Purpose. This study explored the effect of autologous blood injection (with ultrasound guidance) to the elbows of patients who had radiologically assessed degeneration of the origin of extensor carpi radialis brevis and failed cortisone injection/s to the lateral epicondylitis. Methods. This prospective longitudinal series involved preinjection assessment of pain, grip strength, and function, using the patient-rated tennis elbow evaluation. Patients were injected with blood from the contralateral limb and then wore a customised wrist support for five days, after which they commenced a stretching, strengthening, and massage programme with an occupational therapist. These patients were assessed after six months and then finally between 18 months and five years after injection, using the patient-rated tennis elbow evaluation. Results. Thirty-eight of 40 patients completed the study, showing significant improvement in pain; the worst pain decreased by two to five points out of a 10-point visual analogue for pain. Self-perceived function improved by 11–25 points out of 100. Women showed significant increase in grip, but men did not. Conclusions. Autologous blood injection improved pain and function in a worker's compensation cohort of patients with chronic lateral epicondylitis, who had not had relief with cortisone injection. Lateral epicondylitis or tennis elbow is a common condition that causes pain on the outside of the elbow, as well as pain and weakness during gripping. It has been found to occur in approximately 1.3% of people in studied populations .There are many conservative treatments, including splinting, massage, injection of nonsteroidal anti-inflammatories, and alteration of tasks performed by the patient. There is high level, high quality evidence to suggest that extracorporeal shock wave therapy has little or no benefit  and thatAutologous blood injection (ABI) is theorized to stimulate a “healing cascade” of events, in the degenerated tendinous origin of extensor carpi radialis brevis . Two to Given the physiological theory behind injecting autologous blood into a degenerated tendon, postinjection therapy regimes would need to support the initial healing phase thought to occur following injection . Four stThere are eight published studies and one conference abstract of level II and IV evidence, of good to poor quality  regardinApproval for this study was obtained from the Ethics and Compliance Committee of the University of South Australia. All patients provided informed consent prior to participation in the study.Patients had to be over the age of 18 years and able to provide informed consent. They had to have experienced lateral epicondylitis as diagnosed by a physician (AP) for a minimum of six months, and they had to have had at least one steroid injection before being offered autologous blood. Patients then underwent a diagnostic ultrasound to confirm their appropriateness for ABI; they had to show signs of tendon origin degeneration rather than inflammation, as diagnosed by one radiologist. Consecutive patients who fit these eligibility criteria were invited into the study.Patients were fitted with a custom fabricated volar wrist resting splint in a neutral to 10° extension wrist position prior to injection. The patients then returned to their physician and had two millilitres of venous blood withdrawn from their contralateral arm, mixed with one millilitre of bupivacaine, which was then injected using ultrasound guidance into the tendinous origin of their extensor carpi radialis brevis tendon. Patients spent five days following injection resting in the custom made wrist splint and then were taught elbow, wrist, and hand range of motion, stretching dynamic concentric and later eccentric strengthening and self-monitoring techniques. Their performance of the exercises was checked fortnightly for the first four weeks by their occupational therapist and then as required for up to 12 weeks.Short-term assessments, made at baseline, three andsix months following injection included visual analoguemeasures of pain ;grip strength, using a Jamar dynamometer and protocol from the American Society of Hand Therapists Clinical Assessment Recommendations .Patients completed the Patient Rated Tennis Elbow Evaluation  (formerlP < 0.05) pain reduction of more than three points on a ten-point visual analogue scale suggested that thirty-two patients were needed for this study. All data were deidentified, and assessment scores of function, pain, and strength were evaluated for normalcy of distribution, and changes in all outcome measures were calculated.Power calculation based upon significant . Three patients were excluded during the study because they had other procedures such as carpal tunnel release and shoulder injections on the same arm, which altered their pain and function. Two further patients were eliminated because they had lateral epicondyle release after their ABI, and six declined to return for assessment as their symptoms were resolved, so there were 28 elbows in the final analysis. Eight patients had shoulder pain or wrist pain on the same side as their lateral epicondylitis.The duration of patients' symptoms ranged from seven months to six years (CI 18 months to three years). Thirty-seven were under workers' compensation, and three were private patients. All had one or more cortisone injection, plus either electric shock wave therapy, ultrasound, NSAIDS, braces to the forearm and wrist, and exercise therapy without satisfactory relief from symptoms. Radiologic assessment of all included patients described degeneration or discontinuity in the tendinous origin of extensor carpi radialis brevis, some with calcification of the tendon.No patients experienced severe bruising, and none had infection on the donor arm or on the injected arm. Significant improvements occurred in self-perceived measures of pain and upper limb function and in women's hand grip strength. Two of the eight men lost hand grip strength, one by five kilograms and the other by seven. P = 0.002).Patient-rated tennis elbow evaluation scores at baseline were (95%CI) 40–52/100. At 12 weeks they were 13–26/100. Between 18 months and 5 years, four patients were lost to followup. Remaining patients rated 13–27100, a significant decrease in pain and increase in function  which have been injected in the same manner as untreated autologous blood. Preparation of PRP involves withdrawing approximately 27 millilitres of anticoagulated blood and placing it in a centrifuge, before adding anaesthetic and injecting , 13.Considerable thought was given to the issue of comorbidity. In this study, eight patients had diagnoses of carpal tunnel syndrome, shoulder overuse, ulnar neuropathy, and osteoarthritis of the wrist. Two patients were excluded from the follow-up analyses because they had surgery to their elbows, but other patients had procedures of carpal tunnel release, wrist fusion, and arthroscopic shoulder repair in the years following their elbow surgery. Although the symptoms from these conditions may affect the results of pain and functional evaluation, these results are representative of occupational overuse syndromes of the upper limbs , 20.A further limitation of this study was that some patients declined to return to the clinic for their six-month assessment of grip function. These patients were under worker's compensation, and it was not reasonable to request that they return to occupational therapy in work hours. Intention to treat analysis was not used as this would likely show an inaccurate picture of their function.When the patient-rated tennis elbow evaluation was completed with the occupational therapist, the patients' comments were recorded; numerous patients said that they had no functional limitations, scoring the highest marks on this evaluation. These patients also said that they now did things differently, had altered their work duties, or ceased certain activities. In one case, a woman changed her vacuum cleaner to a self-propelling model, and she had no pain or difficulty with vacuuming. These strategies were all successful but perhaps give more positive functional results than can be compared with the patients' original activities. Despite these limitations, this study still describes dramatic improvement in the functional ability of patients with chronic degenerative tennis elbow, who had autologous blood injection wrist immobilisation and a home exercise programme, including those under worker's compensation, and having upper limb comorbidities.


Background: Arthroscopic shoulder surgery is increasingly performed as a day case procedure. Optimal post-operative pain relief remains a challenge due to considerable variations in the level of pain experienced between individuals. Our aim was to examine whether the preoperative electrical pain threshold was a strong predictor of elevated postoperative pain levels following arthroscopic subacromial decompression (ASD) surgery.Methods: Forty consenting patients with American Society of Anesthesiologists (ASA) grade 1-2 presenting for elective ASD surgery were recruited. Patients’ electrical pain thresholds were measured preoperatively using a PainMatcher®  device. Following surgery under general anaesthesia, the maximum pain experienced at rest and movement was recorded using a visual analogue scale until the end of postoperative day four.Results: In univariate analyses (t-test), the postoperative pain experienced (Area Under Curve) was significantly greater in patients with a low pain threshold as compared with a high pain threshold at both rest  and on movement . In multivariate analyses, adjusting for additional extra analgesia, the pain experienced postoperatively was significantly greater in the low pain threshold group both at rest  and on movement .Conclusions: Preoperative pain threshold can predict postoperative pain level following ASD of the shoulder.Trial registration: Clinicaltrials.gov identifier: NCT01351363Level of Evidence: II In this setting, optimal post-operative pain relief is the goal. This not only improves patient comfort and allows expedient discharge from hospital, but also reduces the risk of developing post-operative chronic pain and may improve surgical outcome5. There is considerable variation in the level of post-operative pain experienced between individuals and subsequent analgesia requirements. Previous studies have attempted to predict the level of acute post-operative pain an individual will experience, using a variety of complex pre-operative pain and psychological assessments7. Other investigators have focussed on a simpler approach, by testing an individual’s pain threshold to a single pre-operative nociceptive stimulus, e.g. heat or pressure11. An increase in pain sensitivity in these pre-operative experimental tests appears to correlate with a higher level of post-operative pain and an increased risk of developing persistent post-operative pain12. Electrocutaneous stimulation has also been shown to be a reliable and safe method for assessment of pain and sensory thresholds18. The technique has previously been used as a predictive tool in the Obstetric surgery setting using the Pain Matcher® 19.Optimal post-operative pain control in day-case surgery remains a challenge24. When the contact pads on the Pain Matcher are gripped between the thumb and forefinger, the device delivers a small, micro-processor controlled, non-harmful electric current to the individual. Variations between individuals’ skin resistance are compensated for. The electrical current consists of rectangular pulses at 10 Hz with 10mA amplitude, which is gradually increased by 4 μs rises in pulse width, from zero to a maximum of 396 μs. This occurs over a total of 99 steps and ceases when the individual releases their grip on the device. The results are displayed on an LCD screen, on a scale from 1 to 99, which is directly related to the pulse width. Higher Pain Matcher values indicate a higher pain threshold21.The Pain Matcher is a small hand held device that has been validated against the visual analogue scale (VAS) for reliable pain assessment in patients with a range of acute and chronic pain, as well as for pre-operative pain threshold assessmentWe aimed to assess the predictive value of pre-operative pain threshold measurements, made via electrocutaneous stimulation, for the intensity of post-operative pain experienced following arthroscopic subacromial decompression surgery.th March 2009.Ethical approval for this study (09/S0501/25) was provided by the NHS Fife & Forth Valley Research Ethics Committee, Dundee, UK (Chairperson Mr G Costa) on 9Forty adult patients with American Society of Anesthesiologists (ASA) grade 1–2, presenting for elective day case arthroscopic subacromial decompression surgery at the Victoria Hospital, Kirkcaldy, UK, were recruited into the study between May 2009 and October 2010 at the pre-operative surgical assessment clinic, held one week prior to surgery. Full written consent was obtained from all study participants.Exclusion criteria were: inability to give informed consent; inability to perform a telephone interview; an allergy to anaesthetic and analgesic drugs used in this study; drug or alcohol abuse; a formal diagnosis of chronic pain; a formal diagnosis of a neurological or psychiatric disorder; the use of neuromodulatory drugs, or daily analgesics; documented sensory abnormality ; or a documented rotator cuff tear.Patients were tested on the day of surgery following a six hour period of fasting and abstinence from any analgesics. We recorded age, Body Mass Index (BMI), ASA classification and telephone numbers.Pre-operative electrical pain thresholds (EPT) were recorded using the Pain Matcher device. Patients were asked to grip the device until the stimulus was first experienced as painful. After an initial "practice run" with the Pain Matcher, pre-operative pain thresholds were measured using the patient’s hand contra-lateral to that side undergoing surgery.2 50%). In addition, all patients received ondansetron 4mg, glycopyrrolate 200 μg and morphine 0.1mg/kg. All patients received an arthroscopic subacromial decompression, performed by a single orthopaedic surgeon, who also administered a subacromial bursa injection of 30ml 0.5% levobupivacaine  at the commencement of surgery.Anaesthesia was conducted by a single anaesthetist blinded to the patient’s EPT. Following application of standard monitoring, all patients received target controlled total intravenous anaesthesia  using propofol  and remifentanil  for both induction and maintenance of anaesthesia. Intermittent positive pressure ventilation was via a laryngeal mask airway, using oxygen and air  were less than 4. Intravenous morphine was administered to local protocols until this pain score was achieved. Additional rescue analgesia  was available on the day case ward prior to discharge.Patients were discharged home on the day of surgery. Outpatient analgesia consisted of paracetamol 1g 6 hourly, codeine phosphate 60mg 6 hourly and diclofenac 50mg 8 hourly. Additional analgesia, if required, was available from the hospital or the patient’s General Practitioner.Patients were introduced to the use of a VAS pre-operatively and asked to record the worst pain experienced at rest and at movement for the first four postoperative days. Telephone numbers were obtained to allow the VAS scores to be obtained via a telephone interview on postoperative day five.The highest pain score experienced at rest and on movement in each 24 hour period was recorded. The use of additional analgesics was also recorded.23 which was related to the pre-operative EPT scores in univariate and multivariate (linear regression) analyses allowing for potential confounders. A power analysis suggested we needed about 40 subjects for the multiple regression based on a recommendation of 10 patients per variable included20. A p value of less than 0.05 was accepted as being statistically significant and 95% confidence intervals (CI) were generated where relevant.Data were analysed with parametric and non-parametric tests using SPSS. The post-operative daily pain scores were used to determine an Area under the Curve (AUC)2 in 10 patients .Forty patients meeting the inclusion criteria were initially approached and recruited into the study. No eligible patients declined to enter the study. Data were incomplete for 9 patients, who were removed from the study, leaving 31 patients  . Body maThe median EPT for the total study group (n=31) was 21 (range: 4–99). Median EPT was 30 (range: 4–99) in men and 19 (range: 4–37) in women .No patients required additional morphine or tramadol post-operatively before discharge from hospital. Six patients requested additional analgesia in the first four post-operative days. The median post-operative pain scores and AUC are shown inThe post-operative pain experienced (AUC) did not differ by gender (P=0.93 at rest and 0.78 on movement) or ASA grade (P=0.27 at rest and 0.31 on movement). Patients using additional analgesics (n=6) experienced significantly higher post-operative pain than those who did not (n=25) at both rest, mean (SE) AUC 17.8 (2.7) vs 7.6 (1.0) P<0.001 and at movement, mean (SE) AUC 20.7 (1.7) vs 15.4 (1.2) P=0.053 (un-matched t-tests).Due to the significant difference between male and female EPT scores, patients were subdivided into one of two groups depending on whether their EPT was below or above the gender-specific median . Those below the median were judged to have a lower pain threshold compared to those above. In univariate analyses (t-test), the post-operative pain experienced at rest, as expressed by the AUC, was significantly greater in those with a low pain threshold (low EPT) as compared with a high pain threshold (high EPT) (P=0.008) . The levIn multivariate analyses, after adjusting for the requirement for extra analgesia, the pain experienced post-operatively (AUC) was significantly greater in the low pain threshold (low EPT) group both at rest  and on movement .19. The relationship we have demonstrated appears to be clearer with post-operative pain at rest than with pain on movement. This may be because our study did not specify a standardized movement for pain assessment. In addition, we are also in agreement with previous studies, including those using other painful stimuli, which show that women have a lower pain threshold than men24.We have shown that use of a simple pre-operative assessment of pain threshold can be used to predict those patients likely to experience a higher intensity of post-operative pain during the first 4 days following arthroscopic subacromial decompression surgery. Patients with a low pain threshold  reported significantly more post-operative pain both at rest and on movement than those with a high pain threshold (EPT above the gender specific median). These results are in agreement with previous investigations in obstetric surgery that demonstrated pre-operative EPT testing can be used to gain information on the likely intensity of post-operative pain3) with a third of patients having a BMI above 30, and therefore considered obese. We excluded volunteers suffering from conditions that may have influenced the experience of both preoperative and postoperative pain, i.e. chronic pain, heavy analgesic use or any neurological or psychiatric disorder, and only considered one type of arthroscopic shoulder surgery. It is likely that our results may not translate easily to other patient populations and different shoulder pathologies. Further study on these patient population groups is needed.Our study population, whilst being generally healthy (ASA grade 1 and 2) was, on average, middle aged (mean 51 years) and “overweight”  are shown as median and range, referring to that the dataset has ordinal properties, which are adequate for subjectively based assessments such as pain thresholds where the assumption of the distribution of the data is not necessary. In this case, the non-parametric analysis will give more meaning to the analysis than the use of parametric analysis that is based on data that have linear properties and that require knowledge of the data material distribution.The results are presented separate for women and men in table 1 and 2 which is very interesting since obvious gender differences are reported in threshold assessments. It would have been interesting to see separate results based on gender in table 3.The reported values of pain thresholds represent a wide range from 4-99 in men and 4-37 in women. In other studies using the Pain Matcher, the lowest level of your reported pain threshold is reported in the range of the sensory threshold assessed by Pain Matcher. Could the finding be due to the instruction given to the patients on what they were supposed to feel when reaching the pain threshold? In other words, could the sensation of unpleasantness, present before reaching the pain threshold, be a part of the results and thereby explain some of the great dispersion in the data? I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. This is an interesting, well-written and straight-forward study. The analyses appear to be appropriate to the study aims. Some explanation should be given for the exclusion of nine participants and information provided regarding if they are different from the rest of the sample in some way. Additional demographic information would also be of interest. For example, the duration of shoulder pain and pre-operative pain rating would be of value in placing these results in context.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. This study is both interesting and potentially of great importance to help clinicians in improving postoperative pain management for patients. The issue however is that almost 25% of the patients originally enrolled were not included in the analysis without adequate explanation as to why this was (e.g. were they missing at random or not) nor a discussion of the fact that this may have had a major impact on the outcomes. Even though the 'data were incomplete' for these 9 patients there are methods for dealing with this from a statistical perspective that may allow a (more) complete analysis. The other option would have been to recruit more patients to make up for this loss and still meet (or come closer to) the pre-determined sample size.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.


Neuropathic pain must be correctly diagnosed for optimal treatment. The questionnaire named Neuropathic Pain Symptom Inventory (NPSI) was developed in its original French version to evaluate the different symptoms of neuropathic pain. We hypothesized that the NPSI might also be used to differentiate neuropathic from non-neuropathic pain.We translated the NPSI into German using a standard forward-backward translation and administered it in a case-control design to patients with neuropathic (n = 68) and non-neuropathic pain  to validate it and to analyze its discriminant properties, its sensitivity to change, and to detect neuropathic pain subgroups with distinct profiles.Using a sum score (the NPSI-G score), we found sensitivity to change  and could distinguish between neuropathic and other pain on a group basis, but not for individual patients. Post hoc development of a discriminant score with optimized diagnostic properties to distinguish neuropathic pain from non-neuropathic pain resulted in an instrument with high sensitivity (91%) and acceptable specificity (70%). We detected six different pain profiles in the patient group with neuropathic pain; three profiles were found to be distinct.The NPSI-G potentially combines the properties of a diagnostic tool and an instrument to identify subtypes of neuropathic pain. Neuropathic pain must be correctly diagnosed for optimal treatment. Several screening tools have been developed to differentiate neuropathic from non-neuropathic pain . These ihttp://www.rheumatology.org). Osteoarthritis was chosen to include a condition that (like in most patients with neuropathic pain in our sample) entails pain in the extremities. Exclusion criteria were coexistence of several conditions possibly causing pain, severe depression, chronic alcoholism or substance abuse, and an inability to understand the questionnaire. Patients with neuropathic pain received current symptomatic treatment, including analgesic drugs, when admitted or seen as outpatients.Patients with neuropathic pain and headache were recruited from the Department of Neurology, University of Würzburg and the Department of Pain Management (Bergmannsheil), Ruhr University, Bochum. Patients with osteoarthritis related pain were recruited from the Department of Orthopedics (König-Ludwig-Haus), University of Würzburg and the Department of Orthopedics (St. Josefs Klinikum), Ruhr University, Bochum. A diagnosis of neuropathic pain was confirmed when associated with a definite neurological cause as determined during routine in- or outpatient management of the patient. In addition, it was required that the pattern of pain distribution was characteristic of the respective diagnosis. Headache was diagnosed using the International Headache Society criteria for tension type headache and migraine . Only paUsing the original French NPSI, we used a standard forward-back translation to develop the German equivalent. First, two translators who were native French speakers and fluent in German  translated the questionnaire into German. A reconciled language version was developed using these two forward translations. A third professional translator (a native German speaker fluent in French) produced the back-translation. The final version was evaluated by three independent medical professionals fluent in both French and German usage. Discrepancies in wording were analyzed and when required, resolutions were obtained by consensus. A diagram depicting pain attacks and episodes of continuous pain was inserted to facilitate patient comprehension. For quality control, patients were instructed to indicate areas of pain on an additional diagram , the graded chronic pain scale , and thDepressive symptoms were assessed using the CES-D questionnaire. Scores above 23 points were considered indicative of depressive states. Pain intensities were graded using the 11-point numerical scales (0 - 10) of the GCPS.Sample description included diagnostic data, age, gender, depression score (CES-D) and general pain characteristics (GCPS scores) for each diagnostic group.A sum score (NPSI-G score) for assessing the severity of neuropathic pain was calculated using the sum score methodology of our reference study . A possiFor the group of patients with neuropathic pain, we assessed the test-retest reliability of the NPSI-G and the NPSIG score and analyzed its convergent and divergent validities. The test-retest reliability of the interval-scaled items and the NPSI-G score was assessed by calculating intra-class correlations  for all items included in the initial measurements and the 24-hour follow-up. Since there are no validated instruments available in German comparable to the NPSI, we used two widely employed comparators for convergent validity; the German version of the NPS  (NPS-D) The Pearson correlations between the 4-week change of the NPSI-G score and the changes of current, average, and maximum pain in the GCPS, the PGIC-score, and the change of the CES-D-score were calculated in patients with neuropathic pain, whereby the CES-D was used as a control measure for divergent characteristics. Correlations were considered low, medium or high as they reached levels of r = 0.1, r = 0.3, or r = 0.5 respectively . To concResponses to the NPSI-G items were compared between the diagnostic groups by analyzing the mean values and the frequencies of positive item responses , indicating the occurrence of the different qualities of pain for the 10 interval scaled items Q1 - Q3, Q5 - Q6, Q8 - Q12. Mean values of items and sum score were calculated and compared between diagnostic groups. The distribution of the NPSI-G score within the groups was analyzed using box plots. The correlation of the NPSI-G score with age, sex, pain intensity in the CGPS, and the CES-D score was calculated by Pearson correlations to control for a possible bias caused by between-group differences of these parameters. We then examined the diagnostic power of the NPSI-G score using a receiver operating characteristic (ROC) diagram . The ROCTo develop a tool that would separate patients with neuropathic pain from the other groups, we calculated a discriminant score (NPSI-G-dis) using discriminant analysis. This weighted sum score of the variables was constructed using specific coefficients for each variable to allow optimal separation of the different diagnostic groups. We used all variables from the NPSI-G including the two categorical variables Q4 and Q7, which were transformed into dichotomous variables similar to the construction described in the definition of the NPSI-G score, but without weight coefficients which were dispensable in this context. In this case an optimal ROC-diagram was the criterion for an appropriate transformation.Using a cluster analysis  was done by t-tests in the case of two groups and by ANOVAs with post hoc tests (Sidak resp. Dunnett T-3 adjustments for multiple testing) when more than two independent groups were involved ,19. To aOut of 255 patients screened, we recruited 241 participants who fulfilled the inclusion criteria. Four patients (n = 2 with osteoarthritis and headache each) were later excluded from analysis because of failure to complete the NPSI-questionnaire. The study cohort consisted of the remaining 237 patients. Patient data are provided in Table Cronbach's alpha for the 10 interval items (α = 0.75) allowed accepting a one dimensional latent construct and thus calculating a sum score ,22, the The test-retest reliabilities for a 24 h time interval are shown in Table Construct validity information is given in Table The Pearson correlations for a 4-week change in the NPSI-G score, a parallel change in the GCPS and the PGIC are shown in Table The pain drawings confirmed that the pain the patients described was directly related to the syndrome they were initially diagnosed with: headache patients localized their pain to the head, the osteoarthritis patients to the respective joints, and the patients with neuropathic pain to their feet or the area of their nerve lesion. Table When we calculated the NPSI-G scores for the different diagnostic groups, the mean value for neuropathic pain patients was significantly higher than that of the comparison groups . There was no significant difference between the two comparison groups (p > 0.98). In spite of these findings, the box plots in Figure Since the separation quality of the NPSI-G score for neuropathic versus non-neuropathic pain was not satisfactory, we used discriminant analysis to construct an improved score for the separation of neuropathic and non-neuropathic pain. The optimal transformations of the categorical items 4 and 7 into dichotomous scores are: Q4_d = 0/1 if Q 4 ≥ 4/<4; Q7_d = 0/1 if Q7 ≥2/<2 .The resulting post-hoc discriminant score (NPSI-G-dis) is calculated by the coefficients given in Table To obtain a flexible diagnostic instrument, appropriate cut-off values need to be chosen. Figure 1 = 16, n2 = 10, n5 = 9), were mutually different with statistical significance. The differences between cluster 1 and 2 or between cluster 2 and 5 were due to different shapes and not to different levels alone. Clusters 1 and 2 were different for the items "pins and needles" and "tingling" (p < 0.001 for both comparisons) whereas all other differences may be neglected . A comparison of cluster 2 and 5 led to the opposite result, with no difference in the items "pins and needles" and "tingling" (p = 0.180 resp. p = 0.774) but significant differences for all other items (p < 0.015 for each case). Cluster 1 and 5 were similar in shape but with different levels of values. To control for the influence of global pain intensity on the differences between clusters, we show in Figure The cluster analysis led to a six-cluster solution Figure . CompariThe NPSI-G score demonstrated a high test-retest reliability and convergent as well as divergent construct validity when applied to neuropathic pain patients. This allows us to conclude that the NPSI-G is a useful and reliable instrument for assessing the severity of neuropathic pain. However, since our patient population was biased toward neuropathic pain of peripheral origin, the NPSI-G will have to be validated in a separate sample including also patients with other neuropathic pain syndromes, e.g. with central pain. Nearly all properties of the NPSI-G score were comparable to the original French results. In contrast to the reference study, test-retest-reliability on a per item basis did not reach acceptable values in all cases. This might possibly be attributed to the different time lags, which were 24 h in the current as opposed to 3 h in the reference study. The possibility of different connotations of some items in the respective languages as another possibility for divergent results has recently been discussed for several non-validated translations of the NPSI . For neuThe correlation with data from the CGPS for current pain was high, for pain in the last 4 weeks it was only medium high  [The cluster analysis revealed six clusters with different patterns. Three of them  were not possible, and with any latency longer than 24 h, influences of treatment or spontaneous fluctuations in pain characteristics that would disturb identical conditions for the responses to the items would have to be expected. Given the high number of statistical tests, some spuriously random results cannot be excluded with certainty. The discriminant function was optimized for the given data, and we did not crossvalidate the results. Crossvalidation was not possible because of the relatively small sample size. Our results indicate that a follow-up study to achieve this aim might be worthwhile. Differences in group parameters  may have caused some biases when analyzing group differences. This mainly concerns responses to single items or the NPSI-G score. The correlations of this score  with age and gender are low, but are considerable for the pain variables (about 0.5) and for depressiveness (> 0.3). The discriminant score NPSI-G-dis was only marginally influenced by these parameters, with only low correlations.The NPSI-G is the first questionnaire that is capable of discriminating subtypes of neuropathic pain and provides additional information as a diagnostic tool. Using specifically constructed scores, the NPSI-G can distinguish neuropathic from non-neuropathic pain with high sensitivity and acceptable specificity. This combination of properties suggests that it may be ideally suited for use in clinical trials. Further studies with larger numbers of participants are required to confirm our findings.The authors declare that they have no competing interests.CS participated in the design of the study, in data collection and writing of the manuscript. HR performed the statistical analysis and participated in writing of the manuscript. JPR participated in data collection and data analysis. JF participated in the design of the study and data analysis. ML participated in data collection and data analysis. CM participated in the design of the study, statistical analysis, and writing of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2377/11/104/prepubEnglish translation of the original NPSI by Bouhassira et al. (2004). This is not a not a back translated and validated version of the NPSI, do not use! The English translation is only given for the benefit of those readers who do not read German or French.Click here for fileFull version of the NPSI-G as it was used in the study.Click here for file


There are still many things to be found out about interstitial cystitis/painful bladder syndrome (IC/PBS) because the pathological processes underlying the condition are not yet elucidated, biological markers of the condition are not yet available, and the type and severity of symptoms can vary, so, clearly defining the condition is not yet possible. For example, it is not clearly understood whether IC/PBS represents a systemic disease, if it is localized in the bladder, or if it was initially localized in the bladder and it later evolved into a systemic disease. This condition is best managed by using a multidisciplinary approach. Management requires a good integration and knowledge of all pelvic organ systems and other systems including musculoskeletal, neurologic, and psychiatric systems.  Patients with IC/PBS suffer from a ‘silent ordeal’; they often appear healthy but experience unrelenting pain that requires frequent trips to the bathroom, both day and night. They may curtail activities due to an extreme urinary frequency. Sleep deprivation caused by pain and nocturia can lead to fatigue and depression. Many are unable to work in this situation. In addition to the personal costs that IC/PBS exacts, the condition is associated with significant health care costs. Experts estimated the total medical expenditures associated with IC/PBS in the United States to be of 65.9 million dollars in 2000 .Chronic pelvic pain (known as persistent) occurs for at least 3 months. It is associated with changes in the central nervous system (CNS) that may maintain the perception of pain in the absence of acute injury. These changes may also magnify perception so that non–painful stimuli are perceived as painful  and painful stimuli become more painful than expected  . Curtis Nickel reported data from the Interstitial Cystitis Deep Phenotyping Research Group that confirms the relationship of BPS/IC to other chronic pain syndromes. Irritable bowel syndrome was self–reported in 38.7% of patients vs. 5.6% of controls, fibromyalgia was self–reported in 17.6% of patients vs. 1.7% of controls, and chronic fatigue syndrome in 9.4% vs. 1.1% respectively. No other pain condition was found in 52.4% of the BPS/IC patients studied [PBS/IC includes a major slice of the ‘painful bladder’ disease complex, which consists of a large group of patients with bladder and/or urethral and/or pelvic pain, irritative voiding symptoms , and sterile urine cultures. Painful bladder conditions with well–established causes include radiation cystitis, cystitis caused by microorganisms that are not detected by routine culture methodologies, and systemic disorders that affect the bladder. In addition, many gynecologic disorders can mimic PBS/IC .interstitial cystitis, was not at all describing the clinical syndrome or even the pathologic findings in many cases has led to the current effort of reconsidering the name of the disorder and even the way it is positioned in the medical spectrum [The perception that the original term, spectrum . What waspectrum  that mayspectrum . Its relspectrum .interstitial cystitis, painful bladder syndrome, urethral syndrome, trigonitis, and bladder pain syndrome, among others. In recent years, a variety of groups have proposed different names, based in part on their beliefs about the underlying etiology of IC/CBS.Not only has the definition of IC/PBS been controversial but even the name is under debate. A number of other names have been used to describe this condition, including IC was recognized as a pathologic entity during the 19th century. Joseph Parrish, a Philadelphia surgeon, described three cases of severe lower urinary tract symptoms in the absence of a bladder stone in an 1836 paper and termed the disorder ‘tic doloureux of the bladder’ [interstitial cystitis to describe an inflammation that has ‘destroyed the mucous membrane partly or wholly and extended to the muscular parietes’ in his book ‘Diseases of the Bladder and Urethra in Women’. Early in the 20th century, at a New England Section meeting of the American Urological Association, Guy Hunner reported the case of eight women with a history of suprapubic pain, frequency, nocturia, and urgency lasting for an average of 17 years [Fifty years later, Skene (1887) used the term 17 years . In BaltIn 1987, the NIH–NIDDK  came with the criteria for the diagnosis of interstitial cystitis. This was probably the first structured forma proposal of diagnostic standards in IC.Although it was proposed some years before, in 2002, The International Continence Society (ICS) defined the term (PBS/IC) as the complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased daytime and night time frequency, in the absence of a proven urinary infection and other obvious pathology. At this time, the ICS stated that the Interstitial Cystitis is a specific diagnosis (part of PBS) and requires confirmation by typical cystoscopic and histological features. Many consultations that took place in the following years discussed all data that became available, but the terminology and algorithms remained unchanged until now.In February 2007, the Association of Reproductive Health Professionals and the Interstitial Cystitis Association held the Consensus Meeting on Interstitial Cystitis in Washington DC and developed statements concerning the definition and nomenclature of the condition. In their opinion, the nomenclature of IC/PBS may need to change, but change should not be undertaken now because there is insufficient evidence to support it . Chronic Pelvic Pain associated with bladder symptoms, described more than 150 years ago, is a common cause of complaint for a large number of women. Probably, the term Bladder Pain Syndrome is the most accurate to describe the CPP associated with the bladder, but the inclusion of IC to the term (BPS/IC) has to be considered. Work is needed to unify terms and promote the use of validated diagnostic tools.The 2009 Guidelines of the European Association of Urology dedicates 90 pages to the CPP, without changing or improving terminology, but rather concentrating all definitions, diagnostic or treatment algorithms and lots of clinical evidence that support this new approach to a very old disease.Interstitial cystitis/painful bladder syndrome (IC/PBS) predominantly affects women, with an average age at onset of 40 years old. It also affects men and, in rare cases, children . The estIn other countries, the prevalence is of 18–450/100.000 women (Finland), 8-16/100.000 (Netherlands) and 4.5/100.000 (Japan) [The only definitive risk factor for IC/PBS is female gender: the female–to–male ratio is generally estimated to be of 9:1 . HoweverAdults with a prior history of abuse or traumatization demonstrate hypothalamic–pituitary–adrenal (HPA) axis abnormalities, similar to IC/PBS patients. Childhood sexual abuse and physical traumatization are associated with subsequent lifelong risks of chronic pain syndromes .Although the exact cause of PBS/IC is still unknown, several theories exist. No single theory has been proven to explain the symptoms in all cases; thus, many consider PBS/IC to be multifactorial in nature. One widespread hypothesis is that the bladder lining (epithelium) is deficient and therefore permeable to urinary irritants . This thIn a normal bladder, large, negatively charged molecules called glycoproteins and glycosaminoglycans (GAG) line the epithelium and provide an impermeable barrier. This is considered the main barrier between urine and circulating blood. A defect in the GAG layer allows leakage and absorption of urinary solutes to occur, the major solute being potassium. Ongoing exposure of the bladder wall to potassium causes inflammation, tissue irritation and injury, mast cell degranulation, and sensory nerve depolarization. This process results in symptoms associated with PBS/IC including urinary frequency, urgency, and pain . Recent For example, most patients with vulvodynia have a positive PST and urgency/frequency, indicating pain of bladder origin (IC). IC deserves far greater consideration in the differential diagnosis of patients with vulvodynia .An alternate hypothesis is that an initial insult to the bladder occurs , which excites sensory nerves located in the bladder wall. This excitation triggers an inflammatory response, or neurogenic inflammation. This in turn releases the neuropeptide substance P, causing the release of mast–cell mediators, histamines, leukotrienes , cell and tissue damage, and fibrosis. Ultimately, there is a wind–up of the nervous system with neuroplasticity (c–fibers) and visceral allodynia, and pain beyond the bladder occurs .PBS/IC has also been theorized to be an autoimmune condition because some clinical features resemble a disorder of the immune system. Examples include the chronicity, the exacerbations and remissions, and response to immunosuppressants seen in PBS/IC. It also appears that PBS/IC may have a yet unexplained association with autoimmune diseases and pain syndromes such as vulvar vestibulitis, fibromyalgia, Hashimoto's thyroiditis, and irritable bowel syndrome .A recent study  showed iAnother study  investigThe sialic acid content of THP  , a critiBecause of the lack of criteria appropriate for use in the clinical setting, the general approach to diagnosis of IC/PBS nowadays tends to be empirical. If other conditions can be excluded, patients with characteristic signs and symptoms are generally treated for presumed IC/PBS. In certain circumstances, some clinicians may choose to evaluate further, with cystoscopy with hydrodistention under general anesthesia, urodynamic studies, or lidocaine instillation. The potassium chloride challenge, or Parsons' test, has also been used for diagnosis. This test involves instillation of potassium chloride into the bladder; a positive result is pain and reproduction of IC/PBS symptoms. Because it tests for epithelial permeability, the potassium chloride challenge is not specific for IC/PBS and provides a positive result in other disorders that involve epithelial leakage . The resThe diagnosis is generally subject to more rigorous testing in Europe than in North America, where symptoms in the absence of other obvious causes seem to be the gold standard .Cystometry in conscious IC patients generally demonstrates normal function, the exception being a decreased bladder capacity and hypersensitivity. Pain on bladder filling that reproduces the patient's symptoms is very suggestive of IC.2O to 80 cm for 1 to 2 minutes, the bladder is drained and refilled. The terminal portion of the effluent is often blood tinged. Reinspection will reveal the pinpoint petechial hemorrhages that develop throughout the bladder after distention and, they are not usually seen after the examination without anesthesia [Performing cystoscopy with the patient under anesthesia allows a sufficient distention of the bladder to afford visualization of either glomerulations or Hunner's ulcers. After filling it with Hesthesia .Bladder biopsy is necessary only if needed to rule out other etiologies of the patient's symptoms.Glomerulations are not specific for IC , and onlAs for the markers, the urine antiproliferative factor (APF), identified by Keay, may prove to be the most accurate marker of PBS/IC when confirmed by other centers. It appears to have the highest sensitivity and specificity of the variety of possible markers tested and fits nicely into an etiologic schema .An ultra–performance liquid chromatography–mass spectrometry (UPLC–MS) based on a metabonomic approach was applied to identify a candidate metabolite with an unknown association with the interstitial cystitis (IC). The urinary marker of IC was identified as phenylacetylglutamine (PAGN) by using NMR and MS/MS analysis. In addition, quantitative methods were developed to determine the urinary PAGN levels by using UPLC-UV. The urinary level of PAGN, measured relative to creatinine (Cr), was significantly elevated in IC patients (mean 0.47mg/mg Cr) compared with BC  patients (mean 0.25mg/mg Cr) and HVs  (mean 0.11mg/mg Cr). Interestingly, urinary PAGN/Cr ratios in patients with mild IC (grade Ⅰ) and moderate IC (grade Ⅱ) were higher than for patients with severe IC (grade Ⅲ). Moreover, urinary PAGN/Cr ratios with mild and moderate IC patients (mean 0.30mg/mg Cr) were higher than HVs (mean 0.059mg/mg Cr), in the validation set. These findings establish urinary PAGN/Cr ratios as a novel urinary marker of IC, and may contribute to early diagnosis of IC patients .Another recent study  aims to Examining the urinary bladder mucosa with a flexible cystoscope with the NBI system makes it possible to easily detect ulcers of bladder mucosa and areas with angiogenesis. Therefore, it is considered that the use of a flexible cystoscope with the NBI system is highly practical for the IC/PBS diagnosis .One study evaluated the safety and efficacy of intravesical liposomes, a mucosal protective agent, compared to oral pentosan polysulfate sodium for interstitial cystitis/painful bladder syndrome . A prospEach glycosaminoglycan directed treatment seemed beneficial. Liposome intravesical instillation is safe for interstitial cystitis/painful bladder syndrome with potential improvement after 1 course of therapy for up to 8 weeks. Intravesical liposomes achieved efficacy similar to that of oral pentosan polysulfate sodium. Further large–scale placebo controlled studies are needed. Intravesical liposomes appear to be a promising new treatment for interstitial cystitis/painful bladder syndrome.Another study compared the clinical effectiveness of type A botulinum toxin (BoNT–A) injections followed by hydrodistention (HD) with HD alone, in patients with interstitial cystitis/painful bladder syndrome (IC/PBS). A prospective, randomized study was performed in a urological referral centre . In all,The IC/PBS symptom score significantly decreased in all three groups, but VAS reduction, FBC and cystometric bladder capacity increases were significant only in the BoNT–A groups at 3 months. Out of the 44 patients in the BoNT–A group 31 (71%) had a successful result at 6 months. A successful result at 12 and 24 months was reported in 24 (55%) and 13 (30%) patients in BoNT–A group, respectively, compared with only six (26%) and four (17%) in the control group (P = 0.002). Intravesical injections of BoNT–A followed by HD produced significantly better clinical results than HD alone in patients with IC/PBS.Intravesical Alkalinized Lidocaine (PSD597) Offers Sustained Relief from Symptoms of Interstitial Cystitis and Painful Bladder Syndrome. The aim of this study was to assess the immediate and sustained relief of the symptoms of interstitial cystitis/painful bladder syndrome (IC/PBlS) after a consecutive 5–day course of treatment with intravesical alkalinized lidocaine (PSD597), and to characterize the pharmacokinetics of single and multiple doses of intravesical PSD597 in a subgroup of patients. This preliminary study showed that PSD597 was effective in providing sustained amelioration of symptoms of IC/PBlS beyond the acute treatment phase. The drug was safe, well tolerated and devoid of the systemic side effects, often experienced with oral drug administration .Intravesical Nanocrystalline Silver (NCS) Decreases Experimental Bladder Inflammation . BoucherTimely hyaluronan instillation therapy  may leadShort–Term Results of Bilateral S2–S4 Sacral Neuromodulation are suitable in the Treatment of Refractory Interstitial Cystitis, Painful Bladder Syndrome, and Chronic Pelvic Pain . The eff


Cervical spondylosis is a common and disabling condition. It is generally felt thatthe initial management should be nonoperative, and these modalities includephysiotherapy, analgesia and selective nerve root injections. Surgery should bereserved for moderate to severe myelopathy patients who have failed a period ofconservative treatment and patients whose symptoms are not adequately controlled bynonoperative means. A review of the literature supporting various modalities ofconservative management is presented, and it is concluded that although effective,nonoperative treatment is labour intensive, requiring regular review and carefulselection of medications and physical therapy on a case by case basis. Spondylosis refers to age-related degenerative changes within the spinal column , which iIn the vast majority of patients axial neck pain is related to muscular and ligamentous factors related to injury, poor posture, stress, or chronic muscle fatigue . The cerAge-related degeneration of the intervertebral disc results in loss of viscoelasticity and a loss of height with associated posterior bulging. As the disc height decreases the ligamentum flavum folds, as does the facet joint capsule, causing a decrease in the dimensions of the canal and exit foramina. Osteophytes form posteriorly around the disc, and these combined with the disc bulge and the aforementioned in folding of ligament and joint capsule cause pressure on the exiting nerve roots or the spinal cord itself.The underlying mechanism of radicular pain is not clearly understood, but it is generally believed that an inflamed nerve root will produce pain when compressed. This inflammation is most likely a result of neurogenic chemical mediators released from the cell bodies of sensory neurons and nonneurogenic mediators released from the degenerate disc , 21. It Myelopathy is invariably caused by compression of the spinal cord. Animal studies have demonstrated that the spinal cord must be subjected to at least 40% compression to produce reversible neurological deficits . To achiDespite an absence of clinical trials in the use of NSAIDs in the treatment of cervical spondylosis, their use is widespread. Theoretically in addition to a purely analgesic effect NSAIDs will reduce inflammation around the nerve route decreasing its sensitivity to compression. There is no evidence that NSAIDs are more effective than pure analgesics such as acetaminophen; however their efficacy has been shown in hip and knee arthritis , 26, andThe use of opioid analgesics in spondylotic syndromes has been limited by the possibility of their ineffectiveness in neuropathic pain  in additThe use of muscle relaxants in cervical spondylosis is aimed at relieving any associated spasm of the trapezius and paraspinal muscles, as well improved sleep from sedative effects of these medications. This has been demonstrated using the agent carbobenzaprine in mixed back and neck pain populations , 35, thoThere is little evidence to support the use of antidepressants for the treatment of cervical spondylosis, but there is evidence of a modest improvement in pain severity with minimal functional improvement in low back pain , 38.Gabapentin has been shown to improve pain in the treatment of diabetic neuropathy and has therefore become widely used for the treatment of other sources of neuropathic pain. Again there is no evidence to support its use in cervical radiculopathy, but there is evidence of small improvements in pain scores when used in lumbar radiculopathy , 40. A tThere is limited evidence to support the use of systemic corticosteroids in the treatment of cervical radiculopathy. If used the general advice is that a 1-2-week course (tapered after 3 days) of steroid such as prednisone should be used only in carefully selected patients refractory to other medication . There iThere is moderate evidence that botulinum-A injections are of no benefit .There have been several trials and systematic reviews into the use of a structured physical therapy programme for the treatment of cervical spondylosis and its sequelae. The overall message or the prospective randomised trials appears to be that surgically treated patients receive greater improvements in pain, muscle strength, and sensory function in the early follow-up period, but at 1 year there is no difference between groups either objectively or in terms of patient satisfaction. This applies to pure axial neck pain, cervical radiculopathy , 48, or Chinese herbal medicine is a popular method of alternative medical therapy. The literature is sparse regarding the effectiveness of Chinese medicine for any condition, and what little literature does exist is in Chinese and is not easy to search. There is one meta-analysis that investigated the effectiveness of Chinese herbal medicine, finding only 4 studies (two of which were unpublished). This study concluded that there was weak evidence to suggest that Compound Qishe Tablet was superior to placebo and that topical Compound Extractum Nucis Vomicae was more effective than topical diclofenac gel.Accupuncture has been shown to be effective for pain relief in the immediate and short term posttreatment period; however there is no medium to long-term benefit in pain control or functional improvement –54.Cervical spondylosis is a common and disabling condition. The initial management should be nonoperative for the first 3 months. Surgery should be reserved for moderate to severe myelopathy patients who have failed a period of conservative treatment and patients whose symptoms are not adequately controlled by nonoperative means. Nonoperative treatment is labour intensive, requiring regular review and careful selection of medications and physical therapy on a case by case basis. More invasive treatments such as epidurals may be of benefit in a select group of patients that do not respond to simpler measures.


Background. The incidence of spine metastasis is expected to increase as the population ages, and so is the number of palliative spinal procedures. Minimally invasive procedures are attractive options in that they offer the theoretical advantage of less morbidity. Purpose. The purpose of our study was to evaluate whether minimally invasive posterior spinal instrumentation provided significant pain relief and improved function. Study Design. We compared pre- and postoperative pain scores as well as ambulatory status in a population of patients suffering from oncologic conditions in the spine. Patient Sample. A consecutive series of patients with spine tumors treated minimally invasively with stabilization were reviewed. Outcome Measures. Visual analog pain scale as well as pre- and postoperative ambulatory status were used as outcome measures. Methods. Twenty-four patients who underwent minimally invasive posterior spinal instrumentation for metastasis were retrospectively reviewed. Results. Seven (29%) patients were unable to ambulate secondary to pain and instability prior to surgery. All patients were ambulating within 2 to 3 days after having surgery (P = 0.01). The mean visual analog scale value for the preoperative patients was 2.8, and the mean postoperative value was 1.0 (P = 0.001). Conclusion. Minimally invasive posterior spinal instrumentation significantly improved pain and ambulatory status in this series. It is estimated that over 1.5 million new cases of cancer occur each year in the United States. Roughly 500,000 people die each year in the United States from cancer-related causes, most of whom have metastatic disease . The majMinimally invasive techniques offer potential advantages over open techniques particularly in the population of patients suffering from metastatic disease of bone. Minimally invasive techniques, as the name implies, are potentially associated with less soft tissue injury than their open surgical counterparts . FurtherWe present the short-term followup of 24 cases of metastatic disease in the spine treated minimally invasively with posterior instrumentation. We compared preoperative ambulatory status and preoperative pain levels with postoperative levels. Our goal was to determine whether minimally invasive posterior instrumentation could provide meaningful improvement in pain control and ambulatory status in the short term.We performed a retrospective review of 24 consecutive cases treated with minimally invasive posterior spinal instrumentation for spine tumors. The patients were followed for an average of 9 months (range 3–21). There were 13 male and 11 female patients. The average age was 62 (range 33–86). Patients with spinal cord compression are not suitable candidates for this procedure and thus were excluded. The following cancer diagnoses were included: plasmacytoma (9), metastatic breast cancer (5), metastatic hepatocellular carcinoma (2), metastatic lung cancer (1), metastatic prostate cancer (1), metastatic colon cancer (2), metastatic angiosarcoma (1), metastatic liver cancer (1), metastatic thyroid cancer (1), and lymphoma (1). The thoracic spine was the primary site of disease in 10 cases, and the lumbar spine was the primary site of disease in 14 cases. Only cases where instrumentation was used were included in this paper. The indications for instrumentation were made on a case-by-case basis. In general, an unstable fracture or an impending fracture were indicated for surgery. The decision to proceed with surgery was made on a case-by-case basis. Patients with mechanical back pain, defined as pain with movement which is relieved by rest, that corresponded to an area of metastases were considered for surgery. t-test was used to compare the mean VAS between preoperative and postoperative groups. A P value of less than 0.05 was used to determine whether a value was statistically significant.We were interested in examining whether surgical stabilization had a statistically significant impact on ambulatory status and self-reported pain levels. We categorized patients into one of two categories with regard to ambulation. If they were able to ambulate with or without a gait aid, they were given a score of 1. If they were unable to ambulate, then they were given a score of 0. We utilized the Fisher's exact test to evaluate whether the patients' ambulatory status was improved by our intervention. We used a visual analog scale (VAS) to assess pain as reported by the patients. A score of 1 was given for mild or no pain (0–3). A score of 2 was given for moderate pain (4–6), and a score of 3 was given for severe pain (7–10). The student's The procedure involves the use of fluoroscopic imaging in order to place the pedicle screws percutaneously. Adequate imaging is required to visualize the pedicles well in both the lateral as well as a/p views. This may require the radiology technician to cant the fluoroscope in order to visualize the pedicles clearly. This is particularly true in the sacrum. A radiopaque marker is placed on the skin so that the incisions are appropriately placed just lateral to the pedicles. This allows medialization of the trochar. The trochar is passed through the soft tissues down to the bony surface. Prior to penetrating the cortex with the trochar, it is important to confirm that the trochar is on the lateral border of the pedicle silhouette. In addition, it is useful to place the trochar along the superior quarter of the pedicle as seen on the a/p and lateral image. Placement of the trochar in this manner allows one to medialize the pedicle screw as it passes into the vertebral body. After the trochar has been successfully placed into the vertebral body, a guide wire is placed through it. The trochar is then removed, and a series of dilators are passed over the wire. Each system has a slightly different mechanism of screw/rod placement, and thus the technique should be tailored to the implant used as well as particular anatomy of the patient. The unifying theme behind these systems is that they provide a percutaneous/minimally invasive means by which they can stabilize the spine.P = 0.01). The mean visual analog scale value for the preoperative patients was 2.8, and the mean postoperative value was 1.0 (P = 0.001).Seven (29%) of the 24 patients were unable to ambulate secondary to pain and instability prior to surgery . All 24 Twenty-one of 24 patients presented with severe pain. Seven patients were unable to ambulate secondary to pain. One patient complained of radicular pain in addition to their back pain. The rest of the patients complained primarily of back pain. The two patients who presented with minimal back pain had lytic lesions that were concerning for impending collapse. Both of them were to undergo surgery for pathologic fractures of their limbs. In one case a proximal femoral replacement was performed secondary to a pathologic fracture. The other patient underwent a proximal humerus resection secondary to pathologic fracture. Both of these patients underwent minimally invasive spinal stabilization under the same anesthetic. Both of these patients were in need of chemotherapy. It was felt that their spines were going to collapse secondary to the lytic nature of their lesions. It was determined that minimally invasive stabilization under the same anesthetic as the one used for their limb reconstructions made the most sense. If their spines became a problem in the ensuing months, then their chemotherapy would have to be interrupted in order to stabilize their spines. This decision was made in conjunction with the patients and their medical oncologists.Another patient with metastatic hepatocellular carcinoma underwent open decompression and stabilization for high-grade spinal cord compression in the thoracic spine. They had a painful lumbar metastasis at L4 and L5, which was stabilized minimally invasively from L3-S1 under the same anesthetic.One 86-year-old patient with metastatic prostate cancer presented with back pain and radicular pain in an L5 distribution. He underwent a minimally invasive decompression along with minimally invasive stabilization .Three patients had deformities associated with pathologic fractures. In two instances the patients had kyphotic deformities, and in the other case the patient had scoliosis. All three deformities were noted in the lumbar spine. The kyphotic deformities measured 25° and 15° over the involved lumbar vertebrae. The scoliosis measured 15° around L1. All three of these patients were managed with minimally invasive posterior instrumentation. The kyphotic deformities improved by 10° and 9°, respectively, and the scoliosis improved by 13°.We report the successful management of 24 patients treated with minimally invasive posterior spinal instrumentation for malignancies of the spine. The patients had a statistically significant improvement in ambulatory status as well as pain levels after their minimally invasive stabilization. All patients in our series were ambulatory without a brace after surgery. The rationale behind this form of treatment is that it balances the need to stabilize the spine while avoiding the morbidity associated with open procedures [It is important to maintain proper oncologic perspective when managing this patient population. Many of these patients do not have long to live, and the goal must be to improve or maintain their quality of life during the remaining time. This concept is predicated on the notion that appropriate staging and diagnostic work-ups have been performed prior to rendering treatment. Anecdotally, we have had several patients sent to us for management of their metastatic disease when in fact they had spondylodiscitis. These patients had a history of cancer, and it was assumed that their spine pathology was related. The opposite situation has also occurred in which a patient was thought to have an infection when in fact they had metastatic disease. A biopsy should be performed and cultures should be sent before deciding on and rendering treatment.While there seems to be an important role for minimally invasive procedures in this patient population, there are instances in which minimally invasive approaches are not appropriate. In the setting of high-grade spinal cord compression, percutaneous procedures should not be entertained. At this time, percutaneous fusions are unproven and if a patient requires a fusion, they should not be treated percutaneously. Furthermore, minimally invasive instrumentation is to be used alongside other adjuvant therapies such as radiation or chemotherapy. If a tumor is not sensitive to either, then one should pause before using a minimally invasive approach.Traumatic fractures of the thoracolumbar spine have been treated successfully using a similar approach , 6. It iRecent studies have questioned the utility of percutaneous cement augmentation of osteoporotic vertebral fractures –9. CurreClose consultation with medical and radiation oncology is an important component care in these cases. Survival expectations must be discussed and the treatment rendered tailored to each individual case. Local radiation is often an important adjuvant in the setting of spinal metastases, and this is particularly true when one is considering a minimally invasive approach. The goals of surgery are to stabilize and/or decompress the spine. Debulking of tumor is possible in a minimally invasive fashion, but if tumor debulking is a central part of the local control plan, then an open procedure may be more suitable. Local failure due to tumor regrowth is a concern in the setting of minimally invasive approaches, and one is relying more heavily on radiation/chemotherapy when approaching these cases in a minimally invasive fashion. Our study demonstrates the short-term successes associated with minimally invasive approaches to spine metastasis. However, longer followup is needed to assess whether local failure, whether from tumor regrowth or hardware failure, becomes a problem.  We report the successful short-term treatment of 24 patients with a minimally invasive approach for malignancies in the spine. Pain and ambulatory status were both improved after this minimally invasive approach. The role of minimal access surgery continues to evolve, and further studies are needed to elucidate the most appropriate patients for this approach.


Despite the advances in pain control following surgery, data on the location and distribution of pain following coronary artery bypass grafting (CABG) are lacking.This study was intended to investigate the location, distribution, and intensity of pain in patients undergoing CABG during their postoperative hospital stay from the operation to the end of the first postoperative week. Factors that could affect pain intensity and distribution were analyzed as well.The present study was conducted on 138 patients who underwent CABG surgery at Rajaei cardiovascular, Medical and Research Center during May and July 2011. Location and intensity of pain were assessed using numeric rating scale (NRS) over time: every six hours after the operation on the first day , and on two (POD2), three (POD3), and seven days after the operation (POD7).Among 138 patients assessed in the study, the greatest severity of pain was reported on T2, with the mean severity of 3.4, followed by POD2 with the mean severity of 2.9 (P < 0.01). The location of the surgical incision had the most severity of pain in all patients (P < 0.01). On the site of surgical incision, a negative correlation was seen between the age and the severity of pain on T1 . Women experienced more severe pain compared to men at POD7. A significant correlation was seen between the severity of pain on POD7 and body mass index (BMI) . In patients who had the longer duration of cardiopulmonary bypass (CBD), the most pain intensity was reported on T1 . A significant correlation was seen on the pain intensity on T4 and chest tube drainage . The correlation between the pain severity pain and duration of admission in intensive care unit (ICU), was significant on T1 , T4 , POD2  and POD7 .Following CABG, the most severity of pain was reported at surgical incision on time T2. Pain began to decrease from the third day following the operation. Age, sex and BMI along with operation-related factors such as duration of CBP or chest tube drainage may affect the pain pattern following CABG surgery. The World Health Organization in 2002 reported that coronary heart disease causes about 7.2 millions of deaths per year. With increasing incidence of coronary artery diseases, Coronary artery bypass grafting (CABG) has become one of the most common cardiac surgeries performed all over the world , 2. ApprA vast majority of research exists regarding the pain following surgeries, but a few studies have focused on cardiac surgery patients , 11-14. This study was intended to investigate the location, distribution, and intensity of pain in patients undergoing CABG during their postoperative hospital stay from the operation to the end of the first postoperative week. Factors that could affect pain intensity were analyzed as well.This study employed a longitudinal approach to evaluate the pain patterns of patients after CABG surgery over time: every six hours after the operation on the first day , and on two (POD2), three (POD3), and seven days after the operation (POD-7). The primary end point of the present study was to assess the location and intensity of pain in patients undergoing CABG during their postoperative hospital stay from the operation to the end of the first postoperative week. Secondary end points were investigating factors able to affect pain intensity.This prospective study was conducted on 138 consecutive patients, American Society of Anesthesiologists (ASA) physical status class II or III, scheduled to undergo CABG with conventional method (sternotomy) in Rajaei Cardiovascular, Medical and Research Center, Tehran, Iran, during May and July 2011. Inclusion criteria were as follows: 1) extubation before the first morning following the operation; 2) ability to seeing, hearing and speaking; 3) staying in hospital during the first week after the operation. Patients undergone surgery emergently, those who needed balloon pump postoperatively, and those undergone the second operation at the same admission were excluded from the study. Patients with a history of opium addiction were also excluded. Before the study, the Numeric Rating Scale (NRS) was introduced to all of the patients. Patients learned how to use the NRS to represent the severity of their pain. To unify described anatomic locations of the pain in all patients a schematic picture of the body was designed . PatientInformed written consent was obtained from all patients, and the research project was approved by the ethics committee of Tehran University of Medical Sciences. Premedication included oral lorazepam (1 mg) the night before the operation, and intramuscular morphine (0.1 mg/kg) and oral lorazepam (1 mg) approximately one hour before the operation for all patients. Anesthesia was induced by midazolam (0.1 mg/kg), sufentanil (0.1-0.3 µg/kg), and atracurium (0.5 mg/kg). All patients underwent standard bypass with oxygenation and moderate hypothermia. Anesthesia was maintained using midazolam (1 µg/kg/min), sufentanil (0.005-0.01 µg/kg/min), and atracurium (6 µg/kg/min). Hands were positioned along the trunk on the operation bed, and sternum was opened with wire. Thoracic and mediastinal drains were inserted in rectus abdominis muscle, just under the xiphoid process. Saphenous vein, in the absence of varices, and internal mammillary artery were used for grafting. Patients were monitored during the operation by electrocardiogram, central venous pressure, pulse oximetry, arterial blood gases, and core temperature. Intravenous inotropes or nitroglycerine was used during the operation, as needed. Pain was assessed with the numeric rating scale four times including every six hours on the first morning, and on second, third and seventh days after the operation. Based on the NRS, score zero reveals “absence of pain” and score 10 demonstrates “the most severe pain imaginable”. Patients used the schematic picture to localize their pain. During the study severe and intolerable pain was controlled with adequate doses of opiate analgesics or Apotel (intravenous acetaminophen), as required. Data were analyzed by Statistical Package for Social Sciences (SPSS) version 16 software . For each of the measured variables or indexes, descriptive values were expressed as the mean ± SD. All data initially were analyzed using the Kolmogorov-Smirnov test to assess the normality. For analysis of quantitative variables, One-Way ANOVA and repeated measurement AVOVA were used. Mean values were compared using t-test, and the chi-squared test or Fisher's test when appropriate. Relationships were assessed using Pearson, Spearman or Kendall tests as appropriate. All P-values were two-tailed, and P < 0.05 was considered statistically significant.One hundred-thirty eight patients including 68 (49.3%) male and 70 (50.7%) female were enrolled in the study. The mean age was 61.43 ± 9.09 years . The mean body mass index (BMI) was 27.66 ± 4.48. Among 138 patients assessed in the study the greatest intensity of pain at the LOC1 was reported on T2, with the mean intensity of 3.4, followed by POD2 with the mean intensity of 2.9 (P < 0.01) . The paiThe correlation between the pain severity and the duration of admission in ICU was significant on T1 , T4 , POD2 , and POD7 . Post operation pain has high incidence among patients undergoing cardiac surgeries. To best of our knowledge, this is the first study which investigated post- CABG patients’ pain patterns in the Iranian population. Although in our study population the pain intensity had alterations during the first week following operation, the location of maximal pain intensity did not change significantly. In all assessed time intervals, the pain was conspicuously more severe in the surgical incision site compared to all other parts of the body. In the recent study, pain intensity had fluctuations during the first 2 PODs, and started to decline from POD2. Similar results to ours were found in previous literature , 16. Our2 had higher intensity of pain in comparison with those with BMI of less than 30 kg/m2. However, Mueller et al.  admission or duration of insertion of chest tubes. Our study demonstrated that patients with younger age experienced more severe pain at the site of surgical incision on T1 compared to older population. However, there are discrepancies in the previous literature regarding the association between ageing and postoperative pain. Several studies have reported that older patients experience lower pain intensity than younger ones -19 whiler et al.  believedive pain , 26. Meeive pain  in a stuive pain . Our study revealed that the intensity of pain during the first week after cardiac surgery has an association with the duration of ICU admission. However besides pain intensity, a wide range of possibilities would predict the duration of ICU admission in patients undergoing cardiac surgery. Our results showed that as the duration of chest tube drainage increases, the mean severity of pain increases, especially on T4. In the study of Paiement et al. 22% of patients who have undergone cardiac surgery believed that the drains were their worst experience during postoperation period . This stIn the present study we excluded patients with a history of chronic opium addiction to ameliorate possible effects of opium on pain perception or tolerability. However, it was shown previously that both addicted and nonaddicted patients undergoing CABG have reported comparable body pain . The major limitation of our study was its relative small sample size. We also did not analyze the effects of either various modalities for pain management  or the medications used . All of these factors have been shown to affect the postoperative pain management. In conclusion among patients undergoing CABG, the most severity of pain was detected as the site of surgical incision on time T2. Pain began to decrease from the third day following the operation. The location of pain did not change during the first week following CABG. Some of patients ‘characteristics such as age, sex and BMI along with operation-related factors such as duration of CBP or chest tube drainage may affect the pain pattern following CABG surgery.


P < 0.0001) and related symptoms (P < 0.0001) evaluated by Michigan Neuropathy Screening instrument, Total Symptom Score, and Neuropathic Pain Symptoms Inventory. Hematological and urine analyses did not reveal any alterations associated with PEA-m treatment, and no serious adverse events were reported. These results suggest that PEA-m could be considered as a promising and well-tolerated new treatment for symptomatology experienced by diabetic patients suffering from peripheral neuropathy.The present study evaluated the effectiveness of micronized palmitoylethanolamide (PEA-m) treatment in reducing the painful symptoms experienced by diabetic patients with peripheral neuropathy. PEA-m, a fatty acid amide of the N-acylethanolamine family, was administered (300 mg twice daily) to 30 diabetic patients suffering from painful diabetic neuropathy. Before treatment start, after 30 and 60 days the following parameters were assessed: painful symptoms of diabetic peripheral neuropathy using the Michigan Neuropathy Screening instrument; intensity of symptoms characteristic of diabetic neuropathic pain by the Total Symptom Score; and intensity of different subcategories of neuropathic pain by the Neuropathic Pain Symptoms Inventory. Hematological and blood chemistry tests to evaluate metabolic control and safety were also performed. Statistical analysis (ANOVA) indicated a highly significant reduction in pain severity ( More thsitivity .α) through Ca2+-activated K+ channels [γ-aminobutyric acid A receptors that in turn could contribute to pain perception involving chloride inward flux [The inability to prevent the onset of neuropathy in diabetic patients, even with good glycemic control, suggests that a dysregulation in the secretion of proinflammatory mediators may underlie the pathogenesis of neuropathic painful symptoms. In fact these mediators, independently of the initial metabolic stimulus and because of their pleiotropic effects, affect glial and neuronal cell homeostasis in the central and peripheral nervous systems. They are secreted by resident tissue cells or infiltrating cells, such as macrophages, mast cells, and lymphocytes . Considechannels –14. PEA channels , 16. Furard flux , 18. Theard flux –23. Admiard flux .μm) [Clinical results obtained in a large number of patients, suffering from neuropathic pain associated with pathologies of various etiology, provide ample support for the anti-inflammatory and analgesic effects of micronized PEA  –32. Thesμm) . With thThe patients were selected among the diabetic patients attending the MOV.I.S. Onlus Health Care Center in Giarre . The specific inclusion/exclusion criteria are detailed below.The Health Care Center receives patients diagnosed with various chronic diseases  undergoing continuous/periodic monitoring and clinical control by medical specialists. From this population, 30 patients, having confirmed diagnosis of Type II diabetes mellitus and complaining of painful symptoms of peripheral neuropathy, were screened. Patient inclusion was based on the following criteria: diagnosis of Type II diabetes mellitus; satisfactory metabolic compensation; and presence of moderate symptoms of painful diabetic neuropathy as judged by the Michigan Neuropathy Screening Instrument  , 35, verIn accordance with guidelines established for Good Clinical Practice, the study protocol was communicated to the health care managers of the MOV.I.S. Onlus. The study was conducted, according to the ethical principles set out in the Declaration of Helsinki and its revisions. All eligible patients were properly informed about the study and gave their written informed consent to participate. Epitech Group srl, Saccolongo, Italy) for 60 days. They were allowed to continue with their usual treatment if they had other comorbidities.This was an open-label study, in which all patients were treated with PEA-m . Particular attention was given to the presence of signs and symptoms of diabetic peripheral neuropathy. For this purpose we made use of the MNSI score , which During the treatment period, the assessment of safety and tolerability of PEA was carried out by monitoring the onset and/or reports of adverse events and by hematology and blood chemistry/urine tests performed at baseline and at treatment end.P < 0.05. The McNemar Test was used instead to evaluate the haematological and blood chemistry analyses performed at baseline and at treatment end.Data relative to evaluation of pain symptoms were analyzed by Analysis of Variance (ANOVA) for repeated measures. Statistical significance was taken at Thirty patients, 15 males and 15 females, between the ages of 53 and 86 (mean 68.3 ± 9.4 years) affected by Type II diabetes (mean time from onset 18.2 ± 9.0 years) and complaining of neuropathic painful symptoms were enrolled in the study between March and November, 2010. Patient medical histories revealed the presence of the following comorbidities: hypertension, 46%; cardiopathies, 10%; and chronic obstructive pulmonary disease, Parkinson's disease, and multiple sclerosis, 3%. The study was completed by 96.7% of the patients (29); one patient withdrew 10 days after the start of treatment, citing excessive sleepiness.P < 0.0001) in the intensity and presence of painful symptoms (P < 0.0001) was seen in relation to the intensity and frequency of occurrence in individual symptoms, namely, pain, burning, paresthesia, and numbness (P < 0.0001) effect of PEA-m in mitigating the intensity of both global neuropathic pain and individual subcategories, such as spontaneous superficial pain, deep spontaneous pain, paroxysmal and evoked pain, and paresthesia/dysesthesia (P > 0.05) between T60 and T90 for every single symptom (P < 0.0040) in global mean value which, however, remained significantly lower (P < 0.0001) over baseline (T0) and comparable to the value at T30 (P > 0.05). Using the McNemar Test, hematology and blood chemistry/urine analyses showed no changes attributable to treatment with micronized PEA, nor were any adverse events noted.Statistical analysis (ANOVA) of the data demonstrated that treatment with micronized PEA resulted in a significant reduction in the pain symptoms characteristic of diabetic neuropathy already after 30 days. In fact, the median values obtained from MNSI, TSS, and NPSI diminished, compared to baseline (T0), at various observation points until the end of treatment (T60), confirming a significant attenuation (symptoms . The varnumbness . NPSI, westhesia . Moreoveesthesia . The Tuk symptom . OverallNeuropathic pain results from damage or disease affecting the somatosensory system. Up to 7 to 8% of the Western population is affected and in 5% of persons it may be severe. Diabetes and other metabolic conditions represent the common causes of painful peripheral neuropathies. Neuropathic pain can be very difficult to treat, with less than half of patients achieving partial relief from therapeutics which currently comprise mainly opioids and nonsteroidal anti-inflammatory drugs . The choon-demand,” has seen a remarkable rise in the number of studies published on its anti-inflammatory actions in the past 15 years [There is ever-increasing appreciation for a role of microglia and mast cells in neuropathic pain. As such, pharmacological attenuation of microglial and mast cell activation represents a promising therapeutic avenue for pathologies where neuropathic pain is a major element . We are 15 years . A PEA k15 years . The fin