In the pethidine and morphine arms 60.0% (24/40) and 62.5% (25/40) of participants respectively achieved adequate pain control within 72 h of initiating therapy, p = 0.296. Most participants, 96.3% (79/82) had no side effects to opioids. The commonest side effects were generalized pruritus, nausea and vomiting, and headaches. More pethidine than morphine participants experienced side effects 29.3% and 22.0% respectively; p = 0.448. In conclusion, more morphine participants achieved a sustained pain response compared to the pethidine participants. There was no difference in the tolerability and side effect profile of the opioids. No participant experienced respiratory suppression.Vaso‐occlusive crises (VOC) is common and opioids are the treatment of choice.This study compared parenteral pethidine and morphine in the elimination/reduction of pain in acute VOC to tolerable levels. This open‐label randomized study compared intravenous morphine 5 mg 4 hourly to intramuscular pethidine 75 mg 4 hourly. Eighty‐two consenting adult sickle cell disease participants were recruited from the Korle‐Bu Polyclinic. (Forty‐one participants in each arm). There were 42 male and 40 female participants. Median age was 25 years. Pethidine participants totalling 31.7% (13/41) and 53.7% (22/41) in the morphine arm had a sustained response within 6 h,  First, there are concerns from healthcare workers, family members and even the patients related to the possible side effects, the development of tolerance associated with chronic use, and the risk of dependence/addiction. In the USA, pethidine and morphine are categorized as schedule II for controlled substances. This classification indicates their level of addiction potential .The acute pain of SCD is sometimes difficult to treat . There aThis study compared parenteral pethidine and morphine in the elimination/reduction of the acute pain of vaso‐occlusive crises (VOC) in adult SCD patients. We tested the hypothesis ‘There is no difference between morphine and pethidine in time to achieving sustained pain relief and their safety profiles in adult SCD patients with an acute pain crisis’.2The study was an open randomized comparative study of parenteral Morphine and Pethidine in adult (18 years and above) Sickle Cell Disease patients presenting to the Korle Bu Polyclinic. Previous studies suggest that morphine is more effective in relieving pain crises than pethidine , 10.All consenting adult sickle cell patients in acute pain crisis, with a minimum pain score of 7 on the McCaffery et al Pain Scale  during tAll patients received the standard of care that sickle cell patients receive at the study site. The primary outcome of the study was the proportion of participants in each arm who achieved pain control. That is, the proportion of participants whose admission pain reduced from a rating of at least seven to a level three or below (and remained so continuously for 24 h) within 72 h following the commencement of the analgesia. Secondary outcome measures were, the time taken for the initial pain to reduce by a margin of at least 2 within a 6‐h period (even if the pain went up thereafter), as well as the incidence of adverse events in the two treatment groups. The time interval for the complete resolution of crisis between the two arms was measured.Operative definitions derived for the purposes of this study. They were: (1) duration for initial response: defined as the time taken for a reduction in pain score of at least 2 points, even if pain score went up later; (2) duration for sustained response: defined as the time taken for a decrease in the pain score of 2 or more points and continuing as such (the pain does not go up again); (3) duration for pain control: defined as the time taken for the pain to decrease from at least 7 to 3 or below and remain so continuously for a minimum of 24 h.t‐test was used to compare the pain duration between pethidine and morphine. The chi‐squared test was used to compare the tolerability levels and the side effect profile between the two analgesics. Regression analysis was carried out to determine the effect of demographic characteristics on pain control and to account for possible confounders. Pain control indices were used as dependent variables whilst the demographic characteristics and the presenting pain grade were used as independent or explanatory variables in the regression model. p‐Values were considered significant if less than 0.05 at a confidence interval of 95%  and registered with the Pan African Clinical Trial Registry database (PACTR201812917283565). Unpaired Student's 3There were a total of 82 participants, aged 18 to 47 years. The median age 25.0 years (SD‐6.3years) and 42 (51.2%) were males. Sixty‐seven (81.7%) of the participants were SS phenotype; the remainder were SC. The proportions of haemoglobin phenotype in the age categories did not differ significantly from each other at the 0.05 level  of the 40 participants had their pain controlled within 72 h of initiating therapy. In the morphine arm, 25 (62.5%) of the 40 participants had their pain controlled within 72 h of initiating therapy. The difference in duration for pain control between the two groups was not statistically significant, Twenty‐two participants in the morphine arm achieved a sustained response within 6 h of initiating treatment, and 15 between 6 to 24 h. In the pethidine arm, 13 participants achieved a sustained response within 6 h of treatment, and 19 between 6 and 24 h.p = 0.027) with morphine significantly faster than pethidine.Twenty‐two participants (52.4%) in the morphine arm and 13 (31.7%) in the pethidine arm, achieved a sustained response within 6 h of commencing treatment. The duration for sustained response showed a statistically significant difference between the two opioids  compared to those in the morphine arm 9 (22.0%) . This shows that participants in the morphine arm experienced a faster initial decline in their pain grade compared with the pethidine participants.Sustained response was observed within 6 h of starting treatment in 35 (42.7%) of the participants; 13 (32.5%) of the pethidine participants compared with 22 (52.4%) of the morphine participants , compared to pethidine, four of 13 participants (30.8%), to achieve a sustained pain response after the maximum allowable duration of 24 h. According to Bryant and Knight (2010), the average plasma half‐life of morphine is 2–3 h with the effect of a parenteral dose lasting for 4–6 h . On the p = 0.448. Neither was there any difference in what the specific type of side effect experienced was; p = 0.292.In this study, side effects were experienced 23 times affecting 21 participants (25.6%), 14 (60.9%) in the pethidine arm and 9 (39.1%) in the morphine arm. The side effects manifested were pruritus, nausea/vomiting, headaches, dizziness/drowsiness and seizures. There were no significant differences between the two analgesics in terms of whether a side effect was observed or not, Benyamin et al. found constipation and nausea to be the most common adverse effects, and this led to dropouts in controlled trials . This obGenerally, respiratory depression and death are the most feared complications of opioid use. In this study, none of the participants experienced respiratory depression. This observation may have been due to the strict adherence to the study protocol as well as the guidelines of opioid use. Effective patient compliance with appropriate medical treatment programs is needed to prevent rare but life‐threatening adverse events .For 79 (96.3%) of the participants, there were either no side effects 61 (74.4%) or manageable side effects, 18 (22.0%) to the analgesics and hence the opioids were not discontinued. Oral cetirizine 10 mg nocte was given for the pruritus, while the dose of IV metoclopramide was increased to 10 mg 6 hourly for those with nausea and vomiting. Oral paracetamol was increased to 1 g four times a day for one patient who had persistent severe headaches. The headaches were otherwise transient. The dizziness/drowsiness resolved without any intervention. This finding of the current study is supported by Smith who suggested that when these side effects occur, they are largely manageable . In the unarousable. One of the morphine participants had her analgesia restarted when her sedation improved, and she began to experience significant pain. She later recovered and was discharged home. The other morphine participant got admitted to the Intensive Care Unit and died 16 days thereafter from multiple organ failure.For the other three participants in the current study, their analgesia had to be discontinued while in the study because the side effects were not tolerable. Two were in the morphine arm and the third in the pethidine arm. Both morphine participants developed acute chest syndrome and became The pethidine participant had seizures and died 36 h after stopping the analgesia, and 12 h after an emergency dialysis was done for acute kidney injury perhaps secondary to hypovolaemia from vomiting and diarrhoea. He presented 7 days after his symptoms started.As alluded to by Niscola et al., pethidine has a plasma half‐life of 3–5 h. However, the active metabolite norpethidine with a half‐life 15–40 h accumulates particularly in patients with renal failure. This may lead to potentially serious adverse effects including tremor, myoclonus, delirium, and seizures , probablIt is reassuring to observe that the two analgesics have comparable side effect profiles managed with similar interventions. Even more, these side effect profiles are generally safe and largely fleeting.The advantage of combining paracetamol with opioids is the dual analgesic effect it provides. However, the combination is potentially hepatic toxicity . In this5More morphine participants achieved a sustained pain response during compared to the pethidine participants. This difference was statistically significant. There was no significant difference in the effectiveness of pethidine and morphine in the reduction of acute pain in SCD patients within the first 72 h of initiating analgesia. Finally, there was no difference in the tolerability and side effect profile of pethidine in comparison to morphine in SCD patients presenting in VOC.Conception and Study Design: M O‐A and HL. Data Collection: M O‐A. Data Analysis and Interpretation: M O‐A, HL and EO. Manuscript Drafting: M O‐A. Manuscript Revision: EO and HL. Guarantor of the Study: M O‐A.The authors declare that they have no competing interests.Dr Marian Opoku‐AgyakwaThe study was approved by Korle Bu Teaching Hospital Institutional Review Board (KBTH‐ IRB/004/2015) and registered with the Pan African Clinical Trial Registry database (PACTR201812917283565). All patients recruited provided written informed consent.This clinical trial is registered with the Pan African Clinical Trial Database (PACTR201812917283565).


Thirty-six chronic neuropathic pain patients (8 men and 28 women) of Mexican nationality with a mean age of 44±13.98 were recruited for EEG signal recording in eyes open and eyes closed resting state condition. Each condition was recorded for 5 min, with a total recording session time of 10 min. An ID number was given to each patient after signing up for the study, with which they answered the painDETECT questionnaire as a screening process for neuropathic pain alongside their clinical history. The day of the recording, the patients answered the Brief Pain Inventory, as an evaluation questionnaire for the interference of the pain with their daily life. Twenty-two EEG channels positioned in accordance with the 10/20 international system were registered with Smarting mBrain device. EEG signals were sampled at 250 Hz with a bandwidth between 0.1 and 100 Hz. The article provides two types of data: (1) raw EEG data in resting state and (2) the report of patients for two validated pain questionnaires. The data described in this article can be used for classifier algorithms considering stratifying chronic neuropathic pain patients with EEG data alongside their pain scores. In sum, this data is of extreme relevance for the pain field, where researchers have been seeking to integrate the pain experience with objective physiological data, such as the EEG. Specifications Table•To our knowledge, this is the first available dataset containing the electroencephalographic activity of chronic neuropathic pain patients alongside the patient's pain reports from two validated pain questionnaires. This information is useful for characterization and classification for better pain management.•Pain researchers, neuroscientists, data scientists, or clinicians would benefit from exploring different pain characterization and stratification methods.•This data can be reused to understand the relation of electrophysiological data, such as neuronal brain oscillations, with the patient's experience of pain. For example, creating new algorithms for online monitor systems that assess pain through objective measures. Also, it could be used to train supervised and unsupervised classifiers with different psychological factors that are assessed through the questionnaires.1Chronic neuropathic pain (NP) is a challenge for clinicians and patients. It is present in about 7-10% of the general population in adults 2This section describes the data in the Mendeley Data repository.2.1The raw EEG data is provided for every patient ID in .gdf format. A General Data Format (GDF) file can be read and written by BioSig, an open-source software library for biomedical signal processing implemented in Octave/Matlab, C/C++, Python, Java and R 2.2The excel file contains three sheets. The first contains the demographics of each patient: age, gender, etiology, and clinical history. The second and third sheets contain the answers to the pain questionnaires, Brief Pain Inventory (BPI) and painDETECT questionnaire (PDQ), which were used in their validated Spanish version 2.2.1functionality category of the BPI is divided into seven items: general activity, mood, ability to walk, normal work, relationships with other people, rest, and enjoyment of life. Each item is measured on an 11-point scale from 0 to 10, where 0 is no pain or no interference, and 10 is worst pain or complete interference.The second sheet contains the answers to the BPI. The 2.2.2draw and mark. When the questionnaire asks patients to “Please mark your main area of pain”, we asked them instead to write the main area of pain as specifically as possible. Also, for the question “If yes, please draw the direction in which the pain radiates”, we asked them to write the direction in which it irradiates and to be as explicit as possible . For the PDQ, a total score between -1 and 38 can be calculated from the nine items, with a greater probability of having NP with higher scores. A score less than or equal to 12 indicates pain with a modest probability of being NP, greater than or equal to 19 means that there is a 90% probability that NP exists. The final score of each patient can be calculated with the uploaded questionnaire in the repository.The third sheet contains the answers to the nine items of the PDQ. Two questions had to be acquired differently for dataset purposes since they required for patients to 2.3Two .txt files of channel locations  are available. The rereferenced 22 ch text file can be used when preprocessing the data after referencing to M1 and M2.33.1The sample size was calculated in line with n. Thus, to compute the power with this formula, an expected value from the control group  value, an EEG biomarker taken from the analysis of the alpha band, which is modulated by lifestyle, diet, exercise, sex, age, and other factors. Moreover, it can be affected by neuropathologies such as tinnitus and NP due to the mechanism of thalamocortical dysrhythmia. It has been reported that the IAF of tinnitus and NP patientsis equivalent, given the same thalamocortical dysrhythmia as the background neuronal activity 3.21.The PDQ 2.The BPI isan NP assessment tool As stated previously, two validated questionnaires in Spanish  were use3.3For ethical reasons, patients were allowed to continue their medication if they had been receiving it at least 4 weeks before the study, which is supported by a prior EEG study where patients received co-analgesic treatment (anticonvulsants and antidepressants) 3.4Ten minutes of spontaneous EEG data were recorded using 22 electrodes  positioned according to the International 10/20 System with two earlobe references (M1 and M2). The channel positions for the data are shown in 3.5The experimental procedure was as follows Prior to the start of the experiment, all patients provided written informed consent according to the World Association Declaration of Helsinki. This study was approved by the Clinical Investigation Ethics Committee of Tecnológico de Monterrey (number: P000369-DN-RespElectro-CI-CR005).Daniela M. Zolezzi: Literature Research, Data Recording, Writing – original draft; Norberto E. Naal-Ruiz: Data Recording, Supervision; Luz María Alonso-Valerdi: Supervision, Conceptualization – review & editing; David I. Ibarra-Zarate: Data Supervision, Writing – review & editing.The authors declare that they have no known competing financial interests or personal relationships which have or could be perceived to have influenced the work reported in this article.


PEA is a useful treatment option for patients with chronic lumbar radicular pain refractory to epidural steroid injections. A history of lumbar surgery, spondylolisthesis, depression, and severe foraminal stenosis could be associated with a poor prognosis.Percutaneous adhesiolysis (PEA) is of interest in the treatment of lumbar radicular pain. This study aimed to assess the effectiveness of PEA in patients with chronic lumbar radicular pain refractory to epidural steroid injections and to determine predictive factors, including demographic, clinical, and procedural data, to provide superior treatment efficacy. One hundred and ninety-three patients were reviewed. Successful treatment outcome was described as a 50% reduction in the visual analog scale score. Among the 193 patients, 109 (56.2%) exhibited a positive treatment response at 12 months. In multivariate logistic regression analysis, no depression (OR, 3.105; 95% CI, 1.127–8.547;  Lumbar radicular pain, defined as low back pain accompanied by pain in the lower extremities is a frequent symptom in populations worldwide . The comThe management of lumbar radicular pain consists of a stepwise care approach due to the complexity of the contributors to both the pain and physical disability, such as psychosocial and biophysical factors . TreatmePercutaneous epidural adhesiolysis (PEA) is a minimally invasive treatment option in which a catheter is located into the ventral epidural space or around the nerve root. PEA is associated with long-term benefits for symptom control and reducing the long-term risk of surgery in patients with lumbar radicular pain unresponsive to conservative treatment modalities ,14. The This study includes a retrospective analysis of treatment outcomes in a medical center over a 5-year period. The objectives of this trial were to investigate the effectiveness of the PEA procedure in the treatment of chronic lumbar radicular pain among patients for whom epidural injections were not successful and to determine the demographic, clinical, and technical predictors of the outcome of PEA.Institutional review board approval  was obtained. This study was registered at ClinicalTrials.org PRS under Registration No. NCT05235308. This manuscript adheres to the applicable STROBE checklists for observational studies.Patients with a primary complaint of chronic lumbar radicular pain treated with PEA procedures in Diskapi Yildirim Beyazit Training and Research Hospital, Turkey, between January 2016 and January 2021 were included. Patients had undergone PEA if they had lumbar radicular pain lasting more than 3 months, which was decreased by less than 50% by 4 weeks after conservative therapy including physical therapy and oral analgesics and at least two tranforaminal or interlaminar epidural injections administered over 2 months. Pathologies as the source of persistent lumbar radicular pain for at least 6 weeks were confirmed with the MRI findings. All the included patients were age ≥18; refractory to standard treatments, including physical therapy, oral medications, and caudal or transforaminal epidural injections. Our electronic databases were searched using the code ‘551120′ . Since the patients included in this study were refractory to conventional treatment modalities, including oral medications, physical therapy, and epidural or transforaminal injections, they did not receive additional interventions or physical therapy during the study period. No specific co-interventions were offered. Patients were excluded in cases where adequate follow-up or documentation were missing. Data extraction was hindered under several potential scenarios: patients who missed appointments, those with whom communication was not feasible, or patients who may express dissatisfaction with their treatment and consequently refrain from clinic visits.All the procedures were performed under fluoroscopy in a sterile operating room with standard monitoring. Prior to the initiation of the procedure, the patient’s intravenous access was appropriately established, and antibiotic pretreatment was administered. The patient’s vital signs were meticulously monitored throughout the entire duration of the procedure. The patient was placed in a prone position with a pillow under the abdomen to minimize lumbar lordosis. After local anesthetic infiltration, the 16 G Tuohy needle was inserted through the sacrococcygeal ligament and placed into the epidural space. An epidurogram with 2–5 cc of contrast was obtained to confirm epidural placement of the needle and to avoid intravascular needle placement. Then, a Racz epidural catheter  was inserted through the epidural needle towards the target area. Approximately 5 cc of radiopaque contrast was injected to identify the filling defects and position of the catheter tip at the anterior epidural space of the target site of pathology. After adhesiolysis was carried out with 1500 units of hyaluronidase, a mixture of 10 cc 0.025% bupivacaine and 4 mg dexamethasone was divided and separately injected into each target. The catheter was removed slowly, and a sterile dressing was applied to the injection site. The patient was positioned in the supine position and transferred to the recovery room, where they were closely monitored for any possible complications or side effects. Vital signs were continuously checked throughout the recovery period in the post-procedure recovery unit. Potential complications during the procedure, such as dura matter puncture or subdural injection, were recorded. In the presence of any suspected neurological complications, the patient underwent serial neurological examinations, and discharge from the hospital was considered only upon the consistent attainment of normal results in these assessments.Treatment success was described as achieving at least 50% pain relief compared to the baseline for 12 months, which was defined in previous pain research studies ,22. If aAfter an exhaustive review of prior research concerning the impacts of PEA procedures on treatment effects and subsequent deliberations among the authors of this present study, a comprehensive set of variables was formulated. These variables encompass a wide spectrum of demographic, clinical, and technical clinical attributes. Demographic and clinical variables for logistic regression analysis were age, sex, duration of pain, baseline VAS score, smoking status , grade of central and foraminal stenosis, employment status (employed or retired-unemployed), depression, obesity (body mass index ≥ 30), history of lumbar surgery, spondylolisthesis, and opioid use. Intervention characteristics included target levels, target sites, and the number of target sites. We conducted a retrospective analysis of the patient’s electronic medical records and image archive system to gather variables. The degree of foraminal and spinal canal stenosis was assessed using established classification standards ,24. In cp < 0.200) in univariate analysis. In the univariate analysis, several factors including depression, opioid usage, baseline pain intensity, stenosis severity, spondylolisthesis presence, and history of prior lumbar spinal surgery were identified as the most influential variables. These factors were then incorporated into a multivariate model aimed at predicting the likelihood of procedural success for the PEA procedure. Odds ratio (OR) with 95% confidence interval (CI) was calculated. p < 0.05 was considered statistically significant.The SPSS version 23.0 statistics program was used. . We conducted a post hoc power analysis to confirm the adequacy of the sample size for assessing the predictive factor in determining the success of the PEA procedure. Patients in the trial were categorized as responders or non-responders based on their treatment success. Descriptive statistics were summarized by means and standard deviations for continuous outcomes and frequencies (%) for categorical outcomes. We conducted univariate logistic regression analyses utilizing demographic and clinical factors of the patients as potential predictors to quantify the results of treatment success. Thirteen demographic and baseline clinical characteristics and three procedural characteristics were used to perform univariate regression analysis. Multivariate logistic regression analysis was performed with characteristics which were showing a trend towards statistical significance (n = 109) of the patients achieved a successful treatment outcome at 12 months. In the cohort of non-responder patients, 14 patients had undergone spinal cord stimulation, and 7 patients within this group had undergone surgical interventions. Furthermore, opioid doses were escalated for 30 of the patients as part of their treatment regimen. The study participants’ demographic and baseline clinical characteristics were presented in the following manner: The mean age of the patients was 61.9 ± 10.4. The proportion of females and males was 50.2% and 49.8%, respectively. The average baseline pain score was 7.06 ± 1.3, and the average duration of pain was 10.1 ± 3.72 (months). Of these patients, 30% (n = 58) had prior lumbar surgery, 37.3% (n = 72) were receiving opioids, 20.2% (n = 39) had depression, 33.7% (n = 65) were obese, and 23.3% (n = 45) had a history of spondylolisthesis , moderate foraminal stenosis , no opioid use , and higher baseline pain scores  showed a slight trend towards statistical significance (p < 0.200). There were no statistically significant differences in factors such as age, sex, symptom duration, obesity, employment, degree of central stenosis, smoking status, and procedural characteristics  that exhibited a notable tendency toward statistical significance in the initial univariate analysis. The findings indicate that the multivariate model exhibits statistical significance and explains/calculates 40.2% of the variability in the pain outcome as a dependent variable . The multivariate logistic regression analysis revealed that mild foraminal stenosis  was associated with a positive outcome. No history of previous lumbar surgery was significantly associated with a good prognosis following the PEA procedure . A significant correlation was present between no spondylolisthesis and a higher proportion of successful outcomes . Patients who had no depression obtained better treatment outcomes . Despite showing a trend towards statistical significance (p < 0.2) in univariate analysis, opioid use  and higher baseline VAS scores  were not statistically significant when subjected to the scrutiny of multivariate logistic regression (Multivariate logistic regression analysis included only those regressors (with a significance level of gression .The results of our study confirm the benefits of the PEA procedure in the treatment of patients with chronic lumbar radicular pain recalcitrant to conservative treatment modalities, including epidural steroid injections. Overall, our study demonstrated that PEA procedures provide an improvement of 50% or greater in terms of VAS score in 56% of patients at 12 months. Despite the widespread utilization of PEA in clinical practice and the presence of studies demonstrating its impact on pain scores, the literature is lacking in terms of comprehensive investigations into the clinical, radiological, and demographic factors that influence the efficacy of the PEA procedure. What is striking about this study is that a wide variety of characteristics that were not included in previous studies and different causes of pain gathered under the umbrella of chronic lumbar radicular pain were evaluated to predict the outcomes of PEA. In multivariate logistic regression analysis, depression, severe foraminal stenosis, previous lumbar surgery, and spondylolisthesis were associated with poor outcomes following the PEA procedure. Recently, PEA has become an important part of the minimally invasive procedures in the treatment of lumbar radicular pain refractory to conventional treatment modalities such as interlaminar or transforaminal epidural steroid injections ,12,13. TOne of the prominent factors significantly associated with negative treatment outcomes was severe foraminal stenosis on the MRI findings. Similar to our results, several studies evaluating the outcome after PEA have found that severe foraminal stenosis is a predictor of poor prognosis ,27,28. DIn the univariate logistic regression analysis, but not in the multivariate model, our results showed that a higher pretreatment pain score and opioid use were correlated with a poor prognosis. Several trials investigating characteristics associated with treatment results have reported that subjects with higher pain scores experienced unsuccessful treatment outcomes ,31. ContAccording to our results, the history of lumbar surgery and spondylolisthesis was associated with a negative treatment outcome in logistic regression analysis. Similar to our results, previous studies evaluating the prognostic predictors of PEA procedures reported that previous surgery and spondylolisthesis had a poor influence on the effectiveness of PEA procedures ,34. A maOne of the factors that affects the treatment success of PEA is depression. This trial’s results indicated a diminished likelihood of a positive response among patients with depression. Consistent with these findings, several studies have demonstrated that depression is associated with a poor outcome in the efficacy of interventional procedures for managing chronic pain ,32,33. PThere were several limitations that should be noted. Firstly, as our regression analyses were focused on assessing the influence of predictive factors on outcomes at the 12th month, the ability to predict successful outcomes over the longer period remains uncertain. Secondly, the success of the treatment was confined solely to changes in pain relief. Due to the lack of routine recording in the clinic, we were unable to track changes in pain medication consumption or functional disability. Thirdly, as with many retrospective studies, there were patients who had to be excluded due to missing data. Lastly, it is important to note that this study was conducted retrospectively, lacking a control or sham group for a comparative analysis of the procedure’s outcomes. The prevalence of placebo and nocebo effects in the context of interventional treatments is estimated to range between 13% and 30% and 3% and 8%, respectively . Within This study suggests that the PEA procedure is an effective treatment option for pain relief in patients with lumbar radicular pain who are refractory to conservative treatments, including epidural injection. Previous lumbar surgery, depression, spondylolisthesis, and severe foraminal stenosis were found to be significant predictors of the poor prognosis of PEA. Refining patient selection based on the findings of this study has the potential to optimize the balance between benefits and risks and improve treatment efficacy. Prospective randomized controlled trials are needed to definitively establish the validity of these factors.


The Constant-Murley Score (CMS) is a relatively unique shoulder assessment tool because it combines patient-reported outcomes (pain and activity), performance measurement and clinician-reported outcomes (strength and mobility). With these characteristics, the effect of patient-related psychological factors on the CMS remains debated. We aimed to investigate which parameters of the CMS are influenced by psychological factors by assessing the CMS before and after rehabilitation for chronic shoulder pain.This retrospective study screened all patients (18–65 years old) who were admitted for interdisciplinary rehabilitation for chronic shoulder pain (≥ 3 months) between May 2012 and December 2017. Patients with unilateral shoulder injuries were eligible. Exclusion criteria were shoulder instability, concomitant neurological injuries, complex regional pain syndrome (including Steinbrocker syndrome), heavy psychiatric issues, and missing data. The Hospital Anxiety and Depression Scale, Pain Catastrophizing scale, and Tampa Scale of Kinesiophobia were administered before and after treatment. Regression models were used to estimate associations between psychological factors and the CMS.We included 433 patients  with a median duration of symptoms of 392.2 days (interquartile range: 266.5-583.5). Rotator cuff issue was present in 71% of patients. During interdisciplinary rehabilitation, patients were followed for a mean of 33.6±7.5 days. The mean CMS at entry was 42.8 ±15.5. The mean gain in CMS after treatment was 10.6 ±10.9. Before treatment, psychological factors were significantly associated with only the pain CMS parameter: -0.37 (95% CI: -0.46 to -0.28), p <0.001. After treatment, psychological factors were associated with the evolution of the four CMS parameters: -0.12 (-0.23 to -0.01) to -0.26 (95% CI: -0.36 to -0.16), p<0.05.This study raises the question of a distinct assessment of pain when assessing shoulder function with CMS in patients with chronic shoulder pain. The separation of the “pain parameter” from the overall CMS score seems illusory with this tool that is used worldwide. However, clinicians should be aware that psychological factors can negatively influence the evolution of all CMS parameters during follow-up, which argues for a biopsychosocial approach to patients with chronic shoulder pain.The online version contains supplementary material available at 10.1186/s12891-023-06441-7. Chronic musculoskeletal pain is a health problem with a worldwide prevalence ranging from 11.4 to 24% . In addiThe Constant-Murley Score , 11 is oThe CMS is a relatively unique tool because it combines patient-reported outcomes (pain and activities of daily living: 35 points), performance measurement, and clinician-reported outcomes (strength and mobility: 65 points). Some consider this feature an advantage over patient-reported outcome measures (PROMs), which reflect only the subjective patient’s point of view, which are also influenced by psychological factors , 17. OthFor many years, psychological factors have been considered associated with the patient’s perception of shoulder pain and disability in upper extremity injuries as well as the patient’s perception of the results of both surgery and physiotherapy –21. The For the CMS, the results remain conflicting. When determining to what degree shoulder outcome instruments reflect the patient’s psychological distress, Roh et al. found no such association with the CMS , whereasFollowing these questions, the aim of our study was to investigate which parameters of the CMS are affected by psychological factors by determining the CMS before and after rehabilitation, here chronic shoulder pain. Depending on the results, a reflection on the interpretation and use of the CMS could be initiated. For instance, a more detailed knowledge of the psychological factors affecting each of the components of the CMS could promote a better interpretation of the score. The clinician could then be made aware of the detection of these emotional and cognitive factors, namely in case of discordance of the CMS with other evaluation parameters .We conducted a single-center retrospective study in a Swiss rehabilitation teaching center. The protocol was approved by the local medical ethics committee (CCVEM 034/12). The study was performed in accordance with the ethical standards of the Declaration of Helsinki. Patients included underwent rehabilitation between May 1, 2012 and December 31, 2017.Patients with persistent shoulder pain and functional impairments from the French-speaking part of Switzerland were referred by surgeons, general practitioners, or insurance medical advisors . All patAll patients with persistent musculoskeletal complaints (≥ 3 months) after unilateral shoulder traumatic and nontraumatic injuries were eligible and were identified from electronic patient files. The exclusion criteria were concomitant neurological injuries, complex regional pain syndrome, heavy psychiatric issues  assessed by a psychiatrist and missing data. We also excluded patients with persistent shoulder instability, the CMS being not appropriate for patients with shoulder instability. If the The inpatient therapeutic program, involving a multidisciplinary biopsychosocial approach, lasted 4 to 5 weeks . This program consists of physical components  with individual and group sessions including graded exercise  and psychological components. The program included a mean of four psychological Cognitive-Behavioral Therapy (CBT) sessions as well as social advice and vocational training. After determining the baseline physical capacity of the patient, therapists determined the therapy and then adjusted after a weekly multidisciplinary meeting. Patients had the opportunity to alternate activity and rest according to their activity planning .The primary outcome was the four parameters of the CMS before the therapeutic program began. A health professional scored the first two parameters (pain and activities of daily living) by interviewing the patient (subjective assessment) and the last two parameters (measurement of mobility and strength) by observational measurement. The secondary outcome was the improvement in score for the four parameters between the beginning and end of the therapeutic program.According to our previous study  and the The Tampa Scale for Kinesiophobia (TSK) , 29. “FeThe “Pain Catastrophizing Scale” (PCS) –32 screeThe Hospital Anxiety and Depression Scale (HADS) , 34 seekThe CMS was determined by highly experienced physiotherapists who were familiar with the score via regular training and clear instructions . To not Summary statistics are expressed as mean and SD for continuous variables, and number and percentage for categorical variables. To estimate the association between psychological factors at entry and the CMS parameters at entry and its evolution, we used linear regression models. All predictor variables  were examined individually and adjusted for confounding variables. The following confounding variables were used: age, sex, pain severity, diagnosis (rotator cuff vs. others), surgery (yes/no), and work-related injury. Pain was assessed by the mean of the Brief Pain Inventory (BPI), 38, a PWe first checked that age, sex, pain severity, diagnosis, previous surgery, and work-related injury were not effect modifiers by subgroup analyses. After checking that the associations between predictors and outcomes did not differ between subgroups (non-significant interaction), we considered these variables as confounders.Because the evolution in CMS score is also affected by the level of the score before treatment  , the evoStandardized coefficients were computed for comparability of the scales. Because the HADS-D, PCS and TSK scores were positively correlated, we built the global psychological score (GPS) as their geometric mean to reduce the multi-collinearity risk in multivariable models. Building a geometric mean of the different scores has been used previously . It basiWe included 433 patients, mostly blue-collar workers (93%) and middle-aged males  with various shoulder injuries  and a median duration of symptoms of 392.2 days (interquartile range: 266.5-583.5). The flow chart shows the selection process , p <0.001  to -0.26 (95% CI: -0.36 to -0.16), p < 0.05 . Although the correlation between psychological factors and pain is not surprising , 44, we After treatment, despite the significant improvement in the total CMS (10.55 ± 10.86), the changes in the four CMS parameters were all negatively associated with psychological factors. For the same reason as above, comparisons cannot be made with previous studies. Nevertheless, this finding reinforces the results of our previous study, finding an association of the same psychological factors with the total CMS . This obThe strength of our study is highlighting the effect of psychological factors when assessing and monitoring chronic painful shoulder function with the CMS. Considering this relationship, clinicians should assess pain with another tool and be aware of this effect when following up patients, especially with clinical and imaging discrepancies. Our study also sensitizes clinicians to the search for depression, catastrophizing and kinesiophobia factors for a biopsychosocial management increasingly being used in chronic musculoskeletal pain , 51.The first limitation is that our data are for patients with persistent shoulder pain treated in a rehabilitation teaching center specialized in the management of complex situations , so our results may not be generalizable to other patients or to other settings. Our population was about 10 years younger on average and the percentage of women (12%) lower (26–61%) as compared with the literature . NeverthAn observational study also does not reveal whether a causal relationship exists. Hence, despite considerable efforts to include all eligible patients, we were unable to avoid some missing data. One of the reasons is the retrospective design of this study.Excluded and included patients had similar profiles but a slightly less favorable evolution, without a simple explanation. Thus, the effect of other psychological factors could not be measured because they were not available in our database, especially patient expectation and pain self-efficacy, which seem to be important psychological factors related to the outcome , 52, 53.This study suggests that the “pain parameter” was affected by the psychological factors studied  when measuring the CMS, unlike the three other CMS parameters, which did not seem to be influenced by these factors. This finding raises the question of measuring “pain” separately when using the CMS score. The benefit would be to limit the effect of psychological factors and to have a measure that is as observable as possible. However, such a modification could require revalidating the CMS, which would be a major task. Because the evolution of all CMS parameters during follow-up was affected by the psychological factors investigated, the main conclusion of this study is that clinicians should be aware of this association when interpreting scores, which argues in favor of a biopsychosocial approach to patients with chronic shoulder pain, as is the case for low back pain . In the Below is the link to the electronic supplementary material.Supplementary Material 1


In this prospective observational study, we aimed to evaluate the relationship between serum levels of vitamin D and acute postoperative pain scores, as well as opioid analgesic consumption in patients undergoing laparoscopic cholecystectomy.The study was performed in the Medical Faculty Hospital, from April 2020 to April 2021. Postoperative visual analog scale (VAS) pain scores, total tramadol consumption, number of requests on patient-controlled analgesia (PCA) were compared between the vitamin D deficient  and vitamin D nondeficient  groups at five time points .Postoperative VAS pain scores were similar in the vitamin D deficient group at all time points (T0–4), but differed significantly only at the T-0 time point (p = 0.020). The mean cumulative tramadol consumption was significantly higher in the vitamin D deficiency group than in the nondeficiency group (p = 0.005). Vitamin D levels were lower in patients with VAS ≥ 4 at the postoperative T-0 time point (p = 0.009). In the multivariate linear regression analysis, 15.7% of cumulative tramadol consumption was due to vitamin D deficiency (β = −0.188).Our study shows that preoperative low vitamin D level was associated with an increase in acute postoperative pain scores and consumption of opioid analgesics in patients undergoing laparoscopic cholecystectomy. Our findings may be useful for postoperative pain management in patients with vitamin D deficiency. Cholecystectomy is one of the most common intraabdominal surgical procedures, usually performed laparoscopically. Acute postoperative pain can be observed in 30%–70% of patients after laparoscopic surgery . Many stVitamin D deficiency is very common in both developed and developing countries. Circulating vitamin D is transported to organs via vitamin D binding protein (DBP) and exerts its effects on organs by binding to intracellular vitamin D receptors (VDR) . Bile acThe relationship between vitamin D and pain is one of the contemporary research topics. Vitamin D deficiency has been associated with various pain syndromes including nonspecific musculoskeletal pain, widespread chronic pain , headachThere is no effective preoperative biomarker that can help predict the severity of postoperative pain and opioid analgesic consumption. In a recent study, low serum vitamin D levels were reported to be predictive of higher postoperative opioid analgesic consumption in patients that underwent surgical procedures . DetermiWe hypothesized that the serum vitamin D levels correlate with postoperative pain scores and opioid analgesic consumption. The main objective of this study was therefore to evaluate the postoperative pain scores and opioid analgesic consumption according to serum vitamin D levels in patients undergoing laparoscopic cholecystectomy. Secondary objectives were to determine the correlation of vitamin D levels with postoperative pain scores and opioid analgesic consumption, and factors affecting postoperative 24h cumulative opioid analgesic consumption.ClinicalTrials.gov with the following ID code: NCT04687527. This prospective observational study was reported as per the guidelines in the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement for observational studies.This prospective observational study was conducted between April 2020 and April 2021 at Yozgat Bozok University Medical Faculty Hospital, a tertiary care center. The study was approved by the Ethics Committee of the Bozok University, Turkey (protocol number: KAEK-189_2020.03.25_02) (Chairperson Prof S. Dinç) on 25 March 2020 and Helsinki Declaration guidelines were followed throughout the study. All participants signed a written informed consent to participate in the study. The study was recorded at A total of 92 adult patients who had undergone laparoscopic cholecystectomy under general anesthesia between the specified dates and met the inclusion criteria were included in the study. The study’s inclusion criteria were: (1) age between 18 and 45 years, (2) being scheduled for elective laparoscopic cholecystectomy, and (3) ASA (American Society of Anesthesiologists) physical status I–III. The exclusion criteria were: (1) history of chronic pain or taking regular analgesics preoperatively, (2) known psychiatric and neurological disease and taking medication to treat those diseases, (3) history of alcohol and substance abuse, (4) hearing and visual deficits, (5) sensitivity to nonsteroidal antiinflammatory drugs (NSAIDs) or opioids, documented history of difficult intubation, (6) moderate to severe obesity (body mass index (BMI) > 35 kg/m2), and (7) emergency surgery . In addiPatients’ demographic data such as age, BMI and ASA physical status were recorded before the operation. Venous blood samples were collected from each patient just before induction of anesthesia and kept frozen at −80°C until analysis. Patients were divided into two groups according to serum 25-hydroxyvitamin D concentration: vitamin D deficiency group (serum level less than ≤ 20 ng/mL) and vitamin D nondeficiency group (serum level > 20 ng/mL) ,13–15. IData were analyzed at five time points in the postoperative period: T0: in the recovery room, T1: 1st hour in the ward, T2: 6th hour in the ward, T3: 12th hour in the ward, and T4: 24th hour in the ward . Patient®]). After orotracheal intubation, patients were set to maintain a tidal volume of 8 mL/kg, FIO2 0.6, I:E ratio 1:2, respiratory rate 12 breaths/min, ETCO2 30 to 40 mm Hg in a controlled ventilation mode. Maintenance of anesthesia was provided by inhalation of 60% O2 and 40% air and sevoflurane . Following intubation, 0.1 mg/kg rocuronium was administered when necessary for muscle relaxation. Additional fentanyl supplementation was used to maintain blood pressure and heart rate within 20% of baseline values intraoperatively. The mean blood pressure was maintained above 60 mm Hg with ephedrine boluses. Bradycardia (heart rate < 45 beats/min) was treated with atropine.None of the patients required sedation and analgesics for premedication purposes. Once the patients were in the operating room, routine monitoring  was performed and an 18-gauge IV cannula was inserted into a vein on the dorsum of the right hand. Crystalloid infusion (8 mL/kg) was started in all patients and continued throughout the surgery. Preoxygenation was performed for 3 min with 100% O2. All patients received standardized anesthesia induction , and 1 g paracetamol IV  for postoperative nausea and analgesia, 30 min before the end of the operation. At the end of the surgery, residual neuromuscular blockade was antagonized with an IV neostigmine (50 μg/kg) and atropine (20 μg/kg) combination. When the patient was awake, the endotracheal tube was extubated.All laparoscopic cholecystectomies were managed by the same highly experienced team (surgeons and anesthesiologists). All clinical steps such as anesthetic technique and administration of medications were managed according to standard institutional protocols. As a standard surgical technique, 4 trocars were used: 10 mm from the umbilical region, 5 and 10 mm on the left and 5 mm on the right. The gallbladder was retracted via the subumbilical 10-mm port site. The intraoperative carbondioxide pneumoperitoneum pressure was maintained at 12–14 mm Hg with carbondioxide and this gas was evacuated at the end of surgery.During the preoperative visit, all patients were informed about the use of the PCA device and VAS for postoperative at rest pain assessment (where 0 = no pain and 10 = worst possible pain). Postoperative pain at the recovery room and the ward was assessed by an investigator using the VAS at 1st, 6th, 12th and 24th h after surgery.In the recovery room, patients were asked to estimate, on a horizontal VAS ruler (by awake patients), to rate their baseline pain (T-0) between 0 and 10 according to VAS and recorded to one decimal point (0.0–10.0). Pain sensation was evaluated every 10 min, patients with VAS scores of 4–5 were treated with 10 mg IV tramadol bolus, while those with VAS scores > 5 were treated with 20 mg IV tramadol bolus. If VAS scores did not fall below 4 after 50 mg tramadol bolus, rescue analgesia was planned to be provided with 2 mg IV morphine. After 30 min of follow-up in the recovery room, a PCA device  containing a tramadol set to a bolus dose of 10 mg, a basal infusion of 10 mg/h, and a 10-minute lock interval was placed in the venous line and the infusion was initiated. IV metoclopramide was given every 8 h for 24 h. Any side effects such as nausea and vomiting were reported and treated. Patients who were hemodynamically stable and had a VAS less than 4 were transferred to the ward after 30 min in the recovery room.The patients were followed up in a similar way at the 1st, 6th, 12th and 24th hours in the postoperative period. At each time point, VAS pain scores, tramadol requests (number of PCA button presses), total tramadol amount administered to the patient, and cumulative tramadol consumed within 24 h were retrieved from PCA pump memory. The pain management strategy and indication for rescue analgesia were the same as for the recovery room. After the initiation of PCA, the patient’s vitals were closely monitored, and overdose of PCA solution (tramadol) was avoided.Venous blood was collected from patients just before the induction of anesthesia to measure the serum concentration of vitamin D, VDR and VDBP. Collected blood samples were centrifuged at 3000 rpm for 10 min. Then, the supernatant was removed and kept frozen at −80 °C. Serum vitamin D, VDR and VDBP concentrations were measured with Olympus AU 600 autoanalyzer  by using commercial ELISA kits . Serum vitamin D and DBP concentrations were expressed as ng/mL, while VDR concentrations were expressed as pg/mL.p-value of less than 0.05 was considered to be statistically significant.The data was analyzed with IBM SPSS Statistics Standard Concurrent User V 25 . Descriptive statistics were presented as mean (standard deviation), frequency distribution and percentage. The normality of distribution was checked using the Kolmogorov-Smirnov test and histograms. The significance of differences between groups in terms of averages were assessed with chi-square test, independent samples t-test, Mann-Whitney U test, Pearson’s and Spearman’s rho correlation, and linear regression (LR). The effects of categorical variables  and covariates  as independent variables on postoperative pain score and 24h cumulative tramadol consumption were analyzed using the LR backward model (Adjusted R2) while adjusting for potential confounding factors. Sex , which are categorical variables, were converted into a dummy variable and included in the regression analysis. The model fit was assessed using appropriate residual and goodness of fit statistics. Variables were the relationships between serum vitamin D levels, VAS pain scores, total tramadol consumption at each time point and 24h cumulative tramadol consumption were examined by a Pearson correlation analysis. All comparative analyzes were 2-tailed, and a The sample size was calculated using the G*Power 3.1 program  based on the difference of the arithmetic mean in two independent groups. Hao-Wei Xu et al.  found thA total of 80 patients between the ages of 28 to 45 years with a mean (SD) age of 37.9 (4.01) years that underwent elective laparoscopic cholecystectomy and had ASA physical status I–III were included in the study. Among the patients 54 (67.5%) were female. The mean serum vitamin D, DBP and VDR concentrations (SD) were 23.91 (5.61) ng/mL, 47.25 (11.54) ng/mL and 55.35 (13.58) pg/mL, respectively. Demographic and surgical data of the patient groups were similar in terms of serum vitamin D concentrations .p = 0.020) . Cumulative tramadol consumption was significantly higher in the vitamin D deficiency group (SD) (252.40 [13.93]) than in the nondeficiency group (243.82 [5.93]) (p = 0.005) (p = 0.439). In both the recovery room and the ward, none of the patients required rescue analgesia with morphine. Nausea was observed in 15% (12/80) patients, and vomiting in 6.3% (5/80). There were no significant differences between the groups with regard to postoperative side effects such as nausea and vomiting.Postoperative VAS pain scores were higher in the vitamin D deficiency group at all time points (T0–4), but differed significantly only at the T-0 time point (= 0.020) . Tramado= 0.005) . Twenty-p = 0.009, p = 0.007, p = 0.024, respectively). In addition, the mean cumulative tramadol consumed in patients with VAS ≥ 4 (255.94 [9.79]) was significantly higher than in patients with VAS < 4 (240.21 [1.44])  . The patr = −0.407) (r = 0.977) and VDR (r = 0.942) (p < 0.001).There was a weak negative correlation between patients’ serum vitamin D levels and their postoperative pain scores  as well as the amount of tramadol consumed (T-0 and T-1). However, there was a moderate negative correlation between serum vitamin D levels and cumulative tramadol consumption ( −0.407) . As expeβ = −0.338) and high BMI (β = 0.263) were determined as independent risk factors for increased postoperative T-0 VAS pain score. These two factors accounted for 16.2% of the pain (Adj.R2 = 0.162). No correlation was found between the pain scores and age and sex  and vitamin D deficiency (β = −0.188). It was determined that 1 unit increase in VAS pain score caused a 4.8 mg increase in cumulative tramadol consumption, and 1 ng/mL increase in vitamin D level caused a 0.334 mg decrease in cumulative tramadol consumption. Age, sex, and BMI did not cause a significant change in the cumulative tramadol consumption  of cumulative tramadol consumption was related to the severity of postoperative pain . Accordingly, these similar results in pain scores were achieved at the expense of significantly higher opioid analgesic consumption in the vitamin D deficient group. Patients in both groups had immediate access to tramadol with IV PCA so that they could achieve adequate analgesic effect. These results suggest that high serum vitamin D levels may have a dose-sparing effect on postoperative opioid analgesic consumption. Studies in the literature have shown that vitamin D supplements can increase the efficacy of opioids by reducing opioid tolerance ,23. HoweOne of the major findings of our study was that low serum vitamin D level was an independent risk factor for postoperative opioid analgesic consumption. In previous studies, low vitamin D levels have been associated with the amount and duration of short-term opioid use in palliative cancer patients ,25. A reDetailed examination of our results showed that despite exclusion of patients with BMI >35 kg/m2, it was found that high BMI was a risk factor for VAS-T0 pain score in the regression analysis, but not for cumulative tramadol consumption. However, BMI values did not differ significantly between vitamin D groups. There are conflicting results in the literature regarding the relationship between BMI and pain. In a metaanalysis of 33 studies examining negative predictors associated with postoperative pain control, it was reported that higher BMI was an independent risk factor for postoperative pain . On the Our study has several limitations. First, no adjustments were made for seasonal variation and climate-related factors affecting serum vitamin D levels during the study period. However, blood samples were taken from all patients before induction of anesthesia to determine their current serum vitamin D levels. In future studies, the relationship between seasonal vitamin D levels and postoperative pain can be investigated. Our second limitation is that various factors that have been shown to affect acute postoperative pain  were not investigated. Future research may focus on analyzing effects of various pain predictors in conjunction with vitamin D deficiency on postoperative pain with a larger patient population. Finally, our study was conducted in a single institution and only included patients undergoing laparoscopic cholecystectomy. Thus, it cannot be generalized to all patients undergoing surgery. Nevertheless, in the light of the literature, we think that the present study addresses an important issue in the field of pain.In conclusion, our study showed that preoperative low serum vitamin D levels were associated with an increase in acute postoperative pain scores and opioid analgesic consumption in patients undergoing laparoscopic cholecystectomy. These findings may be useful for managing postoperative pain in patients with vitamin D deficiency. We believe that it will be useful to apply preventive treatments for postoperative pain in patients with vitamin D deficiency. Larger clinical studies are needed to confirm the relationship between serum vitamin D levels and postoperative pain.


Endometrial polyps are one of the most common pathological conditions in gynecology. Hysteroscopy is the gold standard for the diagnosis and treatment of endometrial polyps. The purpose of this multicenter, retrospective study was to compare patients’ pain perception during an operative hysteroscopic endometrial polypectomy in an outpatient setting with two different hysteroscopes (rigid and semirigid) and to identify some clinical and intraoperative characteristics that are related to worsening pain during the procedure. We included women that underwent, at the same time as an diagnostic hysteroscopy, the complete removal of an endometrial polyp (using the see-and-treat strategy) without any kind of analgesia. A total of 166 patients were enrolled, of which 102 patients underwent a polypectomy with a semirigid hysteroscope and 64 patients underwent the procedure with a rigid hysteroscope. No differences were found during the diagnostic step; on the contrary, after the operative procedure, a statistically significant greater degree of pain was reported when the semirigid hysteroscope was used. Cervical stenosis and menopausal status were risk factors for pain both in the diagnostic step and in the operative one. Our results confirm that operative hysteroscopic endometrial polypectomy in an outpatient setting is an effective, safe, and well-tolerated procedure and indicate that it might be better tolerated if a rigid rather than semirigid instrument is used. Hysteroscopy is the best method for the direct evaluation of the endometrial cavity of patients with a broad spectrum of gynecological pathologies, such as abnormal uterine bleeding, endometrial polyps, submucous myomas, infertility, mullerian abnormalities, endometrial hyperplasia, and cancer.Endometrial polyps are among the most common pathological conditions in gynecology; their prevalence is estimated between 10% and 40% in symptomatic women and up to 12% in asymptomatic women .Nowadays, hysteroscopy represents the gold standard not only for diagnosis but even for the treatment of intra-uterine pathologies, which can be performed in outpatient or inpatient settings . The advOperative outpatient procedures, also called “office hysteroscopies”, are usually performed without any medication; in fact, there is no high-quality evidence that using local anesthetics, nonsteroidal anti-inflammatory drugs, or other medical approaches, either when compared amongst themselves or with a placebo, improves a patient’s compliance or reduces their pain scores during hysteroscopy .It has been proven that the outpatient procedure is also less expensive in terms of direct and indirect costs when compared with an inpatient hysteroscopy, for which the latter is usually performed in an operative room under general or local anesthesia ,10.Polypectomy is the most common hysteroscopic operative procedure worldwide and many studies have proven its safety and efficacy both in general and in an outpatient setting ,7. The phttp://publicationethics.org/ (accessed on 1 September 2022)), and the reporting of the study was conducted using observational, routinely collected health data statements [www.equator-network.org (accessed on 1 September 2022)). The study was unadvertised, and no remuneration was offered to participants. Each enrolled patient was informed about aims and procedures and signed an informed consent to facilitate data collection for research purposes.This article reports the results of a multicenter, retrospective pilot study. The study was approved by the local Ethical Committee of the IRCCS “Regina Elena” National Cancer Institute of Rome (promotion center) and of the Fondazione Policlinico Universitario A. Gemelli—IRCCS of Rome (participant center) . The design, analysis, interpretation of data, drafting, and revision of the study followed the Helsinki Declaration’s Committee on Publication Ethics guidelines  to assess which technique is more effective and less painful; the second goal was to identify clinical and intraoperative characteristics related to increased pain during the procedure.We retrospectively and consecutively included all women with hysteroscopic diagnosis of endometrial polyp that underwent, at the same time of the diagnostic hysteroscopy, an outpatient operative procedure for the complete removal of the polyp (using the see-and-treat strategy) with the two different hysteroscopes mentioned earlier from March 2021 to July 2022. The study took place at the IRCCS “Regina Elena” National Cancer Institute of Rome (promoting center) and at the CLASS Hysteroscopy Center of Fondazione Policlinico Universitario A. Gemelli—IRCCS of Rome (participant center). We excluded patients with multiple polyps and other concomitant intrauterine pathologies requiring an additional procedure, patients with final histological diagnosis of myoma and endometrial carcinoma, patients that postponed the procedure, patients treated with instruments other than those under study, and patients that underwent procedures under any type of analgesia and those performed by trainees or unexperienced surgeons.Patients were divided into two groups: the first group underwent polypectomy with a semirigid office hysteroscope , and the second group underwent the procedure using a rigid office hysteroscope . In the present study, the choice of the instrument depended on physician’s preferences.TM is a 3.2 mm semirigid hysteroscope; it has a 1.9 mm optic (fiber optic) with a 0° viewing angle and a single-use outer sheath equipped with irrigation and suction channels and an additional expandable plastic channel for the insertion of 7 or 5 Fr operative instruments [Gynecare Versascopetruments .Bettocchi continuous-flow is an outpatient operating hysteroscope ; it consists of a 2.9 mm optic (lens optic) with a 30° hole-oblique range of vision, an inner operating sheath for irrigation that is 4.3 mm in diameter, and an outer sheath for fluid aspiration that is 5 mm in diameter . In bothWe evaluated the following clinical parameters in both groups: age, menopause, and number of attempts, and type of delivery. Intra- and post-procedural parameters evaluated were stenosis of the cervical canal , intra- and post-operative complications, and the size (largest diameter) and histologic type of the removed lesions. Individual pain sensation at two different times during the exam was recorded using a 10 cm visual analogue scale (VAS); each patient was asked to describe the intensity of pain during the hysteroscopy, after the diagnostic phase, and after the operative procedure.t-test were used for the analysis of continuous variables; additionally, Mann–Whitney test was used to compare VAS scores for all different groups between diagnostic and operative hysteroscopic steps since data were found to be non-parametric. t-test was used to confirm that the two groups were homogeneous in terms of clinical characteristics, since data were normally distributed, together with the Fisher’s exact test, which was used in the analysis of contingency tables for categorical data. Spearman correlation test was used to verify any correlation between polyps’ size and VAS 2. Significance was set at p ≤ 0.05. Statistical analyses were performed using GraphPad Prism ver. 9.0.0 .Kolmogorov–Smirnov test was used to analyze data distribution. Data were expressed as mean ± standard deviation (SD) and median ± range when appropriate. Mann–Whitney test or Post hoc power analysis was conducted to estimate the power of our sample size in order to detect meaningful differences between groups in the operative phase. The model by Noether et al. was applied .A total of 166 patients were enrolled from March 2021 to July 2022. Of these, 102 underwent a polypectomy with a semirigid hysteroscope (GYN group) in the promotion center, and 64 underwent the procedure with a rigid hysteroscope (BETT group) in the participant center. All the procedures were carried out by two surgeons experienced in hysteroscopy, namely, B.C. and U.C.Both groups were homogenous in terms of clinical parameters, the number of patients with an intra-procedural finding of severe cervical stenosis, and the size and histologic type of the polyps; furthermore, all the removed lesions were pedunculated, not sessile .No intra- or post-operative complications were detected in the two groups. With regard to the VAS scores during the procedure, no differences were found after the diagnostic step ; on the contrary, after the operative procedure, a statistically significant greater pain degree of was reported in the GYN group  .p = 0.2 in the diagnostic step; p = 0.3 in the operative step) and previous cesarean section vs. those without previous cesarean section . Conversely, cervical stenosis and menopause status were identified as statistically significant risk factors for pain both in the diagnostic step and in the operative one. Regarding the polyp size and histological type of the removed lesions, no correlations were found with VAS score during the operative step   .Following post hoc power analysis, our sample resulted in a 37.6% level of power for detecting statistical differences between comparators, with an alpha error of 0.05.Hysteroscopy represents the gold standard for the diagnosis and treatment of intrauterine pathologies, and it should be considered for the treatment of endometrial polyps whenever possible ,16,17.Several types of hysteroscopes with different technological capabilities are currently available, and it is widely known that the smaller the diameter of the endoscope, the lower the degree of pain perceived; however, other factors must play a role in the genesis of pain during hysteroscopy.The use of mini-hysteroscopes (3.3 mm with diagnostic sheath) seems to reduce the level of pelvic pain during this procedure .Our study aimed to investigate pain perception during an office-based polypectomy among two groups of patients treated with a rigid and a semirigid hysteroscope; the results have shown that in the diagnostic phase, the procedure is painless and well-tolerated when using both rigid and semirigid hysteroscopes, each with two different diameters (3.6 vs. 5 mm). With regard to the operative procedure, the data show that the women who had a polypectomy with the rigid hysteroscope (BETT group) experienced less pain when compared with the GYN group.The results regarding the GYN group, although higher than the BETT group, are still acceptable, and are similar to other data obtained by a previous study, wherein a Gynecare Versascope was used to perform outpatient hysteroscopies, and the mean intraoperative VAS score during the procedure was 1.2 .The reason for such a difference could be related to the semirigid nature of the working channel of the Gynecare hysteroscope; indeed, the introduction of the operative instrument inside the expandable plastic channel provokes a sudden increase in the diameter of the hysteroscope; moreover, the position of the channel is uncontrollable due to its flexibility.With the rigid hysteroscope, thanks to its 30° degree optical range, lateral movements of the instruments during the procedure can be avoided. This theory, although it cannot be adequately proven, can explain the increase in pain in the GYN group during the operative step.Our secondary aim was to identify clinical characteristics and intraoperative parameters related to increased pain during the procedure. Our findings suggest that the correlation of pain with menopause and cervical stenosis was statistically significant; indeed, it is reasonable to think that cervical stenosis is more frequent in menopausal patients, for whom even partial synechiae render the transit of the instrument less comfortable and, therefore, more painful. These findings were confirmed both in the diagnostic and operative step, independently of the type of instrumentation used.Furthermore, no correlations were found between the pain score and diameter of the lesion or the histologic type of the removed polyps. Our personal experience suggests that the surgical complexity is independent of the nature of the polyps, and it is likely that several factors play a role in this regard. The data regarding pain scores and polyp sizes are conflicting in the literature; however, few studies have considered the correlation with the histologic type ,21.There are conflicting data regarding the correlations between menopause, speculum placement, and a lack of previous vaginal delivery; according to a previous study, they seem to be associated with pain occurrence and intensity .On the contrary, a Hungarian study found did not find any differences in the level of pain felt by the patients with different parity and menopausal statuses .The majority of patients enrolled in the present study tolerated the outpatient procedure with low pain levels; this choice made it possible for them to receive a safe, efficient, and effective assessment and treatment, which avoided the disadvantages of a general anesthesia and hospital staying.In a randomized trial, a significant patient preference for office-based hysteroscopy was reported, offering faster recovery times compared to an inpatient operative hysteroscopy and, of no small degree of importance, minimized procedural costs .Conversely, other authors have observed that an office hysteroscopic polypectomy may be associated with a higher risk of failed or incomplete polyp removal ,26.In our centers, more than 90% of hysteroscopic polypectomies are performed in an outpatient setting, and, in the present study, all the procedures were successfully completed, with no residual polyp fragments.The anxiety of patients undergoing hysteroscopy is mainly caused by the fear of feeling pain during the procedure; it is also associated with increased and persistent postoperative pain, and it seems to reduce patient satisfaction ,28.Obviously, it is very important to provide a patient with comfort and a friendly atmosphere while trying to medicalize the procedure as little as possible by using the vaginoscopic technique . ‘No-touCommunication and patient education have been proven to be effective tools with which to reduce preoperative anxiety; preoperative anxiety is reduced by the ability of doctors to answer patients’ questions, which also increases patients’ satisfaction .In an outpatient setting, accurate counselling should be considered an essential part of the procedure, with the objective of achieving pain and anxiety reduction .In this study, the patients were welcomed in both participating centers in dedicated clinics, with the presence of nurses adequately trained to support each woman. During the procedure, the surgeons provided support to the patient, involving her in the procedure and explaining the different steps of the procedure and any abnormalities, if present. These findings may have contributed to the very low pain levels reported during the hysteroscopic procedure.Unsurprisingly, in the sample used in this study, even in cases where the VAS score was high, no vaso–vagal reactions occurred, and the use of atropine was not necessary in any case.In a randomized perspective trial that evaluated the acceptance and feasibility of rigid hysteroscopes versus the flexible kind, the level of discomfort caused by the introduction of a rigid instrument was higher than that of the flexible one, even though rigid hysteroscopes provide superior optical qualities . AlthougTo the best of our knowledge, this is the first study that compares two different hysteroscopes for operative hysteroscopic polypectomy in an outpatient setting. In the literature, there are no studies that are similar to the ours; therefore, it is difficult, in a field that has been invaded by new, different optics and instruments over the last 10 years, each with different technologies, to find studies that can constitute a valid form of comparison.Our data are not robust enough to draw any definite conclusions; however, despite the limitations of a retrospective series with low statistical power, our study showed that an operative hysteroscopic endometrial polypectomy in an outpatient setting with different types of instruments seems to be an effective, safe, and well-tolerated procedure. Moreover, it may be better tolerated if a rigid rather than a semirigid instrument is used. To clarify this last point, further studies and prospective randomized trials are required to establish the best way to perform endometrial polypectomy, while also considering surgeons’ and patients’ preferences.Due to the advent of new technologies such as uterine morcellators, well-designed prospective studies are expected to be able to determine the best surgical techniques with which to perform outpatient endometrial polypectomy .


The purpose of this study was to determine the effect of the presence, size, or type of calcaneal spurs on pain or the outcomes of extracorporeal shock wave therapy (ESWT) therapy in patients with plantar fasciitis.Seventy-four patients with unilateral plantar fasciitis who had no pain in the contralateral foot, either currently or in the past, were included in the study. The length, base width, type, and presence of plantar calcaneal spurs in both heels of the patients were determined using radiography. A total of five sessions of ESWT  with an interval of 3 days were performed on the painful sides of the patients. Symptom duration and numerical rating scale (NRS) scores were recorded pretreatment and 1 week and 12 weeks after treatment.Spurs were detected in 85.1% of painful feet and 71.6% of painless feet, this difference was statistically significant (p = 0.046). There was no significant correlation between the type of the spurs and whether the foot was painful. Patients with spur sizes of >5 mm or with horizontal and hooked spurs had a higher NRS decrease than patients with spur sizes of ≤5 mm or with a vertical spur. Symptom duration, spur length, and base width were found to be correlated with pretreatment NRS scores.The presence and size of calcaneal spurs are associated with pain. However, it should be kept in mind that a high rate of spurs can also be found in painless feet, so spur is not the only factor that causes pain. Patients with a spur size of ≤5 mm or a vertical spur have less pain relief with ESWT. Plantar fasciitis (PF) is the most common cause of heel pain . One in Whether calcaneal spurs contribute to the symptoms is controversial. Some authors have described heel spur formation as a continuing process through constant traction from adjacent soft tissue, followed by chronic inflammation, periostitis, and osteogenesis of the spur, respectively . Some inThe effectiveness of rest, activity modification, ice massage, oral analgesics, stretching techniques, physical therapy modalities, foot orthotics, night splinting, corticosteroid injections, extracorporeal shock wave therapy (ESWT), and plantar fasciotomy have been demonstrated in the treatment of PF . ESWT, wThe relation between calcaneal spurs with pain is not clear, and studies investigating the relationship between the size and type of spurs with pain or response to treatment are also limited. Ahmad et al. divided calcaneal spurs into three groups according to their type as horizontal, vertical, and hooked. They examined their types and sizes and their relationship with treatment outcomes consisting of weight-bearing, controlled ankle motion (CAM) walking boots, and a supervised rehabilitative physical therapy program. They found better improvement in horizontal and hook or large spurs than vertical or small spurs .Although there is a study examining the effects of ESWT on radiological changes and pain in the calcaneal spur , we did Seventy-eight patients who were diagnosed as having unilateral PF were evaluated for inclusion in this prospective study. Since there is no study similar to ours, the sample size was calculated using the standard effect sizes recommended by Cohen , which aThe study was conducted at Kırşehir Ahi Evran University Hospital between June 2020 and June 2021. The presenting symptom of these patients was plantar heel pain. Patients who were diagnosed as having PF by a physiatrist based on patient history, risk factors, and physical examination were recruited for the study. All patients were evaluated by the same physician (FAK) in terms of diagnosis. All patients had plantar heel pain, which is typical of PF, which was felt strongly when getting out of bed in the morning and then subsided with ambulation. In addition, a detailed physical examination was performed on all patients. Other diseases in the differential diagnosis  were evaluated comprehensively. Other specific tests were performed to rule out these disorders.The inclusion criteria were age of 18–65 years, being diagnosed as having unilateral PF and approving to participate in the study. The exclusion criteria were having a history of heel pain in the opposite foot currently or in the past, having received treatment for PF in the last 6 months, a history of foot/heel fracture, surgery, inflammatory rheumatic disease, having a disease that might affect foot function .The age, sex, height, weight, BMI, painful side, and the duration of symptoms of the patients were recorded. Perceived pain intensity was evaluated using a numerical rating scale (NRS) pretreatment and 1 week and 12 weeks after treatment. In NRS measurements, the patients were asked to give pain scores between 0 and 10 depending on the severity of the pain. High scores meant more severe pain . On lateThe protocol was performed in accordance with the ethical standards laid down in the 1975 Declaration of Helsinki and approved by Kırşehir Ahi Evran University Medical Faculty Clinical Research Ethics Committee . All patients gave written informed consent.A total of five sessions of ESWT with an interval of 3 days were performed on the painful sides of the patients . The treatment was performed in the supine position using a Modus ESWT Touch Shock Waves device (origin: Turkey). The five most sensitive and painful points in the plantar fascia area were determined and 400 beats were given to each point. No analgesic or local anesthetic medication was administered before or during the treatment. The same physiotherapist performed the ESWT on all patients. Patients did not receive any treatment other than ESWT.The normality assumption for quantitative variables was tested using the Kolmogorov–Smirnov and Shapiro–Wilk tests. Explanatory statistics of the variables are given as mean ± standard deviation, median (min–max), and frequencies n (%). For the univariate analysis of the variables in the study, the Mann–Whitney U, Kruskal–Wallis, and Wilcoxon tests were used according to the variable type and the assumptions. The differences between the categories of the observations in the categorical variables were tested using the chi-squared test. Relationships between categorical data were tested using the Fisher–Freeman–Halton exact test. Relationships between quantitative variables were analyzed using Spearman’s correlation analysis. In all statistical analyses, cases with a p-value below 0.05 were interpreted as statistically significant. Statistical analysis of the study was performed using SPSS v. 21.0 software for Windows .Seventy-eight patients were examined to reach the required sample size calculated as 74. Two patients refused to participate in the study. Another two patients were excluded because corticosteroids were administered by physicians from another center. As a result, 74 patients were included in the study.The mean age of the patients was 47.7 ± 10.06 years. The mean duration of symptoms was 10.8 ± 11.02 months. The general characteristics of the participants are summarized in In radiologic examinations, no statistically significant difference was found between the painful sides and the nonpainful sides in terms of spur length and base width (p > 0.05). The spur types in the foot radiographs were divided into four groups: 0 = absent, 1 = hooked, 2 = horizontal, and 3 = vertical [The median pretreatment NRS value was 8 and was determined as 5 in the 1st week after treatment. At the 12th-week evaluation, the median NRS was found as 3.5. The differences between the pretreatment, 1st-week, and 12th-week NRS values were found to be statistically significant .The relationships between the pretreatment, 1st-week, and 12th-week NRS scores of the patients and sex, spur type, and spur length are shown in The patients were divided into two groups according to the length of the spur on the painful side as ≤5 mm and >5mm .The pretreatment NRS scores of the patients with a spur length of >5 mm on the painful side were higher than those of the ≤5 mm group (p < 0.05). There was no significant difference between the 1st- and 12th-week NRS scores between the two groups (p > 0.05). In the ≤5 mm group, a significant decrease in NRS scores was observed at the 1st and 12th weeks compared with pretreatment (p < 0.01). The difference between the 12th-week NRS scores and the 1st-week NRS scores in the ≤5 mm group was not statistically significant. In the group with spurs > 5 mm, a significant decrease in NRS scores was found at the 1st and 12th weeks compared with pretreatment (p < 0.01). However, unlike the ≤5 mm group, the 12th-week NRS scores were lower than the 1st-week NRS scores in the group with spurs > 5 mm. In other words, the downward trend in NRS scores continued until the 12th week.The relationship between symptom duration and pretreatment NRS scores was also positively significant . The relationship between pretreatment NRS scores with the length  and base width  of spurs in the painful feet was also positive and significant .The relationship between the symptom duration of the patients and the spur length on the painful side was positive and statistically significant . Among the patients with spurs on the painful side, 23 (37%) patients had spur lengths shorter than those on the painless side.In this study, it was determined that PF was associated with the presence of spurs, and spur length and base width were associated with pain level, but spurs were also detected in many painless feet. No relationship was found between spur type and pretreatment pain levels. However, vertical spurs were associated with worse treatment outcomes than the other types. Patients with longer spurs had more pain relief with ESWT than those with smaller spurs.In a study by Kuyucu et al., which did not include a control group, the authors found 80% of spurs in patients with PF. They showed that the length of calcaneal spurs was correlated with symptom duration, pain, and function . In theiIn the present study, a significant correlation was found between spur length and pain level, and symptom duration. Some authors have described heel spur formation as a continuing process through constant traction from adjacent soft tissue, followed by chronic inflammation, periostitis, and osteogenesis of the spur, respectively. Considering that this process will take time, it can be thought that PF, which lasts longer and more severely, contributes more to the development of spurs over time. This may explain the positive correlation of spur length with pain level and symptom duration in our study . Unlike Studies investigating the relationship between spur type and pain level are limited. Ahmad et al. showed that spur types were not associated with pain and function . SimilarHayta et al. reported that ESWT reduced calcaneal spur lengths and pain in patients with symptomatic calcaneal spurs . Mishra Although the sample size was calculated before the study, the small number of participants is one of the limitations of this study. More patient participation and longer follow-up would have made the study more valuable. In addition, the fact that the distribution of symptom duration had a wide range may have affected the results of the study. The lack of MRI, USG, and functional evaluations can be counted as other limitations. However, this study is the first study to compare the PF side of the same patient with the asymptomatic side without a history of PF. It is also the first study to examine the effect of spur size or type on ESWT outcomes and to evaluate calcaneal spur base width.In this study, it was determined that PF was associated with the presence of spurs, and spur length and base width were associated with pain level. Spurs were also detected in many painless feet, so although the spur affects the pain, it is not the only source of the pain. Patients with longer spurs had more pain relief with ESWT than those with smaller spurs. No relationship was found between spur type and pretreatment pain levels, but vertical spurs were associated with worse treatment outcomes than the other types.