range, and were analyzed by Student’s The results of the present study indicate that the removal of posterior instruments does not lead to back pain free life especially in patients who have been instrumented after recurrent disk herniations. We saw that in 20% of our patients, no change was observed in their back pains.Reoperation after posterior segmental instrumentation is not a rare application. Reoperation indications include delayed surgical site infection, breakage of instruments, malposition of instruments, development of adjacent segment disease, implant prominence, and operative site pain . It was The removal of spinal instrument for the pain management is a known application. Reoperation rates for the management of pain range between 8% and 19% . HoweverIn a similar study, Stavridis et al reported that 12% of their patients (seven of 57) were free of pain. They stated that the 61% of their patients showed some benefit. Authors also reported the occurrence of complication in 8.8% of patients . HoweverIn conclusion, the results of the present study and previous studies clearly show that the removal of instruments for the management of back pain does not lead to free of pain in all patients. Because of this reason, patients should be strictly informed that their back pain may sustain in spite of a successful surgery.


Although post-traumatic stress disorder (PTSD) is a common co-morbidity in chronic pain, little is known about the association between PTSD and pain in the context of chronic pain rehabilitation.The aim of the present study was two-fold: (1) to investigate the association of a possible PTSD diagnosis with symptoms of pain, physical and mental functioning, as well as the use of opioids, and (2) to compare the outcome of multidisciplinary chronic pain rehabilitation for patients with a possible PTSD diagnosis at admission with patients without PTSD at admission.A consecutively referred cohort of 194 patients completed a baseline questionnaire at admission covering post-traumatic stress, pain symptoms, physical and mental functioning, as well as self-reported sleep quality and cognitive difficulties. Medication use was calculated from their medical records. A total of 95 were admitted to further multidisciplinary treatment and included in the outcome study.A high prevalence of possible PTSD was found (26.3%). Patients with possible co-morbid PTSD experienced significantly poorer general and mental health, poorer sleep quality, and more cognitive problems as well as inferior social functioning compared to patients without PTSD. Possible co-morbid PTSD did not result in higher use of opioids or sedatives. Surprisingly, possible co-morbid PTSD at admission was not associated with lower levels of symptom reduction from pre- to post-treatment.Possible co-morbid PTSD in chronic pain is a major problem associated with significantly poorer functioning on several domains. Nevertheless, our results indicate that pain-related symptoms could be treated with success despite possible co-morbid PTSD. However, since PTSD was only measured at admission it is not known whether rehabilitation actually reduced PTSD. A common co-morbidity among patients referred to chronic pain rehabilitation is post-traumatic stress disorder (PTSD)  to investigate the association of a possible PTSD diagnosis with symptoms of pain, physical, and mental functioning as well as on the use of opioids, and (2) to compare the outcome of multidisciplinary chronic pain rehabilitation for patients with a possible PTSD diagnosis at admission with patients without PTSD at admission.First, it was hypothesised that chronic pain patients with possible co-morbid PTSD at admission to chronic pain rehabilitation experienced lower levels of physical and mental functioning compared to patients without PTSD at admission. Second, a higher use of opioids and sedatives was expected to be reported among patients with possible co-morbid PTSD at admission compared to patients without PTSD. Finally, it was expected that patients with possible co-morbid PTSD at admission experienced poorer sleep quality and more cognitive problems compared to patients without PTSD. Given that very few studies have actually compared outcome of multidisciplinary pain rehabilitation for patients with and without PTSD and that they tend to report mixed findings, the aforementioned hypotheses are the first to put forward.All of the patients in this study were consecutively referred to multidisciplinary pain rehabilitation between the period of May 2009 to May 2010, and they were thoroughly assessed by a multidisciplinary team before admission. A total of 194 patients who were assessed completed the PTSD measures as well as the various outcome measures featured in this study: pain; physical and mental functioning; use of opioids, antidepressants, benzodiazepines and sleeping pills; sleep quality and cognitive problems. The total sample was used for the purposes of investigating the primary aim of this study and to test the hypotheses. Demographic details and sample characteristics are presented in p≥0.062) from the total sample with regard to age, gender, or years with chronic pain or on any of the outcome variables . However, the 95 patients admitted for further multidisciplinary treatment in the pain centre were significantly (p=0.024) younger than the total sample (mean age years 41.3 vs. 48.24) and have had pain for significantly (p=0.047) fewer years (mean number of years with pain 8.8 vs. 10.85). Also, a higher prevalence of possible PTSD (30.4%) was found among patients admitted to further multidisciplinary treatment in the pain centre. However, the difference in prevalence was not statistically significant (p=0.300). Only 46 patients returned the final questionnaire administered post-treatment. The responders did not differ significantly from the non-responders on any variables (p≥0.095). This final sample (n=46) was used for the purpose of investigating the secondary aim of this study, that is, to compare outcome of multidisciplinary chronic pain rehabilitation for patients with a possible PTSD diagnosis at admission with patients without PTSD at admission.Only 95 patients were admitted to further multidisciplinary treatment. In total, 29 patients were discharged after their first visit with the physician, either because the waiting list for further multidisciplinary treatment in the pain centre was too long or because they chose another treatment outside the pain centre. The other 70 patients only received medical treatment. These 99 patients (the 29+70) did not differ significantly  was coded as either present (1) or absent (0). Opioid use was measured according to intake of mg morphine per day.Patients were asked to rate their general sleep quality during the past month on a 5-point numerical rating scale . Experienced cognitive problems (concentration and memory) were measured using a simple self-report scale from 0–5. .Descriptive analyses and demographic details are presented as percentages, means, and standard deviations. Outcome scores were calculated as transformed scores ranging from 0–100, with higher scores indicating better results. Missing values for the SF-36 subscales were approximated according to the SF-36 guidelines, by using the mean values of the remaining items if at least half of the corresponding items were valid.t-tests with Holm's adjustment for multiple testing. Adjusted p-values were calculated by sorting the unadjusted p-values in decreasing order of significance and then adjusted sequentially by multiplying the first (lowest) unadjusted p-value by k (number of conditions), the next by k-1, the next by k-2, and so forth.At admission, a comparison regarding scores on outcome variables  was made between patients with and without possible co-morbid PTSD. This was done using independent, 2-tailed 2) tests. Finally, repeated measures analysis of variance (ANOVA) was used to compare outcome of multidisciplinary pain rehabilitation (pre- to post-treatment scores) for patients with and without possible co-morbid PTSD. The groups were compared on the two general dimensions comprising the SF-36: the physical and mental component scales. Only these two general dimensions were used due to the small sample size of the study. It was for this same reason that covariates such as gender and age were not adjusted for. Effect sizes for t-tests were calculated using Cohen's d  were evaluated based on the following criteria: 0.2=small effect, 0.5=medium effect, and 0.8=large effect. Partial eta-squares (η2p) were evaluated based on the following criteria: 0.01=small effect, 0.09=medium effect, and 0.25=large effect  and having experienced serious illness or having witnessed serious illness to someone close (11.8%). No significant association was found between the prevalence of possible PTSD and specific pain diagnosis (p≥0.084). Furthermore, of those patients admitted to rehabilitation, no significant differences regarding gender, age, and number of years of having a chronic pain diagnosis were found between patients with and without possible co-morbid PTSD (p ≥0.082).Using the DSM-IV diagnostic criteria for PTSD, the prevalence of a possible PTSD diagnosis in the present sample was 26.3%. The most frequently reported traumatic events among PTSD cases were t-tests showed that, regarding the physical health component, only general health reached statistical significance (p=0.012), indicating that patients with possible co-morbid PTSD experienced poorer general health compared to patients without PTSD. Regarding the psycho-social outcomes, patients with possible co-morbid PTSD experienced significantly poorer mental health (p=0.007) as well as inferior social functioning (p<0.001) compared to patients without PTSD. Moreover, patients with possible co-morbid PTSD reported significantly poorer sleep quality (M=63.73) compared to those without PTSD (M=87.72), U=1,773, Z=−2.96, p=0.003, r=0.23. Finally, patients with possible co-morbid PTSD reported significantly more cognitive problems (M=61.74) compared to patients without PTSD (M=88.64), U=1,709, Z=−3.48, p=0.001, r=0.27.As presented in p≥0.195), the only exception being for antidepressants. Patients with possible co-morbid PTSD used significantly more antidepressants compared to patients without PTSD (p=0.013).Categories of medication use among the two patient groups are presented in F(1.38)=11.89, p=0.001, η2p=0.24). However, no significant group difference was found in level of symptom reduction from pre- to post-treatment (F(1.38)=3.07, p=0.088, η2p=0.08)  .F(1.44)=11.13, p=0.002, η2p=0.20). Moreover, there was a significant group difference on the mental component scale (F(1.44)=4.16, p=0.047, η2p=0.09). This indicates that the group with possible co-morbid PTSD achieved a larger symptom reduction from pre- to post-treatment compared with patients without co-morbid PTSD  is believed to be representative of chronic pain patients admitted to multidisciplinary chronic pain rehabilitation, which is essential given that very few studies have investigated co-morbid chronic pain and PTSD in the context of multidisciplinary pain rehabilitation. However, the sample may not be representative of chronic pain patients in general.Future studies should investigate the impact of co-morbid PTSD on chronic pain rehabilitation in the context of a randomised controlled trial comparing different treatment conditions. In addition, it is extremely relevant to examine whether the outcome of chronic pain rehabilitation is influenced by the aetiology of the pain condition and trauma. When the onset of pain is related to a traumatic event, as it is in many traffic accidents, the mutually maintaining mechanisms of the two disorders may be different for patients suffering from co-morbid PTSD unrelated to the onset of pain. When the onset of pain is associated with a traumatic event, pain may serve as a reminder of the traumatic event leading to re-experiencing (Asmundson et al.,


Low back pain is a very common disorder. In this field chronic low back pain represents a special challenge. The management of chronic low back pain consists of a range of different intervention strategies. Usually operative intervention should be avoided if possible. However, there are constellations were surgical therapy in patients with chronic low back pain seems to be meaningful.The aim of this study was to investigate the clinical outcomes after spine surgery and hip replacement in patients with chronic low back pain after undergoing a structured rehabilitation program including cognitive – behavioral therapy.From January 1, 2007 to January 1, 2010 patients were indicated for total hip replacement (THA) or spine surgery after receiving inpatient multidisciplinary pain programs including cognitive – behavioral therapy at our orthopedic institute with a specialized unit for the rehabilitation of chronic pain patients. Indications for surgery were based on the synopsis of clinical and imaging findings and on positive effects after local injections during the multidisciplinary pain program. The tools for assessment included follow-up at 6 and 12 months and analyses of pain, chronicity, physical functioning and depression.Of the 256 patients admitted for multidisciplinary pain program, fifteen were indicated to benefit from a surgical intervention during multidisciplinary pain program. Ten patients received spine surgery. THA was indicated in five patients. In all cases, the peri- and postoperative clinical courses were uneventful. Only two of the patients subjected to spine surgery and three patients who had THA were improved after 12 months. One patient reported a worsened condition. All patients presented with good functional outcomes and normal radiological findings.The indication for surgical intervention in patients with chronic low back pain and degenerative diseases must be critically assessed. THA in this cohort should focus on functional aspects, such as the improvement of range of motion, rather than the reduction of pain. Spine surgery in chronic low back pain patients after multidisciplinary pain program including cognitive – behavioral therapy cannot be recommended due to its questionable success. Low back pain is one of the most common physical disorders in industrialized countries. Approximately 10 percent of these patients present with a chronic course with varying degrees of severity . To dateIn 1977, Engel . An multWe retrospectively analyzed all patients included in a prospective data bank from January 1, 2007 to January 1, 2010 with chronic non-specific low back pain who received inpatient treatment for multidisciplinary pain program and surgery for degenerative conditions of the lumbar spine or THA in our orthopedic institution. All were patients of our multidisciplinary unit that specializes in the rehabilitation of chronic low back pain and mixed pain from coexisting degenerative hip symptoms. Further assessment of the spine or hip pathology was achieved through careful observation of medical histories, physical examination findings, and all imaging studies ,11]. Th. Th11]. Patients with both at least 50 percent pain relief on an 11-point numeric rating scale (NRS) from the local anesthetic injections of the lumbar spine or hip and concordant clinical and radiological findings explaining the symptoms were indicated for surgical intervention and enrolled in our study. Those who benefited from the hip injections underwent a total hip replacement (THA), and those for whom the lumbar region injections were successful underwent spine surgery e.g. pain release after facet joint injection L4/5 and selective nerve root injections L5 correlating to clinical and radiological findings TLIF L4/5 was performed.The clinical and radiological follow-up was assessed 6 and 12 months postoperatively. All detailed medical histories were recorded by the same professional who conducted the initial pain therapy. Data assessments of every patient were completed before multidisciplinary pain program, preoperatively and at each follow-up. Clinical outcome measures were evaluated with the 11-point pain intensity numerical rating scale (NRS) . DepressIn fifteen of the 256 enrolled patients, the clinical course and diagnostic evidence indicated a surgical intervention. These fifteen patients  with a mean age of 64 years (range 38–82 years) were eventually subjected to surgery. All patients had an average pain history of 10 months (range 6–17 months).Ten patients underwent surgery on the lumbar or thoracolumbar spine Table ; their cTotal hip replacement was indicated and performed in five patients (n = 5) with osteoarthritis of the hip joint accompanying the chronic back pain Table . All patFour patients from the spine group  reported an improvement of their pain symptoms at the 6-month postoperative follow-up. However, after 12 months, only two patients (n = 1 after TLIF and n = 1 after decompression) maintained their improved postoperative status. Worsening of pain was noted in one case (n = 1) after TLIF at the 6- and 12-month follow-up visits. In contrast, all patients presented good functional results and normal imaging findings in follow-up. All five patients receiving THA (n = 5) experienced improvements with reduced pain at 6 months postoperatively. However, only 3 patients (n = 3) maintained their pain improvement after 12 months postoperatively, again with unremarkable radiological findings and improved function.The pain levels were unchanged in the remaining patients, without worsening or improvement. Additionally, the preoperative capacities to perform daily activities related to their disability within the spine-group were not significantly different compared to the postoperative values from the Hannover Functional Ability Questionnaire (HFAQ). In contrast, only two patients in the THA group (n = 2) showed improvement in both their pain and their HFAQ scores, while one patient (n = 1) presented decreased functional capacity with an increase of pain symptoms in the follow-up.The psychologist’s reports confirmed persistent chronicity in all patients (100% of cases). During the observation period, MPSS levels remained consistent. Level II and III scores were identified in ten and five patients, respectively. The results of the PHQ-9 revealed evidence of mild depression in three patients (n = 3), moderate depression in 6 patients (n = 6) and moderately severe depression in two patients (n = 2). Four patients (n = 4) presented with severe depression. Two patients of the THA group improved after surgery, with changes from moderate to mild depression. In all other cases, there were no changes after 6 or 12 months in the PHQ-9 score values. All patients continued their daily intake of analgesic medications for ongoing pain syndromes. None of the patients were able to reduce their preoperative pain medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), opiates or benzodiazepines, at any point throughout the follow-up period.Multidisciplinary pain programs that focus on physical, psychological, social and related factors have clear therapeutic aims and strategies. The objectives of multidisciplinary pain programs are the mild or moderate reduction of pain intensity and improvement in quality of life. Thus, the main goal of this rehabilitation program is functional restoration ,8],15],[15]8],8],. ThoracoNone of the patients demonstrated associated complications after surgical intervention. Nevertheless, only two patients from the spine group improved in their overall values. One patient even reported a worsened pain level. Eight patients in this group maintained their levels throughout the 12-month follow-up period. Despite proper functional and unremarkable radiological results, the presence of behavioral disorders or psychiatric comorbidities is well known to significantly impair the subjective clinical course in patients with musculoskeletal interventions . IbrahimIn the THA group, three patients exhibited a reduction in pain symptoms without a change in the level of chronicity. In recent studies, up to 12.1% of patients undergoing THA develop chronic low back pain . RegardiDepressive symptoms are very common in chronic pain patients. Studies have reported prevalences of 30-80% of patients with some depressive symptoms and 20% of patients who fulfill the criteria for a true major depressive disorder . Boos etIn patients with chronic low back pain, yellow flags indicating diverse psychosocial prognostic factors for the development of disability following the onset of musculoskeletal pain are often present. Additionally, depression and psychosomatic disorders are common in patients receiving multidisciplinary pain programs. Hence, with the existence of these risk factors, an operative intervention is not recommended due to the increased incidence of developing postoperative pain and chronicity ,9],10],[10]9],9],–27]. Wi. Wi27]. In our cohort, clinical and radiological findings were evident, and probatory infiltrations eliminated pain locally. Nevertheless, despite the functionally and radiologically unremarkable findings, the postoperative results were disappointing. If the decision is made for a surgical intervention, the patient should be adequately informed about the expected effectiveness and outcome. Moreover, the achievable reduction in pain did not always fulfill the expectations of the patient . SubsequIn conclusion, the indication to perform any surgical intervention in patients with chronic low back pain and degenerative diseases must be critically assessed. In his conclusion, Don et al. emphasizes the poor correlation between apparent degenerative changes and the clinical presentation of chronic low back pain, arguing against the expectation that surgically modifying the degenerative process will be highly effective in modifying pain and disability . High-quPatients were informed verbal and in written form and confirmed their approval on a consent form.The authors declare that they have no competing interests.NHVDH made substantial contributions for conception, design, analysis and interpretation of the data. AV did the main part of data acquisition. JG has been involved in drafting the manuscript. RP have been involved in design and analysis of the data. UU has been involved in analyses of the psychological data. CEH has given final approval of the version to be published. All authors read and approved the final manuscript.