Background and purpose — Previous studies have investigated risk factors related to prolonged length of stay following total knee arthroplasty (TKA), but little is known about specific factors resulting in continued hospitalization within the 1st postoperative days after unicompartmental knee arthroplasty (UKA). We investigated what specific factors prevent patients from being discharged on the day of surgery (DOS) and the first postoperative day (POD-1) following primary UKA in a fast-track setting.Patients and methods — We prospectively collected data on 100 consecutive and unselected medial UKA patients operated from December 2017 to May 2019. All patients were operated in a standardized fast-track setup with functional discharge criteria continuously evaluated from DOS and until discharge.Results — Median length of stay for the entire cohort was 1 day. 22% and 78% of all patients were discharged on DOS and POD-1, respectively. Lack of mobilization and pain separately delayed discharge in respectively 78% and 24% of patients on DOS. The main reasons for lack of mobilization were motor blockade (37%) and logistical factors (26%). For patients placed 1st or 2nd on the operating list, we estimate that the same-day discharge rate would increase to 55% and 40% respectively, assuming that pain and mobilization were successfully managed.Interpretation — One-fifth of unselected UKA patients operated in a standardized fast-track setup were discharged on DOS. Pain and lack of mobilization were the major reasons for continued hospitalization within the initial postoperative 24–48 hours. Strategies aimed at decreasing length of stay after UKA should strive to improve analgesia and postoperative mobilization. The number of unicompartmental knee arthroplasties (UKAs) performed in patients suffering from osteoarthritis has steadily increased. UKA has the potential benefit of not only improving patient-reported outcomes, but also to reduce morbidity, complications, and cost  and an increase in both complication and readmission rates  with 2 mL 0.5% hyperbaric bupivacaine, unless the patient specifically requested general anesthesia (GA) or GA was chosen by the anesthesiologist due to patient characteristics. If GA was chosen, remifentanil and propofol was used.All patients received local infiltration analgesia (LIA) with 200 mL 0.2% ropivacaine injected in the posterior capsule, periarticular tissues, and subcutaneous tissue. Standard 3-layer closure with tissue adhesive was performed and a compression bandage was applied to the limb , where they stayed until fulfilling modified Aldrete discharge criteria  and postoperative day 2 (POD-2). Fulfillment of the following criteria was recorded and included: independent mobilization, postoperative nausea and vomiting (PONV), circulatory insufficiency, pain, wound issues, and urinary retention. If patients were not sufficiently mobilized, the following possible underlying reasons were recorded and registered as 1 or more of following: logistics, motor blockade, PONV, pain, muscle weakness, or dizziness. Logistics included lack of postoperative radiographs and limited access to physiotherapy due to organizational factors. Acceptable pain levels were < 5 VAS at rest and < 7 VAS during physical activity. Patients were regarded as circulatory stabile with a pulse < 90 and systolic blood pressure > 100. Wound issues covered bleeding from the surgical wound. Urinary retention was evaluated using a bladder scanner, with 800 mL being the cutoff for catheterization.Approval from the ethical committee was not required since this was purely an observational study. Data access was approved by the national data committee (HVH-2012-048). This research did not receive any financial support. The authors declare no conflicts of interest.Patient demographics are given in Among all patients, 22% were discharged on DOS, with 78% discharged on POD-1, and 98% on POD 2. Of the 22 patients (22%) discharged on DOS, 18 patients were ASA 1–2, and the remaining 4 patients were ASA 3–4.Of the 11 patients operated using GA, 3 were discharged on DOS, 5 on POD-1, and 3 on POD-2.When only looking at patients operated as #1 or #2 on the surgery schedule, 27% of patients were discharged on DOS and 80% and 99% of patients discharged on POD-1 and POD-2, respectively. Median LOS for the entire group was 1 day (range 0–3).Lack of mobilization (81%), pain (19%), and urinary retention (18%) were the main reasons for patients not meeting the discharge criteria on DOS . When onSeveral reasons for patients not being sufficiently mobilized were recorded. In patients with mobilization issues still hospitalized on DOS the major reasons were motor blockade (44%), logistics (24%), and pain (19%) . 1 patieWhen looking only at patients operated as #1 or #2 on the surgery schedule, the percentage of patients not mobilized sufficiently due to motor blockade decreases to 37%, while the percentage of patients not mobilized sufficiently due to pain increases to 26%. PONV, muscle weakness, and dizziness were infrequent reasons for lack of mobilization.Assuming the lack of mobilization could be managed successfully in patients operated as #1 or #2 on the surgery schedule, we estimate an increase in discharge percentage up to 55% on DOS. Sorted for the specific issues resulting in lack of mobilization, an additional 11 and 9 patients could possibly be discharged, when assuming successful management of motor blockade and logistics, respectively, and thus potentially increasing DOS discharge to 41% and 39%, respectively. Assuming pain could be managed successfully in patients operated as #1 or #2 on the surgery schedule, we estimate an increase in discharge percentage up to 40% on DOS .In this prospective single-center study, we investigated specific factors responsible for continued hospitalization following medial UKA in a fast-track setting. Reasons for not being discharged on the DOS were primarily lack of mobilization and pain. Primary reasons for lack of mobilization were motor-blockade, pain and logistics.We found that 22% of unselected patients were discharged on DOS. A study by Jenkins et al.  reportedWe found a substantially lower number of UKA patients discharged on DOS compared with the studies mentioned above. In the case of Jenkins et al.  the mainPain was an issue in 24% of cases in our study, which is lower compared with a similar study investigating TKA conducted in the same surgical department in 2011, which found pain to be an issue in 53% of cases (Husted et al. The multimodal opioid-sparing analgesic regime in our setting consists of a single-shot intravenous injection of 125 mg methylprednisolone as well as paracetamol 1g x 4 and celecoxib 200 mg x 2 daily for 7 days postoperatively with morphine used as rescue medication only.A preoperative injection of methylprednisolone has been shown to reduce pain at rest, pain during walking, and opioid consumption in the first 24 hours after UKA surgery (Rytter et al. LIA is a part of our intraoperative procedure because it has been found to reduce postoperative pain following TKA surgery, and also when combined with a multimodal opioid-sparing analgesic regime (Andersen and Kehlet Improved pain management could possibly be achieved using opioids or peripheral nerve blocks as part of the standard analgesic regime, but adverse effects such as an increased risk of falls upon initiation of opioid use as well as sedation, delirium, nausea, and urinary retention have been reported (Golladay et al. Reduction of pain is crucial, but it is not only desirable as a short-term goal regarding discharge as a recent study found control of early postoperative pain to be associated with improved 2-year functional outcome following UKA (Lakra et al. Among patients not discharged due to insufficient mobilization on DOS, a motor blockade was registered as the main reason in 44% of patients. Management of motor blockade in patients operated as #1 or #2 would allow for additional discharge of 11 patients on DOS. Interestingly, 1 patient operated using GA was reported to have motor blockade suggesting difficulty distinguishing between muscle weakness and “true” motor blockade. Therefore, the proportions of motor blockade and muscle weakness reported in our study might also be a product of difficulty distinguishing between the two. It is possible to speculate that GA might be better suited for UKA surgery with intended DOS discharge, though there is insufficient evidence to advocate for one over the other (Kehlet and Joshi Since logistical factors such as limited access to physiotherapy impacted 24% of insufficiently mobilized patients on DOS, organizational factors are to be further optimized. Physiotherapy is an important factor in short-term recovery since a loss of quadriceps function close to 80% is reported after knee arthroplasty (Bandholm and Kehlet Our study has several limitations. Mainly, our results might have limited external validity since alternative setups regarding anesthesia, perioperative care, and treatment could impact reasons for continued hospitalization. However, our fast-track setup is well described and our study investigates an unselected patient population, increasing the ability for other surgical centers to compare their results with ours. Also, all patients eligible for UKA surgery were considered eligible for DOS discharge. Additionally, both GA and SA were used, but no specific distinctions between the 2 groups were made, even though differences between the groups might be present.One fifth of unselected UKA patients operated in a standardized fast-track setup were discharged on DOS. Pain and lack of mobilization were the major reasons for continued hospitalization within the initial postoperative 24–48 hours. To improve the number of patients discharged on the day of surgery, initiatives should focus on improving postoperative mobilization and postoperative pain management.


To explore the influencing factors of age at onset of pain and severe pain in patients with Hartofilakidis type I developmental dysplasia of the hip (DDH).A retrospective study of 83 patients with DDH treated at our hospital from January 2017 to June 2021 was conducted. The age at onset of pain, patients’ demographic data, and radiographic parameters were collected. Multiple linear regression was used to determine the influencing factors of age at onset of pain. Cox regression analysis was used to determine the influencing factors of severe pain attacks.β = − 1.738, 95% CI − 1.914–[− 1.561], p < 0.001). When the sharp angle increases by one degree, the age at onset of pain decreases by 0.3 years . According to the results of the Cox regression analysis, for each additional degree of the lateral centre-edge angle (LCEA), the probability of severe pain was reduced by 5% . For each additional millimetre in the distance between the medial femoral head and the ilioischial line, the likelihood of severe pain increased by 2.4 times .According to the results of multiple linear regression analysis, when the distance between the medial femoral head and the ilioischial line increased by one millimetre, the age at onset of pain decreased by 1.7 years (Larger distances between the medial femoral head and the ilioischial line and sharp angle can lead to an earlier age at onset of pain in patients with DDH. Small LCEA and excessive distance between the medial femoral head and the ilioischial line are risk factors for severe pain. Developmental dysplasia of the hip (DDH) is characterised by insufficient coverage of the femoral head and the upper lateral inclination of the acetabular articular surface, resulting in a reduction in the contact area between the femoral head and the acetabulum, joint instability, and acetabular edge overloading, resulting in acetabular labrum and cartilage injury, eventually progressing to secondary osteoarthritis –3. Many The inclusion criteria were patients with Hartofilakidis type I DDH treated at our hospital from January 2017 to June 2021. The exclusion criteria were ① a history of hip joint trauma; ② existing nerve, muscle, or connective tissue disease; ③ a history of hip surgery; ④ severe joint deformity; ⑤ lack of follow-up or incomplete radiographic data; ⑥ patients who could not accurately determine the age of pain onset.During this period, a total of 104 patients with Hartofilakidis type I DDH were treated at our hospital. Four cases were excluded for lack of follow-up, five cases had incomplete radiographic data, and 12 patients could not accurately determine the age of pain onset. Finally, 83 patients were included in this study. The general information of the patients is shown in Table P/A ratio ). Categorical variables were expressed as a percentage (%). The patients’ general demographic data and radiographic parameters were analysed by a single-factor linear regression analysis taking the age at onset of pain as the dependent variable, and the test level α was set as 0.05. If the independent variable was p < 0.05 in a single-factor linear regression analysis, the variable was included in the multiple linear regression model. According to the statistical results determining which variable influences the age at onset of pain factor, p < 0.05 for the difference was statistically significant. The age at onset of pain was taken as the time variable and the WOMAC pain score ≥ 10 as the state variable. The demographic data and radiographic parameters of the patients were analysed by a single-factor Cox regression analysis. If the independent variable was p < 0.05 in the results of a single-factor Cox regression analysis, the variable was included in the Cox proportional hazard model, and which variables were the influencing factors of severe pain were determined according to the statistical results. All the statistical analyses were performed with SPSS software for Windows .A Kolmogorov–Smirnov test was used to test the normal distribution of quantitative variables. Normally distributed measurement data were expressed as mean ± standard deviation (p < 0.001) and the sharp angle (p = 0.012)  and the various radiographic parameters  were screened out by a single-factor linear regression analysis of the distance between the medial femoral head and the ilioischial line . When the sharp angle increases by one degree, the age at onset of pain decreases by 0.3 years . No statistical correlation was found between other demographic data or radiographic parameters and the age of pain onset.The distance between the medial femoral head and the ilioischial line and sharp angle was included in multiple linear regression. It was found that there was significant statistical significance between them and age at onset of pain Table . Accordip < 0.001), LCEA (p = 0.045), and the sharp angle (p = 0.036) (Table β) = 0.947, 95% CI 0.898–0.999, p = 0.044). For each additional millimetre in the distance between the medial femoral head and the ilioischial line, the likelihood of severe pain increased by 2.4 times (Exp (β): 2.417, 95% CI 1.653–3.533, p < 0.001). An omnibus test showed that the constructed Cox regression model was statistically significant . No statistical correlation was found between other demographic data or radiographic parameters and severe pain.Cox regression analysis was used to screen the demographic data of the patients  and the various radiographic parameters listed above. The corresponding independent variables screened out were the distance between the medial femoral head and the ilioischial line (A p = 0.05, and thThe clinical symptoms of patients with DDH are primarily related to the increase in local mechanical stress and dynamic hip instability caused by insufficient coverage of the hip joint . AlthougIn this study, we found that a large distance between the medial femoral head and the ilioischial line and the sharp angle can lead to an earlier age at onset of pain in patients with DDH; a small LCEA and a large distance between the medial femoral head and the ilioischial line are the risk factors for severe pain Table .Table 5RThe external movement of the centre of the hip joint is one of the imaging findings of patients with DDH. John C. Clohisy uses the distance between the medial femoral head and the ilioischial line on x-rays to describe the degree of external movement of the centre of the hip joint and proposes that the distance between the medial femoral head and the ilioischial line is 0–10 mm . The extWe found that the sharp angle negatively affects the age at onset of pain of patients with DDH, which may be due to the increase in joint contact pressure caused by insufficient coverage of the femoral head when the sharp angle is large. The subsequent static overload leads to the degeneration of articular cartilage, and the overload of soft tissue structure is the ultimate common cause of pain in patients with DDH .Yusuke Kohno et al. also found that an extremely sharp angle is associated with early pain in patients with dysplastic hips . In addiPrevious studies have shown that acetabular retroversion is related to the decrease in the coverage area of the femoral head, and hip pain occurs earlier in patients with acetabular dysplasia with acetabular retroversion than those without acetabular retroversion . Since tSmall LCEA is a risk factor for severe pain in patients with DDH, which is related to the contact area of the femoral head and the biomechanical state of the hip joint. LCEA is an independent factor affecting the contact area of the femoral head. The smaller LCEA limits the area that can be used for proper load distribution and increases the hip joint instability, which leads to articular cartilage injury . In patiIn addition, Eduardo N. Novais et al.  found thThis study had certain limitations, however. First, our sample size was small. Second, our study was a retrospective case study. This type of study inherently has various sources of bias, including selection bias, measurement and evaluation bias, as well as lack of follow-up. Finally, this was a short-term follow-up study, and it did not provide medium- to long-term follow-up results.A larger distance between the medial femoral head and the ilioischial line and sharp angle can lead to earlier age at onset of pain in patients with DDH. A small LCEA and excessive distance between the medial femoral head and the ilioischial line are risk factors for severe pain. How to define the surgical indication more accurately, choose the best operation time, and realise the effective correction of hip joint deformity still needs further research.


The 5As model is a standard component of most guidelines for tobacco treatment. Unfortunately, provider adherence to this model is modest.  Providing physicians with adjunctive tools to adhere to 5As guidelines may serve as a catalyst for brief advice delivery. Results/Findings. Medication sampling did not improve compliance with ask, advise, or assess. Receipt of “assistance” was significantly higher among NRT recipients (70%) (p ≤ 0.0001). The NRT sampling group was more likely to have received all components (p = 0.004). As age increased, being asked (p = 0.006), advised (p = 0.05), and assessed (p = 0.003) decreased. Non-Whites reported higher rates of assessment (p = 0.02).  This was a secondary data analysis of a cluster randomized clinical trial assessing the uptake and impact of free nicotine replacement therapy (NRT) sampling versus standard care in primary care. Patients reported receipt of separate elements of the 5As model, assessed one month following a baseline visit. Analyses compared patients who recalled receipt of brief advice among those who received NRT vs. standard care. Additional analyses examined demographic predictors of receiving brief advice. Trial Registration. This trial is registered with ClinicalTrials.gov NCT02096029. Provision of NRT sampling increased provider compliance with some elements of the brief advice model, thus enhancing the impact of cessation advice within primary care.  Ask all patients for their smoking status, Advise all smokers to quit, Assess cessation preparedness, Assist in each quit attempt with referral or treatment, and Arrange follow-up [For the nearly 40 million smokers in the U.S., tobacco cessation remains the most important health-modifying goal , 2. Effiollow-up . The 5Asollow-up .Implementation of each of the 5As by providers has been varied . AlthougA number of barriers limit physician adherence to the 5As. At the provider level, these include a perceived lack of time, skills, and expertise and a false belief that attempts to alter patient behavior is an unwise use of time or this task is outside of their clinical purview , 14. ThuWe report herein on receipt of cessation advice from a recently completed cluster randomized clinical trial that evaluated the impact of medication sampling on patient outcomes. Both the study methods  and partThe parent trial assessed the uptake and impact of medication (NRT) sampling, delivered naturalistically and pragmatically within the primary care setting . Twenty-Inclusion criteria were (1) age 18+, (2) smoker of ≥5 cigarettes per day on ≥25 days of the last 30 days, and (3) English speaking. Exclusion criteria were based on the FDA contraindications to NRT. Neither motivation to quit smoking nor a willingness to try the cessation medication was required for eligibility.Standard of care was in concordance with the brief intervention model. Each clinic received 60-90 minutes of training on the 5As and a review of cessation medications from a tobacco treatment specialist prior to study onset. However, it was imperative to study design that healthcare providers could continue to counsel their smoking patients in their normal manner. All participants were provided with a packet that included smoking cessation information, a list of cessation medications, and contact information for the state quitline. In addition, the NRT sampling arm received a 2-week supply of both nicotine lozenge and patch , with minimal instructions on use. Both participants and providers were aware of group assignment.Patient response to questions regarding receipt of brief advice during their baseline visit, asked at 1-month follow-up, was recorded. Participants reported whether their provider (a) asked their smoking status, (b) advised them to quit, and (c) assessed willingness to quit, each asked via yes/no questions. Receipt of assist advice was ascertained through (d) discussion of cessation medications, (e) advice to use medications to quit smoking, or (f) provision of cessation medication. We did not formally assess follow-up (arrange) under the assumption that few patients would see their provider more than once in a 30-day window. Therefore, our analyses are restricted to 4As only and are referenced throughout as “brief advice.”N = 923. This subsample was similar to the larger study in all respects except age (responders slightly older). Receipt for each of the 4As separately and the aggregate receipt of all were compared by treatment group via generalized linear mixed models with receipt (yes/no) as the binary outcome and treatment as the main effect. All models were adjusted for the Heaviness of Smoking Index (HSI), race, and gender (in addition to including a random effect for the clinic site). To determine other factors associated with receipt of brief advice, each factor was individually examined through a generalized linear model that included a random effect for size as well as adjusted for any treatment effect that existed.Of the 1245 participants enrolled in the study, 923 (74%) completed 1-month follow-up. We made no assumptions on missing data, and thus, analyses are based on The average (SD) age was 52 (13) years, with slightly more females (60%) and smoking 15 (9) cigarettes per day on average. One-third were African American (36%), 85% were insured, and 22% were unemployed.p = 0.004). This in large part was due to higher rates of receiving “assistance” within the NRT sampling group (70%) vs. standard care alone (48%) (p ≤ 0.0001). Receipt of the other As was similar between groups.p = 0.006), advised (p = 0.05), and assessed (p = 0.003). Non-Whites reported higher rates of assessment of willingness to quit (p = 0.02).There were several demographic factors associated with receipt of the 5As, but none were associated with receipt of all 4As . Older pThis study prospectively assessed 4 of the 5As: ask, advice, assess, and assist within the context of a randomized controlled trial comparing standard of care to free NRT replacement in a primary care setting. Receipt of brief advice in aggregate was significantly improved in the NRT group compared to controls, driven largely by increased assistance. However, NRT sampling had no effect on compliance with ask, advise, or assess, despite our hypothesis that it might do so. These results add to our knowledge of tobacco control because most studies show high adherence to ask, advise, and assess and low adherence for assistance . Thus, oCuriously, only 70% of patients in the NRT group reported that they had received help with quitting, despite receiving a 2-week supply of medication. There are several possible explanations for this discrepancy. Patients may not have remembered the NRT . It is also possible that receipt of NRT from their primary care doctor was not deemed as assistance. Of note, the control group also had the opportunity to answer in the affirmative to the question of assistance as each provider had the opportunity to discuss cessation medications with their patients, even without the provision of it. In addition, while the literature deems assistance as a counseling session, medication counseling, or referral to treatment, our questionnaire was limited to a medication-focused assistance . This teWith regard to overall predictors of 5A receipt, many of the usual disparities were confirmed: smokers of older age or with less education were less likely to receive advice to quit smoking. These associations have been documented elsewhere , 12 and In summary, this large randomized clinical trial examined medication sampling as a brief and disseminable treatment to promote smoking cessation in primary care. Patient outcomes of medication sampling were favorable , with an


Corticosteroid injections are used in the treatment of hand and wrist conditions. The co-administration of a local anaesthetic and corticosteroid aims to reduce pain after the injection, although no studies have directly compared this with using corticosteroid alone. The aim is to determine whether pain experienced during the 24 h after a corticosteroid injection to the hand and wrist is no worse than (not inferior to) the pain experienced after a corticosteroid and local anaesthetic injection.A single-site, patient- and assessor-blinded, non-inferiority randomised control trial recording pain visual analogue scale (VAS) scores in patients with a clinical diagnosis of trigger finger, de Quervains tenosynovitis or carpal tunnel syndrome, treated with a 1-ml triamcinolone (40 mg/1 ml) injection co-administered with or without 1 ml of 1% lidocaine. The primary aim is to investigate a difference in pain VAS scores at 1 h after the injection using a mean change score.A 95% power calculation was made using a minimally clinical important difference of 20 mm as the clinically admissible margin of non-inferiority and an assumed standard deviation of 25 mm, from previous studies. Including a 20% fall out rate, 100 patients are required.Patients with a clinical diagnosis of trigger finger, de Quervains and carpal tunnel syndrome, are over the age 18 years old and who are able to give written informed consent will be included. Patients will be excluded if they have had previous surgery or corticosteroid injection for the condition being treated at the site considered for injection.Patients will be electronically randomised and injections delivered during their clinic appointment. Pain is assessed using a 100-mm VAS score taken, before and at the time of injection and at 5 min, 1 h, 2 h, 3 h and 24 h after the injection. The secondary outcomes are to determine a difference in pain VAS score at the time of injection and during the 24 h after.ClinicalTrials.gov (NCT04253457) on February 5, 2020.This study is registered on the IRAS (259336) on November 11, 2019, and EudraCT database on October 31, 2019 (2019-003742-32). REC/HRA approval was given in January 2020, and Clinical Trial Authorisation from the MHRA was given in December 2019. The study is registered on The online version contains supplementary material available at 10.1186/s13063-021-05627-5. Title:The SToICAL Trial: Study protocol for The Soft Tissue Injection of Corticosteroid And Local aneasthetic trial – A single site, non-inferiority randomised control trial evaluating pain after soft tissue corticosteroid injections with and without local anaestheticTrial registration:ClinicalTrials.gov Identifier: NCT04253457Protocol version:Version 2  – 7 January 2020Funding:This study will be funded from the research budget held by Trauma and Orthopaedic Department at the University Hospital Plymouth NHS Trust, and is not commercially funded.Role and responsibilities:Lead Co-Author and Principle Investigator:Mr M JonesTrauma and Orthopaedic DepartmentUniversity Hospitals Plymouth NHS TrustPL6 8DHm.jones16@nhs.netLead Co-Author:Mr J Evans*NIHR Clinical Lecturer - University of ExeterHealth Services and Policy research GroupSt Lukes Campus79 Heavitree RoadExeterEX1 1TXj.p.evans@exeter.ac.ukChief Investigator:Mr C GozzardTrauma and Orthopaedic DepartmentUniversity Hospitals Plymouth NHS TrustPL6 8DHcharlesgozzard@nhs.netCo-investigators:Miss S FulliloveTrauma and Orthopaedic DepartmentUniversity Hospitals Plymouth NHS TrustPL6 8DHsue.fullilove@nhs.netCo-investigators:Dr E DoyleTrauma and Orthopaedic DepartmentUniversity Hospitals Plymouth NHS TrustPL6 8DHedoyle@nhs.netTrial Sponsor:Corinna MossopResearch Development and Innovation (RD&I)University Hospital Plymouth NHS TrustThe Research OfficeLevel 2 MSCPBircham Park Office1 Roscoff RiseDerrifordPlymouthTrial Steering Committee:Independent ChairmanMr Jon KeenanTrauma and Orthopaedic DepartmentUniversity Hospitals Plymouth NHS Trustjonathan.keenan@nhs.netMr C GozzardTrauma and Orthopaedic DepartmentUniversity Hospitals Plymouth NHS Trustcharlesgozzard@nhs.netIndependent ExpertDr M ChopraConsultant in Paediatric AnaesthesiaUniversity Hospitals Plymouth NHS Trustmichellechopra@nhs.netPharmacy RepresentativeMark MarnerPharmacy Clinical Trials Support ManagerUniversity Hospitals Plymouth NHS Trustmike.marner@nhs.netChief InvestigatorMr C GozzardTrauma and Orthopaedic DepartmentUniversity Hospitals Plymouth NHS Trustcharlesgozzard@nhs.netPrinciple InvestigatorMr M JonesTrauma and Orthopaedic DepartmentUniversity Hospitals Plymouth NHS TrustPL6 8DHm.jones16@nhs.netSponsor RepresentativeVictoria YatesSenior Research Support FacilitatorUniversity Hospitals Plymouth NHS Trustvictoriayates@nhs.netCorticosteroid injections are used in the treatment of a variety of hand and wrist conditions. The local anti-inflammatory effect they impart is believed to be due to downregulation of the cytokine pathway . The injTrigger finger, de Quervains tenosynovitis and carpal tunnel syndrome are all painful conditions of the hand and wrist where corticosteroid injections have a role in their treatment. Trigger finger is a condition that causes locking on flexion of the involved finger, dysfunction and pain as a result of thickening of the first annular pulley , 3. CortCorticosteroid injections administered into soft tissue for these conditions can be performed under ultrasound guidance or by using anatomical landmarks. A cadaveric study showed no statistical difference in the accuracy between the two methods of injecting for de Quervains tenosynovitis or carpal tunnel syndrome . No supeCorticosteroids are not immediately effective; it is often 3 to 7 days before their therapeutic benefit is felt . CorticoLidocaine is the most commonly administered local anaesthetic for this indication and has a rapid onset of less than 2 min, and its analgesic effects can last for 1 to 3 h . It is, The authors are not aware that a study exists that assesses pain immediately following soft tissue corticosteroid injections in the hand and wrist, co-administered with and without local anaesthetic. Although corticosteroids and local anaesthetic are often co-administered, no evidence is currently available to support this.The effects of the local anaesthetic only last for 2–3 h; therefore, it would not provide relief from post-procedure corticosteroid flare nor bridge the time until the corticosteroid became effective. A post injection flare is an increase in pain that results from a local increase in inflammation that develops within hours and can last 2–3 days . AdminisSoft tissue injections of corticosteroid in the hand are widely used by health professionals across different specialities; therefore, the potential implications of the trial are far reaching. A definitive outcome would help minimise variation in practice. If post injection pain with administering corticosteroid alone is not inferior to co-administering it with local anaesthetic, this could stop unnecessary medication being given to patients. This would reduce any potential temporary numbness which may result from injecting local anaesthetic and may prevent patients from driving home after their appointment. Adding local anaesthetic also increases the cost, time and clinical waste of the treatment. Although the additional cost per treatment may not be significant when considering the number performed across the National Health Service, the saving may be considerable. However, any findings will only be relevant for the specific procedures studied and may not be applicable to other procedures where corticosteroid and local anaesthetic are co-administered.We hypothesise that the pain experienced at 1 h after a corticosteroid injection for trigger finger, de Quervains tenosynovitis and carpal tunnel syndrome is no worse than when the corticosteroid is co-administered with local anaesthetic.This is a single-site, patient- and assessor-blinded, non-inferiority randomised control trial where patients will be randomised with a 1:1 allocation ratio to receive an injection of corticosteroid alone or an injection of corticosteroid co-administered with local anaesthetic to treat, trigger finger, de Quervains tenosynovitis or carpal tunnel syndrome.This study will be set in the Orthopaedic Outpatient clinic at a single University Hospital in the UK, UHPT.The reviewing physician will approach potentially eligible patients within the Outpatient Clinic.Male or female ages ≥ 18 years oldA clinical diagnosis of trigger finger, de Quervains tenosynovitis or carpal tunnel syndrome made by a consultant physicianTreatment with corticosteroid injection is recommended by the consultant physician and agreed by the patientPatient is willing and able to give informed consent for participation in the studyPrevious surgery for the condition being treated at the desired location of injection*Previous steroid injection for the condition being treated at the desired location of injection*Clinical suspicion of local or systematic sepsis or infectionHistory of hypersensitivity to the corticosteroid or local anaestheticPregnant or breast-feeding femalesUnable to understand and complete self-report questionnaires written in English*Previous surgery or a corticosteroid injection elsewhere in the hand or wrist does not exclude the patient from the trialThere are a variety of injectable synthetic corticosteroids with different half-lives and variable duration of clinical benefit . TriamciA.1 ml of triamcinolone (40 mg/1 ml)orB.1 ml of triamcinolone (40 mg/1 ml) + 1 ml 1% lidocaineStudy participants will receive a single injection containing one of the two following solutions, delivered under landmarks guidance by a physician to treat either trigger finger, de Quervains tenosynovitis or carpal tunnel syndrome:This trials’ primary outcome is a difference in pain visual analogue scale (VAS) scores at 1 h after a corticosteroid injection for trigger finger, de Quervains tenosynovitis or carpal tunnel syndrome co-administered with or without local anaesthetic.i)The difference in pain VAS scores during the 24 h after injection ii)The difference in the pain VAS scores at the time of the injection iii)The difference in the additional analgesia required and in the functional use of the hand during the first 3 h following an injection The secondary outcomes include:Pain is subjective and multi-dimensional; therefore, it is difficult to fully evaluate the complete pain experience. The 100-mm pain VAS score is a widely used method for assessing pain. Pain will be assessed using this method, prior to any intervention, during the intervention, and then 5 min, 1 h, 2 h, 3 h and 24 h following the intervention . All documents will be stored securely and only be accessible by trial staff and authorised personnel. The study will comply with the Data Protection Act 2018. No participants will be individually identified in any subsequent publications relating to this study. Archiving will be authorised by the sponsor following submission of the end of study report. All essential documents will be archived for a minimum of 5 years after completion of trial. Destruction of essential documents will require authorisation from the study sponsor.T test) dependent upon the assessment of score distribution (skewness and kurtosis). Non-parametric testing will be employed if the mean distribution fails tests of normality. Secondary outcome measures of the primary objective will involve determining the effect size at 1 h post injection to measure significance of the difference between the study and control group.The primary objective of investigating a difference in pain VAS scores at 1 h after a corticosteroid injection will primarily be determined by analysing the mean change in pain VAC score between 1-h post injection and baseline pre-injection will be performed. The primary intention will be the use of parametric tests  will be calculated. Multilevel linear regression analysis will be conducted to compare 24-h pain VAS with injection intervention nested in patient condition.Sensitivity analysis will be conducted to investigate whether there is a difference in the pain VAS scores at the time of the injection by using a multilevel linear regression analysis to compare pain VAS scores with injection intervention nested in the patient condition.The percentage of patients requiring additional analgesia or who experienced worsening hand function will be determined from the three questions asked in the patient assessment record. The results will be presented as numbers with additional details given in the patients’ response, but no statistical analysis will be performed on these results. No subgroup analysis will be performed.The data monitoring committee will monitor the return rate for the patient assessment record. These records will remain sealed until recruitment is complete, so no interim analysis of outcome data or compliance will be performed. All adverse events will be record and reported, depending on the nature of the event. There are no additional provisions for trial patients beyond the normal standard of care as the trial compares two treatments routinely used in normal practice.ClinicalTrials.gov (Identifier: NCT04253457).This study has been reviewed by the South West – Central Bristol Research Ethics Committee and received a favourable opinion. In accordance with approval conditions, the study has been registered on Any amendments to the study protocol will be reviewed by the Health Research Authority and, if required, the Research and Ethics Committee and will not be implemented until a favourable opinion is granted. Amendments will then be reviewed and accepted by the NHS Research and Development department before they can be implemented in practice.It is proposed that the study team will prepare a plain English summary of the study results, which will be sent to the study participants as soon as possible after the end of the study. The final results of the study will be disseminated via presentations at appropriate scientific meetings and conferences and publication in appropriate peer-reviewed journals. The final dataset will be made available to on the trial delegation log and anonymised patient level date submitted as an appendix with any subsequent publication submission.This study will be funded by available department research funds, held by the Research and Development department, and is not commercially funded.Findings for the proposed study are expected to benefit both primary and secondary care settings involved in the administration of soft tissue corticosteroid injections into the hand.Despite the large number of corticosteroid injections administered in the National Health Service (NHS) and the variability in practice, there is no published data on the pain following soft tissue corticosteroid injections in the hand and wrist, co-administered with and without local anaesthetic.Co-administering corticosteroid and local anaesthetic in an injection should not improve the pain experienced from the injection itself. The effects of the local anaesthetic are short lived and will not provide relief from any post-procedure corticosteroid flare nor bridge the time until the corticosteroid became effective.Adding local anaesthetic may potentially make the injection more painful because of the acidity of the solution and the higher volume administered. In addition, the use of local anaesthetic may even worsen paraesthesia symptoms or result in paraesthesia in parts of the hand, preventing normal function for the duration of its action.It is also notable that adding local anaesthetic increases the cost, time and clinical waste of the treatment. Although the additional cost per treatment may not be significant, when considering the number performed across the NHS, the saving may be considerable.Protocol version 2 , 7 January 2020. Recruitment will commence in November 2020 and is anticipated to be completed by November 2021.Additional file 1. Participant consent form.Additional file 2. Patient participation record.


This study aimed to investigate the effects of popliteal sciatic nerve block (PSNB) in the treatment of postinjection sciatic neuropathy (PISN) resistant to conservative treatments. Patients diagnosed with PISN were included in the study. A damaged branch of the sciatic nerve was detected after neurological and electrophysiologic studies (EPSs). Visual analogue scale (VAS) was administered before, one hour after, and one month after the procedure. Also Leeds Assessment of Neuropathic Symptoms and Signs pain scale (LANSS) was administered before and one month after the procedure. The effects of EPSs findings and loss of muscle strength on the VAS and LANSS scores that measured after PSNB were evaluated.PSNB was performed in 17 patients  with a diagnosis of PISN. Their mean age was 54.95 ± 12.55 years, and the mean duration of symptoms was 3.53 ± 1.28 months. The EPS findings revealed a lateral truncus injury in 5, a medial truncus injury in 3, and injury to both in 9 patients. The initial muscle power scale scores were grade 0 in 2, grade 2 in 1, grade 3 in 7, grade 4 in 5, and grade 5 in 2 patients. The initial VAS and LANSS scores were 7.53 ± 1.06 and 17.35 ± 3.12. The mean VAS scores at the first hour and one month after the procedure decreased to 2.53 ± 1.70 and 4.18 ± 1.74 while the mean LANSS score one month after the procedure was reduced to 7.88 ± 5.84. The effects of EPSs findings and loss of muscle strength were found significant (p = 0.001), but the duration of symptoms was not found significant (p = 0.36) on the VAS and LANSS scores that measured after PSNB.The outcome of this research proved the effectiveness of PSNB with methylprednisolone in the management of PISN, especially in patients whose pain was located below the knee. EPSs findings and loss of muscle strength indicated the severity of the nerve damage affect the success of PSNB in pain management, but the length of time that elapsed after the nerve injury did not. The most common injury mechanism that affects the sciatic nerve is receiving an intramuscular injection in the gluteal region, which is an iatrogenic cause with a frequency of 28% [1]. Direct trauma from the needle is often associated with the use of a more medial and/or inferior site for the injection [2]. There is a consensus the upper outer region of the buttock is the most reliable location for an injection [3]. In addition, the patient’s subcutaneous tissue and gluteus muscle thickness in this area are effective at preventing sciatic nerve injury after intramuscular injection [4]. The other mechanism for postinjection sciatic neuropathy (PISN) is nerve fiber damage induced by neurotoxic chemicals in the agent injected. The most common intramuscularly delivered agents that are injected into the nerve are analgesics, antiemetics, antibiotics, vitamins, vaccines, and steroid drugs [5].The clinical presentation of a sciatic nerve injury includes immediate electric-like shock sensations down to the extremity. Concomitantly, patients often report the onset of variable motor and sensory deficits with pain from the injection site in the buttock that extends over the knee and may even be felt in the foot [6].Electrophysiologic studies (EPSs) are more sensitive than a physical examination, which makes them invaluable in helping to define the location and to grade the severity of the lesion, exclude other lesions, and predict recovery [7]. EPSs are best performed three or more weeks after the injury since Wallerian degeneration will have been completed by this time.Recommended treatments for PISN include surgical and nonsurgical methods including the administration of drugs and physical therapy. Physiotherapy is often required, but patients have difficulty completing early physiotherapy due to severe pain. Adequate pain management may not be possible in some patients when the time required for the drug to reach the effective dose is long or when the dose cannot be increased due to side effects. However, performing physiotherapy a long time after the nerve damage occurs may lead to permanent neurological deficits [8].Successful reduction of pain in PISN increases compliance with physiotherapy in patients so that impaired motor and sensory functions can be restored. Therefore, the purpose of this study was to present popliteal sciatic nerve block (PSNB) therapy for pain management in PISN that is resistant to conservative treatments. Twenty patients who complained of varying degrees of pain, loss of sensation, and weakness in the lower extremity following gluteal injection who visited the Algology Clinic of Health Sciences University at the Yüksek İhtisas Research and Training Hospital in Bursa between January and June 2019 were included in this study. The diagnosis of PISN was based on the patient’s clinical history, neurological examination, and EPSs findings.The inclusion criteria were as follows: 1) pain that extends from the knee to the foot, which is certain to develop after gluteal injection, 2) pain that is resistant to drug therapy and a VAS score > 3, 3) damage detection in the medial or lateral truncus of the sciatic nerve on EPSs. The exclusion criteria were as follows: 1) the presence of lumbar radiculopathy and other causes of sciatica, 2) pain that extended from the gluteal region, 3) successful pain therapy with drugs and a VAS score ≤ 3; and 4) the use of anticoagulants. This prospective randomized controlled study received approval by the Local Ethics Committee . After being given information about the study, written informed consent was obtained from all participants.A neurophysiology specialist physician performed the neurological examinations and EPSs in all patients and made the diagnosis of PISN. EPSs were done between three weeks and six months after the nerve injury. A pain physician identified the patients suitable for PSNB and performed the procedure using ultrasound guidance. The patients were allowed to continue their drug therapy at the same dose during the study. Demographic data, duration of symptoms, causes of pain, pain localization, neurological examination findings, and nerve damage detected by the EPS were recorded. Visual analogue scale (VAS) was administered before, one hour after, and one month after the procedure. Also Leeds Assessment of Neuropathic Symptoms and Signs pain scale (LANSS) was administered before and one month after the procedure. The study design is illustrated in Figure 1.Blocks were performed in an operating room by a pain physician with a 12–18 MHz linear ultrasound transducer  under sterile conditions with the patient placed in a prone position. Intravenous access, supplemental oxygen, and standard monitoring  were established in all patients. None of the patients experienced complications during or after the procedure.The PSNB technique was as follows. A linear ultrasound transducer was placed in the transverse position at the popliteal crease, and then the popliteal artery and vein were identified. The biceps femoris muscle was observed lateral to the popliteal artery, and the semimembranosus and semitendinosus muscles were identified in the medial plane. The tibial nerve was seen as a hyperechoic, rounded structure lateral to the popliteal vein. The common peroneal nerve was visible lateral to the tibial nerve. The transducer was advanced proximally until the tibial and peroneal nerves that come together to form the sciatic nerve were visualized before dividing. A 10-cm, 22-G Stimuplex needle  was inserted from 2–3 cm lateral to the transducer using an in-plane approach from a lateral to medial direct. The needle tip was contacted with either branch of the nerve; during nerve stimulation (0.5 mA for 0.1 ms), a motor response of the calf or foot was observed. The needle tip was then placed into the space between the two components of the sciatic nerve that were slightly separated by adipose tissue. It was observed that 80 mg methylprednisolone with 2% lidocaine in a 10-mL solution was distributed in the epineural sheath, and the tibial and peroneal nerves were separated.The injection site was pressed to achieve hemostasis. Sensory and motor examinations were performed to ensure a successful block assessment. Sensory examinations of the dorsum of the foot for the common peroneal nerve and the middle part of the foot for the tibial nerve were performed. The plantar dorsiflexion strength of the ankle was evaluated during a motor examination.The severity of pain along the sciatic nerve distribution was evaluated using the VAS, which was developed by Price et al. [9]. Patients rated their pain on a scale of 0–10, with 0 representing no pain and 10 representing the worst pain imaginable. The pain assessment was performed before, one hour after, and one month after the PSNB by the VAS.The amount of neuropathic pain was confirmed with the Turkish version of the LANSS pain scale [10]. This scale has a 24 total possible points; a LANSS score ≥12 indicates that neuropathic pain mechanisms are effective, while a LANSS score <12 signifies that current neuropathic pain mechanisms are not effective.In this study, the descriptive statistics were expressed as follows: the mean ± standard deviation (SD) for continuous variables with a normal distribution; the median (interquartile range) for continuous variables without a normal distribution; frequencies and percentages for categorical variables. To determine the normality of continuous variables, the results of the Shapiro–Wilk test were evaluated. The change in VAS score over time was evaluated using the Friedman test. The difference between the initial and final LANSS score was examined with the Wilcoxon test. The significance level was set as p < 0.05. The data analysis was performed using the Statistical Package for the Social Sciences (SPSS) software, version 23.0 .PSNB was performed in 17 patients diagnosed with PISN: 12 (70.6%) males and 5 (29.4%) females. Their mean age was 54.95 ± 12.55 (range: 27–75) years, and the mean duration of symptoms was 3.53 ± 1.28 (2–6) months. (Table 1)The EPS findings revealed lateral truncus injury in 5 (29.4%), medial truncus injury in 3 (17.6%), and both types of truncus injury in 9 (52.9%) patients. In 6 of these 9 (52.9%) patients, severe partial or full denervation in the muscles innervated from the lateral trunk was found, and mild partial denervation in the muscles innervated from the medial trunk was observed. In 3 of these 9 (52.9%) patients, severe partial denervation or full denervation in the muscles innervated by both trunci were recorded. Of the 5 patients with only a lateral trunk deficit, 2 had mild partial denervation, while 3 exhibited complete denervation of the muscles innervated by the lateral trunk. In 3 patients with only a medial trunk deficit, complete denervation was observed in the muscles innervated by the medial trunk. (Table 1)Based on their clinical features, all patients had severe pain accompanied by sensory symptoms. The initial VAS and LANSS scores were 7.53 ± 1.06 (range: 6–9) and 17.35 ± 3.12 (range: 13–24). Except for 2 patients with only sensory symptoms, all patients had drop foot. The initial MRC Muscle Power Scale classifications were grade 0 in 2 (11.8%), grade 2 in 1 (5.9%), grade 3 in 7 (41.2%), grade 4 in 5 (29.4%), and grade 5 in 2 (11.8%) patients. The type of injection that caused the PISN was an analgesic in 14 (82.4%), a vitamin in 2 (11.8%), and an antibiotic in 1 (5.9%) patient. (Table 1)The median VAS scores at the first hour and one month after the PSNB were 3 and 4. The pairwise comparison of VAS scores measured after 1 h and before (p = 0.000), 1 month after and before (p = 0.008), after 1 h and after 1 month (p = 0.039) were found to be significant. The median LANSS score at before and one month after the PSNB was 16 and 6. LANSS differenced measured before and 1 month after PSNB (p = 0.000) was found to be significant .LANSS: Leeds Assessment of Neuropathic Symptoms and Signs pain scale, PSNB: popliteal sciatic nerve blockThe mean VAS scores before and one month after the PSNB in the patients with lateral or medial truncus injury were 6.75 ± 0.46 and 3.00 ± 0.75, while patients with both types of truncus injury were 8.22 ± 0.97 and 5.22 ± 1.71. The mean LANSS before and one month after the PSNB in the patients with lateral or medial truncus injury were 14.88 ± 1.24 and 19.56 ± 2.55, while patients with both types of truncus injury were 3.88 ± 2.53 and 11.44 ± 5.68. (Table 3) The mean VAS scores before and one month after the PSNB in the patients with duration of symptoms ≤3 months were 7.64 ± 1.02 and 3.64 ± 1.12, while patients with a duration of symptoms >3 months were 7.33 ± 1.21 and 5.17 ± 2.31. The mean LANSS before and one month after the PSNB in the patients with a duration of symptoms ≤3 months were 17.36 ± 2.90 and 6.91 ± 4.23, while patients with a duration of symptoms >3 months were 17.33 ± 3.77 and 9.67 ± 8.21. (Table 3)The mean VAS scores before and one month after the PSNB in the patients with MRC of 3,4,5 (maximum) were 8.20 ± 0.78 and 5.00 ± 1.764, while patients with MRC score of 0,1,2 (minimum) were 6.57 ± 0.53 and 3.00 ± 0.816, respectively .The mean LANSS before and one month after the PSNB in the patients with MRC of 3,4,5 (maximum) were 19.10 ± 2.80 and 10.80 ± 5.73 , while patients with MRC of 0,1,2 (minimum) were 14.86 ± 1.34 and 3.71 ± 2.69. (Table 3)The effects of EPSs findings (p=0.001) and loss of muscle strength (p = 0.001) were found significance, but the duration of symptoms (p=0.36) was not found significant on the VAS scores that measured after PSNB. And also the effects of EPSs findings (p = 0.001) and loss of muscle strength (p=0.004) were found significance, but the duration of symptoms (p = 0.55) was not found significant on the VAS scores that measured after PSNB (Table 4)Many morphological and metabolic changes occur after trauma to the peripheral nerve. These changes take place not only in the region of damage but also in the nerve trunk, in segments proximal and distal to the location of the injury, and in the neuromuscular junction or sensory receptors where the nerve fiber ends [11]. The biggest difference between peripheral nerve injuries and other tissue injuries is demonstrated by Wallerian degeneration, which proceeds towards the neuronal structures distal to the lesion [12]. In patients with PISN, the pain initially extends from the hip to the foot and then may migrate from the knee to the foot or from the ankle to the foot, this phenomenon is likely due to Wallerian degeneration. Inflammatory reactions and mediators play an important role in nerve repair, but prolonged inflammation may negatively affect recovery and lead to the development of neuropathic pain [13]. The ectopic discharge of activity from the injured site up-regulates and sensitizes the nociceptors and thereby contributes to the development of central sensitization [14]. Corticosteroids may be an effective therapy for neuropathic pain because they inhibit pro-inflammatory cytokines, prostaglandin synthesis, neural firing, input to central neurons, and also neurogenic extravasation and perineural edema formation by reducing substance P at the site of the nerve injury . Perineural corticosteroid injections also produce analgesia in a variety of pain-related disorders, including neuromas [17] and nerve entrapments [18]. Nevertheless, only a few trials have investigated perineural corticosteroid injections for PISN.Trans-sacral block with corticosteroids through the unilateral S1-S2-S3 sacral foramina has been reported to induce recovery from pain with PISN . In these case series, a corticosteroid nerve blockade was performed proximal to the damaged nerve, whereas, in our study, it was performed distal to the damaged nerve. We selected the location of the nerve block based on the results of neurological examinations and EPSs. We performed PSNB because pain localization did not cover the entire sciatic nerve dermatome but was mostly located in the tibial or peroneal nerve dermatome, which was confirmed with EPSs. In a study that investigated transcutaneous electrical nerve stimulation (TENS) for the treatment of PISN, placing the electrodes in the painful area was reported to be sufficient for maximum pain relief [21]. Similarly, in the present study, we performed PSNB because patients with PISN reported that their pain was localized below the knee. A previous study reported the outcomes of distal decompression of the peroneal nerve at the fibular tunnel following sciatic nerve injury secondary to total hip arthroplasty [22]. After performing peroneal nerve decompression at the fibular tunnel, 65% of the patients recovered dorsiflexion strength. The authors explained this finding as follows: Disruption of axoplasmic flow as a result of the nerve injury may also enlarge the nerve, further exacerbating potential compression at known sites of entrapment. Decompression of the peroneal nerve at the fibular tunnel may then also allow improvement when performing nerve glide exercises and also lessen existing tension, which may promote potential recovery.The loss of motor and sensory function in the expected dermatome indicates the success of the PSNB, which is typically administered with 2% lidocaine. Complete pain relief one hour after the popliteal block depends on the amount of membrane stabilizing and the analgesic effects of the local anesthetic. After this local anesthetic wears off, the VAS and LANSS pain scores had increased one month after PSNB compared to only one hour after the PSNB. Even so, the VAS and LANSS pain scores one month later had decreased compared to the scores recorded before the PSNB due to the anti-inflammatory effect of the corticosteroid. We think that stronger and longer-term analgesia can be achieved with repetitive blocks or pulsed radiofrequency [23].EPSs findings can vary from mild to severe involvement depending on the severity of the PISN [24]. In studies involving large case groups, the lateral trunk is often more severely affected because it is located more lateral to the sciatic nerve, where protective epineural connective tissue and blood vessels are more tense [25]. In our study, the lateral trunk was isolated or affected along with the medial trunk, which confirmed this hypothesis. Proximal nerve injuries above the knee are difficult to treat because before irreversible changes occur, sprouts must travel the long distance to reinnervate distal muscles. While recovery is expected with conservative treatment in partial function losses, if there is a complete or severe loss of function in one or both trunks of the sciatic nerve, spontaneous recovery does not occur, and surgical intervention is required [26]. In our study, patients with a greater severity of nerve damage on EPSs findings (injury to both trunci) and a loss of muscle strength  experienced a lower success of PSNB in pain management. Although further studies involving a greater number of patients are necessary, our study indicated the effectiveness of PSNB with methylprednisolone in the management of PISN, especially in patients with pain that is below the knee. The effect of the proximity of the injection to the site of the nerve injury remains unknown, and further studies are needed. The length of time that elapsed after the nerve injury did not affect but EPSs findings and loss of muscle strength indicated the severity of the nerve damage affect the success of PSNB in pain management. PSNB can be applied before surgery in PISN patients who have not recovered with spontaneous or conservative treatment.The study protocol received institutional review board approval, and all participants gave informed consent in the format required by the relevant authorities and/or boards.


Was nonpharmacologic therapy —a low-risk alternative treatment for acute and chronic pain—replaced by prescription opioid analgesics during the COVID-19 pandemic?This cross-sectional study of weekly claims data from 24 million commercially insured patients in the US found evidence of substitution of nonpharmacologic therapy with increased opioid prescribing, accompanied by more potent and longer prescriptions, at the population and individual levels during the early months of the COVID-19 pandemic.These findings suggest that progress toward reversing the opioid epidemic may have been stalled by the pandemic as practitioners resorted to higher levels of opioid prescribing to control pain in the absence of less risky alternatives. During the pandemic, access to medical care unrelated to COVID-19 was limited because of concerns about viral spread and corresponding policies. It is critical to assess how these conditions affected modes of pain treatment, given the addiction risks of prescription opioids.To assess the trends in opioid prescription and nonpharmacologic therapy  for pain management during the COVID-19 pandemic in 2020 compared with the patterns in 2019.This retrospective, cross-sectional study used weekly claims data from 24 million US patients in a nationwide commercial insurance database (Optum’s deidentified Clinformatics Data Mart Database) from January 1, 2019, to September 31, 2020. Among patients with diagnoses of limb, extremity, or joint pain, back pain, and neck pain for each week, patterns of treatment use were identified and evaluated. Data analysis was performed from April 1, 2021, to September 31, 2021.The main outcomes of interest were weekly rates of opioid prescriptions, the strength and duration of related opioid prescriptions, and the use of nonpharmacologic therapy. Transition rates between different treatment options before the outbreak and during the early months of the pandemic were also assessed.A total of 21 430 339 patients  were enrolled during the first 3 quarters in 2019 and 20 759 788  in the first 3 quarters of 2020. During the COVID-19 pandemic, the proportion of patients receiving a pain diagnosis was smaller than that for the same period in 2019 . Patients with pain were more likely to receive opioids  and less likely to receive nonpharmacologic therapy , and opioid prescriptions were longer and more potent during the early pandemic in 2020 relative to 2019 . Analysis of individuals’ transitions between treatment options for pain found that patients were more likely to transition out of nonpharmacologic therapy, replacing it with opioid prescriptions for pain management during the COVID-19 pandemic than in the year before.Nonpharmacologic therapy is a benign treatment for pain often recommended instead of opioid therapy. The decrease in nonpharmacologic therapy and increase in opioid prescription during the COVID-19 pandemic found in this cross-sectional study, especially given longer days of prescription and more potent doses, may exacerbate the US opioid epidemic. These findings suggest that it is imperative to investigate the implications of limited medical access on treatment substitution, which may increase patient risk, and implement policies and guidelines to prevent those substitutions. This cross-sectional study of claims data from 24 million US patients in a nationwide commercial insurance database assesses patterns of pain management treatment in the period before the COVID-19 pandemic vs during the COVID-19 pandemic. In response to the epidemic, nonpharmacologic therapies, including physical therapies and complementary medicine, have garnered attention as safer alternative treatments for managing nonmalignant chronic pain.15 However, nonpharmacologic therapies are more expensive and time-consuming than opioid therapy. The COVID-19 pandemic added an additional barrier because these treatments require physical contact with health care professionals. Because of the risk of COVID-19 infection from close physical contact, many states enacted policies that discouraged nonurgent medical care to preserve health care capacity to cope with the COVID-19–related surge in use, and many patients elected to forgo health care visits to reduce their transmission risk.17 These issues raise questions about how the COVID-19 pandemic has affected patterns of pharmacologic and nonpharmacologic therapy for pain management.Opioids are a relatively inexpensive and effective treatment option for patients experiencing chronic pain.21 provide inconclusive evidence of the effect of the COVID-19 pandemic on pain management. A recent study18 that used a national sample of urine drug tests ordered by health care professionals found a substantial increase in the prevalence of riskier opioids, such as fentanyl and heroin, after the national emergency declaration on March, 13, 2020, although contradictory evidence has also emerged.20 Another study21 reported that outpatient and elective interventional procedures, including exercise therapy, massage therapy, and spinal manipulation, were significantly interrupted during the pandemic. However, because the study used a small convenience sample, it may lack external validity.Existing studies22 We hypothesized that during the pandemic, nonpharmacologic therapy may have been replaced with prescription opioids, which do not require physical contact or even an office visit. This treatment substitution may have contributed to an increased risk of opioid-related overdoses or incident cases of substance use disorder among those with acute and chronic pain. Because of the unexpectedness of the COVID-19 pandemic, the event provides a crucial opportunity to assess the extent to which physicians and patients may rely on riskier but easier solutions  vs difficult but safer ones  under conditions of limited access.Our study aims to resolve these discrepancies by providing a comprehensive assessment of treatment use patterns for pain management, comparing the period before the COVID-19 pandemic with the period during the COVID-19 pandemic using large-scale claims data from patients representative of the commercially insured and Medicare Advantage populations in the US.24 Among patients in the database with diagnoses of limb, extremity, or joint pain, back pain, and neck pain for each week, patterns of treatment use were identified and evaluated. Data analysis was performed from April 1, 2021, to September 31, 2021. This study was approved by the Indiana University institutional review board and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Owing to the use of deidentified patient data, the need for informed consent was waived by the institutional review board.This retrospective, observational cross-sectional study used weekly claims data from 24 million US patients in a nationwide commercial insurance database (Optum’s deidentified Clinformatics Data Mart Database) from January 1, 2019, to September 31, 2020. This database includes 20% of the commercially insured population in all 50 US states and Washington, DC, and 24% of the Medicare Advantage population, which was of similar age and sex to the US commercially insured population more broadly.25 reported that annual opioid use prevalence was 14% for commercial beneficiaries, 26% for aged Medicare beneficiaries, and 52% for disabled Medicare beneficiaries. Our analytic sample includes 21 430 339 who enrolled during the first 3 quarters in 2019 and 20 759 788 patients who enrolled during the first 3 quarters of 2020, excluding 3395 patients whose age and sex information are missing. The eFigure in the Using the deidentified Clinformatics Data Mart Database, a previous studyInternational Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code list that includes a full spectrum of common pain conditions.26 We used a subset of 10 548 ICD-10-CM codes to identify patients with any of these common pain conditions: limb or extremity pain; joint pain and nonsystemic, noninflammatory arthritic disorders; back pain; and neck pain. eTable 1 in the For this study, we relied on the We designated patients as at risk if they received any pain diagnosis in the week regardless of previous pain diagnoses. Of patients with pain, 2 types of treatments were measured. First, we identified prescriptions for opioid analgesics using the list of National Drug Codes provided by the National Center for Injury Prevention and Control and created a binary indicator for whether a patient received any opioid prescription each week. eTable 2 in the 12 and took the sum of MMEs for all prescriptions received by a patient in a given week. In addition, we identified the nonpharmacologic treatment for pain using 21 Current Procedural Terminology codes . We calculated the length in days of the opioid prescription using the maximum length of days for which each drug is prescribed and taking the sum of all the days prescribed in a given week for a patient. We calculated MMEs for each opioid prescription using strength per unit × (number of units/days’ supply) × MME conversion factorWe described weekly trends in pain prevalence from the first week to the 40th week of 2020 using trends from the same period in 2019 as a baseline for comparison. We used the same strategy to describe weekly trends in indicators of opioid prescriptions and nonpharmacologic therapy for patients with pain. In doing so, we calculated the proportion of patients with pain in a given week and the prevalence of treatment use  as well as the length in days and strength in MMEs of opioid prescriptions among patients with pain who visited physicians in the same week.27 We compared differences in the proportion of patients with pain, patients with pain receiving opioids, and patients with pain receiving nonpharmacologic therapy, as well as the mean of weekly total MMEs and the mean of weekly total days of opioid prescriptions between 2019 and 2020 during the prepandemic and the early pandemic period, respectively, using linear probability models for binary outcomes and regression models for continuous outcomes with robust SEs that account for clustering across overlapping patients between 2019 and 2020. Specifically, we regressed the outcome for each patient within each period on an indicator for the pandemic year  and interpreted the coefficient on the 2020 indicator as the difference in mean outcomes between 2019 and 2020. We present 95% CIs to characterize the uncertainty associated with our estimates of the trends and differences.To conduct statistical tests for changes in these indicators from 2019 to 2020, we broadly defined the prepandemic , the early pandemic , and the later pandemic period (weeks 28-40) for 2020 based on 2 major discontinuities in the COVID-19 pandemic in the US.Finally, we investigated how patients transitioned between treatment options by producing a Markov transition matrix. We assigned patients to 4 different categories based on the treatment they received each week. Specifically, a patient might receive no treatment, only opioids, only nonpharmacologic therapy, or both opioid and nonpharmacologic therapy simultaneously in a given week. We only included patients who visited at least in 2 weeks in 2019 and 2020 so that we could identify the transition in treatment options between 2 consecutive visits. We then calculated the rates at which patients transitioned from one category to another in consecutive weeks and aggregated these rates for the prepandemic and early pandemic periods. We produced the same transition matrix for the corresponding 2 periods in 2019 as a baseline. To compare changes between 2019 and 2020 for the same period, we calculated mean differences in the transition rates between 2019 and 2020 during the prepandemic and early pandemic periods, respectively.28Statistical analyses were performed on September 5, 2021, using R statistical software, version 4.0.3  and Stata MP, version 17 (StataCorp LLC). All codes and data to replicate analyses are available on the Harvard dataverse website.A total of 21 430 339 patients  were enrolled during the first 3 quarters in 2019 and 20 759 788  in the first 3 quarters of 2020. eTable 5 in the The patient-level transition rates across the 4 different treatment options  during the prepandemic and the early pandemic period in 2019 and 2020 are presented in eTables 6 and 7 in the eTable 8 in the In this cross-sectional study, we examined the treatment of acute and chronic pain during the early period of the COVID-19 pandemic. With the exponential spread of COVID-19 and the resulting US national emergency declaration, in-person health care visits for elective, nonessential medical care were suspended by many states, practitioners, and patients to reduce community transmission. Using population-level trends and individual-level treatment transitions, we assessed the consequences of these circumstances for pain treatment.32Although the adaptive prescribing response during the shutdowns in March through June 2020 may have provided a necessary stopgap for patients in need of pain management, it may also have increased patient risk. The significant decrease in the proportion of patients with pain during the early COVID-19 pandemic period identified in our study implies that many patients may have experienced pain without an effective treatment because they could not visit physicians and hospitals because of COVID-related restrictions and concerns. Even among patients who could obtain health services, patients with pain using nonpharmacologic therapy alone or in combination with opioid maintenance therapy may have had to introduce opioids or increase their dosage, respectively, to manage pain during a period of limited access to nonpharmacologic therapy. Likewise, patients newly diagnosed with acute pain may have been introduced to opioids when an equally effective nonpharmacologic therapy would typically have been prescribed. Excessive pandemic-driven exposures to opioids and to higher doses and longer prescriptions may have increased the risk of future misuse or dependence.13 Because these recommendations alone have not had significant effects on the opioid epidemic, policies that target the opioid epidemic have continued to focus on managing and controlling the supply of prescription opioids.33 Recent studies35 have found that the success of these policies—shorter duration and lower volume of opioid prescriptions—is not sufficient to reverse the increasing trends in opioid overdose mortality. Against this background, our findings regarding the substitution of nonpharmacologic therapy with opioid therapy during the COVID-19 pandemic suggest that policies that markedly expand the use of nonaddictive treatments, such as physical therapy for chronic pain management, are urgently needed.In 2016, the Centers for Disease Control and Prevention recommended use of nonpharmacologic therapy and nonopioid pharmacologic therapy instead of or in combination with opioid therapy because those options effectively reduce pain and improve physical function without the risk of addiction.36 may have contributed to the substitution of nonpharmacologic therapy with opioid prescriptions, virtual nonpharmacologic therapy holds potential to help reduce disparities caused by unequal access to in-person nonpharmacologic therapy. Although certain procedures require direct in-person contact , other forms of therapy can be effectively provided remotely through telemedicine .37 Although the digital divide remains a problem, especially in rural areas and among patients with low socioeconomic status,39 telemedicine could be a viable strategy to provide nonpharmacologic therapy to patients with pain under social distancing or to those in areas with a shortage of health care professionals.Although the proliferation of telemedicine during the COVID-19 pandemic2 This estimate is the highest number of overdose deaths ever recorded in a 12-month period. This recent increase in overdose mortality is a sharp deviation from trends before the pandemic. Specifically, during 2017 to 2018, opioid-involved overdose deaths had decreased for the first time since 1999. Although synthetic opioids appear to be driving the increase in overdose deaths, increasing 38.4% from the prior year, our findings on excessive exposure to prescription opioids during the pandemic may portend future problems, potentially disrupting large-scale public health efforts to reduce inappropriate prescribing and encourage nonpharmacologic therapies for pain.These findings on pain management should be considered in the context of pandemic-associated changes in the opioid epidemic. Recent estimates from the Centers for Disease Control and Prevention suggest that more than 81 000 drug overdose deaths occurred in the US in the 12 months ending in May 2020.Our study has limitations. First, because the data used for the analysis are only nationally representative of the commercially insured and Medicare Advantage populations, our results may not generalize to other populations . This issue may be particularly problematic during the COVID-19 pandemic because high rates of unemployment could have led to reduced commercial coverage, although our data indicate only a marginal decrease in the enrolled population. Second, because our data reflect only insurance claims, any medications or treatments paid for directly or obtained outside the insurance system would not be captured in our data set, which could bias our results. Third, our measure of opioid dosage per week is based on whether the patient received a prescription on the claim and does not reflect whether the person actually consumed the medication. Fourth, although our findings regarding longer and higher-dosage opioid prescriptions in the early months of the pandemic raise concerns about the downstream harms associated with the deviations from recommended opioid prescribing patterns, the examination of possible long-term effects is left to future work as additional data become available.40 We found that under conditions of reduced access to diverse treatment options, practitioners and patients resorted to riskier alternatives to manage acute and chronic pain. After the pandemic, nonpharmacologic therapy will likely continue to be inaccessible for many patients because of factors such as cost, underinsurance, lack of transportation, lack of childcare, or inability to take time off work. These barriers disproportionately affect people in rural areas, Black and Latinx patients, gender and sex minorities, and those in disadvantaged socioeconomic groups43 and thus may contribute to broader disparities in opioid use disorders and overdose. It is critical to increase universal access to nonpharmacologic treatments for pain management by reducing these barriers.Projecting beyond the pandemic, our findings on substitution of nonpharmacologic therapy with opioids may have broader implications for health disparities.


Clinical outcomes included visual analog scale (VAS) for low back pain and the Oswestry Disability Index (ODI). The distance between the adjacent spinous processes was measured from the preoperative and postoperative CT scan. We calculated and recorded the difference between preoperative and postoperative measurements. Technical procedures and advantages of interspinous plasty are introduced. The three patients showed improvement in terms of the postoperative VAS of low back pain  and ODI  at the 12‐month follow‐up. Compared postoperative ODI index, the ODI index increased from 26.7% to 33.3% and from 24.4% to 28.9% in two of the cases at the 12‐month follow‐up. At 1 week, CT confirmed an obvious reduction in the marginal osteophytes between the adjacent spinous processes. Compared with those on preoperative CT images, the distance between adjacent spinous processes on postoperative CT was enlarged from 1 to 4 mm, and a repeated CT scan 3 months later reconfirmed little recrudescent osteoproliferation. In selected cases, full‐endoscopic surgical treatment for chronic mechanical back pain as part of the phenomena of Baastrup's disease may be beneficial. The operations in this study were performed under local anesthesia, with satisfactory early clinical outcomes and a low incidence of complications or adverse events. This may be a feasible therapeutic method or an alternative option for patients who cannot tolerate general anesthesia surgery.The objective was to introduce a new endoscopic technique‐interspinous plasty for low back pain from Baastrup's disease; based on clinical manifestations, imaging findings and diagnostic test, to discuss a detailed diagnostic procedure for Baastrup's disease; and to explore the mechanism of interspinous plasty in pain relief. To our knowledge, there is no report about the results of endoscopic lumbar technique for Baastrup's disease. This study described the successful full‐endoscopic surgical treatment for Baastrup's disease, providing a brand‐new therapeutic method for patients. Clinical manifestations, imaging findings, including X‐ray, computed tomography (CT) and magnetic resonance imaging, and a “positive” diagnostic test with local anesthetic were used to confirm Baastrup's disease in the three included patients. The interspinous plasty procedure, which aimed to recover a physiological gap between the adjacent spinous processes, was performed by full‐endoscopic resection of marginal osteophytes. The removal of local inflamed tissue and reducing inflammation  The interspinous plasty, aimed to recover a physiological gap between the spinous processes, were performed by full‐endoscopic resecting marginal osteophytes. Our study was designed to describe the successful full‐endoscopic approach for low back pain from Baastrup's disease, providing a brand‐new therapeutic method for patients. Also known as “kissing spines” and lumbar interspinous bursitis, it is characterized by hyperostosis and sclerosis between adjacent spinous processesLow back pain from Baastrup's disease is implicated in mechanical contact between adjacent spinous processes, subsequently resulted in chronic interspinous inflammation. As a clinical syndrome, there are not well‐defined diagnostic criteria of Baastrup disease. In previous study, clinical diagnosis of Baastrup's disease typically relied on patients' symptoms and imaging findings. Baastrup's disease manifests clinically as a long‐term medical history of localized midline lumbar pain, which can be aggravated by lumbar extension and relieved by lumbar flexion.Characteristic imaging findings are usually presented with the “kissing” of closely approximated spinous processes and sclerosis of the articulating surfaces in standard lateral X‐ray. Computed tomography (CT) axial images and sagittal and coronal reconstructions show in detail that sclerosis, flattening and enlargement of the two adjacent spinous processes surfacesHowever, Baastrup's disease is frequently underdiagnosed and often missed owing to lack of knowledge of the disease process or improper diagnostic techniques. As a result, it may lead to inappropriate treatment, treatment delay, even no treatmentWith the rapid development of spinal endoscopic techniques in recent years, full‐endoscopic procedures represent a method of surgical treatment with a smaller “surgical footprint” to treat spinal pathology, such as lumbar disc herniation, lumbar spinal stenosis, and lumbar spondylolisthesisSpecific aims of our study are: (i) to introduce a new endoscopic technique‐interspinous plasty; (ii) to discuss a detailed diagnostic procedure of Baastrup's disease; and (iii) to explore the mechanism of interspinous plasty in pain relief.Inclusion criteria were as follows: (i) diagnosis of Baastrup's disease; (ii) interspinous plasty; (iii) persistent low back pain and conservative measures did not work‐well; (iv) evaluation of pain relief; and (v) case series. Exclusion criteria were as follows: (i) less than 18 years old; (ii) patients experienced radicular leg pain or neurogenic intermittent claudication; and (iii) history of other lumbar surgery.Three patients who experienced recurrent mechanical back pain for more than 1 year, but without associated leg pain were included in this study. Back pain increased with extension, was relieved by flexion and improved only minimally with nonsteroidal anti‐inflammatory drugs  and physical treatments . The focal midline back pain was directly reproduced by palpation over the spinous processes, but no tenderness was observed upon palpation of the lumbar facet joints. Profile views of X‐ray examinations at upright neutral, flexion, and extension positions were performed. Hyperostosis and osteosclerosis of the spinous processes were evaluated by CT. MRI was performed to evaluate edema and inflammation of the interspinous ligaments in fat‐suppressed T2‐weighted images  into the interspinous ligament  with a bevel was docked into the interspinous area and reconfirmed by C‐arm fluoroscopy.The interspinous plasty for case 1 was performed with the patient in the prone position under local anesthesia with 5 mL of 2% lidocaine mixed with 5 mL of normal saline. A blood pressure cuff, pulse oximeter and automatic electrocardiogram were utilized for monitoring. Based on anteroposterior and lateral C‐arm guidance, the surgeon inserted a needle with a 20 mL sterile syringe into the L4 and the superior margin of the L5 spinous processes until the ventral ligamentum flavum was exposed and adequate space was obtained. Significant, excessive extrusion of the ligamentum flavum can compress the nerve root and produce iatrogenic nerve root injury. After excision of the tissue, adequate hemostasis was performed on the internal tissue wound by plasma radiofrequency, and the incision was sewn after withdrawing the endoscopic working cannula  the score is calculated: ) × 100%. From 0% to 20% is considered mild dysfunction, 21%–40% is moderate dysfunction, 41%–60% is severe dysfunction, and 61%–80% is considered as disability. For cases with score of 81%–100%, either long‐term bedridden, or exaggerating the impact of pain on their life.All patients underwent the CT scanner using the 64‐slice spiral CT machine . The following parameter was measured on the CT radiographs: interspinous gap (the distance between the inferior margin of the superior spinous process and the upper margin of the inferior spinous process). An investigator measured the parameter three times, calculated and recorded its average. The interspinous gap was measured again from the postoperative CT scan. Preoperative and postoperative interspinous gaps were comparatively analyzed.Table The three patients showed improvement in terms of the postoperative VAS of low back pain  and ODI  at the 12‐month follow‐up. Compared postoperative ODI index, the ODI index increased from 26.7% to 33.3% and from 24.4% to 28.9% in two of the cases at the 12‐month follow‐up  confirmed an obvious reduction in marginal osteophyte between the adjacent spinous processes. Compared with those on preoperative CT images, the distance between the adjacent spinous processes on postoperative CT was enlarged from 1 to 4 mm (Fig. Chronic low back pain can lead to physical and psychological discomfort and negative effects on one's health and quality of lifeLumbar full‐endoscopic procedures have already become common surgical methods for spinal diseases such as lumbar disc herniation and spinal stenosis, with the clear advantages of safety and effectivenessDuring the 12‐month follow‐up, the ODI index increased from 26.7% to 33.3% and from 24.4% to 28.9% in two of the cases (Table 4‐5 spinous process space was widened on the posterior side and still narrow at the base (Fig. 4 spinous process was not the collision point at the collision moment. The key collision point, caused chronic low back pain, was located in the posterior side of L4‐5 spinous processes space, which had been enlarged by full‐endoscopic partial excision of the L4‐5 spinous processes. Local inflammatory responses to long‐term L4‐5 spinous process impingement was also a cause of chronic pain. The mechanism of pain relief by interspinous plasty may be associated with the surgical enlargement of the interspinous space and the removal of local inflamed tissue, as well as by reducing inflammation via intraoperative saline irrigation.One patient showed an improved VAS score for low back pain and an improved ODI after the operation and at the 12‐month follow‐up, but the postoperative CT showed that the Let al.Singla et al.et al.et al.et al.In 2007, Mitra There is conflicting evidence regarding the clinical efficacy of glucocorticoid infiltration. In general, glucocorticoids have some short‐term benefit for pain relief but no significant long‐term benefitet al.et al.Traditional surgical intervention includes excision of the intraspinous bursa and partial or total removal of the spinous process. Gold and Jang In our study, the patients suffered from a history of mechanical low back pain that increased with extension and was relieved by flexion, without radicular pain or intermittent claudication. The X‐ray images of our patients were characterized by contact between adjacent lumbar spinous processes, known as “kissing spine.” CT showed enlargement, hyperostosis and osteosclerosis between adjacent spinous processes leading to narrow interspinous gaps. MRI showed local inflammation and an edematous zone between the adjacent spinous processes on a fat‐suppressed T2‐weighted sequence. Given the abovementioned clinical manifestations and imaging findings, the patients were finally confirmed to have Baastrup's disease after a diagnostic test with local anesthetic was “positive.” The patients performed an immediate pain relief after the injection of local anesthetic, but localized back pain aggravated gradually in the next 48 h. After failed the conservative treatment, these appropriate patients were scheduled for interspinous plasty.The spinous processes, interspinous ligament, and part of the posterior ligamentous complex play a role in spinal stability4‐5 to reduce exposure (Fig. C‐arm fluoroscopy is an indispensable part of the endoscopic spine procedure that enhances surgical accuracy. The surgeon's exposure to ionizing radiation is harmful and is easily overlookedure Fig. . The abiUndeniably, first, the small sample size and short follow‐up were considered as a major limitation of the presented study. Second, there is no comparison group of other treatment options. Although the patients in this study achieved a good functional recovery, long‐term outcomes are unknown. Moreover, we are unable to draw a convincing conclusion that interspinous plasty is better than other treatments. Compared with spinal fusion, interspinous plasty performed lesser damage to spine motion. The full‐endoscopic approach for Baastrup's disease is a promising technique with its advantages of precision and being a minimally invasive procedure. However, further comparative studies need to be performed to evaluate the efficacy and safety of this method.Various techniques have been proposed to alleviate the mechanical low back pain associated with Baastrup's disease. The full‐endoscopic technique has the advantages of minimal trauma and radiation exposure, rapid recovery and a limited negative effect on spinal stability. This technique was performed under local anesthesia, with satisfactory early clinical outcomes, and avoided the excessive iatrogenic trauma of traditional open operations. In appropriate cases, the full‐endoscopic approach for chronic mechanical back pain as part of the phenomena of Baastrup's disease may be a feasible therapeutic method.