Coblation tonsillectomy induced less pain than electrocautery in pediatric patients; therefore, surgeons could choose the coblator as a surgical instrument for tonsillectomy to improve the pediatric postoperative quality of life.Many surgical instruments have been introduced and compared for safety and surgical efficiency in tonsillectomy. This study aimed to compare postoperative pain between coblation and conventional monopolar electrocautery tonsillectomy by intrapatient comparison in children. Thirty pediatric patients over six years of age undergoing tonsillectomies were enrolled. Coblation and electrocautery were used to remove both tonsils in one patient; one was removed by coblation and the other by electrocautery. The coblation side was randomly selected, and it was blinded to the patients. Each side’s daily pain scores were collected on the visual analogue scale (VAS) during ten postoperative days. On the day of surgery, 22 (73%) patients identified less pain on the coblation side, while others felt similar pain. The mean pain scores were significantly lower on the coblation side during the postoperative ten days (except for the 6th and 8th) than on the electrocautery side. The duration of severe pain (VAS > 5) was significantly shorter on the coblation side than on the electrocautery side (2.0 versus 3.7 days, respectively;  Tonsillectomy is one of the common surgeries performed in otorhinolaryngology, especially for children and adolescents. Many of the surgical techniques and tools have been introduced to tonsillectomy . It has Because pain perception can differ among individuals, analyzing and comparing postoperative pain between two surgical methods is better accomplished in each patient. However, previously reported studies comparing coblation and electrocautery tonsillectomy performed interpatient comparisons of the two tonsillectomies from different patients with different pain perceptions; this might be related to the controversial reports on the advantage of the coblation tonsillectomy. For the first time reported in the literature, to the best of the authors’ knowledge, this study aimed to verify the differences in postoperative pain between coblation and electrocautery tonsillectomies by an intrapatient comparison of pediatric patients who can discriminate pain.http://cris.nih.go.kr, accessed on 2 August 2022), number KCT0002922.The study was conducted according to the principles expressed in the Declaration of Helsinki and was approved by the Institutional Review Board of the Biomedical Research Institute at Seoul National University Hospital (H-1312-074-541). Written informed consent was submitted by all of the subjects (or their caregivers) when they were enrolled. The randomized clinical trial was registered at the Clinical Research Information Service . The pediatric patients over six years of age who could discriminate and provide answers about pain on each side of the tonsils were included in the study. The children with a history of previous adenotonsillectomy, bleeding disorders, psychological disorders, craniofacial anomaly, peri-tonsillar abscess, and neoplasm were excluded.The study design and patient flow are illustrated in www.randomization.com, accessed on 5 February 2014) generated a random sequence to choose the surgical side for coblation and electro-cauterization. The generated random sequence was available only to a surgeon, and the surgeon followed the randomly selected instrument to operate on each tonsil. According to the random sequence, half of the patients underwent coblation tonsillectomy on the right side and electrocautery tonsillectomy on the left side; conversely, the other half underwent coblation on the left and electrocautery on the right. Both the children and the caregivers were blinded to the instruments.An online statistical program  and ondansetron 0.1 mg/kg (maximum 4 mg) were also administered to decrease the postoperative nausea and vomiting. The attending anesthesiologists administered additional opioids (fentanyl), as appropriate. At the end of the surgery, neuromuscular blockade was reversed with neostigmine (0.05 mg/kg) and atropine (0.02 mg/kg). No local anesthetic was applied to the surgical site.One tonsil was removed using coblation , and the other by monopolar electro-cauterization  . During After the surgery, acetaminophen (10 mg/kg) was prescribed for seven days. No other analgesic was administered in the postoperative days. All of the patients were discharged on the next day of surgery and visited the hospital ten days later. A visual analogue scale (VAS) was used to evaluate the severity of postoperative pain on both sides separately. The children and their caregivers checked the postoperative pain score in VAS (0–10) from the day of surgery through the 10th postoperative day, at 1 h after the surgery (on the operation day), and in the morning (from postoperative days 1 to 10). In this study, VAS > 5 was defined as severe postoperative pain.t-test. The severity of pain was compared using the χ2 test. The multivariate analyses were completed by multivariate linear regression. In all of the statistical tests, p < 0.05 was considered statistically significant.R version 3.5.1  was used for statistical analyses and figures. The sample size of 30 cases for analysis was set after calculation by the daily mean pain score and standard deviation : 5%, power = 80%). Because the operation times on the coblation side were not normally distributed, a comparison of operation times on both sides was tested, using the Wilcoxon signed-rank test. The postoperative VAS scores were normally distributed, and they were compared using the paired A total of 32 patients were initially enrolled; however, two patients were excluded. One child failed to report daily pain scores; the other underwent additional surgery to control immediate postoperative bleeding under general anesthesia on the day of surgery . After ep < 0.001). In the multivariate analysis, while the operation time on the coblation side did not correlate with sex, the operation time on the electrocautery side was longer in boys than in girls (p < 0.001 on the coblation side and R = 0.668 with p < 0.001 on the electrocautery side.The median duration of the operation for the coblation tonsillectomy was significantly shorter than the electrocautery tonsillectomy (median 102.5 s (25–75% quartiles: 79.3–113.4 s) and 270.5 s (168.0–344.5), respectively; in girls . Tonsillp = 0.023). The difference in the pain scores was the highest on the day of surgery; the difference in pain scores tended to decrease over time (p = 0.042). The daily VAS scores in the patients with sleep-disordered breathing (n = 26) are separately analyzed in The mean VAS scores were lower on the coblation side than on the electrocautery side during the ten postoperative days . Signifiver time . More thver time . On daysThis study was a randomized and single-blinded investigation examining the postoperative pain of coblation and electrocautery tonsillectomy in children and adolescents. In particular, this study used the intrapatient comparison of postoperative pain, which is different from conventional interpatient comparisons. Previous studies have evaluated an interpatient comparison  without considering the individual differences in the pain threshold, which might have distorted the results and weakened the statistical differences. Single blinding resulted in the children and the caregivers not knowing which tonsil was excised by coblation or electrocautery. The intrapatient comparison and the single blinding can reduce the study bias and strengthen the results in this study.Because adult tonsils have increased fibrosis of the tonsillar capsule and a large diameter of the blood vessels, adult tonsillectomy is often accompanied by extra-capsular muscular and neuronal injuries, with frequent intraoperative bleeding. On the other hand, in pediatric tonsillectomy, dissecting the palatine tonsils from underlying muscle is relatively easy to perform without muscular injury, and the intraoperative bleeding is minimal. Therefore, pediatric tonsils can be better candidates for evaluating tissue damage caused by surgical instruments than adult ones. Because preschool children under six years of age may not distinguish pain on each surgical side, this study included those over six years of age who were able to discriminate and express pain. Although the reduced postoperative pain of coblation compared to electrocautery tonsillectomy in pediatrics has been previously reported in a systematic review and meta-analysis, the study was not based on intrapatient comparisons, as our study was .Postoperative pain after tonsillectomy is an important matter, which is related to the functional recovery of the patient. A decrease in postoperative pain is known to promote an increase in oral intake ,18, earlAlong with the lower tissue temperatures induced by the coblation tonsillectomy, our hypothesis is that less postoperative pain could also be attributed to the shorter operation time in coblation, resulting in a shorter duration of heat exposure to nearby tissues. The operating time of the coblation tonsillectomy was significantly faster than the electrocautery in our study. The significant factors influencing the operation time in the multivariate analysis were three parameters, which are the male sex and surgical indication in the electrocautery group, and the tonsillar adhesion grade in both of the groups. Unlike the electrocautery tonsillectomy, the operation time of the coblation tonsillectomy was not significantly increased in the male or the recurrent tonsillitis group. Nevertheless, the degree of tonsillar adhesion increased the surgical time in both of the groups. However, some previous studies have reported longer operation times in coblation tonsillectomies ,23.Postoperative hemorrhage in our study occurred in 2 of 32 (6.3%) cases (both boys), which is similar to previously reported rates, which ranged from 2.1% to 22.2% . A 7-yeaThis study was designed to objectively compare the postoperative pain between two surgical instruments; nevertheless, there were limitations. Because the surgical skill for the coblation tonsillectomy can be different among surgeons, the operation time and the extracapsular damage that lead to postoperative pain can be increased in other situations. Another limitation of this study is that the correlation between pain and surgical technique is not evaluated for each surgical indication group, i.e., the recurrent tonsillitis group and the sleep-disordered breathing group, while the difference in adhesion or fibrosis of the peritonsillar tissue can also affect the postoperative pain. In addition, the visual analogue scale presented by the children may not precisely reflect the real level of pain. Lastly, the patient population in this study is relatively small. This study did not have sufficient participants to validate the differences between postoperative complications, especially hemorrhage. Because the incidence of postoperative bleeding is rare, hundreds of participants would have been necessary. Nevertheless, we found that postoperative hemorrhage did not exceed the previously reported rates in the literature .To conclude, this randomized controlled trial and the intrapatient comparison revealed that the coblation tonsillectomy could reduce children’s postoperative pain, as compared to the monopolar electrocautery tonsillectomy. Although the pain eventually subsided to similar levels on both the coblation and electrocautery sides, the children experienced less pain during the early postoperative period (from the day of surgery through the 5th postoperative day). Surgeons might consider coblation a safe and less painful surgical technique for pediatric tonsillectomy.


Nigella sativa is commonly known as black seed known to have anti-inflammatory and antibacterial properties along with other reparative properties that enhance bone formation. This study aimed to evaluate and compare the effects of Alvogyl and a mixture of Nigella sativa powder and oil in the treatment of dry sockets.  Alveolar osteitis (AO) is the most common complication faced by exodontia patients and is usually seen 24–74 hours after tooth extraction, heralded by severe throbbing pain. nd day, 4th day, and 7th day. Patients were randomly allocated to three groups, namely, Group 1 (Alvogyl), Group 2 (mixture of Nigella sativa's powder and oil), and Group 3 (control). Pain relief and healing of the socket were compared between the three groups. The collected data were subjected to statistical analysis through Spearman's correlation test, independent t-test, ANOVA, and post hoc test.  Sixty patients above the age of 18 and below 70 years, from both genders, who underwent extraction of teeth and were clinically diagnosed with a dry socket at the clinic of the College of Dentistry, Jouf University, Saudi Arabia, were included in this study. Pain scores were assessed after placement of the dressing at the following intervals: 5 minutes, 30 minutes, 60 minutes, 2Nigella sativa powder and oil showed a statistically significant difference in relieving pain compared to the Alvogyl group. A mixture of Nigella sativa's powder and oil required fewer dressings when compared to the Alvogyl group.  A mixture of Nigella sativa powder and oil is the more efficacious dressing material for the management of dry sockets compared to Alvogyl. It provides immediate and complete pain relief and fewer numbers of repeated visits. A mixture of  Alveolar osteitis or “dry socket” is the most common complication faced by patients following tooth extraction, usually seen after 24–74 hours , 2. The Several previous studies reported diverse incidences of dry socket ranging from 5 to 30% in surgical removal of impacted mandibular third molars and between 1 and 4% in simple extraction cases of permanent teeth , 7. The The local fibrinolytic activity is implicated as the main reason leading to dry socket . The surThe exact pathogenesis of dry socket in association with tobacco cigarette smoking is to date unidentified. The largely accepted and dominant hypothesis suggests that the sucking motion associated with cigarette smoking causes mechanical clot dislodgement , 3.The treatment of this painful condition is wide-ranging including washing and flooding the empty tooth socket with a copious amount of normal saline and or placement of intrasocket medication, namely, Alvogyl, zinc oxide eugenol, chlorhexidine, metronidazole, olive oil-black seed paste, and honey , 10.Despite the availability of various medications for the treatment of dry-socket pain, not a single treatment option provides immediate and complete relief from symptoms. Subsequently, the tooth socket heals secondarily in ten to fourteen days with variable severity of pain continued throughout this healing period , 11. To Ferula assa-foetida oleo-gum resin) have been actively used in the field of dentistry to treat and prevent oral diseases related to oral mucosa and dental caries [Nigella sativa commonly known as black seed, black cumin, black caraway, kalojeera, kalonji, or kalonji [Nigella sativa seed extracts on various body systems in vitro or in vivo. The pharmacological investigation of the seed extracts reveals a broad spectrum of activities including antidiabetic, anti-inflammatory, and osteoreparative properties that enhance bone formation [Complementary and alternative medicine (CAM) is the term for medical products and practices that are not part of standard medical care. There is an increasing interest towards the use of CAM in the field of medicine , 15. Patl caries , 20. One kalonji . Its cheormation .One of the treatment options that is commonly used to treat patients suffering from the dry socket is Alvogyl. Alvogyl consists of active ingredients such as iodoform  and butamben (anesthetic) . AlvogylNagilla Sativa on the postextraction complications of dry socket. To the best of our knowledge, this is the first comparative study of olive oil-black seed oil for the treatment of dry socket at the College of Dentistry, University of Jouf, Kingdom of Saudi Arabia, and is aimed to find out the best and most effective medication for the treatment of dry socket at this institution.Considering the abovementioned there is a need to investigate the efficacy of The OpenEpi software was used to calculate the sample size. Considering the mean value of 2.567 ± 2.678  for dry Patients over the age of 18, from both genders, who had their teeth extracted and were clinically diagnosed with dry socketPatients under the age of 18 years and over the age of 70 yearsPatient with various bone diseases including osteoporosisPatients who had a history of taking oral or intravenous bisphosphonatesPatients with a history of radiotherapy to the head and neck and jawbonesWritten informed consent was obtained from all patients. The demographic information such as age, gender, and address was documented in a performa. The type of treatment and medication provided was beneficial and nonharmful to the patients, according to medical ethics. The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of Jouf University . This trial has been registered under the Saudi Clinical Trial Registry (SCTR) with application no. 21021702. The confounding variables such as age, gender, and history of pain were controlled by matching.Nigella sativa's powder and oil , and (3) normal saline rinse as a control. Both the patient and the investigator assessing the treatment outcome were blinded from identifying the medicament dressing used for the group. The medication used was placed in unmarked identical bottles and saline in a covered syringe without the original label on them and marked as 1, 2, and 3.Patients clinically diagnosed with alveolar osteitis were assigned numbers from first to the sixtieth patient and randomly allocated via lottery to three groups named as follows: (1) Alvogyl  (2) mixture of Patients were allowed to continue their oral analgesic medication, namely, ibuprofen 200 mg, 400 mg, or 600 mg twice daily, depending upon the severity of initial pain upon diagnosis. Pain relief was recorded and compared between the groups on a visual analog pain scale at every appointment. The intraalveolar medication was repeated until the postoperative pain symptoms subsided. Patients were reviewed at 5 minutes, 30 minutes, and 60 minutes after dressing. The patient was requested to note daily pain records on a (0–10) visual analog scale, with zero representing no pain and ten representing the worst pain. The patients were requested to note daily pain records on a (0–10) visual analog scale for 7 days.They also recorded any harmful effects of medication and advised to immediately call the investigator about any problem in the due course. If no side effects were noted, the treatment option was repeated a maximum of four times over two weeks to assess the complete effect of the medication in case complete relief was not achieved the first time. The total time required for complete healing and the number of repeated sessions for each medication till complete relief from all symptoms were recorded.The data was analyzed in SPSS-25 . A descriptive analysis was carried out to calculate the mean and standard deviation, percentage, and frequency of quantitative and qualitative variables such as age, gender, scores of the VAS scale, values for different study groups assigned, and the severity of pain categories.t-test was used to check for gender disparities. ANOVA and the post hoc test were used to compare the outcomes of different groups assigned. Spearman's correlation test was used to evaluate the association of age and gender with the mean VAS scores of patients in each group. The pvalue of ≤0.05 was considered statistically significant.The independent This randomized controlled trial consisted of sixty patients that were randomized into 3 groups as follows: Group 1, Alvogyl; Group 2, black seed; and Group 3, control, as presented in pvalue = 0.047), and gender and Group 2 patients also had a significant relationship , as presented in The mean age of the patients in each group was as follows: Group 1, 41.70; Group 2, 53.15; and Group 3, 49.30. About the gender, the distribution of the males and females in each group was as follows: Group 1, 11 and 9; Group 2, 10 and 10; and Group 3, 8 and 12. As for the comparison of age and gender with VAS pain scores amongst the groups, age and Group 1 patient VAS scores had a significant relationship , , and , respectively, as presented in p=0.001) as compared to the Alvogyl and Nigella sativa powder and oil groups. Additionally, the least VAS scores were found in the Nigella Sativa powder and oil group compared to Alvogyl.The intergroup comparison through the application of the ANOVA test showed a significant difference between the mean scores of the three groups , as presented in Regarding the gender of the patients, an independent Alveolar osteitis is one of the most common complications that arise as a postoperative complication associated frequently with the extraction of mandibular third molars. Since the pain of dry socket as experienced by the patients is severe and excruciating, this mandates timely management to relieve the discomfort and pain of the patients. Different risk factors are associated with a greater tendency to develop dry sockets such as smoking, use of oral contraceptives, female gender, suppression of the immune system, and traumatic extractions.In our study, most of the patients suffered from severe pain using a visual analog scale when they were diagnosed to suffer from dry socket. Such findings have previously been reported in a study by Hawker et al., where patients who were suffering from dry socket reported severe dental pain. Since the bone around the socket is exposed to the oral environment with supplemental action of the bacteria, these factors then lead to the severe pain of the dry socket .Firstly, in our study, patients who were assigned to Alvogyl dressing treatment in the socket reported a mild decrease in pain scores that were still significant, causing patients' pain and discomfort. Such findings have also been reported in a study by Faizel et al., who concluded that patients assigned with Alvogyl dressing experienced a decrease in the level of pain . One of Secondly, in our study, we applied black seed liquid with powder in the sockets of patients suffering from dry sockets. In our study, we found that the pain relief of the patients in this group was significantly less as compared to Alvogyl immediately after its application. Patients belonging to black seed dressing groups were pain-free on the 2nd postmedication day. Dalimunte et al. found that the application of black seed in the sockets of the patients resulted in a significantly higher period of wound healing with 12% black cumin to have the most optimum effect on the healing of the socket . One of In our study, the severity of pain between males and females was equal with no significant relationship between them. These results contrast with studies in the literature that report higher severity of pain in females as compared to males . MoreoveIn the literature, different treatment options are available for the treatment of dry socket. Platelet-rich fibrin (PRF) has been used to treat dry sockets with a study reporting an early reduction in pain levels experienced by patients with minimal need of analgesic intake . MoreoveDry socket is a condition that has a wide choice of treatment options such as Alvogyl, honey, zinc oxide eugenol, and black seed. Despite the strengths of this study such as regular follow-up of the patients and reporting of the pain scores, this study was met with some limitations. Firstly, the sample size of the patients in each group was small, and lastly, patients might not have followed the temporary cessation of habits during the healing period of sockets such as smoking.The use of Alvogyl resulted in a gradual decrease in pain scores; however, black seed powder with oil resulted in immediate pain relief for the patients, being more effective than Alvogyl and the use of normal saline irrigation alone. Hence, a black seed oil mixture can be used effectively in patients suffering from alveolar osteitis.


Total knee arthroplasty (TKA) patients express minimal comfort regarding postoperative pain management. The use of parenteral opioids or epidural analgesia may have unfavorable adverse impacts that interfere with quick healing and rehabilitation. It is uncertain if periarticular multimodal drug injections (PMDI) are effective at easing pain following total knee or total hip arthroplasty (THA). We conducted this study to assess the effectiveness of PMDI following TKA or THA. Articles were sourced using the following keywords on Pubmed, Google scholar, and the Web of Science: multimodal drug cocktail in total knee arthroplasty OR hip arthroplasty, periarticular injections AND multimodal drug cocktail, epidural versus periarticular injections AND pain management after total joint arthroplasty. After screening 438 articles and abstracts, 200 pertinent studies were found, of which a total of 10 articles were included in the study. From this review, we want to conclude that despite the various ways to address postoperative pain, there is no acknowledged gold standard for postoperative pain management following total joint arthroplasty. To reduce narcotic intake and prevent narcotic-related adverse reactions, multimodal techniques utilizing regional anesthetics appear to be on the rise such as periarticular injections, or patient-controlled analgesia with or without femoral nerve block. Even though the ideal duration and kind of medications are unclear, preoperative pain management or preemptive analgesia with anti-inflammatory drugs and opioid analgesics seem to be useful in lowering postoperative pain. For patients with chronic degenerative joint disorders of the hip or knee, total joint arthroplasties (TJA) such as total knee arthroplasty (TKA) or total hip arthroplasty (THA) are considered the most effective treatment option . FollowiOver the past 10 years, the pain management strategy following THA and TKA has undergone numerous changes . CardiorIt is also unclear which area of the wound would aid the infiltration of a local anesthetic to effectively lessen post-operative pain because the high-volume infiltration technique contains infiltration of all tissues incised or instrumented in the procedure . In the early postoperative period, high-volume local infiltration analgesia could be able to give enough post-operative analgesia to ease mobilization and enable early rehabilitation with no need for rescue opioid analgesics.We looked through the databases of PubMed, Google Scholar, and the Web of Science. The following phrases were used by an independent reviewer to search the references lists of the original and review publications: multimodal drug cocktail in total knee arthroplasty OR hip arthroplasty, periarticular injections AND multimodal drug cocktail, epidural versus periarticular injections AND pain management after total joint arthroplasty. While looking for articles, no year limits were used. After screening 438 articles and abstracts, 200 pertinent items were found. Of these, 10 publications were eventually included after 200 eligible articles underwent full-text analysis. We evaluated each article's caliber and key research facets. The factors included specified post-operative pain management and rehabilitation criteria. We collected and evaluated data from the 10 carefully chosen articles. Figure Epidural analgesiaIt is normal practice to employ epidural anesthesia in addition to general anesthesia. Although it is becoming less prevalent as anesthesiologists refine adductor canal blocks, it is frequently used when both knees are replaced at the same time . An advaPeriarticular injectionPeriarticular injections with long-acting liposomal bupivacaine are an effective technique to lessen preoperative discomfort following total hip/knee arthroplasty in the lower limb, while also lowering opiate use and its negative effects. It has the potential to lessen the negative effects of opiates and peripheral nerve blocking while enhancing muscle control during recovery . The infEfficacy of the multimodal drug cocktailTotal hip replacement has developed over the past 40 years into a highly effective treatment for enhancing the quality of life for patients with end-stage degenerative joint disease . The mosApplying a pressure bandage and an ice pack to the wound area may aid to extend the LIA's duration of effect and so enhance the postoperative function of TKA patients . Gomez-CChen et al. in their retrospective study observed that there were numerous postoperative usages of modes of analgesia for patients who have undergone TKA to control their pain. The type of operation, the level of surgery, the length of the surgery, and the anesthesia technique may all need to be taken into account when deciding whether to utilize analgesics . Martin Our findings suggest that there are a variety of perioperative analgesic utilization modes for pain management in patients. The decision about analgesic use might need to take into consideration the surgery type, surgery level, surgery duration, and anesthesia method. The findings of our study unequivocally demonstrate that periarticular cocktail injection in TKR helps in both early healing and rehabilitation in addition to pain relief. Future studies should take measures to prevent nausea and vomiting. The use of regional anesthesia and multimodal pain management strategies that forgo the needless use of drugs can help achieve painless THA or TKA. In the coming years, local, periarticular injections will play a significant role in these programs. Longer-acting injectable medicines still need to be discovered through additional studies. Further clinical evidence is needed to support the development of guidelines for drug use. In the future, larger studies are warranted to help expand our understanding in this regard.


Background: A fundamental principle of pain management is to determine the distribution and causes of pain. However, relevant data among postoperative cancer patients based on a large amount of data remain sparse. Objective: We aimed to investigate the incidence of postoperative pain in cancer patients and to explore the associated risk factors. Methods: We retrospectively collected information on postoperative pain-evaluation records of cancer patients who underwent surgery between 1 January 2014 and 31 December 2019. Descriptive statistics were presented, and multinominal logistic regression analysis was performed to explore the risk factors associated with postoperative pain. Results: Among the 11,383 patients included in the study, the incidence of mild/moderate to severe pain at the 24th hour after surgery was 74.9% and 18.3%, respectively. At the 48th and 72nd hour after surgery, the incidence of mild pain increased slightly, while the incidence of moderate to severe pain continued to decrease. Female patients experienced a higher risk of pain (ORs: 1.37–1.58). Undergoing endoscopic surgery was associated with a higher risk of pain (ORs: 1.40–1.56). Patients with surgical sites located in the respiratory system had a higher risk of pain compared to in the digestive system (ORs: 1.35–2.13), and other patients had a relatively lower risk of pain (ORs: 0.11–0.61). Conclusion: The majority of cancer patients experienced varying degrees of postoperative pain but may not receive adequate attention and timely treatment. Female, young age and endoscopic surgery were associated with increased pain risk, and effective identification of these high-risk groups had positive implications for enhanced postoperative pain management.  Pain is one of the most prevalent and distressing symptoms for cancer patients. In 1985, Bonica evaluated the prevalence of cancer pain (CP) in 15 countries worldwide and found that the average prevalence of pain for all stages of cancer was 50% , but theBecause cancer pain is not a directly measurable entity, proper pain assessment is a prerequisite and foundational for effective pain management. Cancer pain is a widely used term for a range of different pain conditions, and the complexity of its etiology and pathogenesis is often emphasized ,12. TherIn the present study, our goal was to investigate the incidence of postoperative pain in 11,383 cancer patients and to explore risk factors associated with postoperative pain. Our study had a larger study population and extended the observation period to the 72nd hour postoperatively for patients. In addition, our study also involved information on trends in patients’ pain intensity and the incidence of adverse reactions over time postoperatively. The results could help clinicians perform more scientific and effective pain management, thus reducing patients’ pain and improving their postoperative quality of life.This retrospective, observational study was conducted in Nantong Tumor Hospital in China. A total of 11,427 inpatients were recruited according to the inclusion criteria, as follows: (1) patients with tumors; (2) received their first surgical treatment for tumor at Nantong Cancer Hospital between 1 January 2014 and 31 December 2019; and (3) hospitalized for observation for more than three days after surgery. As shown in www.rehn.cc, accessed on 1 July 2021) , which is a big-data intelligence platform that integrates and converges mass  multi-source heterogeneous electronic health-record data from multiple medical centers or hospitals all over China. Data were initially extracted by the platform’s professionally qualified data engineers using a dedicated server and exported from the data system for further collation and analysis by researchers. The data system could set a reasonable range of values for variables, and abnormal data could be automatically identified to avoid errors in data extraction and transmission as much as possible and to ensure data integrity and reliability. The initial extracted data were further collated and analyzed by two researchers independently, and the data processing process and results were reproducible. Missing data were marked and scientifically processed according to the actual situation of the study, and duplicate or invalid data were effectively identified and reasonably handled at an early stage of data collation. Information extracted for our study from this platform’s electronic health records, included the patient’s gender, age, weight, surgical modality, surgical site, type of medication used for analgesia and NRS pain scores after surgery.All data used in the study were extracted from the health data platform of Rehn Medtech .In our study, frequency distributions were calculated and descriptive statistics were performed based on information such as demographics and clinical characteristics. A total of six variables were included in the analysis: gender; age; weight; surgical modality; system in which the surgical site was located; and type of medication used. The surgical modality was divided into two types: endoscopic surgery and non-endoscopic surgery. The surgical sites were classified according to the system to which the organ in which they were located belonged. For example, sites such as lung and trachea were classified as respiratory system; sites such as gastrointestinal tract, liver, and gallbladder were classified as digestive system; sites such as kidney and bladder were classified as urinary system; etc. . In totaOur research protocols were approved by the institutional review boards of the Affiliated Suzhou Science and Technology Town Hospital of Nanjing Medical University (IRB202106001OI). The implementation of the current study adhered to the tenets of the Declaration of Helsinki of the World Medical Association regarding scientific research on human subjects. Information was collected on a total of 11,383 patients who met the study criteria, and personal records of all participants were removed prior to analysis in order to maintain anonymity.n = 2604) patients underwent endoscopic surgery. The largest proportion of surgical sites were in the digestive system (40.9%), followed by the reproductive system (21.6%). About 82.7% (n = 9409) patients were treated with sufentanil-based drugs. There are more details about the frequencies and proportions of each study variable depicted in During a 6-year study period, a total of 11,383 cancer patients who underwent surgery were included in our analysis. Of these patients, 5237 (46.0%) were male and 5628 (49.4%) were female, ranging in age from 18 to 96 years. About 22.9% . Age and weight were associated with only moderate to severe pain intensity . At the 48th hour postoperatively, endoscopic surgery was observed to be associated with a higher risk of both mild pain  and moderate to severe pain . In the three postoperative evaluations, patients with surgical sites in the respiratory system had a higher risk of pain when compared to the digestive system , and other patients had a relatively lower risk of pain. Lower risk was noted for both mild pain  and moderate to severe pain  at the 72nd hour postoperatively for patients treated with sufentanil.In this retrospective study, we investigated the incidence of postoperative pain and adverse reactions in a total of 11,383 patients who underwent surgery between 1 January 2014 and 31 December 2019 and further explored the associated risk factors. We found that at the 24th hour after surgery, the overall pain incidence was 76.9%, with the mild pain being 61.8% and moderate to severe pain being 15.1%. Postoperative pain, especially moderate to severe pain, undoubtedly causes great distress to patients, and the higher incidence of pain also suggests that we may not be providing adequate analgesic treatment to patients in postoperative pain management. The results of a meta-analysis of persistent pain after breast cancer surgery showed that when patients reported a 36% incidence of pain, clinicians assessed only a 23% incidence of pain . PatientIn our study, females had a higher risk of postoperative pain than males, which was particularly evident at the 24th and 48th hour after surgery and especially for mild pain. This finding was in line with existing results of other studies in which gender as female was a risk factor that increased the intensity of postoperative pain . HoweverOur study found that older adults had a lower risk of moderate to severe pain. Several studies have demonstrated that age was associated with postoperative pain ,22, BeinOur findings showed that endoscopic surgery was associated with a higher risk of pain. In the majority of these kinds of studies, as one would expect, patients undergoing endoscopic surgery had less intensity of postoperative pain compared to open surgery ,27,28. HWe observed an association of pain intensity with surgical sites in the present study. Our results showed that the highest risk of pain occurred in patients with surgical sites in the respiratory system, followed by the digestive system, with a relatively low risk of pain in other systems. Related studies have shown that the type of surgery is also a risk factor associated with postoperative pain. The most painful surgeries were orthopedic major joint surgery, thoracic surgery, and open abdominal surgery ,30,31. TA wide variety of analgesic drugs had been administered to patients in our study, which were divided into two categories, sufentanil and non-sufentanil. In total, 9409 patients used sufentanil, which accounted for 82.7% of the total number of patients. The results showed that at the 72nd hour after surgery, patients using sufentanil had a lower risk of pain than those using non-sufentanil, however, there was no significant difference in pain level and risk between the two groups in the first two postoperative evaluations, which may be explained by the time required to accumulate the differences in the effects of the drug treatments.We considered the large number of people in the study to be a strength of our research. In addition, compared to most studies that have focused only on pain within the first 24 h postoperatively, our study expanded the focus to 72 h after surgery. Therefore, a more comprehensive understanding of cancer patient’s postsurgical pain can be obtained, and the trend of changes in patient’s postsurgical pain level can be analyzed.However, there are some limitations of our study. First, in this retrospective study, we were unable to obtain certain confounding factors regarding pain, such as psychological variables. It was also not possible to consider the variability of each case during the treatment process, such as the impact of different health care providers and different surgical incisions on pain. We ended up with a limited number of factors that could be included in the multifactor model for analysis. Second, the assessment of pain level was scored by patients based on their own pain perceptions under specific criteria, which may be biased to some extent due to inter-individual differences in pain sensitivity and tolerance. Third, at the 24th hour postoperatively, 2001 patients did not participate in the pain evaluation, accounting for 17.6% of the total study population, but the number of participants in the three pain scores was increasing. The reason for this phenomenon may be that some patients were experiencing very severe pain just after surgery and were unable to participate in pain scoring or did not have the will or energy to participate in scoring. This situation may cause the available statistics to be low compared to the true values. In other words, the incidence of pain and pain severity in patients may be underestimated. Fourth, postoperative pain thresholds vary by system and by type of surgery, and it may be interesting to perform a stratified analysis in this way. However, due to the overwhelming workload and reduced statistical power due to stratified analyses, a more detailed stratification analysis based on the system was not performed in the present study. Fifth, both static pain and dynamic pain were assessed postoperatively in our study, but we found that the incidence of static pain was low, and it was not significantly related to various risk factors. Therefore, we have only reported the dynamic pain distribution and associated risk factors. Sixth, our study did not address the specific dose of the drug used. Finally, the adverse reactions in our study included postoperative complications and drug side effects, both of which may cause nausea, vomiting, and uroschesis in clinical practice, so it was difficult to draw a clear line to distinguish them. In conclusion, postoperative pain still has a high incidence in cancer patients, and some patients may also experience very severe pain. The causes of postoperative pain in patients are very complex, and the results of this study showed that postoperative pain in patients was associated with factors, such as gender, surgical modalities, surgical site, type of medication and so on. High-risk groups for pain could be identified using these risk factors and targeted interventions could be made to reduce patients’ pain and improve their postoperative quality of life.


Neuropathic pain is a complication after groin hernia surgery. Triple neurectomy of the iliohypogastric nerve, ilioinguinal nerve and genitofemoral nerve is an efficient treatment modality, with several surgical approaches. The minimally invasive endoscopic method to neurectomy was specifically investigated in this meta-analysis. Our aim is to determine the efficacy of this method in the treatment of chronic neuropathic pain posthernia repair surgery.A systematic review was conducted using four databases to search for the keywords . The NCBI National Library of Medicine, Cochrane Library, MEDLINE Complete and BioMed Central were last searched on 26 May 2022. Randomised control trials and retrospective or prospective papers involving endoscopic retroperitoneal neurectomy operations after inguinal hernia repair were included. All other surgeries, procedures and study designs were excluded. The internal quality of included studies was assessed using the Newcastle–Ottawa Scale. The percentage of patients who had reduction in pain (“positive treatment outcome”) was used to assess the procedure’s effectiveness in each analysis.Q (6) = 1.79, = .775) and the probability ratio test (Q (6) = 4.24, = .374) provide similar findings . The meta-analysis’ key finding is that the intervention was up to 78% effective .Five comparable endoscopic retroperitoneal neurectomy studies with a total of 142 patients were analysed. Both the Wald test (Endoscopic retroperitoneal neurectomy can be an effective treatment option for postoperative neuropathic pain relief following surgical hernia repair. Although there is limited reported experience with this technique, it may provide a clinical benefit to the patient. We recommend further prospective data and long-term follow-up studies be conducted to confirm and expand on these outcomes. Chronic pain, defined as pain that lasts for three to 6 months and frequently fluctuates, is a recognized complication in patients after groin hernia repair . In the Chronic neuropathic pain, also known as persistent pain with characteristics like burning or shooting, can occur due to damage to the somatosensory system . Modern Chronic neuropathic pain significantly influences activity and comfort levels, negatively impacting the patient’s quality of life. It has also been linked to psychiatric illnesses, including anxiety and depression, which may impact a patient’s well-being , 10. ConDespite the fact that case reports and other retrospective studies exist for open, laparoscopic, retroperitoneal and transperitoneal endoscopic techniques to triple neurectomy , 12, thiEndoscopic retroperitoneal neurectomy necessitates a thorough understanding of the IHN, IIN and GFN locations and distributions. The lumbar plexus, represented by T12–L5, gives origin to these three nerves. The IHN, IIN and GFN are attributed to the lumbar plexus and contain parts of T12–L2. All three nerves  innervate the skin above the inguinal ligament and the lateral hip region , 15.The IIN is formed by rami anteriores from T12 to L1. The nerve course is analogous to the IHN from the iliac crest to the inguinal ligament medially but breaks through the superficial inguinal ring directly entering the inguinal canal. The motor fibres of the nerve innervate the same areas as those of the IHN. Moreover, it innervates the skin of the penile root or labia majora, with its scrotal or labial anterior nerves , 15.The GNF consists of rami anteriores from the segments L1 and L2. After penetrating the psoas major muscle, it divides into femoral and genital rami. The former travels to the saphenous hiatus by passing through the lacuna vasorum. In men, the genital ramus is part of the spermatic cord in the inguinal canal and innervates the motor portion of the cremasteric reflex and the skin of the scrotum. In women, it supplies the labia majora as it passes through the round ligament. The femoral ramus of the GFN innervates the skin of the medial side of the thigh regardless of gender , 14, 15.British Journal of Surgery in 1997 [There are many surgical methods allowing for a successful neurectomy of the IHN, IIN and GFN. While analyses of open, laparoscopic transperitoneal and endoscopic procedures for triple neurectomy have been published , 17, thi in 1997 .The process begins with an intravenous antibiotic prophylaxis administered before the surgery. The patient undergoes general anaesthesia and is placed in a supine, slightly lateral posture Fig. . Then, aThe authors A. J., A. T. and D. H. conducted independent searches for literature using the NCBI National Library of Medicine, Cochrane Library, MEDLINE Complete and BioMed Central. The date of the last search was 26 May 2022. The following single-text terms were used in the search strategy: “endoscopic retroperitoneal neurectomy” and “laparoscopic retroperitoneal neurectomy”. The retrieved studies’ reference lists and citations were manually searched for more relevant research.The search technique was based on an orderly structure of core phrases, and only papers involving endoscopic retroperitoneal neurectomy operations after inguinal hernia repair were included. Randomised control trials and retrospective or prospective study designs were included in this study. Exclusion criteria included case reports, case series, comment letters, studies with poor design such as studies with insufficient data and studies with Newcastle–Ottawa quality assessment score of 4 or less . All othAfter the removal of duplicates, full-text evaluation and data extraction was completed by two independent authors. The internal quality of included studies was assessed using the Newcastle–Ottawa Scale by two independent authors .The percentage of patients who had received significant pain reduction postoperatively, in addition to the frequencies and proportions of therapy (“proportion of positive results”), were the primary outcome values assessed in this meta-analysis. Pain reduction was defined as statistically significant pain reduction based on pre- and postoperative questionnaire scores. Questionnaires used in analysed studies include the following: NRS-11: Numeric Rating Scale; I-PROM: Individual Patient-Reported Outcome Measure; NRS: Numerical Rating Scale; PDQ: PainDETECT Questionnaire , 18, 21.p < 0.05 was considered statistically significant. In addition, a funnel plot and a radial plot were developed to detect publication bias, and other statistical tests such as a rank correlation test and three regression tests were utilised.Statistical analysis was conducted using the R programme Meta . The Wald test and the probability ratio test were used to analyse statistical heterogeneity. Furthermore, for the frequencies of positive treatment outcome occurrence, a logistic regression model with a random intercept and a maximum-probability estimator of 2 and the Hartung-Knapp adjustment for random effects models were employed to analyse the outcomes. The model’s outputs were used to calculate the logits of the frequencies’ chances. Due to the fact that the treatments in three separate studies were all positive, the inclusion of the three separate studies in the model was made possible using a continuity correction of 0.5. The findings were accompanied by their 95% Clopper-Pearson confidence intervals. Furthermore, a The initial literature search was carried out, with a specific filter set to display full-text articles. As a result, 97 records were discovered, which were reduced to 62 when duplicates were deleted. As a result, 46 papers were omitted because they did not describe surgical procedures involving retroperitoneal surgical access and hence did not match the inclusion criteria. The full text of 16 articles was reviewed. As a consequence, 11 more papers . The Wald test (Q (6) = 1.79, p = 0.775) and the probability ratio test (Q (6) = 4.24, p = 0.374) did not reveal any significant differences. The meta-analysis was carried out using a fixed effects logistic regression model due to the homogeneity of the research data. Figure The distribution of the findings was highly homogenous  with 111/142 patients experiencing reduced pain. According to the 95% confidence interval, the treatment was successful in at least 71%, meaning in at least two-thirds of cases.Figure In Fig. Figure In addition, four statistical tests were conducted to check the asymmetry of the funnel plot, the results of which are summarized in Table This systematic review was conducted to characterise the success rate of endoscopic triple neurectomy and thus provide a valid recommendation whether this technique should be considered for patients with postoperative inguinal neuropathic pain. Furthermore, the literature on this technique can be considered valid as thorough statistical evaluation did not reveal any indicators that the collected data might have significant publication bias. Of the 142 patients from five studies who underwent endoscopic triple neurectomy for the indication mentioned above, approximately 75% reported complete or at least significant reduction in subjective pain intensity.Even though its exact occurrence rate remains controversial, there is consistent evidence that postoperative neuropathic pain has surpassed hernia recurrence as the most frequent complication of hernia repair –30. HoweTriple neurectomy of the IIN, IHN and GFN has been proven to be an excellent treatment method in cases of chronic pain. Stulz and Pfeiffer  first dePostoperatively, numbness might be felt over the treated area, a possibility that should be explored and discussed with the patient . A smallAnother method that may be used if traditional laparoscopic surgery is not feasible is the “dual two-team approach”. It combines open surgical and endoscopic techniques. Although this method showed promise with high success rates on a comparative scale, no definitive conclusion can be drawn due to only one small descriptive study discussing this method .Endoscopic retroperitoneal neurectomy is a one-stage, minimally invasive procedure for resecting the IHN, IIN and GFN from the lumbar plexus. This method has been found to provide excellent pain relief and morbidity rates comparable to open neurectomy, but it is a challenging procedure even in the hands of experts, and anatomical variances make the identification of the nerves even more complex .The retroperitoneal access may present some inconveniences inherent to any surgical procedure, including extensive dissection, painful incision and complications such as surgical wound infection, hematoma, bleeding, incisional hernia and postoperative paralytic ileus. In the population of 142 patients, 3 patients had complications due to the procedure. Two patients had a laceration of the posteroinferior diaphragm requiring laparoscopical suturing and one patient had a delayed haemorrhage requiring transfusion and embolization. No other complications were reported intra- or perioperatively in the population. The advantage of this technique is providing broad access to the retroperitoneal cavity and efficient control of haemorrhage. This procedure is described to be less painful and provides faster postoperative recovery, discharge and earlier return to usual activities . While tThere are several limitations to this study. First, this review included articles that contained various methods for quantifying chronic neuropathic pain in posthernia repair surgery. Second, the number of patients analysed is small due to the paucity of published literature on this specific approach which will increase the number of type II errors. Third, the total length of follow-up in the studies included was between 3 months and 1 year. Longer follow-up in future studies will help better understand long-term quality-of-life assessments postprocedure. Large, multicentered prospective and randomised control studies using standardized treatments and well-defined pain outcome measurements must be performed in order to increase the predictive power of postoperative outcomes. This surgical technique is the last line of treatment meaning there can be a learning curve and reduced feasibility in practical application [Persistent neuropathic pain is a common complication of surgical hernia repair. However, it is often debilitating as it permanently affects the patient’s physical abilities and mental health. As a result, several techniques have been developed to relieve the symptoms of postoperative inguinal neuropathic pain. We conducted a meta-analysis of five studies on the minimally invasive endoscopic retroperitoneal method for ilioinguinal, iliohypogastric and genitofemoral nerve triple neurectomy. Our analysis showed that endoscopic retroperitoneal neurectomy can be an effective treatment option for postoperative neuropathic pain relief following surgical hernia repair. Considering the small number of patients in this study, data interpretation with regard to efficacy can only be limited. Although there is limited reported experience with this technique, it may provide a clinical benefit to the patient. Further prospective data and long-term follow-up of the triple neurectomy procedure will be needed to confirm these outcomes.


Fibromyalgia symptoms have a significant impact on the quality of life and respond poorly to medications. It has been hypothesized that the use of low-energy pulsed electromagnetic field (PEMF) induces neuroprotective effects that may interfere with pain perception. We explored the efficacy of PEMF in patients affected by fibromyalgia.Twenty-one females  affected by fibromyalgia were randomized to receive pulsed electromagnetic field-triple energy pain treatment (PEMF-TEPT) or placebo at T0 and at 4 weeks and 8 weeks. Fibromyalgia impact questionnaire (FIQ), widespread pain index (WPI), visual analog score (VAS) pain, symptom severity (SS) scale, and short form 36 (SF-36) health survey questionnaire have been evaluated.P < 0.001), of SS score , of VAS pain . They also reported a higher improvement of FIQ and SF-36, albeit not reaching statistical significance.Patients in the PEMF-TEPT group had a significantly higher reduction of WPI compared to placebo (mean difference −12.90 ± standard deviation [SD] 5.32 vs. −1.91 ± 4.55, difference in difference [DD] of −10.99; In our pilot controlled study, PEMF-TEPT appeared to be safe and improved fibromyalgia symptoms. The diagnosis of fibromyalgia is predominantly clinical and does not exclude the presence of other causes for pain. While the etiology and pathogenesis of fibromyalgia remain unknown, some lines of evidence point to a role for the central nervous system in pain amplification and in the development of other symptoms. At the time of onset, some patients start complaining of regional pain and later develop widespread pain, even in the absence of an identifiable input, with a top-down process, while others have a definite disease  and pain becomes generalized afterward, with a bottom-up pattern, possibly related to altered nociception and nerve connectivity.Fibromyalgia affects between 0.4% and 8.8% of the general population, with a marked female predominance, and is characterized by chronic widespread pain associated with dysesthesia, paresthesia or sensation of burning, tingling or numbness, and stiffness, as well as fatigue, poor sleep quality, cognitive impairments in memory and concentration, headache, mood disorders, and bowel alterations. Despite the use of muscle relaxants and antidepressants along with non-pharmacological treatments, symptoms are often uncontrolled, not allowing a good quality of life. Among alternative treatments, transcranial magnetic stimulation and transcutaneous electrical nerve stimulation have been proposed based on data coming from heterogeneous studies with high risks of bias., 9From a therapeutic standpoint, fibromyalgia management is aimed at improving quality of life but anti-inflammatory and analgesic drugs such as opioids have marginal effects and are generally not tolerated. while promoting osteogenesis and angiogenesis. While effective in preventing falls in fragile individuals, PEMF had moderate beneficial effects in treating pain from osteoarthritis when applied to the whole body or to a specific joint or rheumatoid arthritis and fibromyalgia., 15 In a randomized, double-blind, sham-controlled trial, PEMF administered to the whole body was effective in improving function, pain, fatigue, and global status in patients with fibromyalgia, and the results were maintained at 12 weeks, but in another randomized controlled trial, the PEMF system called Bio-Electro-Magnetic-Energy Regulation (BEMER) had no effect on fibromyalgia. As previous studies applied PEMF to the brain or to the whole body with conflicting results, and based on the challenges posed by the evaluation of patient-reported outcomes in fibromyalgia, we performed a randomized single-blind controlled pilot study to determine the potential benefits of PEMF on different disease symptoms.Low-energy pulsed electromagnetic field (PEMF) is based on the use of magnetotherapy, which produces modulatory and neuroprotective effects were enrolled if they fulfilled the following inclusion criteria: a diagnosis of fibromyalgia for at least 1 year, visual analog scale (VAS) score for pain ≥4 in the 2 weeks before the enrollment, and absence of any chronic analgesic treatment  classification criteriareatment . PregnanWe performed a single-center randomized single-blind controlled pilot trial to determine the effect of low-energy PEMF therapy applied to target points on fibromyalgia symptoms ., 19 and the observed response of the parasympathetic and sympathetic system. , 21 Moreover, they were chosen because they are easy to identify and PEMF stimulation can be quickly applied.The chosen points for PEMF application were based on the acupuncture experience in fibromyalgian = 10, herein referred to as active treatment) on pre-specified points or minimal intensity applied on scrambled points (n = 11 controls) for 20 min at baseline (W0) and after 4 weeks (W4) and 8 weeks (W8) (end of follow up: October 2019).Patients with fibromyalgia were consecutively enrolled between May and August 2019 and randomly allocated 1:1 to receive either pulsed electromagnetic field-triple energy pain treatment (PEMF-TEPT)  and disclosed at analysis of data. Throughout the study, a consecutive number was assigned to each patient and also inserted in the device before starting a treatment session. This ensured that each patient received the same type of treatment in the different sessions and remained blind on the treatment allocation. In all cases, the intervention was provided by a trained rheumatologist in individual office sittings in a rheumatologic outpatient clinic in Genova, Italy, and attendance was verified each time. Outcome measures were recorded at each timepoint by the same rheumatologist. The primary outcome was the change observed in VAS pain, while secondary outcomes included other indexes with an impact on quality of life, such as fibromyalgia impact questionnaire (FIQ), widespread pain index (WPI), symptom severity (SS) scale, and short form 36 (SF-36) health survey questionnaires. t-tests for difference in means (difference tested on differences). Formally, let Yi,t,g be the value assumed by the response variable Y for a specific patient i who belongs to the treatment group g (Placebo and Treated), measured at time t (T0 and W8). We calculated the quantities Diffi,g = Yi,W8,g – Yi,T0,g and compared them to the average between the 2 treatment groups (Placebo/Treated). All the assumptions of the t-test have been met and checked before performing it .A difference in difference (DD) approach was used to evaluate the treatment effect on each response variable. In particular, for each patient, we calculated the difference between the value assumed by the response variable at time W8 and the same quantity at time T0. These variations were compared to the average between Placebo and Treated groups by performing 2 independent sample The study included 21 female patients  diagnosed with fibromyalgia, and P-values of the one-sided t-test. Changes between baseline and W8 for WIP, SS, and VAS pain scores are illustrated in n = 10) illustrated in P < 0.001) and significantly more pronounced reduction in the SS  and VAS  scores.Patients receiving active treatment also had improvements between baseline and W8 in FIQ and SF-36 scores, albeit not reaching statistical significance .Both active and placebo treatments were very well-tolerated and no side effects were noted in either group; all 21 patients completed the 8-week period of the study. and fibromyalgia is a predominant cause with an enormous impact on disability and quality of life. Despite numerous studies and recent recommendations, the current medical management of fibromyalgia is largely unsatisfactory and there is a need for new therapeutic options. Data from our pilot study with a randomized single-blind controlled design on a limited number of subjects suggest that the use of PEMF could provide benefits over an 8-week period on the major indices of fibromyalgia activity.Chronic widespread pain has become one of the major reasons for physician consultation in the general population,,14,15 No relevant side effect has been described so far and the treatment is usually well-tolerated. We observed a significant effect of PEMF on WPI, SS, and VAS scores in treated patients compared to placebo. These observations support previous reports of possible beneficial effects of electromagnetic fields on human pain.PEMF is based on the use of magnetic fields that can be applied to the brain, to the whole body, or to specific sites, having a more general effect on pain.  One major hypothesis is that PEMF changes brain waves and reduces hypoxic damage in neuron-like and microglia cells. PEMF induces a direct cellular response, promoting proliferation and differentiation of the human osteoblast, by increasing mitochondrial activity and activating the extracellular signal-regulated kinase (ERK) 1/2 signaling cascade. Furthermore, PEMF can promote anti-oxidative defense mechanisms and mitochondrial repair in osteoblasts. It is of note that these mechanisms have been implicated in the pathogenesis of fibromyalgia, including brain wave alterations at electroencephalography, mitochondrial damage associated with reduced nitric oxide levels in the blood, causing an impaired circulation which is involved in fatigue, a major fibromyalgia symptom, and oxidative stress.The mechanisms by which PEMF may be beneficial in fibromyalgia can only be speculated, and were not explored in the current study. We should observe, however, that this lack of background rationale is frequently encountered in most exploratory studies in fibromyalgia as the understanding of the disease pathogenesis remains elusive and its management challenging. we are particularly intrigued by the effects of PEMF-TEPT on the scores resulting from the FIQ and the SF-36 questionnaires. These changes did not reach statistical significance in comparison with the control treatments, possibly due to the small sample size, or likely due to the fact that emotional features are included, which are marginally affected by PEMF.We observed that the application of PEMF-TEPT on selected points can be helpful in the management of pain in fibromyalgia but also may have an impact on other less defined domains such as fatigue, anxiety, depression, and muscular stiffness, which impact the quality of life and also influence the patient's personal life in terms of their ability to work and be active socially. The changes in SS score, FIQ, and WPI are of particular importance in the management of fibromyalgia as these account for the predominant symptoms of fibromyalgia, i.e., pain, sleep disturbances, and cognitive impairment. As PEMF has been found to be helpful in the treatment of anxiety and depression in human studies, as illustrated by the amelioration observed in all readouts with the control treatment. We should note that the expected changes with the active treatment group, if no real effect due to PEMF was observed . The treatment appears to improve pain and fatigue and the general overall health status in patients affected by this chronic condition, in the absence of relevant side effects. PEMF can be considered a therapeutic choice in the management of fibromyalgia, and further studies are needed to assess whether specific categories of fibromyalgia patients could benefit more from this therapy.


IntroductionBotulinum toxin (Botox®) is considered an effective treatment for nocturnal bruxism when injected into the masseter muscle. Several studies have used different dosages of Botox for this purpose. The objective was to determine whether 10 MU of botulinum toxin type A (BTXA) injections into the masseter muscle could lessen nocturnal bruxism.Material and methodsThe sample consisted of 22 patients who suffered from pain in the masseter muscle and sensitivity of the teeth as a result of its wear due to nocturnal bruxism. The sample was randomly divided into two groups. The Botox (BO) group included 11 patients injected with 10 MU of BTXA, and the placebo (PL) group included 11 patients who received a sham intervention. Pain perception was assessed on visual analogue scales, whereas muscle activity was recorded by electromyography (EMG) to evaluate the effectiveness of this treatment protocol on nocturnal bruxism.ResultsA total of 20 patients entered data analysis with one dropout from each group. The differences in the perceived pain values between the BO and the PL groups before and after the injection were statistically significant (p<0.05). In the BO group, the changes in the perceived pain values over time were statistically significant (p<0.05). The pain levels significantly decreased at two weeks, one month, and three months following the injection. However, the levels increased again at the fourth- and sixth-month assessment times with statistically significant differences (p>0.05). The differences in the EMG recorded values were statistically significant between the two groups (p<0.05).ConclusionsWithin the current study's limitations, injecting 10 MU of BTXA into the masseter muscle reduced muscular activity in this muscle, resulting in decreased muscle spasms and pain symptoms associated with nocturnal bruxism for about three months before symptoms gradually relapsed. Sleep bruxism (SB) is a condition of maxillomandibular activity characterized by nonfunctional teeth grinding and clenching while sleeping ,2. BruxiIn addition to neck pains, headaches, periodontal disease, oral or facial pain, and possibly tooth loss, SB can lead to teeth attrition, dental prostheses/implants failing, tooth sensitivity, pain in the teeth, jaw, masticatory muscle, and temporomandibular joint (TMJ), as well as other problems ,5. The dFor the treatment of bruxism, many treatment approaches such as occlusal splints, pharmacologic medications such as psychobehavioral therapy or L-dopa, and psychobehavioral therapy have been examined but are not enough evidence to define a standard of reference approach for SB treatment .Clostridium botulinum, and it paralyzes muscles by preventing the flow of acetylcholine from cholinergic nerve terminals into the neuromuscular junction [The exotoxin known as botulinum toxin (Botox®) is generated by the bacterium junction . In the junction . These sjunction ,11 and 2junction  to 30 MUjunction ,14 in thjunction . To avoiStudy design and settingsTrials.gov (ID: NCT05620316).A parallel-group randomized controlled trial study was performed at the Department of Oral and Maxillofacial Surgery, University of Damascus Faculty of Dentistry, Syria, between March 2021 and September 2021. The study was approved by the Local Research Ethics Committee of the Faculty of Dentistry, Damascus University (UDDS-722-10072018/SRC2202). The study was funded by the University of Damascus Postgraduate Research Budget (Reference number: 80015489477DEN), and this was registered at Clinical Sample size calculationThe sample size was calculated using G*power 3.1.7 software . The smallest clinically significant difference requiring detection between the two groups on a visual analogue scale (VAS) was assumed to be 20 mm. This variable's standard deviation in a prior study was 11.9 mm . Ten patPatients recruitmentThe Departments of the Faculty of Dentistry at Damascus University referred 80 patients with bruxism symptoms to the Department of Oral and Maxillofacial Surgery. A questionnaire was given to these patients (Appendix 1) based on a previous relevant study , and theAll candidate patients were informed about the research project's purpose and given information sheets. Informed consent was obtained from those who agreed to participate. A total of 28 people consented to participate in the current study. The a priori sample size calculation revealed the need for 22 patients for this trial. A simple random sampling was employed to select these 22 patients out of the 28 individuals who had been found eligible for this trial and accepted participation . They were then randomly divided into the experimental group BO; n=11) and the placebo group  with a one-to-one allocation ratio. The following information was recorded before the intervention: treatment history of nocturnal bruxism and duration of the complaint. The flow diagram for patient recruiting, follow-up, and entry into data analysis according to the Consolidated Standards of Reporting Trials (CONSORT) is given in Figure 1 and theRandomization and allocation concealmentWith a 1:1 allocation ratio, computer-generated random numbers were used to perform the randomization. The allocation sequence was hidden with numbered, opaque, and closed envelopes that were opened before treatment began. The patients were randomly allocated into two groups. In the BO group, the patients received BTXA, whereas in the PL group, the patients received a placebo. An academic staff member not involved in the study project was asked to perform the random allocation sequence and participants' enrollment. The opaque sealed envelopes bearing the patient's name's initials were used to conceal the allocation sequence. The envelope was opened just before the injection for each patient. The first author (Z.S.) has treated patients and was aware of which group each patient belonged to. Blinding of the principal researcher was not applicable. Therefore, blinding was applied only to the patients and during data acquisition and analysis.The experimental group: the Botox groupIn this group, 100 MU of Botox type A  were diluted in 2 mL of saline. Patients were injected with 10 MU of BTXA per side at two sites into masseter muscle bilaterally. The first site was the inferior prominent part of the masseter muscle observed when the subject was asked to clench, and the other site was 5 mm below the first point  used in the blood glucose meter. It is less painful and provides psychological benefits, instead of injecting the physiological saline into the muscle to avoid the severe pain without a benefit to the patient, which would not conform to the ethical standards.Outcome measuresOverall AssessmentThe following information was recorded two weeks after the injection: (1) when the effects were first seen by patients and (2) the side effects of Botox injections. In addition, the time when the patients felt that the effectiveness of the injection started to be lost was recorded at two assessment times: three and four months following the intervention.Pain AssessmentThe pain was measured using a VAS. The patient was asked to mark on a line that measured 100 mm in length where she/he reflected her/his perceived pain. The scores of the scale were determined by measuring the distance in mm from the beginning to the point indicated by the patient (point (0): no pain and point (100): the highest levels of pain). This assessment was made before the injection (T0) and then at two weeks (T1), one month (T2), three months (T3), four months (T4), and six months (T5) after the injection.Electromyography (EMG) AnalysisElectromyography (EMG) signals were recorded with Matrix EP Light EMG  with two channels. The electrodes were placed on the belly of the right and left masseter muscles, with a larger extension of bars perpendicular to the direction of muscle fibers . A circuThe recorded signals were amplified and sampled at 1024 Hz, and the acquired data were analyzed with System Plus Evaluation software (Micromed). The acquisitions were performed twice with the rest position of the mandible (RPM) for 10 seconds, in maximal intercuspal position (MIP) for 5 seconds, and maximal teeth clenching (MTC) with 10-mm thick cotton rolls between the posterior teeth for 5 seconds, bilaterally, and the values obtained were averaged . The uniStatistical analysisSPSS software  was used for the statistical analysis. The Kolmogorov-Smirnov test was used to check the normality of the distributions. Independent t-tests were used to detect significant differences between the two groups. A p-value of <0.05 was considered statistically significant.Basic sample characteristicsThe sample consisted of 20 patients  aged 18 to 40 years. The average age of the recruited sample was 29.81±7.12 years . The mean duration of the complaint before injection was 7.33±4.85 years (Table Pain scoresThe BO group's mean VAS score was 8.62 mm ±1.35) at T0 before injection. After two weeks (T1) and one month (T2) of the injection, it decreased to 2.83 mm (±1.47) and 1.32 mm (±1.33), respectively (Table 5 at T0 bThe PB group's mean VAS score was 8.51 mm (±1.08) at T0 before injection. After two weeks of the injection, it decreased slightly to 8.04 mm (±1.05). During the follow-up periods, the mean VAS scores were 8.07 mm (±1.15), 8.42 mm (±0.99), 8.34 mm (±0.67), and 8.62 mm (±0.51) at T2, T3, T4, and T5, respectively.The mean pain scores were similar between the two groups before injection (T0) without statistically significant differences (p=0.8574). The mean pain scores were smaller in the BO group at T1, T2, T3, T4, and T5, and the differences between the two groups were statistically significant (p<0.001).EMG recordingIn the BO group, the mean EMG records of muscular activity before the injection were 596.38 Microvolt (µV) and 694.77 (µV) for the right and left masseter muscles, respectively. After two weeks (T1) of the injection, the mean values decreased to 258.80 µV and 328.84 µV for the right and left masseter muscles, respectively. After three months (T2), the mean values were 257.26 µV and 336.05 µV for the right and left masseter muscles, respectively. After six months (T3), the mean values increased to 539.91 µV and 700.61 µV for the right and left masseter muscles, respectively , the mean EMG records were 515.56 µV and 620.07 µV for the right and left masseter muscles, respectively. After three months (T2), the mean EMG records were 528.66 µV and 623.69 µV for the right and left masseter muscles, respectively. After six months (T3), the mean EMG records increased to 574.61 µV and 647.76 µV for the right and left masseter muscles, respectively.The mean EMG records of muscular activity were statistically smaller in the BO group compared to the PB group at T1  and T2 . The mean EMG records of muscular activity became similar between the two groups at T3 (p>0.05).Loss of effectiveness and side effectsThe mean time at which the loss of effectiveness started was 3.51±0.36 months. Regarding complications, four patients had pain in the injection points in the first week of injection, and two patients had discomfort at the injection site. No side effects were reported by the rest of the included patients.The management of nocturnal bruxism is usually directed at protecting teeth, restorations, and reducing bruxism and pain relief through stress control, occlusal balancing, occlusal splint, and drugs . Botox wBecause the masseters are the main muscles implicated in the grinding actions seen in bruxism , they weIn our study, we injected 10 MU of BTXA into the masseter muscle and evaluated the efficacy of this dose in reducing nocturnal bruxism. The first major main finding was that, according to the EMG recording, muscular activity significantly decreased in the masseter muscle in the BO group compared with the PL group. Muscle activity was markedly reduced at two weeks after injection and maintained for 12 weeks, and then muscle activity increased after six months and returned to what it was before the injection.The second main finding was that, according to the VAS scales, the pain values were significantly decreased in the BO group compared with the PL group. However, in the fourth month, pain scores began to increase with the loss of effectiveness of Botox. Moreover, they remained lower than the pain scores in the PL group. This is due to injecting a lower dose of Botox into the masseter muscle.An injection of 10 MU of BOTOX into the masseter muscle eliminated active bruxism for three months, after which the symptoms resumed, as demonstrated in our study. However, it has been proposed that BTXA-induced jaw muscle paralysis disrupts the feedback loop from the trigeminal motor nucleus, inhibiting the central bruxism generator. In addition, during mastication, it may deactivate periodontal mechanoreceptors, which have been suggested to facilitate jaw closure of motor neurons .These outcomes are in agreement with a previous study by Guarda-Nardini et al. in which 20 patients were studied to determine the effectiveness of Botox and saline solution in reducing pain associated with myofascial pain caused by bruxism. The pain levels were assessed using a VAS in the range of 0-10 at rest and during mastication, before and after the Botox injection. Ten patients received a saline solution, and the remaining 10 patients were injected with 30 MU of Botox type A (BOTOX) at three places in the masseter muscles and 20 MU at two points in the anterior temporalis muscles. The authors reported a significant decrease in pain scores in the injection group compared to the PB group . AnotherA study by Lee et al. evaluated the efficacy of BTXA (Dysport) injections in treating nocturnal bruxism. The sample included 12 patients: in six patients, 80 MU of BTXA (Dysport) was injected into the masseter muscle, and in the other patients, saline solution was injected. The nocturnal electrical activity (EMG) of the masticatory and temporal muscles was recorded in a normal sleep environment before and after the injection for 4, 8, and 12 weeks, and VAS was used to measure pain. The study’s finding revealed a decrease in the effectiveness of the masseter muscle activity during sleep, which reduced the occurrence of bruxism . AnotherWe agreed with the results of these previous studies. Whereas Botox type A blocks acetylcholine release from cholinergic nerve terminals into the neuromuscular junction, reducing muscular activity  and tempIn addition, it was noted that four patients experienced injection site pain for a week following the injection, and two patients had discomfort at the injection site, with no other Botox injection side effects. These outcomes agreed with a previous study by Park et al.2003 on the occurrence of injection site pain and disagreed with it in the presence of chewing difficulties, speech disturbance, and abnormal facial appearance . At the LimitationsThe current study had some limitations. First, blinding the researcher was not possible, which could have produced a detection bias. Secondly, there was no attempt to evaluate the outcomes following temporal muscle injection. Additionally, differences between the two genders were not assessed. Patients' psychosocial factors that may have affected the degree of bruxism were not evaluated in the current trial. This can be avoided in future studies by a pre-intervention psychological analysis of all possible contributing factors.Within the limitations of the current study, injecting 10 MU of Botox into the masseter muscle reduced muscle activity and pain symptoms associated with nocturnal bruxism. This effect lasted for about three months, and then the symptoms gradually returned.