Objectives. Following thyroid surgery patients complain from swallowing disability and throat pain resembling symptoms of laryngopharyngeal reflux (LPR). The purpose of this study is to assess whether proton pump inhibitors (PPIs) given to patients in the first postoperative week relieve the swallowing disability and throat pain complaints. Materials and Methods. A questionnaire was given to 523 patients who had thyroid surgery between October 2010 and August 2011. In the first postoperative clinic visit each patient was approached to fill out a questionnaire. 208 patients met criteria, 100 of which were on PPIs (study group) and 108 were not on PPIs (control group). Results. When comparing the study group to the control group, the average pain level was 2.57 compared to 3.9 during the first postoperative week, and 1.27 compared to 2.41 at day 7 . Swallowing disability was also lower in the study group when compared to the control group, 1.87 and 3.12, respectively, during the first postoperative week and 0.87 and 1.76, respectively, at day 7 . Conclusion. Patients treated with PPIs had less pain and swallowing disability in the first week following thyroid surgery, when compared to patients not treated with PPIs. It has been observed that patients who undergo thyroidectomy complain of throat pain and short-term dysphagia following their surgery –3. TheirLPR is a common disorder in which patients often complain of throat pain and swallowing discomfort (globus sensation) , 5. LPR The purpose of this study is to compare the complaints of throat pain and dysphagia following thyroid surgery in patients given PPIs versus those who were not.This is a prospective case-controlled pilot study conducted at the McGill Thyroid Cancer Centre from October 2010 until August 2011. Ethics approval was acquired through McGill University Institutional Review Board. 523 patients underwent thyroid surgery from October 2010 to August 2011; 315 were excluded because they were either already on a PPI prior to surgery or the questionnaire was not filled out properly. The patients also provided demographic information. All patients had thyroid surgery with 1 of 4 surgeons using a similar technique. The study group did not know that the prescribed PPI was addressing their pain and swallowing ability. Further information about the research objective was provided to both groups after filling the questionnaire.The collected data was then electronically arranged on Microsoft Excel (12.3.1). Statistical analysis was performed on SPSS (20.0.0). The patients were classified into groups: study and control. The study group consisted of the patients placed on PPIs postoperatively. They were instructed to take one pill per day for 14 days. The patients were asked to fill up the questionnaire at their first postoperative visit , which was scheduled at a similar timeframe for all patients.Questions focused on pain and swallowing difficulty during the postoperative period. The patients were asked to classify their discomfort on a numerical pain score scale. There were 8 questions. Three questions were targeting swallowing difficulty, three targeting throat pain (not incision site pain), and two addressing the kind of PPI that was prescribed to the patient postoperatively. The patients were asked to score their pain and swallowing disability in 3 intervals, first postoperative day, mid first week, and at postoperative day 7.The questionnaire adapted the numerical rating pain scale from 0 to 10 with 10 being the most pain.The questionnaire was sent to four otolaryngologists independently for face and content validity. Afterwards, five patients and three physicians were recruited to perform the initial pretesting of the questionnaire that generated the third draft. Finally it was sent to McGill University research ethics committee for final validation and approval .208 patients were included in this study. There were 108 patients in the control group (no PPI) and 100 in the study group (PPI). The mean age = 50.14 (range 21–80), with 84.1% of patients being female. In the study group, the distribution of the PPIs was given in the following way: 51 dexlansoprazole, 38 lansoprazole, 5 pantoprazole, 5 esomeprazole, and 1 omeprazole. This was done according to the surgeons' preference.For the control group, the mean scores for pain and swallowing disability were 5.26 and 4.7, respectively, at the 1st postoperative day, 3.9 and 3.12, respectively, during the 1st week, and 2.41 and 1.76, respectively, on the 7th postoperative day. For the study group, the mean scores for pain and swallowing disability were 4.58 and 3.74, respectively, at the 1st postoperative day, 2.57 and 1.87, respectively, during the 1st week, and 1.27 and 0.87, respectively, on the 7th postoperative day .P value = 0.001) and 1.27 and 2.41, respectively, at day 7 . Swallowing disability was also lower in the study group when compared to the control group, 1.87 and 3.12, respectively, during the first postoperative week  and 0.87 and 1.76, respectively, at day 7 .When comparing the study group to the control group, the average pain level was 2.57 and 3.9, respectively, during the first postoperative week . The average pain level on the 1st postoperative day was the highest with a score of 4.58. The study group seems to recover more quickly than the control group with pain scores during the first postoperative week and at the 7th postoperative day lower than the control group at 2.57 and 1.27, respectively . Swallowing disability showed similar results. When comparing these results with the study group, it shows that the study group had an overall significantly milder pain score of 2.8  suggesting that both groups have had similar initial insult. During the first week patients who were taking PPIs showed significant improvement in their pain symptoms and a quicker recovery of their swallowing ability. This continues until the end of the first week where the study group still showed better symptomatic control.It is interesting to note that when reviewing the data, the groups did not have any significant difference in their initial pain or swallowing symptoms . This provides evidence that PPI therapy improved the symptoms of patients in the early postoperative period. This fact reinforces the hypothesis that the insult of a thyroid surgery on the larynx leads to laryngeal inflammation and possibly LPR. Moreover, this laryngeal insult may in fact result from tracheal stimulation during thyroid surgery. Since this group of patients are not paralyzed during thyroidectomy, the tracheal manipulation triggers the cough reflex multiple times throughout the surgery [ In comparison to other studies, our study focuses on PPI as a treatment for patients' complaints, which are similar to that of LPR. The average pain and swallowing scores over the course of the postoperative period for the control group were 2.15 and 1.96, respectively, compared to significantly better controlled symptoms in the study group with scores of 1.84 and 1.65 ( surgery .There are several limitations to this study. There is a selection bias, since only one of the 4 surgeons was using PPIs. Second, the duration, extent, and complications associated with the surgery were not taken into account. Finally, the selection of PPI was not random.  To our knowledge this is the first study that studies the effect of PPIs on laryngeal symptoms during the early recovery period after thyroidectomy. A randomized blinded study is warranted to compare the true effects of PPIs on postthyroidectomy pain and swallowing.The pain and swallowing discomfort suffered by patients following thyroid surgery may be reduced by PPIs given postoperatively.An association between surgical insult following thyroid surgery and LPR needs further investigation.Patients treated with PPIs had less pain and swallowing disability in the first week following thyroid surgery, when compared to patients not treated with PPIs.


To examine the effects of a group model of acupuncture treatment on pain for joint replacement patients in an acute care setting.In a large midwestern hospital, group physical therapy is provided to joint replacement patients. Orthopedic surgeons added acupuncture to the standard post-operative care for total knee and hip replacements provided through the Joint Replacement Center (JRC). Acupuncture is introduced in the pre-hospital class for surgery preparation and provided immediately after physical therapy on post-operative days one and two. Pre- and post-acupuncture treatment scores for pain are recorded in the electronic medical record. Mean differences in self-reported pain scores were analyzed using a two-tailed t-test.Between 1/1/2010 and 9/30/2010, 654 acupuncture treatments were provided to 427 unique patients. The sample included 252 women and 172 men ages 27 to 95  and SD 11.33 (men)). Average pre-treatment pain scores were 4.1, and average post-treatment scores were 2.3, demonstrating a 45.3% decrease in self-reported pain level (p<0.001).Group acupuncture significantly decreased self-reported pain in a sample of post-operative joint replacement patients. The addition of acupuncture to the JRC model of delivery is a distinguishing characteristic of the services provided by this midwestern hospital that competes with other hospitals to provide this elective surgery, making it unique among the community options.


Pain is common during colonic insufflation required for CT colonography. We therefore evaluate whether a single intravenous alfentanil bolus has a clinically relevant analgesic effect compared with placebo in patients undergoing CT colonography.A prospective multi-centre randomised double-blind placebo-controlled trial was performed in patients scheduled for elective CT colonography. Patients were randomised to receive either a bolus of 7.5 μg/kg alfentanil (n = 45) or placebo (n = 45). The primary outcome was the difference in maximum pain during colonic insufflation on an 11-point numeric rating scale. We defined a clinically relevant effect as a maximum pain reduction of at least 1.3 points. Secondary outcomes included total pain and burden of CT colonography , the most burdensome aspect and side effects. Our primary outcome was tested using a one-sided independent samples t-test.P < 0.001). Total CT colonography pain and burden were also lower with alfentanil . With alfentanil fewer patients rated the insufflation as most burdensome aspect . Episodes with desaturations < 90% SpO2 were more common with alfentanil (8.1% vs. 44.4%; P < 0.001, but no clinically relevant desaturations occurred.Maximum pain scores during insufflation were lower with alfentanil as compared with placebo, 5.3 versus 3.0 (A low-dose intravenous alfentanil bolus provides a clinically relevant reduction of maximum pain during CT colonography and may improve the CT colonography acceptance, especially for patients with a low pain threshold.NTR2902Dutch Trial Register: Computed tomographic (CT) colonography is an accurate technique for the detection of colorectal cancer and clinically relevant polyps and it is a less invasive alternative for colonoscopy-7. In clSufficient colonic distension is mandatory for visualisation of the bowel wall, but insDuring conventional colonoscopy administration of analgesics is regular practice. To the best of our knowledge, no analgesics are administered during CT colonography and no studies have evaluated this option. To induce sufficient analgesia for acute pain during CT colonography an opioid is most suitable because of the analgesic potency-21. HereIn sigmoidoscopy, a fentanyl bolus has been shown to improve pain scores. BecauseBefore considering the use of opioids during CT colonography, it is necessary to demonstrate a clinically relevant pain reduction, beneficial effect on the burden and acceptance, without detrimental effects on safety, procedure time and recovery time.We hypothesised that a single bolus intravenous alfentanil will give a clinically relevant reduction in maximum pain defined as at least 1.3 point reduction on an 11-point numeric rating scale-28.We performed a prospective, multi-centre, randomised, double-blind, placebo-controlled trial to evaluate whether a single bolus intravenous alfentanil has a clinically relevant analgesic effect in patients scheduled for elective CT colonography. We evaluated possible differences between alfentanil and placebo at different time points Figure . This stThe primary outcome was the difference in maximum pain score between patients receiving alfentanil compared with placebo. We had defined a clinically relevant effect as a pain reduction of at least 1.3 point on an 11-point numeric rating scale, as this is considered the minimally important difference using this scale-28.Secondary outcome measures were differences between patients receiving alfentanil and placebo regarding: pain scores per insufflation position, pain and burden of the CT colonography procedure and individual CT colonography aspects , side effects, vital parameters, procedure time and recovery time.Consecutive patients aged 18–85 years and scheduled for elective CT colonography were assessed for eligibility in two institutions in Amsterdam, the Netherlands: Academic Medical Center, University of Amsterdam (academic institution) and Onze Lieve Vrouwe Gasthuis . Patients were assessed for eligibility by telephone by one of the research physicians . CT colonography was performed in symptomatic and surveillance patients only. We used the following exclusion criteria: heart rate < 50 beats per minute; systolic blood pressure < 90 mmHg; severe chronic obstructive pulmonary disease; liver disease defined as a Child-Pugh score of > 4; alfentanil allergy; pregnancy; increased intracranial pressure; use of MAO-inhibitors within two weeks before CT colonography; use of barbiturates, opiates or daily benzodiazepine.We powered to detect a difference in maximum pain score between the placebo and alfentanil group, using nQuery Advisor 7.0 . Based on our anaesthesiologists (S.E. and M.W.H.) experience a maximum pain reduction of 1.5 points was expected. A previously performed population screening trial served as pilot data to assess distribution and standard deviation. We calcTwo research physicians (J.H.R. and M.C.H.) generated a randomisation list using nQuery. The list was kept by three research physicians  not involved in the patient recruitment, CT colonography procedure or data collection. Included patients were randomised into two groups of 45 patients (1:1 ratio and blocks of six). Group 1 received a single bolus of 7.5 μg/kg actual body weight alfentanil . Group 2 received 0.9% saline solution as placebo. Both groups received 0.075 mL/kg actual body weight fluid. Study medication was prepared by the physicians who kept the randomisation list. The medication ampule was placed in a signed sealed envelope near the CT scanner room to allow deblinding in case of a medical emergency. The study medication was administered (double-blind) through a 20 Gauge intravenous cannula, 1½ minute following administration of a spasmolytic agent. After the procedure one of the physicians who kept the randomisation list collected the envelope.We used a 24-hour preparation with low-fibre diet and three or four bottles 50 mL iodinated contrast, meglumine ioxithalamate ,32. For Pain scores were assessed with an 11-point numeric rating scale at the end of prone scan acquisition position and for all three insufflation positions (0 = no pain and 10 = worst pain imaginable).During the procedure, patients’ vital parameters were monitored . We registered values at standard time points: before spasmolytic injection, 1½ minutes after spasmolytic injection and at 5 and 10 minutes after starting the alfentanil injection. The value 1½ minute after spasmolytic injection was the reference value for comparisons with values after study medication injection, because the spasmolytic can influence the vital parameters. Heart rTo evaluate recovery after the procedure the Aldrete score, a commonly used recovery score,37, was Baseline characteristics, procedure expectations and procedure experience were assessed using a pre- and post-procedural questionnaire and largely originated from a previous study. The preAll patient symptoms reported to their general practitioner up to one month after the procedure were assessed for their likelihood of being related to alfentanil by two blinded anaesthesiologists (S.E. and M.W.H.).Two independent observers  evaluated all CT images for distension, collapse, diagnostic adequacy and diverticulosis. EvaluatP value of < 0.05 indicated a statistically significant difference. All data entry was completed before deblinding. For the difference in maximum pain score during insufflation, we used a one-sided independent samples t-test. Univariate analyses were performed with linear regression to identify possible confounders. The four most influential variables with a P < 0.1 would be included in a multivariate analysis.All calculations were performed using SPSS version 18.0  and a P < 0.1 in univariable analysis were added to the regression analysis as confounder . Logistic regression was used for collapse and diagnostic adequacy scores.For time calculations and pain scores per position we used a two-sided independent t-test. Differences between categorical values were determined using a Chi-square test and binary values with the Fishers exact test. A (weighted) kappa was calculated to assess interobserver agreement with regards to distension, collapse, diagnostic adequacy and diverticulosis scores. We used the first observer scores to perform ordered regression for distension scores. Variables with Between May 2011 and June 2012 a total of 179 patients were screened for eligibility. We included 90 patients, 54 did not consent and 35 were excluded  point lower on the 11-point numeric rating scale compared with the placebo group  were significantly more common in the alfentanil group. All desaturations resolved spontaneously and none of the side effects interfered with the procedure.Side effects during CT colonography are summarised in Table Median pain and burden of intravenous cannula insertion were 1 (IQR 1–2) for both groups combined. Median pain and burden of the bowel preparation were 1 (IQR 1–1.25) and 2 IQR 1–3) for both groups combined. Other experience questionnaire outcomes are reported in Table  for bothVital parameters are shown in Figure P = 0.41). Additionally no difference was found for supine (P = 0.60) and prone (P = 0.54) separately. Alfentanil did not influence the total number of collapsed segments (P = 0.25), nor the diagnostic adequacy (P = 0.15). Interobserver agreement was good for distension and diagnostic adequacy . Interobserver agreement was very good for collapse and diverticulosis, both 0.81.For all segments and both positions combined no correlation was seen between distension scores and randomisation group (BMI and diverticulosis were confounders) .A single bolus 7.5 μg/kg intravenous alfentanil results in a clinically relevant reduction in maximum pain during colonic insufflation required for CT colonography. Importantly, alfentanil also reduced the total pain and burden of the complete CT colonography procedure. Alfentanil did not influence the procedure time and with alfentanil fewer patients considered colonic insufflation the most burdensome aspect of CT colonography. Dizziness and desaturations were the most common side effects of alfentanil, though recovery times were short.The reduction of maximum pain was more than the 1.3 points on an 11-point numeric rating scale as we hypothesised and which is considered the minimum clinically relevant difference-28. For Importantly, also the pain and burden of the total CT colonography procedure were reduced. The effect of alfentanil was more evident on the most burdensome aspect, than on the most painful aspect. This is likely because patients experience the bowel preparation as burdensome, but not as painful. With alfentanil, the insufflation becomes less burdensome and therefore the burden of the bowel preparation becomes relatively more important.The observed dizziness and desaturations are known side effects of alfentanil. The desaturation in the placebo group may indicate that some patients experience spontaneous desaturations during the day. Importantly, all desaturations were not clinically relevant, because they were short and self-limiting we did not had to perform any intervention.Although we found desaturations with alfentanil, we did not find a SpO2 reduction at 5 and 10 minutes after alfentanil injection. Conti et al. observed a significant saturation reduction with a 10 μg/kg bolus intravenous alfentanil in ASA 1 patients during minor surgery or endoscopy.In colonoscopy opioids are commonly used in combination with a benzodiazepine to induce amnesia. We did not consider this mandatory for CT colonography while this combination leads to a greater respiratory depressant effect than opioids only. The benzodiazepine-induced drowsiness may complicate the CT colonography procedure and recovery facilities may be required.A number of limitations have to be acknowledged. The dizziness caused by alfentanil may have partly affected the double blind character of the trial. We had anticipated this however, to our knowledge no substance is available that causes dizziness in an equal number of patients as alfentanil and that does not affect the outcomes. We chose to use 0.9% saline solution for the placebo group because it was the solvent for alfentanil and the viscosity and colour was similar to that of alfentanil. Importantly, patients were not aware that dizziness would be more likely related to alfentanil administration than placebo. Pain was assessed in prone scan acquisition position only, as we wanted to limit the number of questions and the pressure is higher in prone position. The timWhen alfentanil is used it is important to realise that monitoring and airway intervention equipment and sufficient knowledge about the pharmacology of opioids and airway interventions should be present. This means that the attendance of a physician is required. For institutions were a technician is performing the CT colonography procedure, adjustments will have to be made in the procedure. All patients receiving intravenous alfentanil require an intravenous cannula, so emergency medication can be given. The above mentioned issues may lead to an increase in costs. Furthermore, when using alfentanil the patients need to arrange transportation, because driving after alfentanil injection is not allowed for 12–24 hours minimum; this can be a large hurdle for implementation of alfentanil,47.To the best of our knowledge we are the first to study the use of analgesia for CT colonography. Our study shows that alfentanil provides a clinically relevant reduction in maximum pain in CT colonography, reduces total procedural pain and burden, without detrimental effects on procedural time, recovery time and patient safety. Although desaturations were frequently observed with alfentanil, these were not considered clinically relevant because they were all short-lasting and self-limiting. Therefore alfentanil may well be an option to improve acceptance, although it may impact the logistics associated CT colonography examinations. Now that we know the advantage of alfentanil it can be weighed against the practical hurdles, side effects and costs. Especially for patients with a low pain threshold, a low-dose intravenous alfentanil bolus may be viable option. Our secondary outcomes such as the total procedural pain and burden, the effect on procedure time and recovery time should be confirmed in for these outcomes appropriately powered studies. Furthermore, additional data on a low-dose intravenous bolus injection alfentanil during CT colonography is required to further assess the safety profile.The authors declare that they have no competing interests.TNB is responsible for drafting the manuscript. TNB, MPP, SE, MWH, and JS are responsible for the study design. MPP, SE, MWH, GK, JP, LJS, JAWT, JHR and JS are responsible for revising the manuscript. TNB, MPP, GK, JP, LJS, JAWT, JHR are responsible for the data acquisition and TNB for the analysis. All authors have read and approved the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/13/94/prepub


Cervicocephalic arterial dissection can cause both ischemic stroke and hemorrhagic stroke. However, spontaneous cervicocephalic arterial dissection presenting only with headache and neck pain has rarely been reported. The clinical features of patients with spontaneous cervicocephalic arterial dissection presenting only with headache and neck pain were investigated.The subjects were seven patients with spontaneous cervicocephalic arterial dissection with headache and neck pain alone who were admitted to our hospital during the past 3 years. The clinical features of these patients were investigated. The diagnosis of arterial dissection was based on the criteria of the Strategies Against Stroke Study for Young Adults in Japan.The age of the patients  ranged from 35 to 79  years. Six patients had vertebral artery dissection, one had internal carotid artery dissection, and one had an association of vertebral and internal carotid artery dissection. With the exception of one patient, the headache and neck pain were unilateral. All patients with vertebral artery dissection complained of posterior cervical or occipital pain. In the cases of internal carotid artery dissection, one patient complained of temporal pain, and one patient with co-existing vertebral artery dissection complained of posterior cervical pain. The mode of onset was acute in five patients, thunderclap in one, and gradual and progressive in one. The pain was severe in all cases. Five patients complained of continuous pain, while two had intermittent pain. The quality of the pain was described as throbbing by five patients and constrictive by two. The headache and neck pain persisted for 1 week or longer in six of the seven patients.Cervicocephalic arterial dissection should be suspected when patients complain of intense unilateral posterior cervical and occipital pain or temporal pain. Spontaneous cervicocephalic arterial dissection is an important cause of stroke. The Strategies Against Stroke Study for Young Adults in Japan (SASSY Japan), a multicenter study of the diagnosis, treatment, and prevention strategies for stroke in young adults in Japan, found that 3–4% of strokes occur in people under 50 years of age . CervicoBetween April 2007 and March 2010, 61 patients with spontaneous cervicocephalic arterial dissection  were admitted to our stroke center. Of these 61 patients, the clinical presentations were cerebral ischemia in 35 cases, subarachnoid hemorrhage in 13 cases, headache and neck pain only in 7 cases, and asymptomatic in 6 cases. In the asymptomatic cases, cervicocephalic arterial dissection was suspected in the medical checkup of the brain and they were admitted for diagnostic examination. The subjects of this study were the seven cases with headache and neck pain only.For risk factors, the presence or absence of hypertension, diabetes mellitus, hypercholesterolemia, smoking, and migraine was examined. Diabetes mellitus was defined as blood sugar elevation  and HbA1c  ≥6.5%; hypertension was defined as taking an antihypertensive agent or having blood pressure ≥140/90 mmHg; and hypercholesterolemia was defined as taking a hypolipidemic agent or having total cholesterol ≥220 mg/dL or LDL cholesterol ≥140 mg/dL.Headache and neck pain were compared for location and mode of onset , severity of pain , continuousness , and quality . The mode of onset was classified as thunderclap , acute (peaking at longer than 1 min but less than 24 h), and progressive (peaking at 24 h or longer). The severity of pain was classified as severe if it was uncontrollable and the patient took analgesics, or moderate if the pain was controllable.For diagnostic imaging of the cervicocephalic arterial dissection, magnetic resonance imaging/magnetic resonance angiography (MRI/MRA), 3-dimensional computed tomography angiography (3D-CTA), cerebral angiography, and carotid artery ultrasonography were performed, and the diagnostic criteria of SASSY Japan, shown in Table The patients were followed after discharge for 1–23 months .The clinical features of the seven patients  with spontaneous cervicocephalic arterial dissection that presented only as headache and neck pain are shown in Table Six patients had vertebral artery dissection, one had internal carotid artery dissection, and one had an association of vertebral and internal carotid artery dissection. Vertebral artery dissection occurred intracranially in five of the six patients and extracranially in the other patient, and internal carotid artery dissection occurred intracranially in one patient and extracranially in one. Typical imaging findings of the vertebral artery dissection and internal carotid artery dissection are shown in Fig. None of the patients experienced stroke  during hospitalization and follow-up after discharge. With regard to the duration of the cervicocephalic pain, in one patient the condition improved in 1 day, while in the other six patients the pain persisted for 1 week or longer, with a maximum of approximately 3 months. Moreover, improvement vascular dissection such as amelioration of stenosis was seen during the follow-up period in four patients, and all of these patients improved within approximately 3 months.The seven patients with spontaneous cervicocephalic arterial dissection that presented only with headache and neck pain included six patients with vertebral artery dissection and two patients with internal carotid artery dissection, one of whom had co-existing vertebral artery dissection. Recent clinical studies reported that the nature of spontaneous cervicocephalic arterial dissection in Japan may be very different from that in Europe and North America, since a much higher incidence of vertebral artery dissection cases has been reported in Japanese patients , 6. HoweHeadache and neck pain caused by cervicocephalic arterial dissection are thought to be referred pain associated with the nerves distributed to the vessels. The locations of headache and neck pain differ depending on the dissected vessel, and with dissections in the vertebral-basilar arterial system, unilateral cervical pain and occipital pain are frequent, whereas with dissection of the internal carotid artery, temporal pain and facial pain are said to be more frequent than cervical pain . Fay repMokri  reportedThe limitation of our study includes patients selection of cervicocephalic arterial dissection was biased because our institution mainly deals with emergency patients with severe symptoms.Headache and neck pain requiring analgesics are often encountered in daily clinical practice, and identifying spontaneous cervicocephalic arterial dissection in such patients is often very challenging. However, cervicocephalic arterial dissection must be suspected in patients with severe unilateral posterior cervical and occipital pain or temporal pain. In such cases, the combination of multiple diagnostic methods such as MRI/MRA, 3D-CTA, cerebral angiography, carotid artery ultrasonography, and others is needed to make a diagnosis.


Postoperative analgesia is one of the concerns of anesthesiologists and patients. Systemic opioid administration is the gold standard in reducing the severe pain after the surgery but some side effects prevent the use of adequate dosage of opioids.The aim of this study was to evaluate the result of adding magnesium sulphate to sufentanil in patient-controlled intravenous analgesia (PCIA) system.In this randomized clinical trial, 60 patients candidate for lower limb orthopedic surgery were recruited in Poursina Medical Center for six months. They were randomly classified in two group of patient-controlled intravenous analgesia for postoperative pain control, one was group S [(sufentanil) (n = 30)] and the other was group S + M [(magnesium sulphate/sufentanil) (n = 30)]. The drug infusion rate was 5 mL/h. Each mL of solution in group S contained 1 mcg of sufentanil and in group M + S, 1 mcg of sufentanil and 200 mcg magnesium sulphate, respectively. Pain score, sedation score, satisfaction score, nausea and vomiting score were evaluated 6, 12, 24, 36 and 48 hours after surgery.The demographic data between two groups were not significantly different. The pain scores after 6, 12 and 24 hours in S and S + M groups were significantly different. But the comparison of Visual Analogue Scale (VAS) scores after 36 and 48 hours didn’t show significant differences (P < 0.001). Comparison of the sedation, nausea and vomiting scores between two groups did not show any difference. But the number of patient’s satisfaction in S + M group was more than S group which suggests significant differences (P < 0.05).This study showed that magnesium sulphate added to sufentanil through PCIA is an effective method to alleviate pain in patients undergoing lower limb orthopedic surgery. Moreover, we found fewer side effects on magnesium-sufentanil regimen in terms of in nausea, vomiting, and sedation; and patients’ satisfaction in this regimen was more rather than that in the regiment of sufentanil alone. The optimal pain control after the major surgery is a concern for the Anesthesiologists and patients. Also, it should be noted that every treatment for pain control has some adverse drug effects, especially when the opioid is used -4. The pActually, various studies have been done regarding the role of magnesium sulphate in post-operative analgesia. Because there are some conflicting evidences to support analgesic efficacy of magnesium sulphate, it was attempted to study the role of magnesium sulphate for post-operative analgesia. The effect of magnesium plus sufentanil and sufentanil alone were compared regarding the Visual Analogue Scale (VAS), ramsay score, nausea and vomiting score and pethedine consumption. The findings of this study showed the beneficial effect of magnesium sulfate for effective pain control in post-operative period.The agreement of the study was confirmed by the Ethical Committee of Anesthesiology Department, Guilan University of Medical Sciences. 4), respectively. A patient - controlled intravenous pump (270 mL)  was installed in both groups with an infusion rate of 5 mL /h. In control group, the PCA pump contains 40 mL sufentanil  plus 230 mL of normal saline whereas in drug group (S + M), the tank contains 40 mL sufentanil with 2000 mg MgSO4 20 %  with a total volume of 270 mL. Patients were evaluated at 6, 12, 24, 36 and 48 hours after filling the pump. Need to mention that all patients who transferred to recovery room were administered with PCA pump. So, the magnesium sulfate was infused through the PCA pump over 24 hours at the end of the operation in recovery room, without subsequent infusion. As mention above, the operation usually takes less than 90 min. The patient's primary states were pain score, nausea and vomiting, restfulness; and satisfaction were recorded in questioner. The pain score was estimated based on visual analog scale from zero (pain free) to 10 (maximum level of pain). Nausea and vomiting scored from 1 to 4  and satisfaction scored from 1 to 4   , 15. Thecellent) . The patAll 60 patients divided into two groups (30 patients in each group).There were no significant differences between these groups regarding the demographic data like age, weight, sex and body mass index (BMI). Almost all of patients in each group were men . Visual This study revealed that addition of sufentanil to magnesium sulfate can reduce the post-operative pain significantly and pain reduction after passing 24 hours of operation is considerable. The mechanism of analgesic effect of magnesium is not clear but may interfere with calcium channel and NMDA receptors may play a role. Magnesium acts as a noncompetitive inhibitor of the inositol 1, 4, 5-triphosphate gated calcium channel and IP3 binding , 17. TheThe patient controlled analgesia system is a highly satisfactory method to reduce the post-operative pain , 21-24. Pain control is a multi-modal approach , 7, 22,


Objective. To investigate whether chronic low back pain therapy with deep tissue massage (DTM) gives similar results to combined therapy consisting of DTM and non-steroid anti-inflammatory drugs (NSAID). Design. Prospective controlled randomized single blinded trial. Settings. Ambulatory care of rehabilitation. Participants. 59 patients, age 51.8 ± 9.0 years, with chronic low back pain. Interventions. 2 weeks of DTM in the treatment group (TG) versus 2 weeks of DTM combined with NSAID in the control group (CG). Main Outcome Measures. Visual analogue scale, Oswestry disability index (ODI), and Roland-Morris questionnaire (RM). Results. In both the TG and the CG, a significant pain reduction and function improvement were observed. VAS decreased from 58.3 ± 18.2 to 42.2 ± 21.1 (TG) and from 51.8 ± 18.8 to 30.6 ± 21.9 (CG). RM value decreased from 9.8 ± 5.1 to 6.4 ± 4.4 (TG), and from 9.3 ± 5.5 to 6.1 ± 4.6 (CG). ODI value decreased from 29.2 ± 17.3 to 21.4 ± 15.1 (TG) and from 21.4 ± 9.4 to 16.6 ± 9.4 (CG). All pre-post-treatment differences were significant; however, there was no significant difference between the TG and the CG. Conclusion. DTM had a positive effect on reducing pain in patients with chronic low back pain. Concurrent use of DTM and NSAID contributed to low back pain reduction in a similar degree that the DTM did.  Treatment of patients with low back pain is based primarily on rehabilitation, which includes physical exercises and manual procedures, as well as pharmacotherapy. A small percentage of patients is treated surgically. Pharmacotherapy utilizes mainly nonsteroidal anti-inflammatory drugs, but in cases where severe pain occurs, opioid analgesics are used to amplify the treatment, and when increased muscle tone appears, the myorelaxant drugs are given –3.In the treatment of chronic lumbosacral pain, therapy is aimed at improving patient's physical ability, relaxing the contracted structures and strengthening relevant muscle groups. Correct daily habits are taught, so incorrect and traumatizing body positions can be avoided. Additionally, the rehabilitation should instill the habit of daily physical activity .Using nonsteroidal anti-inflammatory drugs to treat chronic pain in the lumbosacral area gives short term benefits; however, their use is poorly supported by the evidence , 6. ManyWe hypothesized that the use of therapy based on a series of 10 sessions of 30 minutes each consisting of deep tissue massage for chronic low back pain would have the same effect as the use of deep tissue massage combined with nonsteroidal anti-inflammatory drugs. Positive verification of the hypothesis could show the deep tissue massage to be effective and might result in limiting the overuse of nonsteroidal anti-inflammatory drugs in chronic low back pain patients.Study subjects were recruited among patients admitted to the orthopedic and rehabilitation outpatient clinic.The study was conducted on the group of 59 people (mean age: 51.8 ± 9.0 years). Recruitment was carried out among patients referred by physicians specialized in rehabilitation, orthopedics and traumatology, neurology, internal medicine, or rheumatology. The patients were referred to an ambulatory rehabilitation clinic with prescription to undergo a procedure of therapeutic massage. All study subjects suffered from low back pain, and they were diagnosed by a consultant with one of following: M47 (degenerative changes of the spine), M51 , and M54 (spine pain), according to the ICD-10 .The patients with low back pain were classified as lumbosacral pain syndrome using one of the most popular classification tests—Quebec Task Force test –13. The The study used the criteria of inclusion and exclusion reported in Participants were randomly assigned in a 1 : 1 ratio to receive usual care, deep tissue massage—Treatment Group (TG)—or deep tissue massage and NSAID—Control Group (CG). The procedure of randomization was carried out using unmarked envelopes. The deep tissue massage was performed by certified therapists who did not know which patient belongs to which group. The flow of the participants through the trial is shown in The Institutional Review Board of the Poznan University of Medical Sciences approved the study, resolution number 817/07. Each patient signed an informed consent form.Patients from both the treatment group and the control group underwent daily 30-minute session of deep tissue massage for 2 weeks . In the control group, an additional pain relief was used in the form of nonsteroidal anti-inflammatory drugs. The drugs were used for symptomatic benefit but not more often than once daily.The following functional questionnaires and pain scales were used: The Roland-Morris questionnaire (RM), the Oswestry disability index (ODI) , 14 and The tests were performed twice: (1) before therapy, during the initial medical examination, and (2) one day after the therapy ended. The physician who performed the tests did not know which patient belonged to which group.P value of <0.05 was considered significant.The data distribution was assessed with the Shapiro-Wilk test. As data was not normally distributed, the comparisons between the two groups were assessed with Mann-Whitney test. For paired variables, the Wilcoxon test was used. Patients from the TG and the CG did not differ in basic characteristics before therapy .The results presented in No statistically significant differences were observed between the groups with regard to baseline and end results as well as with regard to differences between the initial and final results.After having conducted MEDLINE, AMED, and Science Citation Index search, it was demonstrated that the functional questionnaires were most commonly used to measure the effect of back pain on daily activity of the patient . Due to The study showed a significant improvement with regard to the experienced pain and the self-reported disability, both in the TG (deep tissue massage) and in the CG , which may suggest the effectiveness of deep tissue massage in back pain.The Quebec Task Force test confirmed the validity of choosing the patients with chronic pain, and it excluded patients who underwent spine surgery up to 6 months before the study. The test also showed that most patients experienced pain without radiation and with no neurological symptoms. Those patients were susceptible to deep tissue massage therapy.DTM is a form of massage used with “the understanding of the layers of the body and the ability to work with tissues in layers to relax, extend, and unlock the persisting, incorrect tensions, in the most effective and energy-efficient manner” . TherapiMedical literature contains very few studies showing that massage reduces lumbosacral pain in the acute stage. It was suggested, on the other hand, that massage in the subacute stage and in the early chronic stage of lumbosacral pain reduces the intensity and the quality of pain as effectively as a placebo therapy. Comparing the therapeutic effect of massage with other forms of therapy in lumbosacral pain, the results were similar to the effect of exercises and manipulation . ResearcIt is suggested that there are no individual and objective forms of therapy in chronic low back pain and that the spine care community needs to develop or update high-quality treatment guidelines . Sole asThe effectiveness of using NSAID in the treatment of chronic low back pain is questionable –28. SomeThis study is one of the first studies assessing the effect of deep tissue massage on chronic lumbar pain. An attempt was made to check the effect of deep tissue massage on the possible reduction of nonsteroidal anti-inflammatory drugs. In our study we propose that the use of deep tissue massage causes fast therapeutic results and that, in practice, it could help to reduce the use of NSAID in the treatment of chronic low back pain.The eligibility of patients for the study was based on subjective criteria. Methods were based on patient's subjective experience of pain. In the future, the study protocol could be supplemented with objective functional tests, daily activity tests, and assessment of tissue tension.This study did not distinguish between different nonsteroidal anti-inflammatory drugs. In the future similar studies could be conducted to evaluate the effectiveness of the therapy depending on the type of administered drug.Deep tissue massage had positive effect on reducing pain in patients with chronic low back pain.


Background. SI joint pain is difficult to diagnose due to overlapping symptoms of the lumbar spine, and until recently, treatment options have been limited. The purpose of this retrospective study is to report on the safety and effectiveness of MIS SI joint arthrodesis using a series of triangular, porous plasma coated implants in patients refractory to conservative care. Methods. We report on the first 40 consecutive patients with one-year follow-up data that underwent MIS SI joint fusion with the iFuse Implant System  by a single surgeon. Medical charts were reviewed for demographics, perioperative metrics, complications, pain scores, and satisfaction. Results. Mean age was 58 years (range 30–81) and 75% of patients were female. Postoperative complications were minimal and included transient trochanteric bursitis (5%), facet joint pain (20%), and new low back pain (2.5%). There were no reoperations at one year. Mean pain score improved from 8.7 (1.5 SD) at baseline to 0.9 (1.6) at 12 months, a 7.8-point improvement (P < .001). Patient satisfaction was very high. Conclusions. The results of this case series reveal that MIS SI joint fusion using the iFuse Implant System is a safe and effective treatment option in carefully selected patients. Low back pain (LBP) is exceedingly common in modern society, affecting well over 90% of adults at some point in their lives . Apart fDespite the large number of patients with SI joint pain, treatment options have been limited to conservative care involving physical therapy and joint injections or traditional open SI joint arthrodesis surgery until recently. Open arthrodesis procedures reported in the literature require relatively large incisions, significant bone harvesting, and lengthy hospital stays; moreover, they may require nonweight bearing for several months –13. Recent case series reports of a minimally invasive arthrodesis system  have shown excellent outcomes –17. The We report outcomes of the first consecutive 40 patients with one-year follow-up data treated at a single, community-based spine practice between April 2011 and March 2012. Medical charts were reviewed for perioperative metrics, complications, and pain scores using a numerical rating scale (NRS) preoperatively and at 6 weeks, 3-, 6-, and 12-months post-operatively. Patient satisfaction with surgical results (yes or no) was obtained at 12 months post-operatively. IRB approval was obtained before beginning the study.Mean age was 58 years (range 30–81), and three quarters of the patients were women (75%) . PatientAll patients failed a minimum 6-month course of conservative care consisting of medication optimization, physical therapy, and SI joint injections. A thorough physical and clinical exam was performed on all patients in order to determine the primary pain generator as accurately as possible in this complex back pain population. Positive results on 3 or more provocative physical examination maneuvers  were used as criteria to guide subsequent diagnostic activities . DiagnosMinimally invasive SI joint fusion using the iFuse Implant System  was performed in all cases by a single neurosurgeon in private practice. This system entails the placement of 3 triangular, porous plasma coated titanium implants across the SI joint in order to stabilize and fuse the joint without the need for additional bone graft. The procedure is performed with the patient positioned prone on a radiolucent table and under general endotracheal anesthesia. Intermittent fluoroscopy is used to monitor instrument and implant placement. After a 3 cm lateral incision is made into the buttock region, the gluteal fascia is bluntly dissected to reach the outer table of the ilium. A Steinmann pin is passed through the ilium across the SI joint into the center of the sacrum, lateral to the neural foramen. A soft tissue protector is inserted over the pin, and a drill is used to create a pathway and decorticate bone through the ilium to the sacrum. After the drill is removed, a triangular broach is used before the first implant is malleted into place. A total of three implants are placed. . In somePain related to the SI joint was assessed preoperatively and postoperatively at 12 months. Patients were asked to rate their pain using a 0–10 numerical rating scale with 0 representing no pain and 10 representing the worst pain imaginable. Satisfaction was assessed by asking the patient (yes or no) if s/he would have the same surgery again for the same outcome. A total of 41 SI joints in 40 patients were treated: 17 right- and 24 left sided. One patient underwent bilateral surgery . One patt test, P < .001). A subgroup analysis revealed that there was no difference in outcomes between patients with and without prior lumbar spinal fusion. A clinically significant benefit, defined as a >2 point change from baseline, was observed in all but one patient [Mean (±SD) preoperative pain score as measured using a numerical rating scale (NRS) was 8.7 ± 1.5. Improvement in pain was observed as early as the 6-week follow-up visit (mean 1.2 ± 1.7), and patients continued to have symptom relief at the 3- and 6-month follow-up visits, means 0.6 ± 1.2 and 0.8 ± 1.8, respectively. This improvement was durable through the 12-month followup with a reported mean pain score of 0.9 (±1.6). The mean (±SD) change in pain score was −7.8 (±2.3) points . Positive provocative physical examination maneuvers  combined with marked  pain relief after image-guided SI joint injection are a reliable method for diagnosing the SI joint as a pain generator , 20.Recent reports of other MIS approaches to SI joint arthrodesis using screws show relatively good clinical results with room for improvement in outcomes and technique . Al-KhaySeveral case series reports using the same MIS technique used in this current study report favorable results with minimal complications and no suggestion of implant loosening , 15, 17.Advantages of MIS SI joint fusion using the iFuse Implant System include a small incision, relatively short operating time, minimal blood loss, a relatively short period of immobilization, and most importantly bone and ligament preservation. The triangular shape combined with an interference fit of the titanium implant used in this cohort was designed to minimize rotation, and micromotion and avoid issues encountered with traditional screws. In our cohort of patients undergoing MIS SI joint fusion, clinical outcomes were favorable with 98% of patients experiencing a clinically significant benefit at 12 months. Postoperative complications were minimal. Two patients (5%) went on to have fusion surgery for significant degenerative disc disease or spinal stenosis. Both conditions were present prior to SI joint fusion surgery; however the patient's chief complaint was the SI joint necessitating primary attention to this area. There were 2 cases (5%) of transient trochanteric bursitis and 1 episode of piriformis syndrome. These are neither uncommon nor unexpected and can be a result of altered gait pattern due to low back or hip pain, postoperative hip abductor weakness, and other trauma in the region . Facet pAlthough our study sample size is small, the results of minimally invasive SI joint surgery appear promising. All patients presented with low back and SI joint pain. Favorable outcomes in these patients underscore the necessity to suspect the SI joint as a pain generator in patients with low back pain. Special attention should be paid to the SI joint after lumbar spine surgery to avoid the potential for inaccurate diagnosis and treatment. Furthermore, this minimally invasive approach may significantly benefit the elderly population, who are not candidates for other conventional techniques due to poor bone quality, delayed healing and reduced mobility. Thirty-eight percent (38%) of our patients were over the age of 65. This segment of the population is not likely to respond well to physical therapy alone in part because of the degenerative nature of SI joint disease. The MIS procedure described herein may afford this segment of the population an opportunity to regain mobility, alleviate SI joint and low back pain caused by SI joint issues, and experience an improved quality of life.When conservative measures fail, minimally invasive SI joint fusion using a series of triangular porous plasma coated titanium implants is a safe and effective treatment option in carefully selected patients. Additional prospective controlled trials are underway.


In the present review, the analgesic effects of lidocaine in acute or chronic painful conditions in the emergency department are discussed. Lidocaine, as a medium-acting local anesthetic with short onset time, is well-recognized, not only as a valuable medication for numerous neuropathic pain conditions, but also for the management of both acute and chronic pain.Research studies related to the different applications of lidocaine in the emergency department were collected from different databases including Cochrane library, Medline (Ovid) and PubMed. The pooled data were categorized, summarized and finally compared.Our study revealed that lidocaine is broadly used in various therapeutic approaches for different types of pain, such as visceral/central pain, renal colic etc., in the emergency department.The antinociceptive properties of lidocaine are derived from multifaceted mechanisms, turning it into a medication that is safe to administer via different routes which makes it available for use in a variety of medical conditions. Local anesthetics halt impulse initiation and transmission process in the axons, by blocking voltage-dependent sodium channels. Common local anesthetics are categorized into two major chemical classes: amino esters and amino amides. Amino esters are metabolized by plasma esterases, while amino amides are metabolized in the liver by hepatic enzymes .Lidocaine, the most-frequently applied local anesthetic of the amide group, is used broadly in different fields of medicine; e.g. antiarrhythmic therapy, in addition to its administration as a local anesthetic  2-25).-25.2-25)The analgesic properties of intravenous (IV) lidocaine were first reported in cancer and postoperative patients. Later, lidocaine was shown to provide analgesia, by blocking both peripheral and central voltage-dependent sodium channels. In the IV administration route, it can also relieve both deafferentation and central pain. The antinociceptive properties of lidocaine seem to be derived from a more multifaceted process, rather than simple inhibition of neuronal ectopic discharges .While lidocaine is efficient for both visceral and central pain, its IV form can be considered as a proper choice in scenarios where opioids are either ineffective or associated with undesirable complications. In addition to its extensive applications, lidocaine can be administrated via various routes  and nerve blocks). Intravenous lidocaine is used broadly in the management of neuropathic pain, postoperative pain, postherpetic neuralgia, centrally mediated pain, headache and infiltrative malignant neurological lesions . LidocaiScientific search engines including Cochrane library, Medline (Ovid) and PubMed were used to collect different types of articles, including systematic reviews, evidence-based clinical practice guidelines, health technology assessments, and randomized controlled trials related to lidocaine and its administration in the emergency department. The following key words were used: Lidocaine; Therapeutic approaches; Treatment; Emergency department.Our search resulted in 548 articles. The irrelevant papers by title review (332) were excluded, leaving 216 articles. Twenty-nine articles were selected for further use; the remaining 187 articles were excluded due to the following reasons: irrelevant abstracts or full-text review, duplicate records and lack of access to the full-text of the articles.In the following sections, indications forlidocaine administration for pain management in the emergency department is discussed:Intravenous lidocaine infusion has been suggested to be effective in the management of both visceral and central pain, even in patients in whom opiates cause side effects and fail to provide appropriate analgesia , 17-19.This approach has been successfully used in the management of renal colic. In a study, patients who received a local injection of lidocaine 1% (10-15 mL) in the renal colic trigger point, were reported to experience significantly less pain, compared to their counterparts who had received an IV injection of analgesic combination . Success rates of 29/30 versus 22/30 were reported in the lidocaine versus butylscopolamine groups, respectively . No complications were reported in the lidocaine group. Hence, trigger point injection approach using lidocaine is a safe, easy and efficient method in the management of renal colic .Lidocaine alters sympathetic smooth muscle tone by reducing the transmission in the afferent sensory pathways. Ultimately, considerable pain reduction could be achieved by administration of IV lidocaine, a possibility that has turned lidocaine into a suitable alternative for cases in which opioids are ineffective or associated with undesirable complications .In a study performed on eight patients with renal colic refractory to nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids, IV infusion of lidocaine (1.5 mg/kg in 5 minutes) was used. Interestingly, the mean visual analogue scale (VAS) scores decreased from 8.87 to 1, in just 30 minutes after receiving the IV analgesic. Colic pain disappeared completely within 10, 20, and 30 minutes in four, 68, and 78 patients, respectively. Regarding the complications, two and three patients experienced transient mild dizziness and minimal slurring of speech, respectively, while no serious adverse event was reported. Complete pain relief was reported in seven patients after lidocaine administration, which lasted until hospital discharge. One patient required supplementary analgesia after 30 minutes. In the follow-up period, renal colic recurrence was reported in six patients, which was managed by NSAID therapy  and those in morphine group received IV morphine solution (0.1 mg/kg). Success in pain management was defined as pain score of less than 3 for 30 minutes after the last analgesic dose, or if all the 10mL of solution in the syringe was used up. Proper response to treatment was observed in 90% vs. 70% of the patients in the lidocaine vs. morphine groups (P = 0.0001). No serious or life-threatening complication was reported in any of the lidocaine group patients, emphasizing the fact that IV lidocaine is a safe and efficient choice in patients with renal colic  and morphine (8 mg) failed to reduce her severe pain. Subcutaneous paravertebral block with lidocaine 2% (6 mL) was considered and performed in left lateral decubitus position. Patient’s pain decreased dramatically from 10/10 to 2/10 and 0/10 at 5 and 10 minutes after the block, respectively. However, her pain increased to 7/10 just 2 hours later. Consequently, she was given a SC injection of bupivacaine 0.25% (6 mL), which was effective and the patient was pain-free for another 2 hours. Subsequently, analgesia was maintained by IV meperidine (75 mg). Afterwards, spinal anesthesia was performed for the patient to undergo nephrostomy and pelvic stenting  due to spinal compression at T6-T8, IV morphine (bolus dose of 25 mg and infusion rate of 50 mg/h) was reported to have failed to reduce pain. Other supplementary analgesics were tried, which were of no significant efficacy. Hence, IV lidocaine was considered with an initial treatment course consisting of 100 mg lidocaine (1.5 mg/kg) within 20 minutes, which associated with a dramatic decline in the pain score of the patient. Consequently, IV lidocaine infusion at the rate of 100 mg/h was selected for analgesia maintenance. Throughout treatment course, different routesof lidocaine administration were examined; bolus and continuous infusion of lidocaine were the most effective approaches .+ channels very slowly in order to achieve the most appropriate blockade. The main purpose of such a regimen is to allow time for other treatments to take effect, as the lidocaine treatment course is often not long-lasting (lasting for less than 48 hours). Intravenous lidocaine and calcium channel blockade (through IV MgSO4) can be particularly effective along with IV dexamethasone, especially for chronic daily headache (CDH).However, much of its therapeutic mechanism remains to be discovered , by several studies. In one of them, the effect of IV lidocaine at two doses (0.5 mg/kg/h and 2.5 mg/kg/h over 2 hours) on PHN pain and allodynia was evaluated. A significant effect on PHN pain and allodynia following a brief IV infusion of lidocaine was observed, indicating the fact that lidocaine infusion might be effective in PHN .Considered to be one of the most refractory pain challenges, post-stroke pain syndrome (PSPS) seems difficult to treat. In a study performed on four patients with refractory PSPS, 48-hours infusion of lidocaine was administered after an initial intravenous bolus of 50-100 mg. Pain scores of all patients decreased significantly within the first 12 hours of infusion; therefore, to maintain the analgesia, mexiletine  was administered. Later, 50% of the patients pursued taking the medication with an outstanding pain relief throughout the 12 month follow-up period, while 50% of the patients failed to continue the treatment course due to the emergence of side effects. Consequently, an algorithm was proposed for the treatment of PSPS .Previously known as reflex sympathetic dystrophy (RSD) and causalgia, complex regional pain syndrome (CRPS) types I and/or II are challenging medical conditions which can be associated with other symptoms such as allodynia, hyperpathia, dysesthesia, changes in hair and nail growth, decreased range of motion of the involved extremities and color and temperature changes. In a study performed on CRPS patients, continuous 4 - 8 weeks subcutaneous infusion of lidocaine 10% was considered. The regimen significantly decreased the pain scores in most of the patients, an effect that persisted after termination of the continuous subcutaneous infusion as well. However, in some cases, periodic maintenance infusions was required .Neuropathic pain is defined by the International Association for the Study of Pain as “pain resulting from damage to the peripheral or central nervous system”. It is characterized by major clinical features such as lancination and spontaneous character, variable onset after injury, association with allodynia and hyperesthesia, and evoked summation and hyperpathia. Densely expressed sodium channels in injured peripheral nerves are blamed for creating persistent spontaneous discharges, resulting in a central hyperexcitable state. Lidocaine inhibits ectopic discharges originating from the injured nerve, the dorsal root ganglion, and peripheral neuromata . SubcutaShoulder dislocations are common and many of them are reduced without any or proper analgesia, in either outpatient or emergency settings. The use of intra-articular lidocaine injection for reduction of anterior shoulder dislocations has been reported to be helpful in both outpatient clinical settings and emergency departments .Topical lidocaine is available in solution, gel, and ointment forms. Viscous Lidocaine can be utilized temporarily on the inflamed mucous membranes. For catheter insertion (Foley catheters and nasogastric tubes) or similar painful procedures, lidocaine gel is an excellent choice. However, special attention must be devoted not to exceed maximal doses while using any form of the medication. Diverse combinations of topical anesthetics mostly contain lidocaine, such as lidocaine, epinephrine and tetracaine (LET), or lidocaine and prilocaine (EMLA). The LET combination is commonly used in infiltrative anesthesia and has the advantages of maintaining proper homeostasis, painless administration, no injection requirement, and not distorting wound edges. In order to achieve the maximal effect, LET should be applied for at least 20 minutes and it should not be used on mucous membranes or in end-artery fields. The EMLA cream is a 1:1 combination of lidocaine 2.5% and Prilocaine 2.5%, which is used preoperatively in pediatric patients. It is recommended to be applied for 45 minutes to 2 hours, and it provides abundant analgesia for minor procedures, to a satisfactory degree of pain tolerance .First introduced by August Bier in 1908, this block aims at exsanguinating the extremity by an arterial tourniquet. Subsequently, local anesthetic is injected into the venous system of the extremity in order to provide anesthesia. The block is mostly used in surgical procedures that will be completed within 40-60 minutes and involve the forearm and leg (open procedures or closed reductions). Numerous mechanisms have been proposed for intravenous regional anesthesia, yet the exact mechanism remains to be discovered. Early anesthetic action of the local anesthetic is due to its effect on major nerve trunks, small nerves, and nerve endings. Associated hypothermia and acidosis are considered as local anesthetic activity enhancing factors. Lidocaine 0.5% (maximum dose of 3 mg/kg) is considered an excellent choice as it has a relatively low toxicity and high therapeutic index. Lidocaine should not contain epinephrine or any preservatives as it would lead to catastrophic consequences , 29.Lidocaine, with an action onset of 2-5 minutes and duration of 1-2 hours, is an unsurpassed choice. Pain on injection site caused by lidocaine could be diminished by adding bicarbonate (in a proportion of 1 NaHCO3:9 lidocaine), using needles with small gauge 27 or 30 gauge), warming the solution prior to injection and the last, but not the least, slow injection of the solution. Epinephrine, if added to lidocaine, could enhance the blocking and provide longer durations of anesthesia, wound homeostasis, less systemic absorption and, consequently, decreased toxicity. It, however, would lower the pH of the solution and increase the pain on the injection site. Based on the fact that epinephrine reduces local perfusion, it should not be used in the ring block of the digits, penis, nose, ears or where there is risk of ischemia. The maximum dose of lidocaine is 4.5 mg/kg without epinephrine, and 7 mg/kg with epinephrine. However, the maximum safe dose in intercostal nerve block is 10 times less than the standard doses. In order to avoid any allergic reactions in patients with history of allergy to any local anesthetic, skin test with 0.1 mL of preservative-free anesthetic from another class of local anesthetics should be performed. Alternatively, diphenhydramine (0.5 to 1%) can be used simultaneously , 30. gauge, wLocal anesthetic (LA) infiltration is the most common use of LAs, which can provide anesthesia for numerous invasive procedures. Wound or incision margins are infiltrated by LA, or LA is injected directly into the wound, which is called “field block”. In order to avoid any further pain in an intact skin, raising a skin wheal would prevent further pain caused by consequent infiltration. The LA can also be used in orthopedic procedures, such as fracture and joint reduction, by directly injecting LA into the affected joint or fracture hematoma , 30.Axillary brachial plexus block, first described by Halstead in 1884, is an excellent choice for the procedures performed on the forearm and hand injuries and fractures. Reasonably large volumes of local anesthetic (35-40 mL) are required in order to guarantee complete anesthesia. Lidocaine 2% in combination with bicarbonate and epinephrine would provide analgesia for 3-6 hours, with an onset time of 5-15 minutes. In this block, slow approaches with frequent aspirations are recommended as the injection field is highly vascular and inadvertent intravascular injection is probable .Digital blocks performed on fingers or toes are uniquely valuable, as fewer volumes of anesthetics are required. However, a better-quality anesthesia could be achieved. Nevertheless, delayed onset of action is inevitable. Prior to block, neurovascular examination must be performed and epinephrine administration should be avoided. Although rare, complications include nerve injury and systemic toxicity following intravascular injection .Hematoma block with lidocaineis regularly used in the emergency departments for the reduction of Colles' fracture. Lidocaine 2% (5-10 mL) is directly injected into the fracture hematoma. Although hematoma block is an extremely practical approach, lidocaine toxicity is one of its few potential complications which could be prevented by proper dosing of the LA .Lidocaine is a safe medication that is administered via different routes in different fields of the emergency medicine including visceral/central pain, renal colic, terminally ill patients, headache, postherpetic neuralgia, post-stroke pain syndrome, CRPS, neuropathic pain, intra-articular injection, topical anesthesia, Bier block, local and regional anesthesia, local anesthetic infiltration, digital blocks and hematoma blocks.


The prevalence of pain in patients with sarcoma is not well documented. We investigated this in outpatients at a tertiary cancer referral centre, assessing the adequacy of pain control and for risk factors leading to higher prevalence and severity of pain. 149 patients were surveyed. Patients with pain within the previous 7 days completed pain assessment tools . 53% of patients had pain within the previous 7 days, and 25% had significant pain. Of those with pain, 63% was inadequately controlled and neuropathic pain was identified in 36%. Age, gender, tumour type, and the type of cancer treatment were not significant predictors of the prevalence or severity of the pain. Based on our results, patients with sarcoma should be actively screened for pain and have regular reviews of their analgesic requirements. The prevalence of pain in cancer patients was recently investigated in a meta-analysis involving 52 studies . StudiesDeandrea et al.  analysedWith regards to pain prevalence related specifically to sarcoma, there is very little documentation at all. Sarcoma is a relatively rare, heterogenous type of cancer of the connective tissue which may occur almost anywhere in the body. It is not gender or age specific. The true incidence of sarcoma is difficult to ascertain as tumours are generally documented with respect to their site of origin rather than tissue type. The Sarcoma Trust/Sarcoma UK quotes 3200 cases in the UK each year, or about 1% of all cancer diagnoses . The RoyWe undertook a cross-sectional, prevalence study of pain in patients who attended the sarcoma outpatient clinics at the Royal Marsden Hospital. In patients who had any pain we attempted to specify the characteristics of their pain, including severity, duration of pain, and the presence of breakthrough pain. We questioned the adequacy of pain control by using the PMI, the perceived aetiology of their pain, and also recorded the incidence of neuropathic pain in these patients. Finally, we tested the hypothesis that particular risk factors were associated with significant pain. The study encompasses the first steps in the recommendations from the American Pain Society —to screeEthics approval was granted by the Ethics Committee of the Royal Marsden Hospita, and the study was registered with the Hospital Committee for Clinical Research prior to the study commencing. The research was carried out according to Good Clinical Practice guidelines  and recoPatients were recruited from all sarcoma outpatient clinics in our hospital over 6 months from May–November 2009.All eligible consecutive patients attending sarcoma outpatient clinics within the study period were contacted via post or telephone a week before their clinic appointment to inform them of the study. These patients were then approached by the research team  on the day of their appointment to consent to the study. Those recruited filled out a screening questionnaire, with the assistance of the research team.The screening questionnaire collected the following information.Age, treatment history (from the electronic patient records).Pain in the previous 7 days, analgesic medication, patients who had pain then had further assessments of the characteristics and management of their pain.Duration of primary pain, presence of breakthrough pain, aetiology of pain , the Brief Pain Inventory (BPI) , researcThe Pain Management Index (PMI)  is anothThe following information was collected to investigate whether they were predictors of pain: age, gender, tumour type, staging, and treatment type . Binary logistic regression was used to identify risk factors for pain. The relationship between the severity of pain and the potential risk factors was investigated by using ordinal regression. The analyses were performed using SPSS version 17.The primary outcomes were the prevalence of “significant pain” in all patients—pain score of 5.0 or more—and the proportion of patients with negative PMI, that is, pain that was inadequately managed. The pain score was a composite of the VAS for average pain, worst pain, least pain, and pain right now. The secondary outcomes were the prevalence of significant pain association with risk factors as mentioned above, the severity of pain associated with risk factors, and the proportion of patients with neuropathic pain as determined by using S-LANSS.Patients inadequately treated for pain, as determined by a negative PMI, were offered advice regarding ongoing pain management. They were given advice and contact details for our pain team, prescribed analgesia, advised to seek further medical input from their GP, or booked into our or patient's own pain management clinic as required.149 subjects were recruited from 228 eligible patients. 79 did not participate due to reasons outlined in The overall prevalence of any pain in the previous 7 days in the study population was 53% (79/149). Using the Visual Analogue Scale (VAS) to score their worst pain (range 1–10), 27 patients had mild pain (VAS 1–4), 28 patients had moderate pain (VAS 5–7), and 24 patients described severe pain according to the VAS (8–10). Significant pain (≥5.0 by the composite pain score) occurred in 25% of patients with pain (20/79), 95% confidence interval was 16–36.48/79 (61%) of patients who reported pain had background pain for over 3 months in duration. The majority of the remainder (32%) had pain for more than 1 week but less than 3 months. 3/79 (4%) had pain for less than 1 week. 3 patients described no background pain.Breakthrough pain was problematic for 45 patients (57%). 31 patients (39%) had unresolved breakthrough pain for more than 3 months. 7 patients had breakthrough pain for more than 1 week, but less than 3 months. The remaining 7 patients had breakthrough pain for less than 1 week.The aetiology of their pain was discussed with the patients. 7 patients felt that their pain was due to direct pressure from the tumour, 1 due to metastatic disease. 50 patients had pain due to anticancer treatment, and 21 had pain from noncancer causes—17 musculoskeletal, 2 abdominal, 2 unspecified.50/79 patients (63%) who reported pain were found to have a negative PMI—that is, not adequately treated with regards to their pain.From the description of their pain, 36 patients were assessed by the research team to have pain of nociceptive origin, 7 neuropathic, and 36 mixed nociceptive and neuropathic. Of those with a neuropathic component, 11 were taking adjuvant analgesics such as antidepressants or anticonvulsants—3 from the purely neuropathic group, 8 from the mixed nociceptive and neuropathic pain group.By using the S-LANSS questionnaire, 29 patients (36%) fit the neuropathic pain criteria . 11 of these patients (38%) had significant pain with a composite pain score of ≥5 in the previous seven days. The worst VAS in the previous seven days for 14 patients (48%) was ≥8.χ2-testing (Age (comparing those greater to less than 60 years old), gender, tumour type, and cancer treatment type were not implicated as predictors of pain by using the binary logistic regression analysis . The sev-testing .Not all patients who had pain wanted poststudy surveillance. No intervention was performed in 35 patients (44%). 24/79 (31%) patients were given advice by the researchers and given contact details of our hospital pain team. 5 were advised to see their GP, 3 were prescribed an additional analgesic, and 13 were advised to liaise with their local pain services, including 3 in our own pain management clinics. Of the group for further contact with pain management services, 9 had breakthrough pain for more than 3 months and 9 scored positive for neuropathic pain using the S-LANSS questionnaire. 2 patients required referral back to their clinical team for further investigation of the source of their pain.In our paper, we found the prevalence of pain in our patients with sarcoma to be 53%, which confirms the overall figure quoted in the meta-analysis of 52 studies of pain prevalence in cancer patients . With 25This high prevalence of pain was unfortunately accompanied by a similarly high incidence of inadequately treated pain, as seen by 63% of patients having a negative PMI. This again echoes current evidence that a high percentage of cancer patients are still being undertreated for pain , despiteWe did not specifically question patients regarding pain syndromes, but rather any pain that they may have. However, it is concerning that 61% patients had pain for more than 3 months in duration. We know from other studies that undertreatment of pain may result in patients having increased morbidity , 24, incBreakthrough pain was a difficulty for over half of our patients with pain. Again, this has ramifications regarding poor prognosis, reduced function, mood, and hospitalisations –37. It sNearly two-thirds of patients with pain felt that it was as a result of anticancer treatment. With this in mind, clinicians ought to be more vigilant regarding repeated pain assessment and management alongside their anticancer treatments. Patients are known to be reluctant to draw attention to their pain due to many reasons , 38–40 aA third of the patients with pain were assessed by the research team to have a neuropathic component using S-LANSS. A high percentage of those who scored positive for neuropathic pain with the S-LANSS questionnaire rated their pain to be significant. Neuropathic pain clearly plays a considerable role in this patient group, and wider use of adjuvant analgesic therapy may be necessary to help to control the pain. We were unable to identify any predictors of presence of any pain or severity of pain in our patient group. This may be as a result of insufficient sample size, or be due to the aforementioned heterogeneity in sarcoma. There may also be other factors not analysed in the study. Due to the rarity of sarcoma, it would take some time to organise a larger study to confirm this. Suffice to say that it would be prudent for clinicians to be aware of pain as a potential problem in all patients with sarcoma.We have shown pain to be a significant problem in patients who attend sarcoma outpatient clinics, irrespective of the stage of their disease. Highlighted issues include severity of pain, duration of pain, and presence of breakthrough pain. Treatment of pain is generally inadequate and requires a full initial assessment and regular reviews, alongside treatment of the cancer. This should be a holistic approach to ensure that patients who have pain from non-cancer causes are also evaluated and referred as appropriate. Frequently, a neuropathic component to the pain may make treatment strategies complicated and adjuvants or specialist input may be beneficial. Future studies into pain prevalence in patients with sarcoma would be worthwhile to identify risk factors. In the meantime, it is up to the clinician to be aware of the possibility of a patient in pain who may be wary of drawing attention to the problem, resulting in long-lasting consequences.


Introduction. Tension-Type Headache (TTH) is the most prevalent headache often associated with impaired function and quality of life. Temporomandibular Disorders (TMD) and TTH frequently coexist; characterized by pericranial tenderness and impact on daily life. We aim to apply a standardized questionnaire for TMD to characterize and analyse an eventual relation between sleep and oral health in TTH in a controlled design. Material and Methods. 58 consecutive TTH patients and 58 healthy controls were included. The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) questionnaire, Oral Health Impact profile (OHIP) and questionnaires for sleep were applied. Results. TTH-patients had significantly higher pain scores (P < 0.001), decreased quality of life (P < 0.001), and higher total sleep scores (P < 0.001) compared to controls. Conclusion. For the first time we have identified a clear relation between TTH and TMD symptoms, depression, anxiety, poor sleep, and impairments of oral function in carefully classified patients. These findings indicate a close, but incomplete, overlap between TTH and TMD. Their underlying pathophysiological mechanisms need further research. Epidemiological studies of sleep and headache disorders point to a close connection, but the causal relations are unclear . Sleep iIn a large Danish longitudinal epidemiological study, we have identified disturbed sleep as a very important risk factor for poor prognosis of TTH , but detLocal pain may be viewed as the most important complaint of TMD patients. In particular, pain from the masticatory or preauricular areas is frequently reported, but also headache is one of the symptoms which often occur in TMD patients . In a poIn this study, we hypothesized that TTH patients suffer more from craniofacial pain, sleep problems, and oral health problems than healthy controls. Our study aim was therefore to clarify whether there was an association between TTH and self-reported TMD pain and disability and to identify potential relationships between self-reported TMD pain, sleep quality, and oral health-related quality of life in well-characterized TTH patients in comparison with healthy controls.A total of 116 age- and sex-matched individuals participated in this study. We included 58 consecutive headache patients and 58 healthy controls without headache and asked them to complete 3 detailed and validated questionnaires –9 relateThe headache patients were recruited from a tertiary multidisciplinary headache center in denmark (DHC) and they fulfilled the ICHD-2 criteria for frequent episodic TTH (FETTH) or chronic TTH (CTTH) . They weThe inclusion criteria for TTH were age between 18 and 65 years, TTH for at least 1 year before the inclusion, and completion a diagnostic headache diary for at least one month before inclusion in accordance with ICHD-II . The exclusion criteria were more than 4 migraine days a month, medication overuse headache or head trauma, overuse of alcohol or other substance abuse, and pregnant women; cerebrovascular diseases; epilepsy or other seizure disorders. The TTH patients were not allowed to use an occlusal splint during the study and they should have kept any eventual prophylactic medication stable for at least one month before the inclusion. The healthy controls were recruited from the Internet or among their friends and relatives and were defined as individuals with no headache or less than 12 headache days a year; between 18 and 65 years of age; no use of medication except birth control pills; and no substance abuse. Twenty-six of our headache patients had a history of migraine and their average frequency of migraine was 2 days/month confirming that TTH is their predominant headache. The remaining 32 TTH patients reported no history of migraine. Three of the controls had also a history of migraine but no current attacks.Both healthy controls and TTH patients gave their written informed consent and the study was approved by Local Ethical Committee as a part of the randomised controlled study (no. H-A-2007-0084).The RDC/TMD Axis II Questionnaire is a validated self-report questionnaire with 27 questions aiming to assess both functional and psychosocial aspects related to TMD pain .The RDC/TMD Axis II analysis is divided into 4 parts.Characteristic pain intensity (CPI) consists of the mean of 3 pain scores multiplied by 100 (0–100): (1) the intensity of the present pain on a visual analogue scale 0–10 (VAS) where represents 0 “no pain” and 10 represents “pain as bad as could be,” (2) the intensity of the worst pain experienced during the past six months on the same VAS, and (3) the average intensity of the pain during the past six months. The graded chronic pain scale (GCP) describes the patients' psychosocial functional level based on information from the questionnaire about, for example, the number of sick days and problems with participation of daily activities (disability points: 1–6). It rates the disabilities due to TMD pain during daily life into four grades: grade 1; low intensity of pain (CPI < 50) and low disability (less than 3 disability points): Grade 2 represents high intensity of pain (CPI > 50) and low disability (less than 3 disability points) and grades 3 (3-4 disability points) and 4 (5-6 disability points) describe increased psychosocial disability due to TMD pain regardless of the pain intensity (CPI) . Question 15 is divided into 7 questions regarding self-reported bruxism and question 19 is a jaw disability checklist with 12 questions . The symptom checklist (SCL) 90 is used to assess the possible involvement of depression and somatisation. On a 0–4 point scale, where 0 represents not at all, 1 represents a little bit, 2 represents moderately, 3 represents severe and 4 represents extremely severe. Furthermore all subjects indicated how much they have been bothered by pain during the past month [OHIP is a validated questionnaire with 49 questions , 12 and The sleep quality questionnaire contains 20 questions . Its purt-tests between groups. The proportions of TTH patients and controls answering yes to RDC/TMD Axis II questions 15a-g and 19a-l were compared between groups by means of χ2-tests. P values <0.05 were considered statistically significant. Data were checked for distribution of normality and parametric tests were used and the mean values are presented. Analysis for the relation between CPI, sleep, OHIP, and sleep was conducted by means of Pearson analysis of correlation. The statistical analysis was performed using the Stata 10 and Excel 2010.The results from the RDC/TMD Axis II , weighted OHIP domain scores, total weighted OHIP, score and sleep scores were analysed with unpaired More than 120 questionnaires were distributed to healthy controls and 65 men and women (54%) returned the questionnaire. Seven of these were deficient and excluded from the following analysis. There were no statistically significant differences in age or gender between healthy controls and TTH patients and between responders and non-responders. The clinical baseline characteristics are described in P < 0.001)  were significantly higher in TTH patients than in control (< 0.001) .P < 0.001). The OHIP questionnaire revealed no significant differences between TTH patients and controls regarding psychological discomfort and physical incompetence . TTH patThe total sleep score was higher in TTH patients than in healthy controls and the total numbers of hours tended also to be lower in TTH patients, although not significantly different from controls . Regarding oral function, TTH patients were also significantly more affected and presented with limitations in jaw functions such as exercising, smiling/laughing and eating hard foods, and having a usual facial appearance compared to controls .r = 0.41, P < 0.05) whereas no such relation between CPI and depression, anxiety, CHI, and total sleep scores could be detected. Total sleep score was significantly correlated to SCL depression  and to SCL anxiety . A less pronounced correlation was found between the total sleep score and the total weighted OHIP . Otherwise, no other significant correlations between sleep, CPI and OHIP were detected. CPI was significantly and positively correlated to frequency of headache  has a combined effect on sleep and headache and may thus contribute to the significant preventive effect of TCAs in TTH. Such combined mechanisms should be pursued in future treatment strategies and a detailed history of eventual sleep disorders in all TTH patients and vice versa can be recommended for providing useful information for the treatment planning and eventual prevention. Sleep quality in patients with migraine and TTH has been studied by Rains et al.  who concOur study has its limitations due to the fact that the patient group was fairly severely affected and consisted mainly of CTTH patients referred to a tertiary headache center and thus not representative of TTH in the general population. Moreover, the study is cross-sectional and causal relations are thus impossible to ascertain. The advantage was the clear ICHD-diagnosis recorded prospectively in diagnostic diaries, the use of standardized instruments, and the broad baseline results. In addition, it was a clinical relevant population, a controlled study, and the patients were allowed multiple headache diagnosis as TTH as the predominant headache.Looking at our study method with a questionnaire-based study, there may be limitations. The patient's immediate response in a questionnaire can be influenced by recall bias and the replies should be confirmed in a prospective study for both patients and controls. Such detailed recording was however out of the scope for our present study but could be of interest in future interventional studies. The advantage of a questionnaire-based study is that it probably reflects the most recent and significant problem for the patients and that the outcome can be compared with previous studies using same methodology. conclusion, we found a clear presence of self-reported TMD symptoms, impaired sleep, and reduced oral health related quality of life in carefully classified TTH-patients compared to healthy controls whereas cause-effect relation is still uncertain. A close relation between self-reported TMD pain and headache frequency may indicate a common pain pathway whereas the sleep scores were more related to anxiety and depression. Based on these clear results, we recommend consideration of a broad treatment strategy with focus not only on the headache but also on these complicating factors. A multidimensional approach that focuses on orofacial problems, psychological reactions, and sleep quality is thus relevant and must be considered in the management of clinical TTH patients.In