Objectives: This study was done to compare the anesthetic efficacy of 4% articaine with 1:100,000 epinephrine with that of 2% lidocaine with 1:80,000 epinephrine during pulpectomy in patients with irreversible pulpitis for inferior alveolar nerve block in mandibular posterior teeth.Material and Methods: Patients with irreversible pulpitis referred to the Department of Conservative Dentistry and Endodontics, K.D. Dental College, randomly received a conventional inferior alveolar nerve block containing 1.8 mL of either 4% articaine with 1:100,000 epinephrine or 2% lidocaine with 1:80,000 epinephrine. After the patient’s subjective assessment of lip anesthesia, the absence/presence of pulpal anesthesia through electric pulp stimulation was recorded and the absence/presence of pain was recorded through visual analogue scale.Results: The pulpal anesthesia success for articaine (76%) was slightly more than with lidocaine (58%) as measured with pulp tester as well as for the pain reported during the procedure the success rate of articaine (88%) was slightly more than that of lidocaine (82%) although the difference between the two solutions was not statistically significant.Conclusions: Both the local anesthetic solutions had similar effects on patients with irreversible pulpitis when used for inferior alveolar nerve block. Key words:Anesthesia, articaine, lignocaine, pulpitis. Articaine comparatively is a new anesthetic, which has recently been introduced in Brazil and was approved for use in the United States in April 2000 . It is tArticaine is the center of heated discussions among dental surgeons as it has a faster onset and higher success rates than lidocaine as well as it has been demonstrated to increase the risk of paresthesia which could not be confirmed in a recent study -8. Artic So far, research on the anesthetic efficacy of articaine in patients with irreversible pulpitis for inferior alveolar nerve block has been very limited -14. TherOne hundred adult patients [n=100] aged between 18-50 years participated in this prospective, randomized, double-blind clinical study. The patients included in this study had been admitted to the Department of Conservative Dentistry and Endodontics, K.D. Dental College with a clinical diagnosis of irreversible pulpitis. The patients had at least 1 adjacent tooth plus a healthy contralateral canine or, alternatively, a contralateral canine without deep carious lesions, extensive restoration, advanced periodontal disease, history of trauma, or sensitivity and gave a positive response on electric pulp testing of the diseased tooth and a prolonged response with moderate to severe pain to a cold testing using Roeko Endo-Frost . While Patients who took medication potentially interacting with any of the anesthetics or with systemic disorders, history of sensitivity to anesthetic agents, presence of periodontal ligament [PDL] widening or periapical radiolucency or pregnancy were not included.The study was approved by the Committee on the Ethics of Research on Human Beings and each patient gave written informed consent to participate in the study. Before the IAN block injections, the tooth with irreversible pulpitis, the adjacent tooth, and the contralateral canine were tested for pulp vitality with an electric pulp stimulator. The electric pulp stimulation of the contralateral canine, which had not been anesthetized, was used as control to ensure that the equipment was working properly and that patients were responding adequately.The 100 participants were divided into 2 groups of 50 patients, who received IAN injections of 1.8 mL [equivalent to 1 cartridge] of either 2% lidocaine with 1:80,000 epinephrine or 4% Articaine with 1:100,000 epinephrine.To ensure the blindness of the study, the label on the cartridges was removed and the cartridges were coded. 1 cartridge [1.8 mL] of either anesthetic solution was sealed in envelopes. At the time of application, one researcher, who administered the anesthesia injections, chose one of the envelopes at random. Electric pulp stimulations to assess pulpal anesthesia were performed by a colleague to guarantee that the anesthetic solution remained unknown and thus maintain the double-blindness of the study. Before the IAN block injections, the tooth with irreversible pulpitis, the adjacent tooth, and the contralateral canine were tested for pulp vitality with an electric pulp stimulator.For the injections, a side-loading carpule syringe fitted with a 27-gauge 0.4 X 35 mm needle and equipped with a blood aspiration device and a thumb ring was used. Blood aspiration tests were carried out before each anesthesia injection as well as when changing needle position.The cartridge of the respective anesthetic solution was applied as follows:The index finger and thumb were used to palpate over the anterior border of the ramus of the mandible until the coronoid notch is felt. The palpating finger was then moved lingually across the retromolar triangle and onto the internal oblique ridge. The syringe was directed from the premolar region of the opposite side, and the needle was inserted until establishing bone contact. Thereafter, the needle was withdrawn 1–2 mm, the blood was aspirated, and the remaining 1.5 ml of anesthetic solution was slowly injected. The needle was then withdrawn to half its length and brought on the same side and remaining 0.3 ml was injected to anesthetise the lingual nerve. The average injection time for each cartridge was approximately 2 minutes.Ten minutes after the IAN block, subjective lip anesthesia was evaluated by asking the patient whether his/her lip was numb. Thereafter and immediately before the pulpectomy, the electric pulp stimulations were repeated to determine pulpal anesthesia. During the pulpectomy procedure, the patients were instructed to report any painful discomfort.To evaluate the intensity of pain during the pulpectomy, a visual analogue scale was used: 0, no pain; 1, mild, bearable pain; 2, moderate, unbearable pain; 3, severe, intense, and unbearable pain. The anesthesia was defined as successful when the dentist accessed the pulp chamber without pain being reported by the patient [pain scores 0 or 1]. In these cases, the pulpectomy procedure was continued. Pain scores of 2 or 3 classified the IAN block as unsuccessful. In these cases, an intrapulpal anesthesia was performed, and the pulpectomy was finalized. This complementary anesthesia was not evaluated, because it was beyond the scope of this study.P < .05.The responses to the electric pulp tester [negative or positive] and the pain  recorded in the 2 test groups [articaine solution and lidocaine solution groups] were compared by using the χ2 test. Potential differences in age between the 2 groups were analyzed with T-test. The Mann-Whitney U test was used to compare the distributions of types of teeth with irreversible pulpitis in both groups. For all performed tests, the level for significance of differences was taken as P = 0.161], age , and the types of teeth with irreversible pulpitis [P = 0.188] (In the present study, there were no statistically significant differences between the patients of the 2 test groups [articaine versus lidocaine solution] concerning gender distribution  .p=0.123].Mann-Whitney U test was also carried out for the types of teeth with irreversible pulpitis in the two groups and no statistically significant difference was found between types of teeth with irreversible pulpitis [P= 0.056].All 100 patients [100%] reported subjective lip anesthesia 10 minutes after the IAN block. Before the pulpectomy procedure, 38 patients [76%] of the articaine group and 29 patients [58%] of the lidocaine group exhibited pulpal anesthesia (Fig. P = 0.401] (Fig. During the pulpectomy, 6 patients of the articaine group 12%] and 9 patients of the lidocaine group [18%] reported pain [pain scores 2 and 3]. Again, this difference was not statistically significant [% and 9 pIn our study there are no significant differences between the patients of the 2 test groups [articaine versus lidocaine solution] regarding their gender, age, and type of posterior tooth with irreversible pulpitis. Consequently, any potential effects of these parameters can be minimized or even neglected, and the results obtained with both anesthetic solutions can be directly compared.The Anesthetic solution of 2% lidocaine with 1:80,000 epinephrine was used in the study as these cartridges are most commonly used the institution in which the study was carried. The concentration of epinephrine does not affect the degree of anesthesia obtained with 2% lidocaine for inferior alveolar nerve block .Our study demonstrates that although both local anesthetic solutions always resulted in profound lip anesthesia 10 minutes after their application, pulpal anesthesia is not necessarily achieved. Only 76% of the patients in the articaine group and 58% of the patients in the lidocaine group exhibited pulpal anesthesia, i.e., a negative response to electrical stimuli generated by an electric pulp tester which is in confirmation to the results of another study that had investigated the effect of articaine and lidocaine used for inferior alveolar nerve block (In the articaine group, 12% of the patients experienced pain during the pulpectomy. The percentage of patients reporting pain during the treatment was only insignificantly higher in the lidocaine group [18%].The results of the study point to the fact that neither of the local anesthetic solutions used guarantees a complete absence of pain during pulpectomy. Although the success rate is slightly more with the articaine solution than with the lidocaine solution, this difference was not statistically significant. Although 42% of all assessed posterior teeth had responded negatively to the electric pulp test, the patients reported pain during the subsequent endodontic treatment. The similarities between the results of this study and those by other authors give rise to the assumption that a negative response of symptomatic teeth with pulp inflammation to the pulp tester is no reliable indicator for analgesia ,17.In this study the anesthesia was defined as successful when the dentist accessed the pulp chamber without pain being reported by the patient [pain scores 0 or 1] measured by the scale made for measuring visual analogue scale. In these cases, the pulpectomy procedure was continued. Pain scores of 2 or 3 classified the IAN block as unsuccessful.et al. 12 and Tortamano et al. (et al. (et al. the success rates were 65% with articaine solutions and 45% with lidocaine solutions. In both the studies the sample size was small and this may have been the reason for the statistically insignificant difference in the two with articaine showing slightly better result than lidocaine.So far, only two other studies, performed by Claffey o et al. , compareSo, in our study with large sample size of 100 patients was taken, the success rates were 88% with articaine and 82% with lidocaine which are higher than the previous studies. These differences in success rates could be also due to potential population differences between both studies.et al. was 2.2 ml while that used by Tortamano et al. was 3.6 ml. The dose used in our study was 1.8 ml as recommended by C. Richard Bennett (Also, the dosage used by Claffey  Bennett  and it iThe increase in dosage of local anesthetic also increases its efficacy is not entirely supported by the literature. It has been postulated that once the effective volume of local anesthetic is attained, no further benefit can be achieved through a further increase in dosage. In the case of 2% lidocaine with adrenaline, this effective volume has been reported to be upto 2.0 ml of solution .The superiority of articaine over lidocaine for inferior alveolar nerve blocks in patients with irreversible pulpitis once again could not be statistically corroborated by the clinical study even with a large sample size. Both solutions presented a similar behaviour, and both were not entirely efficient in controlling pain during the treatment of irreversible pulpitis. Since this study showed no difference in the efficacy of both the dental anesthetic agents in controlling pain during the treatment of irreversible pulpitis, articaine which has lesser toxicity could be substituted with lidocaine as dental anesthetic agent for IAN blocks in patients with irreversible pulpitis.More number of such studies is required to make Articaine as popular anesthetic agent for dental treatment procedures.


The purpose of this study was to introduce arthroscopic partial trapeziectomy and tendon interposition for the treatment of symptomatic thumb carpometacarpal arthritis of Eaton stage II or III.From August 2001 to April 2009, 23 patients with thumb carpometacarpal arthritis were treated using this technique. Pain score, range of motion, and pinch strength were clinically evaluated and compared with the preoperative values after a minimum follow-up duration of 24 months.p < 0.001) after a 2-year follow-up. The mean ± SD (median) postoperative pain score was 1.0 ± 0.7 (1.0) at rest and 1.3 ± 0.9 (1.0) during daily activities. The postoperative range of motion was 19.1° ± 4.2° (20°) for extension and 35.7° ± 7.1° (35.0°) for flexion, and the postoperative pinch strength was 86.5 % ± 19.9 % (90.0 %). No complications were observed in our patient series.Significant reduction in pain score and increases in range of motion and pinch strength were found (all Arthroscopic partial trapeziectomy and soft tissue interposition could be an alternative treatment method for patients with symptomatic thumb carpometacarpal arthritis of Eaton stage II or III. Thumb carpometacarpal (CMC) joint arthritis is a common disease and usually affects women in the postmenopausal age group –3. TypicThe specific types of surgical procedures for thumb CMC joint arthritis are usually divided between those for Eaton stage I and II–IV disease, depending on whether the cartilage of the basal joint remains unaffected or has existing evidence of degeneration .Procedures for stage I disease include volar ligament reconstruction, arthroscopy, and first metacarpal extension osteotomy. Volar ligament reconstruction has the advantages of halting the radiographic progression of the disease and the disadvantage of relatively poor pain relief. Arthroscopy is a less invasive procedure and can be used simultaneously in the treatment of ligament laxity. First, metacarpal extension osteotomy has the benefit of correction of an adduction contracture but is associated with the possibility of nonunion and implant problems.For stage II–IV disease, surgical treatment options have evolved over the past 50 years, including trapeziectomy, hemitrapeziectomy, arthrodesis, artificial prosthesis replacement, LRTI, suspensionplasty, osteochondral allografting, and hematoma distraction arthroplasty. Simple trapeziectomy/hemitrapeziectomy has the advantages of decreased operative time, pain relief, and minimal donor site morbidity. Its disadvantages include significant functional problem and loss of pinch strength. Arthrodesis is mainly performed in workers with heavy workload and cases of posttraumatic arthritis in young patients and as a salvage procedure for failed reconstructive surgery. Although this technique preserves pinch strength, concurrent problems occur, including nonunion, degenerative changes in neighboring joints, and loss of mobility. The artificial prosthesis replacement procedure shows good short-term results , but itsWe introduced arthroscopic treatment of stage II and III disease to achieve a minimally invasive surgery . In addiOur institutional review board approved this study. The study included all patients treated between August 2001 and April 2009 whose conditions required surgical intervention and who met the inclusion criteria. Patients with symptomatic Eaton stage II or III thumb CMC joint arthritis based on preoperative radiographs Fig.  and prevAll of the operations were performed under general anesthesia and tourniquet control. A single finger trap was used on the thumb with 5 to 10 lb of longitudinal traction by using a traction tower. The CMC joint was identified and localized by palpation or fluoroscopy. Two incision portals were marked. One was located radial to the first extensor compartment tendons, while the other was ulnar to the first extensor compartment tendons along the line of the joint. The distance between each portal and insertion of the first extensor compartment tendons was about 1 cm Fig. . The radAll patients complained of preoperative pain at the thumb base that impaired performance of daily activities. Physical examinations of the patients included an assessment of the thumb CMC joint range of motion (flexion and extension) with a protractor goniometer Fig. , determiEach patient was assessed clinically at 2, 3, 6, 12, and 24 months after surgery. After 24 months, they returned for evaluation according to their own volition. The assessment included pain (VAS score), thumb pinch strength measured with a Jamar dynamometer, and thumb CMC joint range of motion Fig. . The prep value <0.05.Statistical analysis was performed with the SPSS software . Continuous data were presented as mean ± SD. Categorical variables were presented as frequency (%). The Wilcoxon signed-rank test was used to compare postoperative thumb pain, range of motion of the thumb CMC joint, and thumb pinch strength with the preoperative measurements. Statistical significance was defined as a p < 0.001). The mean postoperative pain score was 1.0 ± 0.7  at rest and 1.3 ± 0.9 (1.0) during daily activities. The postoperative ROM was 19.1° ± 4.2° (20°) for extension and 35.7° ± 7.1° (35.0°) for flexion, and the postoperative pinch strength was 86.5 % ± 19.9 % (90.0 %).At enrollment, the mean pain scores at rest and during daily activities were 5.7 ± 0.5  and 7.0 ± 0.6 (7.0), while the extension and flexion ranges of motion (ROMs) and pinch strength were 15.9° ± 3.9° (15.0°); 27.8° ± 8.2° (30.0°); and 47.2 % ± 9.4 % (50.0 %), respectively. The data of the clinical outcomes are summarized in Table None of the patients who underwent the procedure had infections or other complications. All patients were satisfied with the surgical results within three postoperative months. Follow-up radiographs obtained at 24 postoperative months were compared with the immediate postoperative radiographs and demonstrated a mean proximal subsidence of 2.1 mm (0–4 mm) of the metacarpal shaft (Table Small joint arthroscopy for the smaller joints of the hand, first introduced by Watanabe , has beeThe stability of the thumb CMC joint depends on static ligamentous restraints because of the lack of bony congruity . Laxity Total excision of the trapezium results in good pain relief but also in substantial loss of thumb strength and stability . To avoiAfter hemitrapeziectomy, interposition arthroplasty preserves the stability of the thumb CMC joint by maintaining the joint space . The besLong-term clinical studies on arthroscopic hemitrapeziectomy with interposition arthroplasty have not been well reported in the literature. Pegoli et al.  evaluateFurthermore, in our previous study , we recoThe present surgical method is less invasive than the conventional open method. The capsule is not destroyed during the procedure, and a closed space is maintained for true soft tissue interpositional arthroplasty. Furthermore, this reduces the chance of damage to the radial sensory nerve branch. However, this procedure is technically demanding and could require longer operation time. This approach may not be suitable for patients with mild stage I and severe stage IV disease. Hemitrapeziectomy is unnecessary, and arthroscopic treatment alone is enough for patients with stage I disease. It could be contraindicated for patients with stage IV disease. An open procedure would be beneficial for patients with severe disease.This study has some inherent limitations. First, the number of patients was small, and the male to female patient ratio in the group was less than that reported previously –3. SeconArthroscopic partial trapeziectomy and soft tissue interposition could be an alternative treatment method for patients with Eaton stage II and III symptomatic thumb CMC arthritis. Longer-term follow-up would be more helpful to validate the superiority of this procedure to the conventional approach.


To evaluate the efficacy of computed tomography (CT) guided single radiofrequency thermocoagualtion (RFT) in 1137 patients with idiopathic trigeminal neuralgia after a follow-up period of 11 years, specially focused on duration of pain relief in different branches of trigeminal nerve, side effect, and complications.Retrospective study of patients with idiopathic trigeminal neuralgia treated with a single CT guided RFT procedure between January 2002 and December 2013.The mean follow-up time was 46.14 ± 30.91 months. Immediate postprocedure pain relief was 98.4%. V2 division obtained the best pain relief rate: 91%, 89%, 80%, 72%, 60%, and 54% at 1, 3, 5, 7, 9, and 11 years, respectively. No statistical difference pairwise comparison was in other groups. The complications included masseter muscle weakness, corneitis, diplopia, ptosis, hearing loss, limited mouth opening, and low pressure headache. Masticatory weakness mostly occurred in patients with V3 branch involvement, while Corneitis and Diplopia all in patients with V1 branch involvement. No mortalities observed during or after RFT.All different branches division of trigeminal neuralgia achieved comparable satisfactory curative effect; V2 obtained the best excellent pain relief, after RFT procedure. Facial numbness is inevitable after RFT, which patients who have pain in all 3 trigeminal divisions and patients who desire no facial numbness should be cautious. Masticatory weakness is mainly related with V3 injured, while Corneitis and Diplopia in patients with V1 injured by RFT. Fortunately, regardless the mechanism of ITN is currently not well known, various effective treatment modalities have emerged, and treatment guideline has been developed.4 Treatment options for ITN include medications and interventional procedures. First-line treatment should be medications, including anticonvulsant drugs, muscle relax, and neuroleptic agents. For patients who cannot tolerate the medications or with intractable pain, several neuro-surgical procedures  are available to treat ITN. Notably, each procedure has advantages and disadvantages, prompting the question as to which is most suitable for individual patients.Idiopathic trigeminal neuralgia (ITN) is presented as excruciating and causes serious impairments of the quality of life, with mean annual incidence of 12.6 per 100,000 person years.5 For such patients, ablative neurosurgical techniques may be used. Radiofrequency thermocoagulation (RFT) is reported to give higher rates of complete pain relief than either glycerol rhizolysis or stereotactic radio surgery.7 The procedure success rate of RFT approaches 100%, which is superior to that of MVD, which is only 85%. However, its long-term efficacy is lower.6 However, as well as being safe in elderly patients, and in those who are poor surgical risks, it has the advantage that it can be repeated, if required.8 Taha and Tew7 have proposed that neurosurgeons should gain proficiency in different techniques, so as to be able to offer the most suitable procedure for individual patients; MVD only being recommended for otherwise healthy patients with isolated pain in the distribution of the first division or of all 3 divisions of the trigeminal nerve, and in patients who desire no sensory deficit. However, Effective Rate of Different Branches on ITN is poorly known.MVD, although effective, is the most invasive and has a mortality rate of 0.2% to 0.5%. This makes it unsuitable for many elderly patients, and for others who are considered as poor surgical risks.In this study, we report a retrospective study analyzing the outcome in patients with ITN treated with a single RFT procedure. Especially focus was placed on the duration of pain relief of Different Branches of trigeminal nerve, side effect, and complications.Patients were eligible for inclusion if they had undergone RFT treatment for ITN in the Pain Department at our hospital between January 2002 and December 2013. ITN was diagnosed using the criteria of the International Classification of Headache Disorders-II (2004). The patients, if the duration of their symptoms was <2 years, or the characteristics of the pain had changed in the preceding 6 months, had to receive a Cranial magnetic resonance imaging (MRI) to exclude multiple sclerosis, carcinomatous pain, or other causes of STN. We obtained follow-up information on patients by telephone interviews and from their medical records. If patients had died, information was obtained from their relatives. If neither the patient nor a relative could be traced for telephone interview, the patients were considered as lost to follow-up. The study was approved by the local ethics committee. Informed written consent was obtained from all patients.9 After the RFT procedure, patients were put on strict bed rest for 2 days, to prevent intracranial hypotension (low pressure) headache. They were usually discharged from hospital on the 3rd postprocedure day. Carbamazepine, previously prescribed for pain control, was gradually weaned over a period of 1 week, postprocedure, to prevent withdrawal symptoms.Our RFT procedure has been reported previously in detail.Demographic, clinic, and RFT data were all recorded. With regard to the complications, particular attention was paid to reports of masseter weakness, corneal inflammation, hearing loss, ptosis, and difficulty opening the mouth.According to the different branches division of trigeminal nerve, all patients were divided in 6 groups: V1  group, V2 (maxillary division) group, V3 (mandibular division) group, V1 + V2 group, V2 + V3 group, and V1 + V2 + V3 group.9Methods of pain intensity evaluation, pain-relief  and facial numbness/dysesthesia (grades I to IV) classification according to our previous reported.P value of <0.05 was considered statistically significant.Kaplan–Meier survival curves and log-rank test applied in the evaluation of pain-free and dysesthesia-free after RFT. The censor point was: the last contact, the time of any subsequent surgery, or death. For statistical purposes, in patients who died, the duration of pain relief was assessed as the time from the procedure to the time of death. If a second RFT procedure on the same nerve during the same hospital stay was required, this was considered as a single procedure. If bilateral RFT procedures were undertaken on the same patient, this was treated as 2 procedures. All analyses were performed using SPSS for windows version of 17.0 . A The 1113 patients underwent unilateral RFT and 24 patients underwent bilateral RFT, for a total of 1161 single RFT in 1137 patients; 121(10.6%) patients lost to follow-up evaluation and postoperative pain relief or complications did not significantly predict loss to follow-up. The mean postoperative duration was 46.14 ± 30.91 months. According the original pain site, 42 (3.1%) only with V1 trigeminal neuralgia were enrolled in V1 group, 289 (21.2%) in V2 group, 288 (21.1%) in V3 group, 66 (4.8%) in V1 + V2 group, 381 (27.9%) in V2 + V3 group, 89 (6.5%) in V1 + V2 + V3 group, and 6 (0.4%) in V1 + V3 group. So, the highest incidence rate of distribution of trigeminal nerve is V2 + V3, and then V2, V3, V1 + V2 + V3, V1 + V2, the V1 division, and V1 + V3 division of pain alone is the lowest (Table P < 0.05), the log-rank test (for each stratum) did not show any statistical difference pairwise comparison in other groups.Excellent pain relief was achieved 88% at 1 year, 79% at 3 year, 72% at 5 year, 65% at 7 year, 57% at 9 years, and 52% at 11 years  patients within V1 distribution, 31 (10.8% of 289 patients) patients within V2 distribution, 51 (18.1% of 288 patients) patients within V3 distribution, 15 (24.2% of 66 patients) patients within V1 + V2 distribution, 0 (0% of 6 patients) patients within V1 + V3 distribution, 64 (17.2 % of 381 patients) patients within V2 + V3 distribution, and 16 (18.4% of 89 patients) patients within V1 + V2 + V3 distribution at after operation, for a total of 186 (16% of 1161 patients) patients had pain recurrence: 51 (4.4%) patients had medical treatment to control pain satisfactory; 135 (11.6%) patients underwent additional surgery, including repeat RFT (66); stereotactic radiosurgery (19); MVD (38); and percutaneous microballoon compression (12). Of 135, 14 (10.4%) did not achieve pain relief even after the additional surgery.The 983 patients (84.7%) had different degrees of facial numbness immediately after RFT; 57 patients have no facial numbness and 243 patients experienced facial numbness disappeared gradually with mean duration of follow-up of 31.4 ± 14.9 weeks; however, the complete pain relief of these patients was  lower than facial numbness patients . Seven hundred forty patients (63.7%) complained different degrees of facial numbness in the follow-up time, grade II in 398 (53.8%), grade III in 289 (39.1%), and grade IV in 53 (7.2%) patients. For the grade IV (painful dysesthesia), the incidence rate of V2 group is 1% (3 of 289 patients), V3 group is 9% (26 of 288 patients), V2 + V3 group is 3.7% (14 of 381 group), and V1 + V2 + V3 group is 11.2% (10 of 89 patients). Notably, all the patients said the facial numbness gradually reduced after the procedure.Other complications include: masseter weakness was observed in 91 (8%) patients, especially 87 patients with V3 involvement (96% of 91 patients); however, all of them improved during follow-up; corneitis was observed in 29 (2.6%) immediately after procedure, all of them with V1 involvement, they were all treated with artificial tears to improve symptom, unfortunately, 1 patient ignored our advice and lose her right eye sight eventually; 14 (1.2%) patients suffered from Diplopia, all of them with V1 involvement, 2 patients were left with permanent diplopia induced by abducens nerve palsy; 2 patients had cerebrospinal fluid leak and suffered from intracranial hypotension headache because they get up within 2 days; these 2 patients improved by rapid infusion and lie in bed absolutely 1 week. Another complications included dropping eyelid , limited mouth opening  patients, and hearing loss . All these patients improved during the follow-up. We did not experience an occurrence of cranial nerve paralysis, carotid-cavernous fistula. There were no mortality and no permanent cranial nerve deficit except dysesthesia.10 The heat produced by the RPF needle is thought to selectively destroy the Aδ and C pain fibers by thermocoagulation at temperatures above 65°C.11 This can prevent both triggering of pain and the intensity of pain, but can also cause numbness and other problems.12 A systematic review of ablative neurosurgical techniques for the treatment of trigeminal neuralgia found that when compared to glycerol rhizolysis and stereotactic radiosurgery, RFT achieves higher rates of complete pain relief, but is associated with more complications.6 MVD, which removes vascular compression at the root of the trigeminal nerve, is also reported to have a high success rate. Some14 surgeons consider that it should be preferred to RFT, as it provides pain relief without purposely damaging the gasserian ganglion, thereby avoiding numbness and dysesthesia. However, it is the most invasive technique, involving exploration of the posterior fossa, and when compared to ablative procedures, has a lower success rate.7 Moreover, it is not tolerated by some patients, especially those who are tomophobia and/or have multiple medical problems. It is associated with significant risks, including of mortality. A nationwide study of 3 invasive treatments for trigeminal neuralgia: partial sensory rhizotomy; RFT; and MVD, concluded that, although the likelihood of a repeat procedure being required was less with partial sensory rhizotomy and MVD, when compared to RFT, they were associated with a higher risk of complications requiring hospital readmission.13 Percutaneous techniques have been proposed as safer and more effective alternatives. A number of authorities restrict the use of MVD for treatment of trigeminal neuralgia to younger patients,15 and prefer RFT for older patients and/or those who are in poor health.16 Although we maintain some flexibility, our practice is to use RFT to treat those over 50 years of age, those considered to be poor surgical risks, and those who wish to avoid a craniotomy.Nowadays, there are mainly 2 treatment options for trigeminal neuralgia (TN): ablative neurosurgical techniques  and MVD. There are not any well-established guidelines on the choice of surgical intervention, each technique possess certain attributes and limitations. RFT of the trigeminal gasserian ganglion has been popularized since 1974, as an effective treatment which is less invasive than some alternatives.16 The longest follow-up (20 years) outcomes after RFT reported the complete relief rate was 57.7%, 52.3%, 42.2%, and 41.0% at 5, 10, 15, and 20 years, respectively, despite lack of data within 5 years.17 As we know, the pain relief rate of RFT of different branches division of TN has not been reported before. In our study, we provide the most detailed data after RFT within 11 years follow-up. Each branches division underwent RFT obtained a good curative effect, they are in agreement with those of previous studies. However, the V2 branches division of pain alone achieved better “excellent” pain relief than other division, which indicate V2 branches has higher curative effect underwent RFT. Moreover, our treatment outcome in our patients receiving RFT was better than previous reports.In our retrospective study, excellent pain relief in all patients was 88% at 1 year, 79% at 3 year, 72% at 5 year, 65% at 7 year, 57% at 9 years, and 52% at 11 years. A previous review of the treatment option in TN reported the success rate of pain free was 68% to 85% at 1 year, 54% to 64% at 3 years, and 50% at 5 years after RFT.19 With X-ray fluoroscopy miss-insertion into the foramen spinosum, jugular foramen, inferior orbital fissure, or internal carotid artery are appreciable risks. The better visualization of bone and soft tissue with CT minimizes this. CT guided gasserian ganglion puncture is considered safe and effective.20 In our study, we correctly located the gasserian ganglion in all patients. Our findings support CT over X-ray fluoroscopic guidance.A possible explanation of our better treatment outcomes was that we used computed tomography (CT), rather than X-ray fluoroscopic, guidance to enable the cannula to be passed through the foramen ovale to access the gasserian ganglion, which is located on the floor of the middle cranial fossa. X-ray fluoroscopic guidance improves the ability to locate the ganglion, but with it there remains an appreciable failure rate, reported to be between 4.Modern medicine seeks to develop more efficacious, less invasive surgical treatments, with quicker recovery and fewer complications for the patient. RFT satisfies the first 3 of these aims. A relatively high incidence of adverse effects is its principle drawback, limiting its more widespread use.21 Our radiofrequency temperature was agree with their reported. Facial numbness or painful dysesthesia is a serious side effect of RFT that affects the quality of life. For this reason, we further study the painful dysesthesia occurred in different branches division. We found V1 + V2 + V3 and V3 of pain alone have the higher incidence rate of painful dysesthesia and it mainly occurred in patients with V3 involvement. We inferred this maybe related with higher temperature on V3 branch. The optimal RFT temperature requires further study. Our study showed facial numbness occurs in a high percentage of patients undergoing RFT procedure; fortunately, facial numbness of most patients after RFT is mild, limited, and well tolerated. However, patients with V1 + V2 + V3 branches involvement usually have numbness in the entire face, this is not well tolerated. Therefore, we recommend RFT for patients who have pain in all 3 trigeminal divisions and patients who desire no facial numbness should be cautious.Postoperative facial numbness is common following RFT. It usually accompanies the relief from pain. Temperatures of over 65°C are known to destroy nerve fibers, with the Aδ and C fibers nociceptive fibers, being destroyed at lower temperatures than are required to destroy the Aα and Aβ tactile fibers. So we choose 65 to 85°C as our radiofrequency temperature in procedure. Usually, V1 branches division choose 65 to 70°C, while V2 and V3 choose higher temperature (75–85°C) for avoiding cornea and trochlear nerve damage. Generally temperatures of between 55 and 85°C are used during RFT to treat trigeminal neuralgia.17 These complications were all transient, except 1 patient who lost vision from corneitis, and another 2 patients with permanent diplopia. We found that masticatory weakness mostly occurred in patients with V3 branch involvement (96%). Masseteric nerve and masseteric nerve (originated from the V3 branch) were injured by radiofrequency is the main reason. Our previous study22 clarified that a high rate of masticatory weakness using surface electromyographic activity examination of the ipsilateral anterior temporalis and masseter muscles; however, it would gradual improved to preoperative value in 12 months, which indicated masticatory weakness is only a temporary symptom after RFT. Corneitis is an especially important risk; we tested corneal reflection for each patient after RFT. If there is impaired corneal reflection or other uncomfortable symptoms of eyes, the patients require ophthalmology consultation immediately. We proposal artificial tears is a good medication for this complication, except 1 patient ignored our advice and lose her right eye sight eventually. Diplopia is a complication when abducens nerve was damaged by the RFT procedure, 2 patients were left with permanent diplopia induced by abducens nerve palsy. Corneitis and Diplopia maybe related with the cornea nerve (originated from V1 branch) and abducens nerve were injured in procedure. Because the V1 branch and abducens nerve is located in the deep and rear of Semilunar ganglion, respectively, when V1 involvement, the needle need puncture to the deeper position through foramen oval than V2 or V3 involvement, so the cornea nerve and abducens nerve more easily injured. Corneitis and Diplopia were all found in patients with V1 involvement also confirms this. Intracranial hypotension headache intracranial hypotension headache could be occurred when the needle puncture the wall of Meckel's cave. It is usually happened when the needle inserted to oval foramen, cerebrospinal fluid could be drained out of the hole on the wall of Meckel's cave. The patients should lie in bed absolutely for 2 days to prevent intracranial hypotension headache induced by cerebrospinal fluid outflow, because 2 patients suffered from this symptom who stood up 1 day after operation. After 2 days lie in bed absolutely after surgery, no one has intracranial hypotension headache occurred. There were no mortalities or life-threatening morbidities observed during or after RFT.Our rates for complications including masseter muscle weakness, corneitis, low pressure headaches, diplopia, hearing loss, ptosis, and limitation of mouth opening are similar to other published series of RFT to treat trigeminal neuralgia.CT guided RFT is a safe and effective procedure for ITN patients. It is an attractive treatment can give eligible patients a high success rate with less invasive. From our data, all different branches division of trigeminal neuralgia achieved comparable satisfactory curative effect; V2 obtained the best excellent pain relief, after RFT procedure. Facial numbness should be considered as an expected side effect rather than an unexpected complication, if prolonged freedom from pain is to be achieved. Patients who have pain in all 3 trigeminal divisions and patients who desire no facial numbness should be cautious. Masticatory weakness is mainly related with V3 branch RFT, while Corneitis and Diplopia with V1 branch RFT.


This study assessed pain and observed physiological parameters in sedated andmechanically ventilated children during a routine procedure.This observational study was performed in a pediatric intensive care unit.Thirty-five children between 1 month and 12 years of age were assessedbefore, during, and five minutes after an arterial blood collection for gasanalysis (painful procedure). Face, Legs, Activity, Cry and Consolabilityscale was used to assess pain. In addition, patients' heart rate,respiratory rate, peripheral saturation of oxygen and blood pressure(diastolic and systolic) were recorded. COMFORT-B scale was applied beforethe pain and physiological parameter assessments to verify sedation level ofthe subjects.There was an increase in Face, Legs, Activity, Cry and Consolability score (p= 0.0001) during painful stimuli. There was an increase in heart rate (p =0.03), respiratory rate (p = 0.001) and diastolic blood pressure (p = 0.006)due to pain caused by the routine procedure.This study suggests that assessments of pain using standard scales, such asFace, Legs, Activity, Cry and Consolability score, and other physiologicalparameters should be consistently executed to optimize pain management inpediatric intensive care units. The myths that children do not feel pain in a similar manner to adults and that paindoes not cause problematic consequences prevail, despite the evidence of pain perception beginning at thegestational period.The association between pain and negative physiological, emotional and psychologicalsymptoms is well established.For an adequate pain management, an appropriate assessment is necessary. Pain inchildren is underestimated due to a lack of adequate assessment tools based ondifferent developmental stages and clinical conditions and the fear of oversedation,respiratory depression, addiction or unfamiliarity with use of sedative andanalgesic agents in children. However, sedoanalgesia is not anadequate treatment because ofthe difficulty in measuring pain with the scales developed and validated for thispopulation. In addition, a lack of clinical knowledge, insufficient studies andunknown side effects caused by opioids make effective pain control an unusualpractice in the PICU.In pediatric intensive care units (PICU), pain assessment is difficult, particularlyin sedated patients under mechanical ventilation. It is often not possible todistinguish between pain and anxiety, even though both must be treated at the sametime. Mechanically ventilated newborns and children are exposed to acute illnesses.The PICU environment can produce anxiety and pain caused by routine procedures, suchas tracheal suctioning, arterial blood collection and venipuncture.-12Face, Legs, Activity, Cry and Consolability (FLACC) behavioral scale was developed toreduce the existing barriers in the measurement of pain in children. This scale isconsidered easy to apply and shows excellent validity and reliability when used todemonstrate a change in pain scores before and after analgesic medicineadministration in children. and pain was measured by nurses during endotrachealsuction. However, nopublished studies have used the original FLACC scale to assess pain in childrenunable to self-report during other routine PICU procedures. Thus, this studyassessed pain and measured physiological parameters in pediatric patients sedatedand mechanically ventilated during a routine PICU procedure .This scale was previously used in sedated and mechanically ventilated children on twooccasions: Modified FLACC and COMFORT-B scales were used to analyze psychometricalproperties in the Swedish population,Hospital de Urgências de Sergipe in Aracaju, Sergipe,Brazil. After approval by the Universidade Federal de SergipeEthics Committee (CAAE: 6139.0.000.107-10), patients' legal conservators wereinformed about the aims of the study, and signed consent forms were obtained for allparticipants.This descriptive and observational study was performed in the PICU at theParticipants were chosen from patients admitted to the PICU based oninclusion/exclusion criteria. Children under sedation and mechanical ventilation(assisted-control mode) between 1 month and 12 years of age were included. Victimsof trauma with a level lower than 8 on Glasgow coma scale and patients withdrug-induced neuromuscular blockade were excluded. All subjects were recruited priorto an arterial blood collection for gas analysis. This invasive sample collectiontechnique is routinely performed to monitor mechanically ventilated patients. Theblood draw was performed using a 1mL syringe with a subcutaneous needle and no localanesthetics. The amount of blood collected varied between 0.5 and 1mL. was used toverify the sedation level. Based on this scale, patients can be classified as"excessively sedated" (score between 6 and 10), "sedated" (scores between 11 and 22)and "insufficiently sedated" (scores higher than 23). In this study, only patientsconsidered "sedated" were included.The COMFORT-B scaleAfter establishing the sedation level, pain and physiological parameters wereassessed by a single investigator at three different time points: immediately beforethe arterial blood collection for gas analysis (TPre), during the routine procedure(T0) and five minutes after the procedure (T5). was used tomeasure pain. Each of the five categories used in this assessment is scored from 0to 2 with a total score ranging from 0 to 10. A score of "0" is considered asrelaxed or comfortable, "1 - 3" represents mild discomfort, "4 - 6" representsmoderate pain and "7 - 10" signifies severe pain and/or discomfort. The cardiacmonitor Dash 4000 was used to monitor the respiratory rate (RR), heart rate (HR),peripheral oxygen saturation (SpO2) and blood pressure (BP) of thechildren.The FLACC scaleth and 75th percentile(non-parametric). Categorical data are represented as the frequency or totalcount.The software Statistical Package for the Social Science (SPSS) version 19.0 wasused for statistical analysis. The Shapiro-Wilk test was used to verify datanormality. Quantitative data are presented as the mean and standard deviation(parametric) or as the median and 25To compare FLACC scores from the three assessment moments, the Friedman's testfollowed by the Dunn's post-hoc test was used. Comparisons between painintensity and physiological parameters were performed using a repeated-measureANOVA adjusted for age and Bonferroni post-hoc tests adjusted for confidenceintervals (95%CI).Cronbach's alpha was calculated to analyze intra-rater reliability across thethree assessments completed by a single investigator. A p-value ≤ 0.05was considered statistically significant, the power was set at 0.80, and alltests were two-tailed.Thirty-five patients with a mean age of 5 months (p25 = 3 months and p75 = 19 months)were assessed. The frequency of males and females was 60% and 40%, respectively. Themain diagnoses included seven patients (20%) with pneumonia, 6 patients (17.1%) withacute respiratory insufficiency, 5 patients (14.3%) with sepsis and 4 patients(11.4%) with congenital heart disease.Midazolam was the most frequently used drug for sedoanalgesia (77.1%), followed byfentanyl (65.7%), phenytoin and phenobarbital (14.3% each). All study participantswere considered sedated (n = 35) with a COMFORT-B score between 11 and 22 . None of the subjects were excessively or insufficientlysedated during the assessment. Only 3 (8.6%) children received analgesic medicationprior to the painful procedure.The FLACC scores varied from 0 to 6 with means of 0 (TPre), 3 (T0) and 0 (T5). Duringblood collection (T0), the pain intensity was significantly higher than before theprocedure (TPre moment) and five minutes after the procedure (T5) (p = 0.0001).However, no difference was observed between the pain intensities recorded at TPreand T5 .Approximately 83% of the patients presented with a painful perception during bloodcollection (T0) that varied from a small level of discomfort to an intense pain. An intr2 levels betweentime points (p = 0.4)  when compared with the other time points .The systolic blood pressure (SBP) showed a homogenous distribution across the threeassessments (p = 0.45). The diastolic blood pressure (DBP) was significantly higherat T0 (p = 0.006). The DBP at T5 what higher than at TPre (4.7 ± 2.1);however, the difference was not statistically significant (p = 0.09). In addition, this tool is valid and reliable forthe assessment of postoperative pain assessment in children and teenagers (from 4 to18 years old) with cognitive impairment.Pain assessment in sedated and mechanically ventilated pediatric patients usingvalidated tools is considered important for clinical practice. The necessity for aspecific pain scale in the PICU was evidenced in the present study. In our study,the FLACC scale was chosen because of its large applicability to a wide range ofages within the pediatric population. In accordance with previous studies, the FLACCscale is effective as a pain assessment tool for use by hospital units  in children less than 3 years old. studied the importance of nebulization with lidocaine forreducing pain intensity during nasogastric tube insertion in children. This groupobserved that the FLACC scores were higher during this procedure and that thelidocaine group  had lower scores when compared with the controlgroup.Our results showed a significant variation in FLACC scores during an arterial bloodcollection for gas analysis from mechanically ventilated and sedated children. Thesedata suggest that despite the use of sedoanalgesia and an adequate COMFORT-Bsedation score, patients exhibited a FLACC score ranging from mild discomfort tomoderate pain. Similarly, Babl et al.,17-21 and areroutinely observed in intensive care units, especially in patients under sedation,due to the completely erroneous impression that the patient does not feel pain.Indeed, we clearly observed that behavioral and physiological parameters changedwhen a painful stimulus was applied to our subjects.In addition to intubation, other painful procedures are performed in the PICU withoutanalgesia. These methods have been reported in previous studies Similarly,Voepel-Lewis testedthe reliability and validity of this scale in critically ill adults and childrenunable to self-report pain (intubated or with cognitive impairment) and reported aCronbach's alpha of 0.882. Darnell et al. and Babl et al. reported that the FLACC scale is a valid and reliableassessment tool for pain in the pediatric population and pain related to proceduresin children at pre-verbal and verbal ages.Based on our findings, the FLACC scale can be used to measure pain in sedated andmechanically ventilated children with high reliability .These findings are in accordance with previous FLACC assessments collected fromchildren and adolescents in Brazil . also observed a significantincrease in HR (10%) and BP during painful procedures in patients sedated andmechanically ventilated. Additionally, Weissman et al. reported that HR is frequently used as aphysiological parameter for harmful events and as a complementary measure to detectautonomous nervous system conditions during painful procedures. In contrast, Pereiraet al. observed a decrease inHR during and one minute after a painful procedure  in newborns in intensive care units. Notably, asubsequent increase in HR at 5 minutes after the procedure was observed by Pereiraet al. Our study indicated that the HR returned to baseline by this time (fiveminutes after the painful procedure).In conjunction with the variation in FLACC scores, we observed an abrupt increase inRR and HR during the painful procedure. Aïssaoui et al.2) levels were not found inthis study, and thus cannot be considered as a valid parameter for the directassessment of pain in mechanically ventilated children. In contrast, two previousstudies,26 observed a consistent and acute decrease inoxygen saturation levels during and right after a painful procedure. These data suggest that saturation levelsare a valid parameter for pain assessment in newborns and children. However, thesestudies also highlight that SpO2 levels may have a low specificitybecause it can be changed by other non-painful causes in these subjects.Changes in peripheral oxygen saturation , even when it was performed with the application ofanalgesics in critically ill subjects. In addition, the DBP increased during thepainful procedure, but this increase could be counteracted with the application ofanalgesics. Miranda etal. demonstratedsimilar results in postoperative cardiac patients. However, unlike our study, thisgroup found no significant correlation between SBP, DBP and pain.In our study, the SBP was maintained with no significant changes. Unlike otherphysiological parameters, the DBP increased during the painful stimulus and remainedhigh five minutes after the procedure. Jeitziner et al.,29 Thus,we expected an increase in the SBP and DBP of our patients. Partly confirming ourfindings, Buttner and Finkeaffirmed that physiological parameters, such as HR, RR and blood pressure, havelittle discriminating power to the detect postoperative analgesia need in newborns,infants and young children.Acute pain has a biological purpose, including signaling that an organic injury hasoccurred and stimulating the sympathetic nervous system to evoke physiologicalresponses, such as an increase in HR, BP and RR. provedinter-observer reliability and the construct validity of the Swedish COMFORT-B andmodified FLACC scales (with changes in "cry" item) by detected a decrease in painintensity after morphine administration in postoperative children. Furthermore,Sönmez and Kuğuoğludemonstrated the importance of pain control and sedation by detecting lower FLACCand Wong-Baker Faces scores in subjects who received analgesia and a bolus ofsedatives during endotracheal suctioning when compared with patients who did notreceive pain management. In accordance with our findings, these studies show thatpain and sedation assessments can be used in conjunction to improve pain managementin the PICU.Johansson and KokinskyWe conclude that mechanically ventilated and sedated children feel pain, asdemonstrated by the Face, Legs, Activity, Cry and Consolability scale. Our studyshows that this scale is reliable for measuring pain in children who are intubatedand unable to self-report. High pain intensity scores and changes in heart rate,respiratory rate and diastolic blood pressure during an arterial blood collectionfor gas analysis confirm our hypothesis. Thus, pain should be assessed in amultidimensional approach by incorporating physiological parameters, whichseparately are nonspecific, with objective measurements based on standardized scalesthat provide information on individual pain responses.Healthcare professionals often assume that sedation is an adequate routine practicethat provides effective pain control; however, a child´s inability to verballyexpress discomfort does not mean that pain is not being experienced. Thus, thisstudy aims to alert health professionals to the importance of appropriatelyassessing pain in children, especially in patients for whom it is difficult toverbally expressing painful sensations.


Preoperative identification of individual sensitivity to opioid analgesics could improve the quality of postoperative analgesia. We explored the feasibility and utility of a real-time assessment of sufentanil sensitivity in predicting postoperative analgesic requirement.P < 0.001) 5 minutes after sufentanil infusion, and the percent change in pricking pain threshold was positively associated with sufentanil requirement at 12 and 24 hours after surgery . A receiver-operating characteristic curve analysis showed that patients with a change in pricking pain threshold >188% were >50% likely to require more sufentanil for postoperative pain control. In the exploratory study, experimental pain thresholds significantly decreased after the operation (P < 0.001), and we observed a positive correlation (P < 0.001) between the percent change in pricking pain threshold before and after surgery. Preoperative detection of individual sensitivity to sufentanil via the above described real-time method was effective in predicting postoperative sufentanil requirement. Thus, percent change in pricking pain threshold might be a feasible predictive marker of postoperative analgesia requirement.Our primary study included 111 patients who underwent measurements of pressure and quantitative pricking pain thresholds before and 5 minutes after sufentanil infusion. Pain intensity was assessed during the first 24-hour postsurgery, and patients who reported inadequate levels of analgesia were excluded from the study. The sufentanil requirement for patient-controlled analgesia was recorded, and a subsequent exploratory study of 20 patients facilitated the interpretation of the primary study results. In the primary study, experimental pain thresholds increased ( However, some potential limitations impede the clinical application of these methods. For example, genotype screening is time-consuming and may need further validation, whereas measurement of the pupillary reflex can be confounded by other medications such as anticholinergic agents. Therefore, it is still necessary to explore definitive, rapid, and low-cost strategies for predicting the necessity of postoperative opioid analgesic treatment.Despite the development of numerous approaches in managing acute postoperative pain, the issue remains a relevant clinical challenge. Other studies have also used experimental pain measures to determine opioid sensitivity in patients with chronic pain or healthy volunteers.–12 However, it is still unclear whether such real-time measures can predict opioid dose requirement. Therefore, the present study assessed the potential of this method to predict postoperative analgesic requirement using sufentanil, an opioid commonly used in China for anesthesia induction and postoperative pain management.,14Recently, we investigated individual sensitivity to fentanyl via a real-time method that measured experimental pain before anesthesia induction in the operating room.,15,16 Thus, we speculated that the association between OIH level and sensitivity to sufentanil may have contributed to the findings of our primary study. We therefore performed an exploratory study to test our hypothesis and to aid in the interpretation of our results.Unexpectedly, our study demonstrated a correlation between higher preoperative sufentanil sensitivity and increased analgesic requirement for postoperative pain control. This counterintuitive result requires further investigation. Patient exposure to opioids during preoperative and intraoperative periods is known to cause opioid-induced hyperalgesia (OIH), which is one of the primary causes of increased analgesic requirement.22.1The study was approved by the Huazhong University of Science and Technology Tongji Hospital Ethics Committee (approved ID: 2012–098), and written informed consent was obtained from all patients before their enrollment.As shown in Fig. 2.22) were monitored. All patients were preoxygenated with 6 L/min oxygen via a facemask for 3 minutes before the study onset.Investigators screened potential study participants in the gynecological ward 1 day before the patients’ scheduled operations. Standardized instructions were given for the study procedure, and mechanical pain sensitivity tests were performed using the left forearm to familiarize subjects with the testing procedure at the outset of each testing session. After patients entered the operating room on the day of their scheduled surgeries, electrocardiogram, blood pressure, heart rate (HR), and pulse oxygen saturation  and 5 minutes after (T2) sufentanil infusion, mechanical pain sensitivity was measured. HR, SpO2, and blood pressure  were also recorded.Based on the experience of our previous study,19 a hand-held electronic mechanical algometer  was used to measure mechanical pain sensitivity as defined by the pressure pain threshold (PPT) and pressure pain tolerance (PTO) with 0.1 cm2 probes. We also measured the quantizing pricking pain threshold (QPT) using the mechanical algometer and a 0.01 cm2 probe.Similar to previous studies,,20 The investigator applied the algometer for the pressure pain test at location 1, which corresponded to the lateral brachioradialis of the elbow joint. For the pricking pain test at location 2, the investigator applied the algometer to the midpoint of the medial and lateral borders of the wrist. A standardized procedure was used for all subjects, who were asked to say “pain” when they started to feel pain (PPT or QPT) during stimulation and “okay” when the pain became intolerable (PTO). This procedure was repeated 1 minute later, and the average of the 2 measurements was calculated.Two test locations were selected on the right forearm for the stimulus-evoked pain tests Fig. A.2.4Standardized general anesthesia was administered to all patients after the testing procedure using 0.05 mg/kg midazolam, 2 mg/kg propofol, 0.3 μg/kg sufentanil, and 0.6 mg/kg rocuronium. Anesthesia was maintained with a combined intravenous and inhalation approach: inhalation of 1% to 2% sevoflurane, infusion of remifentanil (0.2 μg/kg/min) and propofol (6–10 mg/kg/h), and intravenous boluses of 0.2 mg/kg rocuronium. The depth of anesthesia was monitored using a Narcotrend instrument , and the Narcotrend index was controlled within the range of 20 to 46.2.5Standard analgesia according to protocols of the acute pain service (APS) in our hospital, including preoperative analgesia and postoperative intravenous PCA, was provided for all patients. For postoperative pain management and prevention of postoperative nausea and vomiting (PONV), 40 mg of parecoxib sodium and 2 mg of tropisetron hydrochloride were administered 15 minutes before incision. PCA was started immediately after surgery using a controlled infusion pump containing sufentanil at 100 μg/100 mL.The pump was programmed to use a loading dose of 2 mL, background infusion at 1.5 mL/h, PCA dose of 1 mL, and lockout period of 10 minutes. Patients were monitored for 30 minutes in the postanesthesia care unit.In the first 24 hour after surgery, all patients received PCA and were followed up by the investigator. When a patient reported inadequate analgesia (defined as presenting VAS >40—even after timely adjustment of the PCA pump), additional medications  were provided; however, it should be noted that such patients were excluded from the final analysis. Sufentanil consumption at 12 and 24 hours after surgery was recorded from the PCA pump and analyzed as μg/kg body weight. Adverse effects such as respiratory depression, pruritus, and PONV were also recorded.2.6,23 As in the primary sample, individual sensitivity to sufentanil was evaluated using pressure pain  and pricking pain (QPT) measurements before anesthesia induction. Similar to previous studies, the sites near the surgical incision were considered to evaluate postoperative hyperpathia  was used for the PPT and PTO, whereas test location 4 (left side of the anterior superior iliac spine) was selected for the QPT. Patients in the exploratory study underwent additional PPT, PTO, and QPT measurements at 8 hours (T3), 16 hours (T4), and 24 hours (T5) after the operation.An additional 20 patients were recruited to validate the occurrence of OIH and its possible association with sufentanil sensitivity. In this exploratory sample, OIH was evaluated using mechanical measurement methods.2.7In the primary study, a maximum of 9 independent variables were included in the final multivariate linear stepwise regression analysis. Therefore, a sample size of 100 was considered sufficient for the study. For the exploratory study, a minimum of 10 individuals was required for a repeated analysis of variance (ANOVA); this figure was based on an estimated 20% change in postoperative QPT at a significance level of 0.05 and power of 0.9 using the sample size calculation software tool, PASS version 11.0 .t test was used to compare PPT, PTO, QPT, HR, MAP, and SpO2 at T1 and T2. Individual sufentanil sensitivity was calculated as the percent change in PPT, PTO, and QPT after sufentanil infusion at T2 versus T1. A Pearson correlation analysis was used to compare the 12 and 24-hour PCA sufentanil requirement with preoperative data including age; body max index (BMI); basal pain sensitivity including PPT, PTO, and QPT at T1; the percent change of PPT, PTO, and QPT; and the duration of surgery. Then, multivariate linear stepwise regression models were used to evaluate the preoperative data as predictors of the postoperative PCA sufentanil requirement at 12 and 24-hours.All variables were summarized using standard descriptive statistics, such as the mean, standard deviation (SD), and frequency. Paired-samples In the exploratory study, a repeated ANOVA was used to compare experimental pain sensitivity at different time points, and least significance difference (LSD) testing was used for multiple comparisons. The percent change in PPT, PTO, and QPT at preoperative T2 and postoperative T3, T4, and T5 versus T1 was calculated. A Pearson correlation analysis was used to compare the preoperative and postoperative percent change in PPT, PTO, and QPT.P < 0.05was considered statistically significant.We also calculated the unilateral 90% normal reference value for postoperative sufentanil consumption and defined patients with postoperative sufentanil consumption above this value as “excess requirement patients.” An exploratory receiver-operating characteristic (ROC) analysis was performed to determine optimal cut-off values for excess requirement, and the area under the curve (AUC) was calculated to assess the overall predictive accuracy of the percent change in QPT. Statistical analyses were performed using SPSS for Windows version 17.0 ; a 2-tailed 33.12 <90%, and 3 patients chose to withdraw from the primary study. To ensure that postoperative sufentanil consumption was similar for all patients, and to avoid the confounding effect of additional medications, 8 patients were excluded for inadequate postoperative analgesia. However, all patients in the exploratory study completed the study procedure. Therefore, in the final analysis, 100 patients were included in the primary study and 20 patients were included in the exploratory study. Demographic data are shown in Table In total, 131 female patients were recruited into the primary and exploratory samples  and there was no significant change in HR, MAP, and SpO2 at 5 minutes after infusion  and negatively correlated with preoperative basal QPT . Thus, the final predictive model was developed through a multiple regression analysis of the postoperative sufentanil requirement, and basal QPT and percent change in QPT were included. Collinearity diagnostics for basal QPT and percent change in QPT showed that the variance inflation factor (VIF) was 1.229, indicating that these 2 factors were independent of each other.As shown in Table r2 = 0.138, P < 0.001). The percent change in QPT alone provided the best predictive model for total sufentanil requirement within the first 24 hours after surgery . Regression coefficients for the percent change in QPT for predicting12 and 24-hour sufentanil requirements were positive (0.226 and 0.335). These findings indicated that the percent change in QPT was an independent predictor, and that patients who were more sensitive to sufentanil required more sufentanil for postoperative pain control.As shown in Table 3.4P > 0.05; Fig. r2 = 0.814, 0.811, and 0.794, respectively; P < 0.001 for all).Measurements of PPT, PTO, and QPT at the anterior superior iliac spine are shown in Table 3.5P = 0.017) at 12 hours and 0.758  at 24 hours after surgery  for postoperative pain control, which was inconsistent with the intuitive assumption. This unexpected association prompted us to further investigate our findings. One of the primary causes of greater analgesic requirement is OIH, which may be induced by intraoperative remifentanil or other opioids.,15,16,33 Thus, under the conditions of the primary study, we hypothesized that OIH might cause a correlation between preoperative sufentanil sensitivity and postoperative analgesic requirement.Our primary intuitive assumption was that a patient who was more sensitive to opioid analgesia would have a lower dose requirement for postoperative analgesia. However, in our study, patients with a higher percent change in QPT required more sufentanil  near the surgical incision were significantly lower after surgery than before, indicating increased pain sensitivity after surgery. Thus, OIH was a factor in the current study. We also found that the percent change in QPT after preoperative sufentanil infusion was positively associated with the percent change in QPT at postoperative time points, indicating that patients with a higher sensitivity to sufentanil were more likely to experience higher levels of postoperative OIH. Taken together, the results of our exploratory study supported our primary findings that patients with higher sensitivity to sufentanil had greater risk of requiring more sufentanil for postoperative pain control.Previous studies have shown the utility of quantitative sensory testing (QST) for the clinical assessment of OIH.Our findings pose several potential advantages to opioid application in postoperative pain treatment. In the clinic, opioid analgesics are essential for anesthesia induction and postoperative pain control. In the present study, we used sufentanil sensitivity to predict sufentanil requirement without disrupting clinical routines or increasing costs. Additionally, our method can easily be applied to determine individual sensitivity to sufentanil before anesthesia induction in the operating room, as the assessment requires only a few minutes. Furthermore, we found that patients with higher sensitivity to sufentanil would need more sufentanil for postoperative pain treatment, as supported by the results of our secondary exploratory study. Most importantly, our ROC diagnostic analysis yielded an optimal cut-off value for predicting “excess” postoperative sufentanil requirement based on the percent change in QPT. The cut-off value for percent change in QPT (188%) may be useful as a marker for predicting increased postoperative sufentanil requirement and therefore could be used to facilitate the choice of more effective postoperative pain treatment strategies when using sufentanil. The preoperative predictive method and ROC diagnostic analysis might also be used as an effective tool for predicting the response to other opioid analgesics in postoperative pain control.Several limitations should be considered when interpreting the results in the current study. First, to obtain a more accurate analysis of the association between the preoperative detection of sufentanil sensitivity and postoperative analgesic requirements, only female patients who received gynecologic surgery under general anesthesia were included in the current study. Thus, the results of the current study were based on a specific cohort, and further validation using another independent cohort is needed to strengthen these findings. Second, the ROC curve analysis was only built on data from the initial study; therefore it remains unclear whether the translation of the ROC cut-off value to other surgeries, populations, and anesthetics will be useful.In conclusion, our findings demonstrate that preoperative detection of individual sensitivities to sufentanil by means of experimental pain measurements could predict postoperative analgesic requirements in patients undergoing gynecologic surgery. Further, our findings suggest that the percent change in QPT may serve as a marker for predicting postoperative sufentanil requirements in the future. Finally, the observed positive association, that is, “higher sensitivity but increased requirement,” may provide a novel viewpoint for good application of opioid analgesics in the perioperative period.


Complex regional pain syndrome or CRPS includes painful conditions characterised by persistent pain, confined to a particular region of the body that is seemingly disproportionate to the initiating injury. The pain is usually associated with any of the following: abnormal sensory, motor, sudomotor, vasomotor or trophic changes, and shows variable progression over time. Many CRPS patients have severe pain and disability as well as impact on sleep and mood, and are often challenging to manage.Management must begin with a thorough assessment of symptoms and signs as well as the psychosocial impact of the pain. The diagnosis of CRPS is usually a clinical one with no specific confirmatory tests required, and treatment should take a multidisciplinary, multimodal approach, with the overall aim of improving not just pain but more importantly, function and mood. Modalities of treatment include medications, interventions (sympathetic nerve blocks), physical therapy and psychological therapy.despite persistent pain.Appropriate medications include antineuropathic agents including tricyclic antidepressants, serotonin-noradrenaline reuptake inhibitors (SNRIs) and anticonvulsants like the alpha2delta ligands. Exercise and rehabilitation with aim of return of function is a crucial part of the management; often, pain prevents the patient from doing effective exercise, and use of opioid medications (weak opioids like tramadol or even strong opioids like oxycodone) may be necessary to enable patients to start their physical therapy. Other modalities of treatment include Mirror therapy and sympathetic blocks . All patients must also be taught to do relaxation and to use it to manage their pain. Patients who are very disabled by their pain, especially those whose pain does not decrease with appropriate medications, may require cognitive behavioural interventions including intensive pain management programs which teach patients how to function normally Our experience in Selayang hospital with patients with difficult-to-manage CRPS will be discussed in the presentation.


Objectives: To compare the three non-steroidal anti-inflammatory agents (NSAIDs) diclofenac potassium, etodolac and naproxen sodium in relation to pain, swelling and trismus following impacted third molar surgery.Study Design: The study was a randomized and a double-blinded study which included 42 healthy young individuals with impacted third molars and bone retention. Patients were randomly assigned to 3 groups (n: 14) to which diclofenac potassium, naproxen sodium and etodolac were administered orally an hour before the operation. Impacted third molars were surgically extracted with local anaesthesia. Visual analog scales (VAS) were used to assess the pain in the 6th, 12th hours and on the 1st, 2nd, 3rd, 5th, and 7th days postoperatively. Swelling was evaluated using ultrasound (US) and mouth opening (trismus) was measured with a composing stick pre and post operatively on the 2nd and 7th days respectively. Results: Regarding pain alleviation, diclofenac potassium was better than naproxen sodium and naproxen sodium was better than etodolac but these differences were not statistically significant. US measurements showed that the swelling on postoperative 2nd day was significantly lowest with diclofenac potassium as compared to others (p= 0.027) while naproxen sodium and etodolac acted similarly (p=0.747). No difference was noted regarding trismus in any of the groups.Conclusions: NSAIDs  are somehow similarly effective for controlling pain and trismus following extraction of mandibular third molars but diclofenac potassium surpasses others in reduction of swelling. Key words:Diclofenac potassium, naproxen sodium, etodolac, impacted third molar surgery, pain, swelling, trismus. The surgical removal of impacted third molars is one of the most frequently performed procedures in oral surgery and afterwards complications such as post-operative pain, swelling and trismus may occur . As prosNon-steroidal anti-inflammatory drugs (NSAIDs) are regarded as effective medications in the management of pain and other discomforts associated with oral surgery and exert their therapeutic effect through inhibition of cyclooxygenase (COX), which inhibits prostaglandin production whose synergistic interactions with other mediators promote local inflammatory reactions and hyperalgesia. Traditionally, two isoforms of COX are known: COX-1, a constitutive form expressed in almost all tissues which is responsible for the routine physiological functions of prostanoids, including gastric mucosal protection and vascular homeostasis and COX-2, which is found in a limited number of tissues such as kidney, prostate and brain which is primarily responsible for the synthesis of prostanoids and mediation of responses to pathological processes, such as inflammation, pain and fever . NaproxeNaproxen sodium is a propionic acid derivative mainly used in osteoarthritis and rheumatoid arthritis and is also used as an antipyretic and anti-analgesic agent. Naproxen sodium is a NSAID that is traditionally orally administered and the usual doses for oral surgical procedures range between 275 and 550mg , when administered pre-operatively, can be absorbed and distributed to oral tissues before the initiation of surgical trauma, thus ensuring a blockade of arachidonic acid pathway, with subsequent reduction in the occurrence of post-operative swelling, trismus, discomfort and pain .The objective of this study is to compare the preemptive administration of diclofenac potassium and etodolac and naproxen sodium on postoperative management of pain, swelling and trismus following removal of impacted mandibular third molars.A clinical, randomized and double-blinded study which included 42 patients was carried out. Healthy outpatients of either gender, between the ages of 17 and 25 years, who presented to the Oral and Maxillofacial Surgery Clinics for surgical removal of mandibular third molars were included in the study. This study lasted a year and a half. The trial was conducted in accordance with the standards of Good Clinical Practices for NSAIDs drugs and guidelines of the Helsinki Declaration on human subjects. Also the local Institutional Review Board approved the design of the study. Exclusion criteria were hepatic or renal disease, blood dyscrasias, gastric ulcer, heart disease, known hypersensitivities, allergies or reactions to any of the study medications, pregnancy and lactation. In addition, patients who had taken any drug within last month before surgery were excluded from the study.The study protocol was explained to all patients in detail and written informed consent was obtained. Patients were randomly allocated into three groups in a double -blinded fashion by using a prepared drug box with three compartments coded A (etodolac group), B (naproxen sodium group) and C (diclofenac potassium group) and each drug was handed as a coated tablet to patients 1 hour before the operations by the auxiliary personnel. In summary; a total of 42 patients were randomly allocated into 3 groups of 14 third molar teeth as mentioned above .Patients in group A were given etodolac . Group B received naproxen so-dium  and group C was administered diclofenac potassium .The degree of surgical difficulty of impacted third molars was assessed using Archers Classification (Class I and II). Vertical or mesio angulation and bony retention were taken into consideration. Oral perioperative antibiotics , were administered to all patients 1 hour before the surgery also chlorhexidine gluconate 0.2%  was given to all patients as mouth wash. On the following day after surgery, rescue analgesic  was made available to all patients for use if needed.- Surgical procedureSurgery of the impacted third molars was carried out under local anaesthesia  with buccal guttering technique after adequate elevation and reflection of buccal mucoperiosteal flap. Tooth delivery was followed by meticulous irrigation of the surgical site with physiologic saline . The three-sided muco-periosteal flap was repositioned and sutured. A single experienced surgeon performed the all surgical procedures. If operation times exceeded 30 minutes, those patients were excluded from the study.- Measurement of Pain Intensity Perioperative pain was assessed using Visual Analogue Scale (VAS). Accordingly, pain was recorded as: ‘no pain’ , ‘mild pain’ , ‘moderate pain’ , ‘heavy pain’ , ‘severe pain’  and ‘intolerable pain’ . For each patient, the subjective appropriate score was recorded by a questionnaire at 6th, 12th hours and on 1st, 2nd, 3rd, 4th, 5th and 7th days postoperatively. Before leaving the clinic, the surgeon ensured that all patients were thoroughly instructed on how to complete the pain self-assessment diary and when to take medications.- Measurement of swellingThe facial swelling was measured quantitatively in milimeters (mm) using ultrasound (US). Ultrasonographic measurements were carried out preoperatively and postoperatively at second and seventh days by single experienced radiologist. The ultrasound examinations were performed using linear 12 MHz probes . The patients were placed in supine position and their faces were slightly turned to the contralateral side. The probe was placed transversely on the buccal space and short axis images were obtained. The anterior border of the ramus of the mandible and anterior border of the masseter muscle was used as reference landmarks for standardization of measurements. The probe was oriented transversely so that the cortex of ramus of mandibula lied as a definitive echogenic horizontal line posteriorly on the image screen. Then the vertical distance from the skin to this echogenic line was measured. Measurements were done on the screen after freezing the optimal image and obtaining three consecutive measurements. The median value was recorded and registered to the closest 0.1 mm. Both sides were measured in the same manner. This distance encompassed the skin and the buccal fat pad. This anatomic area was markedly affected by the edema and hemorrhage caused by tooth extraction. Patients were instructed to close their mouths and contact the upper and lower teeth in a natural relaxed way that maintained light interocclusal contact and told not to forcefully clench the jaw, teeth or masticatory muscles during measurements. Care was taken to avoid compression of buccal space.- Measurement of maximum mouth opening ability (Trismus)Mouth opening ability was measured in millimetres (mm) with a regular composing stick preoperatively and postoperatively at second and seventh postoperative days. The incisal edge of the maxillary central teeth and incisal edge of mandibular central teeth were used as reference points at the most available maximum mouth opening.- Statistical AnalysisData analysis was carried out using commercially available software . Comparison of the independent drug groups were carried out using ‘Kruskal Wallis Test’. Double comparisons of the groups were done with ‘Mann-Whitney U Test’. Multiple comparisons of the data from different re-lated times among drug groups were calculated using ‘Friedman Test’ and double comparisons of the same data were studied with ‘Wilcoxon Signed Ranks Test’. The level of significance was set at P<0.05.ResultsA total of 42 patients , who had impacted molars which were Class I or Class II and in vertical or mesio-angular positions as described in Archer’s Impacted Third Molar Classification  were compared with each other for pain intensity at predetermined times by using Kruskal Wallis Test  and resuThe efficacy of drugs on pain according to time course was also shown graphically in figure - Postoperative swelling assessmentDifferences among groups were compared using ‘Kruskal Wallis Test in terms of efficacy on swelling . Results1- There was no significant difference between the drug groups at preoperative and postoperative 7th days (P>.05).2- Significant differences were detected at postoperative 2th day in terms of efficacy on swelling (P<.05).Double comparison of drug groups was performed by using ‘Mann-Whiney U Test’ at 2th day. Results showed that:1- When Etodolac and Naproxen sodium were compared, in terms of efficacy on swelling, there was no significant difference .2- Diclofenac potassium was significantly more effective on swelling than Etodolac and Naproxen sodium respectively (P=.027) (P=.020).The efficacy of drug groups on swelling according to time courses was shown graphically in figure - Postoperative mouth opening ability (Trismus) assessmentMouth opening ability was used to denote trismus and decreased postoperatively. Results  showed that there were no statistical differences between the drug groups regarding trismus (P>.05) .The efficacy of drugs on mouth opening ability according to the postoperative time course was also graphically shown Fig. . ResultsNone of the patients in any of the groups used the rescue analgesic although it was made available to them. No major or minor complications related to medications were encountered in any of the groups.In the present study, the efficacy of NSAIDs which were diclofenac potassium, naproxen sodium and etodolac were investigated in regards to pain, swelling and trismus following third molar surgery. To our knowledge, there is no comparative study comparing these three drugs on this subject.Close relation between postoperative complications  and operation time was shown in various studies . In the Timing of NSAID administration is a subject of debate. Some authors favour preoperative medication arguing that it allows better postoperative analgesia control by suppression of peripheral and central sensitization while others argue that preemptive medication performs less compared to postoperative administration of the same drugs . In the In this study, diclofenac potassium was slightly more effective on postoperative pain but the difference between diclofenac, etodolac and naproxen regarding pain in any postoperative time period was not statistically significant Fig. . Oncul eThere are only a few studies about the efficacy of Etodolac on molar teeth extraction surgery. Etodolac performed better compared to placebo and showed similar efficacy compared to aspirin , acetamiCombination of NSAID’s with steroids appears to be more effective in controlling complications after third molar surgery as compared to NSAID’s alone especially regarding pain and swelling, but carry a certain risk of adversity such as adrenal suppression and concerns about impaired wound healing, therefore their routine use has not been justified . BamgbosBjørnsson et al. compared naproxen and acetaminophen on postoperative sequelae after impacted third molar surgery. They found that naproxen was more effective on pain than acetaminophen, but acetaminophen was more effective on swelling than naproxen . In the Several methods were employed to measure postoperative swelling including VAS, stereophotography, sutures and face-bow ,27-29. UIn the present study, there were no differences between the drug groups on postoperative mouth opening ability (trismus). If the time courses are surveyed in the present study, a little advanced effect of diclofenac may be encountered as compared to other drugs but the difference was not statistically significant. Many studies support the present study in terms of mouth opening ability ,8.In conclusion, in the present study; diclofenac potassium performed significantly better on swelling and as good as other two drugs naproxen sodium and etodolac regarding pain and trismus. In other words, the present study aligned the drugs as diclofanac potassium> naproxen sodium = etodolac in terms of reducing the postoperative third molar surgery sequelae. Various methods, such as different NSAIDs, laser, steroids etc. were tested and will continue to be tested on this issue.


Background. Our aim was to evaluate the real effect of dysautonomic symptoms on the influence of affective pain perception on quality of life in PD patients. Methods. An observational cross-sectional study was carried out using 105 Parkinson's disease (PD) patients of the Movement Disorders Unit, Hospital de Cruces  . Statistical analysis was made in order to evaluate the possible association of pain with life quality. Results. Quality of life measured by PDQ-39  was statistically associated with affective dimension of pain . However, the influence of this dimension on PDQ-39 was different in the specific case of PD patients that experimented a high score (>12) in SCOPA-AUT . Conclusions. These results confirm the effect of affective perception of pain in life quality of PD patients, indicating the critical role of autonomic symptoms in the modulation of the influence of pain on quality of life and showing the possible utility of dysautonomia as clinical prognostic indicator of quality of life in PD patients affected by pain. Parkinson's disease (PD) is a chronic neurodegenerative illness caused by degeneration of the dopaminergic nigrostriatal pathway of the central nervous system, which implies impairment in quality of life (QoL). Motor  and nonmDopamine signaling alterations can modulate the experience of pain . PD can Sensory and autonomic dysfunction are an important prodromal feature of PD and can result in a major disability and seriously impact the health-related QoL in these patients . HoweverTaken into account the association between the nociceptive and autonomic nervous systems , our aimA total of 105 patients  who fulfilled the UK Parkinson's disease Society Brain Bank criteria for the clinical diagnosis of PD (aged between 43 and 87 years) were included in the study see . PharmacAfter clinical examination, staging of the disease was based upon the findings of the clinical examination and in accordance with the present standards with respect to motor symptoms [Modified Hoehn and Yahr Staging  and UnifScores on clinical scales for evaluation of motor and autonomic symptomatology, as well as several aspects of pain perception and QoL, were the main outcome measure of the study. Thus, the battery of clinical scales used in this study included the Parkinson's Disease Questionnaire for quality of life (PDQ-39), adapted to Spanish language and culture  in order to evaluate HRQoL in PD patients .Pain perception was evaluated using the McGill Pain Questionnaire (McGill Pain Index) (MPQ) in the categories sensory (MPQ-S), affective (MPQ-A), miscellaneous (MPQ-M), pain rating index (PRI), and present pain intensity (PPI). The affective dimension score of the McGill Pain Questionnaire can serve as a useful index of the overall affective status of pain patients and given this interpretation the dimension has good construct validity .Autonomic symptoms were evaluated using the Scale for Outcomes in PD-Autonomic scale (SCOPA-AUT) classified in six dimensions. This scale has good content validity and has good known-groups validity and discriminates between control, mild, moderate, and severe PD groups .All statistical analyses were performed using the IBM SPSS® Statistics for Windows (version 22) . The Shapiro-Wilk test was used to check whether the quantitative variables were normally distributed. The baseline characteristics of the sample were summarized using descriptive statistics  see .t-test was used for mean comparison. For nonparametric distributions, Mann-Whitney test was used. In the case of qualitative variables, Pearson's chi square test was used.With respect to the bivariant analysis, the breakpoint for comparisons in the variable quality of life (PDQ-39SV) was taken at the value of 30. Thus, the sample was divided into a group of patients with good life quality (PDQ-39SV < 30) and another group with impaired life quality (PDQ-39SV > 30). In this case, data of 8 patients were missing due to the fact that questionnaires were not correctly fulfilled. Differences between these two groups were analyzed for the case of several variables, such as pain perception, motor and autonomic symptomatology, sex, age, medication, and time of evolution. The breakpoint for comparisons in the variable pain (PRI) was taken at the categories 0 (including the items no pain + mild) and 1 (including the items discomforting + distressing + horrible + excruciating). Thus, the sample was divided into a group of patients with acceptable pain perception and other group integrated by patients that suffered considerable or even strong pain intensity. Differences between these two groups were analyzed for the case of several variables, such as life quality, motor and autonomic symptomatology, sex, age, medication, and time of evolution. The breakpoint for comparisons in the case of the variable SCOPA-AUT was taken at the value of 12. Thus, the sample was divided in a group of patients with high intensity of dysautonomic symptoms (SCOPA-AUT > 12) and other group with low intensity (SCOPA-AUT < 12). Differences between these two groups were analyzed for the case of several variables, such as pain perception, motor and autonomic symptomatology, sex, age, medication, and time of evolution. Breakpoints for PDQ-39 and SCOPA-AUT were based on the median values of sample distributions. In the bivariant analysis, Student's Correlation analysis among different aspects of MPQ and PDQ-39 was carried out in patients with high and low SCOPA-AUT scores. Pearson's coefficient or Spearman's coefficient for nonparametric distributions were used.X) such as gender, age, medication, time of evolution, and autonomic and motor symptomatology on quality of life (PDQ-39) . With respect to predictive models, R2 coefficient was obtained. Durbin-Watson test was calculated in order to discard a hypothetical nonparametric distribution of residuals. In addition, the presence of collinearity was discarded using variance inflation factor and condition index. All p values presented were two tailed and p < 0.05 was considered statistically significant.Linear regression models were built to evaluate the influence of pain (MPQ)  and other independent variables  and Institute Biocruces. The reference of the Ethical Commission decision was March 31st of 2009. Patients, parents, or legal representatives gave written informed consent and all participants assented to participate in the study.p < 0.01) and PDQ-39SV (p = 0.033) (p < 0.01) and PRIT (p < 0.01) , with respect to those with impaired life quality (PDQ-39SV > 30), were observed in several variables, particularly in SCOPA-AUT and PRIT . Also, d= 0.033) . Moreove < 0.01) .p < 0.01), whereas in the group of PD patients with a high score in SCOPA-AUT it was of 43% (p = 0.003). Also, correlation of PRIA with PDQ-39 was of 13% in the group of low score SCOPA-AUT patients (p = 0.347), whereas in the case of high score SCOPA-AUT patients it was of 27% (p = 0.075)  .Linear regression confirmed that PRIA was statistically associated with PDQ-39SV . HoweverThe reported results confirmed a relation between the affective perception of pain (PRIA) and quality of life (PDQ-39SV) in PD patients. Moreover, we could observe that this influence of affective perception of pain on QoL was considerably higher in the case of those PD patients that suffered a high degree of autonomic symptoms, indicating that they are a determinant factor that modifies the impact of pain in QoL in PD patients. Therefore, our results indicate that dysautonomia could have a role as clinical prognostic indicator of QoL in PD patients affected by pain and should be taken into account in their clinical management.A significant positive correlation between PRIT and PRIA, as well as between PRIA and PDQ-39SV, was observed in the selected patients in the present study. However, these correlations changed considerably when they were calculated in patients with a high degree of dysautonomic symptomatology, with respect to the case of the group of patients with a lesser degree of dysautonomia, indicating the contribution of dysautonomia in pain perception and central nervous system processing of pain in PD patients .As it could be expected, bivariant analysis showed some differences within the group of patients with good QoL, with respect to those with impaired quality, in the degree of dysautonomia, all components of pain perception and motor symptomatology, and daily equivalent levodopa dosage, as well as in disease duration, indicating not only the natural clinical evolution of PD but also the important influence of dysautonomia on the QoL of patients .Differences in several clinical variables were also observed when comparing the group of patients with acceptable pain perception with respect to those who suffered considerable or even strong pain intensity. Thus, the differences in dysautonomia and QoL reported here could indicate not only the well-known effect of pain on QoL , 12, 18 Patients with low levels of autonomic symptoms were compared with those suffering a high degree of dysautonomia. In this case, statistical significant differences were found in several variables, such as QoL and all components of pain perception and motor symptomatology, as well as in daily equivalent levodopa dosage, indicating that dysautonomic PD patients not only have, as could be expected, a lesser degree of QoL , 16, 18 Although the results reported here confirm the effect of affective perception of pain in life quality of PD patients, this influence was considerably higher when it was evaluated only in a selected group of PD patients that suffered from a high degree of dysautonomia, indicating the critical role of autonomic symptoms in the modulation of the influence of pain on QoL and showing the possible utility of dysautonomia as clinical prognostic indicator of QoL in PD patients affected by pain.