Background and Objectives: The purpose of this retrospective study was to identify predictors of short-term outcomes associated with a lumbosacral transforaminal epidural steroid injection (TFESI). Materials and Methods: The medical records of 218 patients, who were diagnosed with lumbosacral radiculopathy and treated with a TFESI, were reviewed in this retrospective study. A mixture of corticosteroid, lidocaine, and hyaluronidase was injected during TFESI. Patients with >50% pain relief on the numerical rating scale compared with the initial visit constituted the good responder group. Demographic, clinical, MRI, and electrodiagnostic data were collected to assess the predictive factors for short-term outcomes of the TFESI. Results: A multivariate logistic regression analysis demonstrated that a shorter duration of symptoms and a positive sharp wave (PSW)/fibrillation (Fib) observed in electrodiagnostic study (EDx) increased the odds of significant improvement 2–4 weeks after the TFESI. Conclusions: Shorter duration of symptoms and PSW/Fib on EDx were predictors of favorable short-term response to TFESI. Low back pain and radiating pain are common health conditions, with a lifetime prevalence of about 40–60% ,2,3. HowThere is controversy regarding the effect of a lumbosacral epidural steroid injection. Some studies have demonstrated the efficacy of epidural steroid injections for the treatment of radiating pain in patients with lumbosacral disk herniation ,5,6,7. OThree different techniques, including transforaminal, interlaminar, and caudal approaches, have been widely used in clinical practice. The transforaminal epidural steroid injection (TFESI) seems to be better than an interlaminar or a caudal approach for radicular pain ,11.Despite the widespread availability of epidural steroid injections, little is known about the factors predicting their success. Studies investigating the predictors of lumbar epidural steroid injections have shown conflicting results ,26,27,28The patients who had undergone lumbosacral TFESI procedures in the Department of Rehabilitation, Korea University Guro Hospital, from March 2014 to October 2017, were included in this study. The electronic medical records of symptomatic patients who were diagnosed with lumbosacral disk herniation, that presented with radiating pain, and were treated with a TFESI, were reviewed. This study was approved by the institutional review board of the relevant institution . The inclusion criteria were: (i) patients aged over 20 years old; (ii) patients who complained of radiating pain; (iii) definitive diagnosis of lumbosacral disk herniation, which was confirmed by MRI; and (iv) TFESI treatment.The exclusion criteria were: (i) inadequate data including history, physical examination, and MRI findings; (ii) failure to visit our clinic again 2–4 weeks after the TFESI; (iii) symptoms after traffic accident or workplace injury; (iv) prior lumbosacral epidural steroid injections in the past 3 months; (v) severe motor weakness of the lower extremity ; (vi) acute bladder or bowel symptoms; (vii) diagnosis of other diseases, such as diabetic polyneuropathy, in addition to lumbosacral radiculopathy, diagnosed either clinically or via electrodiagnostic study (EDx); or (viii) abnormal blood test results. Blood tests were routinely done for all the patients before the epidural injection. Blood tests included a complete blood count, blood chemistry, C-reactive protein, prothrombin time, and activated partial thromboplastin time. Patients with either severe motor weakness (less than a fair grade) or acute bladder and bowel symptoms were referred to a spine surgeon. Based on these criteria, 218 patients were included in this study. Oral analgesia was prescribed to all patients. None of the included patients were involved in other treatment, such as physical therapy.All of the procedures were conducted by two specialists experienced in spinal intervention under fluoroscopic guidance on an outpatient basis. Blood tests, including complete blood count, blood chemistry, erythrocyte sedimentation rate, C-reactive protein, prothrombin time, and activated partial thromboplastin time, were carried out on all the patients before the procedure to determine infection or bleeding risk. Patients taking anti-platelet agents or anticoagulants were asked to discontinue them for a week before the procedure. Informed consent was obtained from each patient. All the procedures were carried out via an extraepineural approach. With the patient lying in a prone position, the C-arm was rotated obliquely to obtain an X-ray image of pedicle and neural foramen. An 89 mm, 23-gauge spinal needle was advanced into the safe triangle. The safe triangle was defined by the pedicle superiorly, the lateral border of the vertebral body laterally, and the outer margin of spinal nerve medially. The contrast agent was spread into the epidural space and externally along the spinal nerve root. A mixture of 20 mg (0.5 cc) of triamcinolone acetonide suspension, 2 cc of 0.5% lidocaine, and 750 IU of hyaluronidase was slowly injected at each level. This mixture has been used to treat acute and chronic low back pain and radicular symptoms via various mechanisms. Corticosteroids exhibit anti-inflammatory effects, as well as interfere with nociceptive C-fiber conduction . Local aAll the patients were asked to visit the outpatient clinic 2 weeks after the TFESI to evaluate the short-term therapeutic effect. However, a few patients failed to visit on the scheduled date because of the patient’s personal circumstances. Therefore, we collected the short-term outcome based on the first visit between 2 and 4 weeks after the TFESI.A retrospective review of medical records was performed. The following data were reviewed: (i) demographics, (ii) clinical characteristics, (iii) MRI, and (iv) EDx measurements. Demographic data included age and sex. Clinical data included past medical history, symptoms, and physical examination. Past medical history, including the presence of diabetes, hypertension, and previous lumbosacral spine surgery, was reviewed. Any sprain or trauma associated with the low back was assessed just before the onset of symptoms. Duration of symptoms was classified as acute (≤4 weeks), subacute (4–24 weeks), and chronic (≥24 weeks). The nature of pain was evaluated as follows: presence of low back pain, buttock pain, or neurogenic claudication. The straight leg raise test (SLR) and motor and sensory examination were performed. The SLR was considered positive if the radiating symptoms were triggered by lifting the leg less than 60 degrees. The motor exam was considered abnormal if there was weakness associated with any of the following muscle groups on manual muscle testing: hip flexors, knee extensors, ankle dorsiflexors, great toe extensors, and ankle plantar flexors. The sensory exam was considered abnormal if allodynia, hypoesthesia, anesthesia, or paresthesia was detected along the nerve root dermatome.All the patients underwent lumbar MRI, and all the MRI data were reviewed by a single radiologist specializing in musculoskeletal imaging at our hospital. MRI data included the level of herniated nucleus pulposus (HNP), the presence of nerve root compression or contact, foraminal stenosis, and moderate-to-severe central canal stenosis.EDx, including a nerve conduction study and needle electromyography, was performed by qualified electromyographers. We used a needle electromyography (EMG) electrode to examine paravertebral and limb muscles, including at least six muscles: gluteus maximus, tensor fascia lata, vastus medialis, tibialis anterior, peroneus longus, and medial gastrocnemius. We reviewed the presence of radiculopathy based on the EDx report. The presence of a positive sharp wave (PSW) or fibrillation (Fib) in the lower limb, and motor unit action potential (MUAP) change, were also reviewed. A MUAP change refers to polyphasia, long duration, and/or large MUAPs in the lower limb muscles.The short-term response of TFESI was determined by the degree of pain relief at the outpatient clinic 2 to 4 weeks after TFESI. Pain intensity at the initial and follow-up visits was assessed using the numerical rating scale (NRS) . Good responders were defined as the group with a reduction greater than 50% on NRS at the follow-up visit compared with the initial visit. The others were defined as poor responders.t-test, the Mann–Whitney test, and the chi-squared test to demonstrate the statistical difference of clinical data between the good and poor response groups. The independent t-test and Mann–Whitney test were used for continuous variables. The chi-squared test was used for categorical variables.Descriptive statistics were used to report the demographic and clinical data. Categorical variables were described using absolute and relative frequencies. Continuous variables were described using the mean and standard deviation, and discrete variables were described using the median and corresponding ranges. We conducted the independent p values <0.05 in the univariate analysis were included in the multivariate analysis. Data were analyzed using SPSS software version 20.0 , and a p value <0.05 was considered significant in all analyses.Univariate logistic regression analysis was first performed for the analysis of the primary outcome. The odds ratios (ORs) and 95% confidence intervals (CIs) were determined to show the reliability of the estimates. Multiple logistic regression analysis was used to identify individual predictors of substantial response suggested by the univariate analysis. All Demographic, clinical, and MRI data were collected from all the patients. However, EDx was performed in 150 of the 218 patients. The number of patients presenting with a favorable response 2–4 weeks after TFESI was 133 (61.0%), and the number of poor responders was 85 (39.0%). Demographics, past medical history, spinal surgery history, duration and presentation of symptoms, physical examination, the number of TFESI levels, and MRI and EDx findings were compared between the favorable and poor response groups . A statiThe results of univariate and multivariate logistic regression analyses are listed in In this study, we measured short-term outcomes 2–4 weeks after TFESI. Previous studies reported that epidural steroid injections may result in improvement in lumbosacral radicular pain between two and six weeks, which may relate to the duration of the therapeutic effect of corticosteroid ,34. All The first finding was that shorter symptom duration was the strongest factor associated with a good response. Having acute symptoms or subacute symptoms increased the odds of significant improvement 2–4 weeks after TFESI compared with manifesting chronic symptoms. These results are consistent with previous studies. Ahilan et al.  reportedA longer duration of symptoms results in chronic inflammation, including fibrosis and necrosis of nerve root fibers ,36. ThesVarious management strategies have been suggested as chronic back pain and radicular pain do not well respond to various approaches. As seen in this study, TFESI is less effective for chronic low back pain. Therefore, we should emphasize non-pharmacologic treatment, such as exercise therapy, especially in chronic low back pain .Whether EDx findings can be a predictor of response to epidural steroid injection has been challenged by several studies. A few studies ,24,26 reSeveral explanations are possible. First, the diagnosis of radiculopathy by EDx is limited to motor neuron axonal damage in most cases. It is impossible to diagnose radiculopathy by EDx in the presence of only mild injury at the nerve root, such as focal demyelination without damage to the motor axons. The patients who were diagnosed with radiculopathy but exhibited normal findings on EDx also responded well to TFESI. This hypothesis explains the absence of association between EDx diagnosis and TFESI outcomes. Second, membrane instability characterized by PSW/Fib is generally detected in limb muscles within three weeks after acute neural insult and continues until the muscle fiber is reinnervated or atrophied completely. When the patient was diagnosed with radiculopathy without PSW/Fib, EDx was performed after reinnervation, because completely atrophied muscle would have been excluded from this study due to severe motor weakness. It is reported that the limb muscles are reinnervated about three months after symptom onset. In contrast to PSW/Fib, most of the MUAP changes, including polyphasic, large, and long duration, were found in chronic and static radiculopathy, even though polyphasic MUAP was detected at an early stage ,41. ThusThe absence of spine surgery could be associated with favorable response to TFESI, even though the association was only present in the univariate analysis. This result can be explained by postoperative scar formation. Epidural scar from low back surgery probably induced soft tissue adhesion and mechanical compression of the nerve root, which is resistant to the anti-inflammatory effects of corticosteroid. The scar also mechanically prevents delivery into the epidural space and eventually decreases the effectiveness of injection. Previous studies report conflicting results. Sivaganesan et al.  reportedWe were unable to determine the association between MRI findings and a good response to the TFESI in the multivariate regression analysis. However, a central canal stenosis observed on MRI may be associated with increased odds of a positive response, even though the association was not statistically significant in multivariate analysis. These associations have been disputed in previous studies ,23,27,28In this study, the short-term success rate of a TFESI at 2–4 weeks was 61%. Previous studies have reported that the success rate is about 34–78% and the success rate of the short-term effect is about 50%, which is similar to our study . One sysThis study has several limitations. First, the outcome was only evaluated by a change in NRS. There are specific tools designed for evaluation of function and pain in patients with low back pain, such as the Oswestry Disability Index and the Pain Disability Questionnaire. Because it is difficult to objectively assess response to treatment, these tools can be also used simultaneously to assess pain, function, or emotion in a variety of ways. This is a limitation of retrospective studies analyzing data derived from pre-existing medical records. Second, the predictive factors suggested in this study are limited to short-term response to TFESIs. It was impossible to accurately and reliably predict long-term treatment response to lumbar TFESIs based on short-term pain relief . AdditioThe short duration of symptoms and the presence of PSW/Fib findings in lower limb muscles in EDx diagnosis are likely to predict a favorable response 2–4 weeks after a TFESI in patients diagnosed with lumbar disk herniation on MRI and who present with radiating leg pain. Clinicians should consider these factors in the risk–benefit analysis of TFESIs. The results should be validated via randomized prospective studies in the future.


Thirteen failed an 80 Gy dose whereas seven failed an 85 Gy dose. Kaplan–Meier analysis found that at 29 months 50% failed an 80 Gy treatment compared with 79% who had durable pain relief after 85 Gy treatment (p = 0.04). Conclusion: The 85 Gy dose for TN provided a more durable pain relief compared to the 80 Gy one without a significantly elevated occurrence of facial sensory disturbance.Purpose: A variety of treatment plans including an array of prescription doses have been used in radiosurgery treatment of trigeminal neuralgia (TN). However, despite a considerable experience in the radiosurgical treatment of TN, an ideal prescription dose that balances facial dysesthesia risk with pain relief durability has not been determined. Methods and Materials: This retrospective study of patients treated with radiosurgery for typical TN evaluates two treatment doses in relation to outcomes of pain freedom, bothersome facial numbness, and patient satisfaction with treatment. All patients were treated with radiosurgery for intractable and disabling TN. A treatment dose protocol change from 80 to 85 Gy provided an opportunity to compare two prescription doses. The variables evaluated were pain relief, treatment side-effect profile, and patient satisfaction. Results: Typical TN was treated with 80 Gy in 26 patients, and 85 Gy in 37 patients. A new face sensory disturbance was reported after 80 Gy in 16% and after 85 Gy in 27% ( Trigeminal neuralgia (TN) is a chronic neuropathic pain condition that affects the regions of the face innervated by the trigeminal nerve. Typical TN causes severe and sudden volleys of shock-like facial pain that lasts a few seconds to a few minutes in the distribution of one or more divisions of the trigeminal nerve. When patients experience attacks of pain that come on repeatedly, the result is a pain condition that is disabling in nature. Typical TN will have a trigger in the trigeminal nerve division distribution the pain is felt in, which often leads to aversive behavior by the patient to avoid the pain. For example, a trigger inside the mouth may make eating so difficult that poor nutrition results.Atypical forms of face pain have symptoms that are not shock-like in nature, do not follow the trigeminal nerve distribution, and/or do not have an associated trigger. Atypical face pain my certainly be disabling in nature, however, the treatment options available to typical TN patients are less likely to benefit individuals with atypical face pain. The etiology of typical TN in most cases is due to vascular compression at the nerve root entry zone as the trigeminal nerve exits the pons. In these cases, microvascular decompression surgery (MVD) in which a small sponge is placed as a cushion between the trigeminal nerve and the offending vessel has a high success rate in eliminating the TN pain. However, the associated risks and inconvenience related to the open surgical procedure of MVD lead many individuals with disabling pain, in particular more elderly and frail individuals, to seek out less-invasive treatment approaches such as radiosurgery and percutaneous rhizotomy. Both these approaches have a good success rate in eliminating the pain of TN, but pain recurrence is generally more common compared with MVD.Lars Leksell introduced radiosurgery as a treatment of trigeminal neuralgia (TN) at the Karolinska Institute in the 1950s , particuRadiosurgery treatment variables that have potential to impact both long-term pain relief and occurrence of treatment side-effects include the radiation dose delivered to the nerve, volume or extent of the nerve treated, and anatomical localization of the treatment target. Of these variables, treatment dose has been most frequently studied. Yet, despite a substantial experience in the radiosurgery community, the optimum radiosurgery prescription dose for TN has not been determined. Herein, the authors present results from their patients with medically intractable TN treated using Gamma Knife radiosurgery (GKR). A retrospective comparison of two treatment dose plans of 80 and 85 Gy was analyzed for the treatment of typical TN. The variables assessed were pain relief, side-effect profile, and patient satisfaction.All patients were treated for medically intractable TN by the authors at a single institution over a seven year period. Patients (or a family member if the patient was deceased or unable to provide answers to a questionnaire) were contacted by phone or had a face-to-face interview to compete a study questionnaire at follow-up time points after treatment had been completed. The questionnaire inquired about timing of pain relief after GKR, quality and severity of pain, and side effects or complications related to GKR. The patient’s subjective assessment of GKR and treatment satisfaction was evaluated by asking two questions: “Are you pleased with GKR?” and “Would you have the procedure again?”.Gamma Knife Model 4c  was used for all treatments. The treatment plan centered the maximum dose on the root entry zone (REZ) of the proximal trigeminal nerve with the 30% isodose line just contacting the brainstem. Treatment was performed using a 4 mm collimated single shot. The earlier treatment plan was with a prescription maximum dose delivered to patients of 80 Gy. Later, the protocol was changed to a prescription maximum dose of 85 Gy in all subsequent patients. These two dose plans were analyzed and compared in treated patients for variables of pain relief, facial numbness, complications of treatment, and patient satisfaction .p < 0.05 was considered significant.A Kaplan–Meier statistic analyzed the duration of pain freedom after GKR for low- and high-dose groups of patients. The Kaplan–Meier (K–M) survival distributions of the two dose groups were compared using the log rank test. A Fisher’s exact or chi square test compared categorical data, such as new onset facial numbness after GKR, patient satisfaction queries, and Barrow Neurological Institute pain intensity (BNI) at last follow-up . p < 0.0p = 0.6). The mean follow-up after GKR in pain free patients was 37 months (range 6–72 months) in individuals treated with 80 Gy and 26 months (range 6–52 months) in patients treated with 85 Gy. A total of 68 patients were treated with GKR for intractable TN over seven years. Three patients with multiple sclerosis (MS) , and two with no available follow-up after treatment (one in each group) were excluded from the analysis. Therefore, in patients with typical TN and post-treatment follow-up, the treatment dose was 80 Gy in 26 individuals, and 85 Gy was delivered to 37 individuals. Mean patient age was 71 years. Twenty-seven were women. Fifteen patients had a procedure for TN prior to GKR . Only one individual reported being bothered by numbness in the 80 Gy group and two reported that the sensory change was bothersome in the 85 Gy group. Patients answered “No” to either question of treatment satisfaction (Are you pleased with GKR? or Would you have the procedure again?) in 22% of the 85 Gy treatment group and in 44% of the 80 Gy treatment group (p = 0.09). A new facial sensory disturbance was reported after an 80 Gy treatment dose in four patients (16%) and in 10 (27%) after an 85 Gy treatment dose (p = 0.04). In addition, significantly more patients who received 85 Gy treatment experienced an overall good result  than patients treated with 80 Gy .BNI pain scores at last follow-up were evaluated in each patient. Pain freedom without medication (BNI score of I) was realized in eight individuals treated with 80 Gy and in 21 treated with 85 Gy, which represented more pain freedom without medication in the 85 Gy group (p = 0.04).A survival curve was analyzed for both treatment groups using the Kaplan–Meier statistic (K–M). Recurrent severe pain despite medication or persisting severe pain after GKR was deemed a treatment failure. At the last follow-up, thirteen patients (52%) who received 80 Gy treatment dose failed GKR whereas seven patients (19%) failed GKR after 85 Gy. K–M analysis found at the 29 months time point that 50% of patients had failed 80 Gy GKR treatment, and at the same time point, 79% of patients had continued pain relief after receiving 85 GY treatment . The K–MPotential confounders of treatment success were evaluated to determine whether age, new numbness after GKR, surgery before GKR, or length of follow-up differed by GKR dosage . There wKondziolka et al. identified that patients who received a 70 Gy dose for treatment of TN fared better with improved pain relief compared to lower prescription doses, and complications were rare . Also, tn = 41) or two (n = 32) isocenters. The authors found no difference in pain relief or sensory disturbance with higher dose, but the patients with multiple-isocenter treatment plans did experience more numbness or paresthesia in the trigeminal distribution [Morbidini-Gaffney et al., in a follow-on study of patients reported in Alpert et al. , assesseribution . Smith et al. used linear accelerator-based radiosurgery to treat TN . Over anHigh-resolution MRI or CT myelography allows for the trigeminal nerve to be clearly delineated from its exit at the brainstem to Meckel’s cave. The imaging well-defined anatomy of the trigeminal nerve allows for accurate radiosurgery targeting at any point along its course in the subarachnoid cistern. The REZ has been the most common radiosurgery treatment site of TN likely because the REZ has a long history in neurosurgery as a lesioning target for a variety of pain conditions. However, in an effort to reduce the pontine radiation dose, some radiosurgery users have moved the target more anteriorly along the nerve ; althougA few reports have described treating a greater nerve volume in an effort to improve pain-free results by employing an additional isocenter along the length of the nerve . In a prHypesthesia was rare in our patients  with no difference between the two treatment doses. Most individuals treated by the authors who developed a sensory disturbance were not bothered by the numbness, typically patients commented that an improved quality of life resulting from resolution of the disabling pain was more relevant compared to the sensory change. Some patients also commented that a new facial numbness was an acceptable trade-off for pain relief. However, it should be noted that in three patients  bothersome sensory change was GKR treatment related, and the resulting dysesthesia in these individuals is reasonably regarded as a toxicity of the radiosurgery treatment. Seventy-eight percent of patients treated with 85 Gy maximum dose to the trigeminal nerve responded that they were pleased with the GKR and would choose the treatment again, which is similar to other reports of patient satisfaction. Debono et al. reported 86.5% patient satisfaction with LINAC radiosurgery of 90 Gy dose for trigeminal neuralgia . Interventions that impact neural function are typically described as either ablative or modulatory. This has been discussed by other authors in regard to treatment of TN ,36. A sep = 0.04). The major limitations of our study are a retrospective analysis of outcome measures and a shorter follow-up period in the high-dose, 85 Gy, treatment group.The optimal radiosurgery treatment dose for TN should strike a balance between providing the most robust pain relief and the least possible risk of radiation-induced complications. The only radiation-related complication identified in our patient population was hemifacial dysesthesia, which was rare (4% in the 80 Gy treatment group and 5.4% in the 85 Gy group) and not significantly different between the two prescription doses. However, the patients who received the higher treatment dose of 85 Gy did realize a more robust treatment response compared with those who received the 80 Gy dose . Dysesthesia or a bothersome facial numbness was rare, and these complications were equally distributed between the treatment groups. The majority of patients were satisfied with radiosurgery for TN and, as expected, patients treated with the more effective dose of 85 Gy demonstrated a trend of greater treatment satisfaction. However, there is no agreement in the published studies of efficacy of dose escalation for the radiosurgical treatment of TN, and determination of the ideal dose prescription that maximizes pain relief and minimizes dysesthesia will likely require a randomized prospective clinical trial.We identified in our patients with typical TN that a GKR prescription dose treatment of 85 Gy provided a longer lasting and more robust pain relief compared to a dose of 80 Gy. A facial sensory change occurred in 11% more of the individuals in the 85 Gy treatment group, although the difference did not reach statistical significance (


Objective Postoperative pain management following scoliosis surgery has traditionally relied on intravenous opioids. The objective of this study was to evaluate the effect of elastomeric pain pumps.MethodsA retrospective chart review of 81 adolescent patients who underwent scoliosis surgery in a seven-year period was performed. Patients were divided into three groups as the practice changed: (1) patient-controlled analgesia group (12 patients) who used intravenous (IV) opioids with oral opioids; (2) elastomeric pain pump group (28 patients) with the added use of bupivacaine; and (3) multimodal pain pump group (41 patients) with the added use of gabapentin and methocarbamol. Endpoints were analyzed for length of stay in the hospital, infection rate, and gastrointestinal retention.ResultsP = 0.004). The length of stay in the multimodal group was 3.9 days shorter than in the patient-controlled analgesia group (P = 0.001). The incidence of prolonged postoperative bowel retention decreased significantly from 25% to 18% to 2% (P = 0.03).The length of stay in the elastomeric pain pump group was 3.1 days shorter than in the patient-controlled analgesia group (ConclusionsTo our knowledge, this is the first study on the use of elastomeric pain pumps in conjunction with multimodal pain medication following scoliosis surgery. The use of elastomeric pain pumps was associated with clinically and statistically significant improvements in the postoperative course. The addition of methocarbamol and gabapentin was associated with a trend toward further improvements. Multimodal analgesia has been shown to be effective in reducing opioid use in adult spine and joint arthroplasty patients, but little data is available on multimodal analgesia in adolescent spine patients -2. TradiShorter hospital stays reduce exposure to infection, allow earlier return to function and normality for the family, and decrease hospital costs. It was hypothesized that the use of elastomeric pain pumps improves the postoperative course of adolescent scoliosis patients.A retrospective chart review of 81 adolescent patients  who underwent scoliosis surgery by a single orthopedic surgeon in a seven-year period from March 2007 to December 2014 was performed. Excluded were surgeries for adjustment of growing rods and anterior surgeries. Patients were divided into three groups as practice changed. The patient-controlled analgesic (PCA) group (12 patients) used intravenous opioids with oral opioids; the elastomeric pain pump (EPP) group (28 patients) added the use of three-day elastomeric pain pumps containing 270 ml of 0.125% or 0.25% bupivacaine; and the multimodal pain pump (MPP) group (41 patients) added multimodal pain management, including gabapentin and methocarbamol. Oral gabapentin was given preoperatively at 15 mg/kg and was continued at 5 mg/kg three times daily for seven days. Methocarbamol 500 mg was given orally every six hours if the patient weighed over 33 kg. Endpoints were analyzed for length of stay (LOS) in the hospital, infection rate, and postoperative gastrointestinal retention, defined as the inability to tolerate a soft diet at 48 hours postoperatively. The elastomeric pain pumps were placed subfascially and were removed on postoperative day three. Patients received Duramorph intrathecally and intravenous ketorolac at the surgeon's discretion. Patient diet was advanced based on clinical improvement and with the auscultation of bowel sounds.There were no formal hospital efforts to reduce LOS during the study. There was no change in physical therapy protocols. Some surgeons might become more comfortable with shorter LOS as their practice matures, but this is difficult to ascertain. Implant material was changed from stainless steel to titanium later in the study, affecting the MPP group. Also, the surgical blood loss was decreasing as the surgeon’s practice matured. Gentamycin was added to the bone graft later in the study as well.t-test and association with age by using correlation. The categorical outcome variables of infection, postoperative gastric retention, and neurogenic etiology of the scoliosis were tested for association with each treatment group and with gender using chi-square and Fisher’s exact test. Association with age was tested using the t-test. Pairwise comparisons of LOS between the three treatment groups were carried out using Tukey’s honestly significant difference (HSD) test.Each of the variables was described using means and standard deviations, or proportions, for continuous and categorical variables. LOS, treatment group, and gender were assessed using analysis of variance (ANOVA) or the Patient demographics are shown in Table P = 0.004). Also, the length of stay in the MPP group was 3.9 days shorter than in the PCA group (P = 0.001). The length of stay in the MPP group was 0.8 days less than the EPP group (P = 0.8).The results also showed a significant difference in the length of stay for the three groups of patients, with the MPP group having a shorter length of stay Table . On averOverall, there were significant and clinically important differences between the PCA group and the elastomeric pain pump groups (EPP and MPP). Differences between the two elastomeric pain pump groups, with and without gabapentin and methocarbamol, were small but trended in a favorable direction in the three variables studied.Postoperative pain control affects patient comfort, the ability to ambulate and eat, and, consequently, the LOS. The addition of elastomeric pain pumps and other multimodal medications reduced the LOS of our patients to values comparable to, or lower than, those cited in the literature. Sources cite as typical five days for adolescent idiopathic scoliosis patients and seven days for neuromuscular scoliosis patients ,4. WhileA study comparing epidural analgesia to intravenous and oral opiates following adolescent scoliosis surgery showed improved pain scores and reduced side effects in the epidural group. However, complications and the effect on LOS were not discussed . AnotherBecause of its effectiveness in neuropathic pain, gabapentin was evaluated in the setting of scoliosis surgery in combination with PCA and oral opioids. Gabapentin has been shown to be opioid-sparing in the adult population in both single preoperative dosing and postoperatively, but it has not been extensively studied in children. One randomized controlled trial showed a decreased amount of postoperative morphine use and lower pain scores with the addition of preoperative and postoperative gabapentin . HoweverThe mechanism of action of methocarbamol is centrally acting muscle relaxation with some mildly sedating effects. It has been used in postoperative pain management in breast reconstruction. One study in children compared open versus minimally invasive pectus excavatum repair. The combination of methocarbamol, nonsteroidal anti-inflammatory drugs (NSAIDs), and narcotics reduced hospital costs .A criticism of elastomeric pain pumps is the concern for increased postoperative infection. Our data showed a decreasing trend of infection during the time when elastomeric pain pumps were introduced. Bupivacaine at the concentrations used (0.125% to 0.25%) has been shown to inhibit the growth of bacteria . Our latThe second most common cause for readmission after wound complications is gastrointestinal disturbance . Our datThis study has limitations. It was retrospective, and so we had to rely on available documentation. Also, the three groups were not equivalent in size and the study periods were not concurrent. However, our LOS improvement compared favorably with other reports. Finally, the cases were done by a single surgeon, which decreases some variability.To our knowledge, this is the first study on the use of elastomeric pain pumps as part of multimodal therapy following scoliosis surgery. The use of pain pumps was associated with clinically and statistically improved postoperative outcomes. The addition of methocarbamol and gabapentin was associated with a trend towards further improvements.


Dysmenorrhea is one of the most common acute pain disorders among women of reproductive age.To compare the effects of IV paracetamol with dexketoprofen in patients presenting with primary dysmenorrhea to the emergency department.Randomized controlled trial.Patients over 18 years old presenting with pelvic pain related to menstruation were eligible for the study. Study patients received 1 g paracetamol or 50 mg dexketoprofen in 100 mL normal saline with a 4-5 minute infusion via the intravenous route. Pain intensity was measured by a visual analog scale at 15 and 30 minutes. Patients were randomized and assigned to either of two study arms via sealed envelopes. Study drugs were identical in color, and thus both personnel and patients were blinded to the study drug. The dexketoprofen group comprised 49 patients, and the paracetamol group had 50 patients in the final analysis.The mean age of the study subjects was 20.9±2.5 and the mean duration of the pain was 1.9±1.7  hours. Both dexketoprofen  and paracetamol  effectively reduced the pain at 15 minutes, which was repeated at 30 minutes . Pain improvement in the dexketoprofen group was better than in the paracetamol group at 15  and 30  minutes, which was statistically significant but not clinically significant.Dexketotoprofen has a better visual analogue scale score that is not clinically relevant compared to paracetamol. Dysmenorrhea is one of the most common acute pain disorders, affects about 40% to 70% of women of reproductive age, and is a frequent cause that leads to time lost from work or school besides interfering with daily living ,2. DysmeNonsteroidal anti-inflammatory drugs (NSAIDs) are drugs most commonly used in the treatment of primary dysmenorrhea. The NSAIDs that are approved by the US Food and Drug Administration for treatment of dysmenorrhea are: diclofenac, ibuprofen, ketoprofen, meclofenamate, mefenamic acid, and naproxen. NSAIDs are used related to findings that prostaglandins have a role in the pathogenesis of dysmenorrhea. Aspirin may not be as effective as these NSAIDs, and paracetamol as adjunctive therapy may be helpful for alleviating mild symptoms ,4.Randomized controlled trials showed that NSAIDs are effective options for relieving primary dysmenorrhea. In a systematic review of 73 randomized trials, NSAIDs were significantly more effective than placebo  or paracetamol  (Intravenous (IV) paracetamol has shown to be an effective treatment option in various painful conditions in the ED ,6,7. TheThis prospective randomized, double-blind, controlled study was conducted in the ED of a tertiary care hospital with an annual census of 75.000 patients between December 15, 2014, and April 15, 2015. The central ethics committee approved the study (2014/70177). The clinicaltrial.gov ID is NCT02373514. The study was planned as a superiority trial with two intervention arms, IV dexketoprofen, and paracetamol. The funding of the study was provided by the authors.Patients over 18 years old presenting with pelvic pain related to menstruation were eligible for the study. All consecutive patients who presented with dysmenorrhea as their chief complaint were enrolled in the study. The analyses focused on the severity of pain, rather than on the length of time it lasted. Patients with signs of peritoneal irritation, allergy to the study drugs, history of renal and liver failure, alcohol or drug abuse and those whose received painkillers within the last six hours, or refused to give informed consent were excluded from the study.Patients were enrolled in the study 24 hours/7 days a week. A senior resident determined the eligibility of patients. Diagnosis of dysmenorrhea was made by pelvic pain related to menstruation and history of painful cycles that resembled the present one. A normal physical examination without a remarkable pathology was also accepted as an eligible diagnosis.Study patients received 1 gr paracetamol  or 50 mg dexketoprofen  in 100 mL normal saline with a 4-5 minute infusion via the IV route. Study drugs were identical in color. Assignment of patients to one of the study arms was established in a 1:1 ratio according to eight computerized randomization blocks performed before the study by a person blinded to the study. Patients eligible for the study were assigned to one of the study arms by designated numbers kept in an opaque envelope. A study nurse prepared the study drug and another nurse unaware of the study drug administered it to the patient. Physician, the nurse administered the drug, and the patients were all blinded to the study drug.A 100 mm visual analog scale displaying the numbers as 10, 20…100  was used to measure the intensity of the pain. Pain measurements of patients were carried out at baseline, 15, and 30 minutes after administration of the study drug. Patients were blinded to previous VAS scores. The need for rescue drug and adverse events were also recorded on the study form. Drug-related side effects attributed to either of the drugs were evaluated in detail. Nausea was not accepted as a side effect if it existed before administration of the drug.The primary outcome measure was pain relief at 15 and 30 minutes after administration of the drug. Secondary outcome measures were the need for rescue drug and adverse effects secondary to study drugs.Study data were analyzed with MedCalc, Statistical Package for Social Sciences 18.0 , and Confidence Interval Analysis software. Numerical data were presented as mean ± standard deviation and median interquartile range (IQR) and frequency data as rates. Study data were also expressed with 95% confidence interval (95% CI). Normality analysis was performed by the Kolmogorov Smirnov test. Two-group comparisons for numerical data were performed by Mann-Whitney U test and chi-square test for frequency data.Power analysis gave the recommendation of a sample of 37 patients in each group, for 95% power and a standard deviation of 19 mm. All hypotheses were constructed as two-tailed, and an alpha-critical value of 0.05 was accepted as significant. All analyses were performed according to the intention-to-treat principle.A total of 133 patients were eligible for the study. Thirty-three patients were excluded from the study for various reasons, and one patient decided to withdraw from the study after 10 minutes of randomization and left the ED without rating the VAS scores . Forty-nThe mean age of study subjects was 20.9±2.5 years, and the mean duration of pain was 1.9±1.7  hours. There was no difference between study groups regarding age and duration of pain .Both dexketoprofen  and paracetamol  effectively reduced pain at 15 minutes , Table 2One patient (2%) in dexketoprofen group and 4 patients (8%) in paracetamol group needed rescue drug (p=0.37). One patient in the dexketoprofen group reported dry mouth, and one patient had nausea, and one patient had both nausea and vomiting in the paracetamol group.The present study showed that either IV dexketoprofen or IV paracetamol effectively provided pain relief in patients presenting with primary dysmenorrhea to the ED. Despite better VAS scores with dexketoprofen over paracetamol at both 15 and 30 minutes, this difference was not clinically significant. Dexketoprofen is also associated with a reduced need for rescue drug but did not have statistical significance.Dysmenorrhea, which reflects itself as severe colicky abdominal pain, is attributed primarily to high levels of prostaglandins in the body. NSAIDs act by decreasing the synthesis of prostaglandins by blocking the cyclooxygenase (COX) enzyme. Dexketoprofen is a non-selective NSAID of the aryl-propionic acid group containing the active S-enantiomer of racemic ketoprofen. Dexketoprofen is an NSAID with a relatively short half-life and rapid onset of action .Paracetamol provides its analgesic effect through central anti-nociceptive actions, specifically by inhibiting COX-3, which is a variant of COX-1. In addition, evidence suggests that paracetamol activates serotoninergic descending pathways that inhibit nociceptive signal transmission within the spinal cord. The most significant advantage of paracetamol is that it does not cause gastrointestinal bleeding or dyspepsia .The current medical literature regarding dysmenorrhea consists mostly of studies examining oral forms of painkillers. We do not have sufficient data regarding the effects of parenteral painkillers in the ED. A Cochrane meta-analysis reported that NSAIDs achieve pain relief between 17% and 95%  of women with an NNT (number of patients needed to treat) value of 2.1 compared with placebo for three to five days albeit gastrointestinal side effects  are still a concern . HoweverDespite its antipyretic and analgesic effects, paracetamol has little or no effect on inflammatory pathways. The analgesic effect of paracetamol partly emerges through supraspinal activation of descending serotonergic pathways, but its primary site of action may still be selective with variable inhibition of prostaglandin production . For acuA retrospective analysis of patients presenting with dysmenorrhea to the ED by Ayan et al. (13) reported that IV paracetamol had better pain relief than intramuscular diclofenac sodium at 30 minutes. However, the study is a retrospective chart analysis rather than a randomized controlled trial.It is unclear whether specific NSAIDs are more effective or safer than others are. Although some studies have not reported differences in effectiveness, others have stated that fenamates  may have slightly better efficacy than phenylproprionic acid derivatives . Both fenamates and phenylproprionic acid derivatives inhibit prostaglandin synthesis, but fenamates also block prostaglandin action, which may be responsible for their enhanced effectiveness in some studies ,14,15. AThere are some limitations to this study. This study is a superiority trial, and we cannot conclude that the two drugs are equal. One patient withdrew informed consent and left the ED without assigning pain intensity on the visual analog scale. There is no follow-up data of study patients as to whether their pain recurred or they attended another medical facility because of their dysmenorrhea.In conclusion, IV dexketoprofen has better VAS scores that are not clinically significant in both groups.


Few studies have investigated the real-life outcomes of interdisciplinary multimodal pain rehabilitation programs (IMMRP) for chronic pain. This study has four aims: investigate effect sizes (ES); analyse correlation patterns of outcome changes; define a multivariate outcome measure; and investigate whether the clinical self-reported presentation pre-IMMRP predicts the multivariate outcome. To this end, this study analysed chronic pain patients in specialist care included in the Swedish Quality Registry for Pain Rehabilitation for 22 outcomes  on three occasions: pre-IMMRP, post-IMMRP, and 12-month follow-up. Moderate stable ES were demonstrated for pain intensity, interference in daily life, vitality, and health; most other outcomes showed small ES. Using a Multivariate Improvement Score (MIS), we identified three clusters. Cluster 1 had marked positive MIS and was associated with the overall worst situation pre-IMMRP. However, the pre-IMMRP situation could only predict 8% of the variation in MIS. Specialist care IMPRPs showed moderate ES for pain, interference, vitality, and health. Outcomes were best for patients with the worst clinical presentation pre-IMMRP. It was not possible to predict who would clinically benefit most from IMMRP. Pain is an unpleasant experience with complex interactions between sensorimotoric, affective, and cognitive brain networks. As such, pain, especially chronic pain, is influenced by and interacts with physical, psychological, social, and contextual factors ,2,3. OneUnlike single/unimodal interventions, interdisciplinary multimodal pain rehabilitation programs (IMMRPs) for chronic pain—an interdisciplinary treatment according to the International Association for the Study of Pain (IASP)—distinguish themselves as well-coordinated complex interventions. Typically, IMMRPs are based on cognitive behavioural therapy (CBT) models  and are administered over several weeks to months ,10,11,12Systematic reviews (SRs) have generally reported higher efficacy both on a general level and for specific outcomes of IMMRP compared with single-treatment or treatment-as-usual programs ,21,22,23Complex interventions such as IMMRP should have several outcomes measured at multiple levels and strategies for handling multiple outcomes ,30. IMMRTo investigate the outcome effect sizes of IMMRP immediately post-IMMRP and at 12-month follow-up.To analyse the multivariate correlation patterns of changes in outcomes of IMMRP: pre-IMMRP versus post IMMRP and pre-IMMRP versus 12-month follow-up.To define a multivariate outcome measure of IMMRP.To investigate if the clinical self-reported presentation pre-IMMRP can predict the multivariate outcome measure.The above knowledge gaps motivated this PBE study of chronic pain patients based on patient reported outcome measures (PROMs) from the Swedish Quality Registry for Pain Rehabilitation (SQRP) . This reThe SQRP, recognised by the Swedish Association of Local Authorities and Regions, receives data from all specialist care units in Sweden . The SQRThis study included SQRP data from women and men ≥18 years old with complex chronic (≥3 months) non-malignant pain who were referred to specialist pain and rehabilitation units  between 2008–2016. These patients can be characterised as complex, as their health profiles included psychiatric comorbidities such as depression and anxiety, low levels of acceptance, high levels of kinesiophobia, decreased working life and participation in social activities, and/or did not respond to routine pharmacological/physiotherapeutic treatments delivered in a monodisciplinary fashion. Strict inclusion and exclusion criteria for inclusion in the registry is not available, since this is a registry study of patients with complex chronic pain conditions referred from mainly the primary care to specialist care in Sweden. A minority of patients were referred from other specialist clinics e.g., orthopedic and rheumatology clinics. The following general inclusion criteria for IMMRP were used: (i) disabling chronic pain (on sick leave or experiencing major interference in daily life due to chronic pain); (ii) age 18 years and above; (iii) no further medical investigations needed; and (iv) written consent to participate and attend IMMRP. General exclusion criteria for IMMRP included severe psychiatric morbidity, abuse of alcohol and/or drugs, diseases that did not allow physical exercise, and specific pain conditions with other treatment options available .The proportions of patients within primary health care with chronic pain conditions are not exactly known, but 10–20% are estimates ,33. FurtThe study was conducted in accordance with the Helsinki Declaration and Good Clinical Practice and approved by the Ethical Review Board in Linköping (Dnr: 2015/108-31). All the participants received written information about the study and gave their written consent.Background variables that were collected pre-IMMRP and symptom-related self-reported variables that were collected at all three times  were used in the analyses. The variables and instruments used are mandatory for the units registering their data with the SQRP.The following background variables were collected: age (years), gender (man or woman), education level, and country of birth. Education level was dichotomised into university and the other alternatives ; this variable was labelled as University. Country of birth was dichotomised as from Europe and outside Europe and labelled as Outside-Europe. In addition, self-reported pain duration (days), persistent pain duration (days), and number of days off work (Days no work) were obtained.Pain distribution was registered using 36 predefined anatomical areas (18 on the front and 18 on the back of the body) and the patients registered the areas with pain: (1) head/face, (2) neck, (3) shoulder, (4) upper arm, (5) elbow, (6) forearm, (7) hand, (8) anterior aspect of chest, (9) lateral aspect of chest, (10) belly, (11) sexual organs, (12) upper back, (13) low back, (14) hip/gluteal area, (15) thigh, (16) knee, (17) shank, and (18) foot. The number of areas with pain (range: 1–36) were summed, and the obtained variable was denoted as the Pain Region Index (PRI).For reports of the psychometric aspects of the self-reported measures, the reader is referred to other studies summarising these ,34,35,36Pain intensity average during the previous seven days was registered using a 0–10 (0 = no pain and 10 = worst possible pain) numeric rating scale (NRS)—NRS-7days.MPI is a 61-item self-report questionnaire that measures the psychosocial, cognitive, and behavioural effects of chronic pain ,38. PartSymptoms of anxiety and depression were registered using the Hospital Anxiety and Depression Scale (HADS) ,41. ThisThe Short Form Health Survey (SF36) attempts to represent multidimensional health concepts and measurements of the full range of health states, including levels of well-being and personal evaluations of health . Scores The European Quality of Life Instrument (EQ-5D) captures a patient’s perceived state of health ,44,45. TThe patients post-IMMRP and at the 12-month FU estimated the degree of positive change in pain (Change-pain) and in their ability to handle life situations in general (Change-life situation). The Change-pain item was rated on a five-point Likert scale from markedly increased pain (0) to markedly decreased pain (4). The Change-life situation item was rated on a five-point Likert scale from markedly worsened (0) to markedly improved (4). All the statistics were performed using the statistical package IBM SPSS Statistics (version 24.0) and SIMCA-P+ . A probability of <0.001 (two-tailed) was accepted as the criteria for significance due to the large number of subjects. t-test for unpaired observations, analysis of variance (ANOVA with post hoc test if significant difference), and Chi square test. Effect sizes  for within-group analysis were computed using a calculator when appropriate (https://webpower.psychstat.org/models/means01/effectsize.php). Hedges’ g, which provides a measure of effect size weighted according to the relative size of each sample, was used for between ES using a calculator (https://www.socscistatistics.com/effectsize/default3.aspx). The absolute effect size was considered very large for values ≥ 1.3, large for values between 0.80–1.29, moderate for values between 0.50–0.79, small for values between 0.20–0.49, and insignificant for values < 0.20 [The text and tables generally report the mean value ± one standard deviation (±1 SD) together with a median and range of continuous variables. Percentages (%) are reported for categorical variables. The detailed analyses also report 95% confidence intervals (95% CI). SQRP uses predetermined rules when handling single missing items of a scale or a subscale; details about this have been reported elsewhere . To comps < 0.20 .Common methods such as logistic regression (LR) and multiple linear regression (MLR) can quantify the level of relations of individual factors but disregard interrelationships among different factors and thereby ignore system-wide aspects . MoreoveHence, using SIMCA-P+, we applied advanced Principal Component Analysis (PCA) for the multivariate correlation analyses of all investigated variables and Orthogonal Partial Least Square Regressions (OPLS) for the multivariate regressions. These techniques do not require normal distributions of the included variables . Note tht-scores) can also be used (score plot), and each subject receives a score (t) for each of the significant components. The t-score was used to calculate a Multivariate Improvement Score (MIS). R2 describes the goodness of fit—the fraction of sum of squares of all the variables explained by a principal component [2 describes the goodness of prediction—the fraction of the total variation of the variables that can be predicted using principal component cross-validation methods [2 and distance to model in the X-space. No extreme outliers were detected. PCA extracts and displays systematic variation in the data matrix. All the variables were log transformed before the statistical analyses if data were skewed. Using PCA, we analysed the multivariate correlation pattern for the changes in the 22 outcome variables for all the subjects. Note that changes in outcomes are calculated so that a positive value indicates an improvement. A cross-validation technique was used to identify nontrivial components (p). Variables loading on the same component p were correlated, and variables with high loadings but with opposing signs were negatively correlated. Variables with high absolute loadings were considered significant. The obtained components are per definition not correlated and are arranged in decreasing order with respect to explained variation. The loading plot reports the multivariate relationships between variables. A corresponding plot reporting the relationships between subjects  [2, Q2, and the p-value of a cross-validated analysis of variance (CV-ANOVA). SIMCA-P+ uses the Non-linear Iterative Partial Least Squares (NIPALS) algorithm to handle missing data: maximum 50% missing data for variables/scales and maximum 50% missing data for subjects. OPLS was used for the longitudinal multivariate regression analyses of the ne data) . The varne data)  p(corr) ne data) . Thus, at-scores of the PCA mentioned above, we performed hierarchical clustering analysis (HCA). Based on the identified clusters (subgroups) defined by HCA, we performed partial least squares discriminant analysis (PLS-DA). In addition, we applied a bottom–up HCA to the principal component score vectors using the default Ward linkage criterion to identify relevant subgroups of patients. HCA can find subtle clusters in the multivariate space. In the resulting dendrogram, clusters were identified and, based on these groups, we performed PLS-DA using group belonging as the Y-variable and the psychometric data as predictors (X-variables). The PLS-DA model was computed to identify associations between the X-variables and the subgroups. Based on the HCA defined clusters, traditional inferential statistics (ANOVA including post hoc tests when appropriate) were computed using SPSS. To identify clusters based on the 2 = 43.437, p < 0.001), and fewer men had university education . Continuous background variables are shown in p < 0.001) and reported more spreading of pain according to PRI . The other variables in There were 14,666 chronic pain patients registered in the SQRP that fulfilled the inclusion criteria: chronic pain; >18 years of age; and completed the SQRP questionnaire before and on at least one of the two time points after the IMMRP. More than half (60%) of the patients answering the questionnaires pre-IMMRP and post-IMMRP also answered the questionnaires at 12-m FU. Most of the patients (76.3%) were women, 25.2% had studied at university, and 10.4% were born outside of Europe. More men were born outside Europe  were performed for pre-IMMRP versus post-IMMRP and pre-IMMRP versus 12-month FU. Significant models were achieved for both analyses . SimilarAt 12-month FU, the PCA also identified two additional components . The sect-score) for each significant component. Patients with high positive t-scores on the first component show prominent changes in the important variables constituting the first component, whereas patients near zero do not benefit, and patients with negative t-scores (located to the left in the score plot) deteriorate in the multivariate context. Hence, the t-score of the first component of both analyses can be considered as a Multivariate Improvement Score, in the following denoted MIS-post-IMMRP and MIS-12-month FU. The loading plot  is shown in 2 = 0.35; Q2 = 0.35; CV-ANOVA p < 0.001; n = 14,666). Using a similar approach, we performed an HCA based on MIS-12-month FU. This analysis identified three subgroups/clusters. Based on the HCA, a PLS-DA model with two predictive components was obtained with group belonging as the Y-variable .An HCA based on MIS-post-IMMRP was performed. Three subgroups/clusters were identified. Based on the HCA, a PLS-DA model with two predictive components was obtained with group belonging as the Y-variable (Rt-score) showed clear positive values  for cluster 1 and negative scores  for cluster 3  and in management of life (Change-life situation) were not included in the PCAs and thus not included in the calculations of MIS. However, these estimations showed a similar pattern: the most prominent positive changes were in cluster 1, and the least positive changes were in cluster 3 . In the next step, the identified three clusters of both analyses were compared for their pre-IMMRP values . For the2 = 0.08 in both analyses). Hence, most of the variations in the two MIS were not possible to predict.The outcome data at baseline (pre-IMMRP) together with the background variables were used to regress MIS-post-IMMRP and MIS-12-month FU . For botSimilar analyses for each of the clusters  revealedModerate long-term ES were found for pain intensity (MPI Pain severity and SF-36 bodily pain), interference in daily life (MPI Interference), and state of health (EQ-5D-index); most other variables showed small ES. Vitality also displayed moderate effect sizes immediately after IMMRP but fell slightly under cut-off for moderate change at 12-month follow-up. The majority of the 22 investigated outcomes were significantly improved.Significant intercorrelations between changes in pain intensity, interference, control, psychological distress, and mental health were confirmed. The changes in 22 outcomes reflected one (pre-IMMRP versus post-IMMRP) or three (pre-IMMRP versus 12-month follow-up) latent components (groups of variables).The outcomes were best for patients with the worst self-reported clinical presentation pre-IMMRP. Based on a defined multivariate improvement score (MIS), three clusters were identified. Cluster 1—overall, the worst situation pre-IMMRP—showed positive multivariate improvements in outcomes. Cluster 3—deteriorated—showed negative scores. Cluster 2, the intermediate cluster, was associated with overall slightly positive multivariate improvements.Certain variables  pre-IMMRP were associated with improvements according to MIS both post-IMMRP and at 12-month FU. However statistically significant, the pre-IMMRP situation could only explain a small part of the variation in MIS (8%); therefore, for clinical use, it was not possible to predict those who would benefit most from IMMRP.The major findings of the present large PROM study from SQRP are listed below:The outcome variables mandatory in SQRP and presented in the present study are in good agreement with the BSP model of chronic pain and the outcome domains presented by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) ,52 and tThe present study was not primarily designed to evaluate the efficacy of IMMRP, which requires RCTs and SRs/meta-analyses. However, our results for the repeated measurements  of chronThe present study reported medium ES for two of three pain intensity variables both post-IMMRP and at 12-month FU ; the third pain intensity variable had effect sizes near medium ES. These results contrasted some SRs reporting of no evidence for efficacy with respect to pain intensity ,11. HoweSRs of IMMRP report that it is an effective intervention with small to moderate effects for patients with chronic pain conditions ,12,62,63The number of outcomes in IMMRPs in RCTs are generally high, which reasonably reflects the broad goals of the complex intervention. The present study used 22 outcomes that are mandatory in SQRP measured on up to three occasions . PCA was applied to handle the pattern of changes in potentially intercorrelated outcomes as suggested by the Medical Research Council of the United Kingdom . From thindependent comparisons [t-scores for the most relevant latent factor (component). Hence, we defined an objective Multivariate Improvement Score , which on an individual patient level defines the multivariate improvement; a positive MIS indicates multivariate improvements because of IMMRP. The presented PCAs also highlight that it may be possible to reduce the number of outcome variables, since several of these appear to measure similar aspects of the chronic pain condition. The fact that 22 outcomes were analysed  may raisparisons . The latparisons , but reqparisons , but thiparisons . Howeverparisons . We usedThree clearly separated clusters based on MIS were identified. On a group level, clusters 1 and 2 were associated with various degrees of improvements, whereas cluster 3 showed negative MIS, indicating deterioration. Although the greater improvement in cluster 1 can be interpreted as a sign of regression to the mean and that these patients did not benefit from IMMRP more than cluster 2, this cluster still improves from IMMRP at least as well as those with e.g., less severe psychological distress symptoms (clusters 2 and 3). This may seem unexpected, but it is important to recognise that addressing psychological symptoms with CBT is an important component of IMMRPs. The patients at post-IMMRP and 12-month follow-up estimated the degree of positive change in pain  and the ability to handle life situation in general . Most patients reported improvements according to both the Change-pain and Change-life situations . RelativN > 35,000) that identified clusters based on the clinical presentation at assessment (decision not taken about participation in IMMRP); the study found that patients with the most severe clinical situation who later participated in IMMRP had the most prominent improvements in six investigated outcomes [We found that cluster 1, which had high MIS values , had a more severe clinical picture at baseline/pre-IMMRP than those with lower MIS . These results agree with another SQRP study (outcomes . Althougoutcomes , both thoutcomes  indicateThe longitudinal regressions of MIS using background variables and pre-IMMRP data as regressors were significant . A blendOutcomes of IMMRP in real-life practice settings agree with the conclusions from SRs. Partly in contrast to SRs, this registry study of patients managed within specialist care found that pain intensity was positively affected because of IMMRP. It was also obvious that not all patients benefit from IMMRP. Hence, there is a need to develop better matching between clinical presentation and participation in MMRP in real-life practice settings. Moreover, the intercorrelations of most changes in outcomes also opens up the possibility of reducing the number of outcome variables and hereby reduce the burden upon patients included in the SQRP. This study’s strengths include a large number of patients with complex chronic pain conditions with a nation-wide representation. However, these patients were referred to specialist clinics and thus represent a selection of the most difficult cases, so our results cannot be generalised to other settings. Another strength was the use of MVDA methods such as PCA and OPLS to handle correlation patterns, repeated measures, and regressions when there were obvious risks for multicollinearity. Changes in the social context may have changed and influenced the longitudinal analyses; however, we used validated and well-known instruments. Repeated evaluations using PROM questionnaires in treatment studies may be problematic . Thus, tThis large-scale study of IMMRPs in real life practise settings demonstrates significant outcome changes in almost all measures. Most short-term and long-term effect sizes were small, but interestingly, moderate long-term effect sizes were demonstrated for pain, pain interference in daily life, and perceived health. In addition, patients reporting higher levels of perceived disability and suffering displayed greater improvement.


Research indicates that perceived support availability is beneficial, with support available from the spouse particularly important for well-being. However, actual support mobilization has shown mixed associations with recipient well-being. The primary goal of the present study was to go beyond examining the effects of global perceptions of support on recipient outcomes. Instead, we examined the effects of several specific types of support that have been found to be important in the clinical literature. In this study, we followed both members of couples in which one partner was diagnosed with rheumatoid arthritis. Patients provided reports on pain for both mornings and evenings across 1 week. Both partners also reported esteem, solicitous, and negative support mobilization received by the patient. We found that patient pain tended to increase across the day following increases in patient reports of negative support receipt and partner reports of solicitous support provision. We also found that patient pain tended to decrease across the day when partners reported increased levels of esteem support provision. Reverse causation analyses indicated higher levels of patient pain may lead partners to increase solicitous support mobilization to the patient. Findings underscore the importance of examining both partners’ reports of support within a dyadic coping framework. They further suggest that not all forms of support are equally beneficial, calling for a finer grained assessment of specific support transactions. What is the best way for the spouse to provide support? Should he express how concerned he is about the patient? Should she assure her spouse that he is loved, valued, and important? Do his avoidant or critical responses influence his partner’s well-being over time? Dyadic coping theory suggests that spouse responses play a critical role in influencing well-being , especiaAlthough research has emerged accounting for the role of both partners’ perceptions of support in key psychosocial outcomes , 2015, tOutside of chronic pain contexts, studies suggest the support recipients’ and support providers’ perceptions both independently predict changes in recipient well-being. For example, in one study examining global levels of support, provider reports of emotional support were associated with decreases in negative affect, but recipient reports of emotional support were associated with increases in negative affect . Other sesteem/emotional support, which refers to expressions that the recipient is loved, valued, and accepted. The second type of support we examined was solicitous support, which involves conveying concern for the support recipient , which is consistent with sex differences in RA prevalence rates , and Caucasian , had children , and had a mean age of 61.1 years . The mean number of years since RA diagnosis was 17.7 . Of the participating RA patients, seven (24%) were employed, twelve (41%) were retired, five (17%) were on sick leave, two (7%) were on disability, and three (11%) were homemakers at the time of the study. Patients and spouses had a relationship length averaging 31 years . Spouses of RA patients were mostly male  and Caucasian , with a mean age of 62.9 years . Of the participating spouses, eleven (38%) were employed, thirteen (45%) were retired, one (3.7%) was on sick leave, and one (3.7%) was a homemaker at the time of the study. The modal family income was between $25,000 and $50,000 CAD.The final sample consisted of 29 couples (29 RA patients and 29 cohabitating spouses). Patients were mostly female  or since the last interview (for the evening assessment). The twice daily phone interviews lasted approximately 10 min per interview and were administered by a trained female research assistant. Consistent interviewers were assigned to each participant to develop and maintain rapport. Participants were asked to find a private and quiet place in which to complete the daily interviews, and interviews were conducted separately with each member of the couple. With the permission of participants, all interview sessions were tape recorded and transcribed. Telephone methods were used (as opposed to electronic methods) due to the difficulties that may have arisen with holding and operating handheld devices and/or typing, given the previously noted functional disabilities and limitations common to individuals with RA. This study was approved by the affiliated institution’s Behavioral Research Ethics Board.Patients reported intensity of pain associated with RA during the previous half-day using a numerical rating scale (NRS) from 0 (no pain) to 10 (pain as bad as it could be). The NRS has demonstrated positive and significant associations with other measures of pain intensity  and sensRc = 0.46; pm Rc = 0.56; all timepoints Rc = 0.53).1 Spouse esteem/emotional support provision was assessed with two parallel items . Solicitous support receipt and provision were each assessed with two items . Negative support receipt and provision were each assessed with two items .2 If participants indicated that they had not seen or spoken to their spouse since the last diary entry, spouse support questions were skipped for that timepoint and treated as missing.Patients and their spouses provided reports on support mobilized from the spouse to the patient using a modified version of the Berlin Social Support Scales BSSS; . ParticiRc = 0.82; pm Rc = 0.78; all timepoints Rc = 0.80). Negative affect was the combined score of the five-item depression and five-item anxiety subscales because they were highly correlated .We asked patients to report the extent to which they saw or spoke to their partner . Positive and negative affect were assessed using the Affects Balance Scale . PositivTable 1). ICCs were higher than 0.18 for all variables, indicating that a multilevel approach was appropriate. We also computed within-couple Pearson correlations for study variables.Because of the multilevel structure of the data in which days were nested within couples, we conducted multilevel analyses in R . In thes3 Morning pain was included in all models so that we could examine effects of support on residualized change in pain from morning to evening. We included both spouses’ reports of support mobilization so that we could examine the unique effects of each partner’s perspective. Following this, we added quantity of time spent with the partner, negative affect, and positive affect to the model. All predictor variables were centered on the mean for each couple  so that we could examine within-couple effects.For our main analyses, we ran a random intercept model examining the roles of morning support receipt and provision in predicting evening pain.We ran a series of additional models examining whether within-patient fluctuations in pain were significantly associated with subsequent residualized changes in each type of patient support receipt and spouse support provision. In these models, evening reports of each type of support were specified as a function of within-couple centered morning levels of that type of support and within-couple centered morning pain.Response rates on the twice-daily interviews were excellent, with 404 of the possible 406 morning and evening interviews completed by patients and 404 of 406 interviews completed by spouses. Twenty-seven of the included patients and twenty-seven of the included spouses completed all 14 interviews. Two patients and two spouses each missed one interview. With few exceptions, there were no missing items within the completed interviews. A single item was missing for patient negative affect for one of the morning interviews. We addressed this by taking the average of the remaining nine items for that interview. Patients and spouses reported not seeing each other on 4% of the half-days. In these cases, participants did not complete the support items. Therefore, some participants had fewer than 14 interviews included in the analyses if they (1) missed an interview, or (2) did not see their spouse. The restricted maximum likelihood estimation of linear mixed-effects models applied here is robust to missingness and can account for unbalanced numbers of observations per group .Table 1 displays descriptive statistics for study variables. As can be seen in the Table, the grand means for emotional support receipt and provision indicate that emotional support was mobilized “somewhat” – “a lot” across person-days. The grand means for solicitous support receipt and provision indicate that solicitous support was mobilized “a little” – “somewhat.” The grand means for negative support receipt and provision were low, corresponding to the “not at all” response option. We inspected frequencies of our study variables. These analyses revealed that frequencies of negative support were low, with values >1 on only 8% of the AM patient reports, 7% of the PM patient reports, 7% of the AM spouse reports, 7% of the PM spouse reports. This is a point we return to in our discussion.Table 2. These correlations were calculated using the statsBy function in the psych package in R . Readers should interpret the between-couple correlations with caution given the low sample size; however, the overall pattern suggests that patients who experienced higher levels of pain tended to receive higher levels of all types of support as reported by patients and partners, although most of these correlations were not significant.Although the focus of this study is on within-couple associations among spouse responses and patient pain, for the purpose of future meta-analyses, we report within- and between-couple correlations of study variables in age in R , which cTable 3. Contrary to expectations, patient reports of esteem and solicitous support were not significantly associated with subsequent changes in pain  = 1.63, p = 0.105; solicitous: b = 0.06, SE = 0.14, t(147) = 0.45, p = 0.656. However, the effects of patient negative support receipt were consistent with expectations: mornings when patients reported receiving higher levels of negative support than typical for them were associated with subsequent increases in pain, b = 0.63, SE = 0.31, t(146) = 2.00, p = 0.045. Additionally, mornings when partners reported providing higher levels of esteem support and lower levels of solicitous support than typical for them were associated with subsequent decreases in patients’ pain from morning to evening  = -2.93, p = 0.004; solicitous: b = 0.35, SE = 0.15, t(147) = 2.38, p = 0.019). Increases in partner negative support provision were not significantly associated with subsequent residualized increases in patient pain, b = 0.74, SE = 0.38, t(147) = 1.94, p = 0.055. When we included time spent with the partner, negative affect, and positive affect in the model, results were unchanged. We examined statistical assumptions of linearity, homoscedasticity, and normal distribution of residuals and all three assumptions were met for both models presented in Table 3.We conducted multilevel regression analysis predicting residualized change in patient pain as a function of each type of support mobilization to patients as reported by patients and partners. These results are displayed in b = 0.02, SE = 0.03, t(156) = 0.71, p = 0.482, or with subsequent changes in levels of esteem support provision reported by partners, b = 0.03, SE = 0.03, t(155) = 1.18, p = 0.240. However, increases in morning pain were significantly associated with subsequent increases in solicitous support receipt reported by patients, b = 0.13, SE = 0.04, t(157) = 2.94, p = 0.004 as well as with subsequent increases in solicitous support provision reported by partners, b = 0.09, SE = 0.03, t(156) = 2.68, p = 0.008. Finally, within-patient increases in pain were not significantly associated with decreases in patient negative support receipt, b = -0.02, SE = 0.01, t(158) = -1.84, p = 0.067. Changes in pain were not significantly associated with changes in negative support provision reported by partners, b = 0.001, SE = 0.01, t(158) = -0.12, p = 0.902.Next, we examined whether morning-to-morning within-patient fluctuations in pain were associated with subsequent changes in each type of support in six multilevel regression models – one for each type of support . Fluctuations in morning pain were not significantly associated with subsequent changes in levels of esteem support receipt reported by patients, We addressed the question of how spouses might best support patients coping with chronic pain. This is one of a handful of intensive longitudinal studies to address this question and this is the first to examine effects of multiple types of spouse responses on subsequent changes in pain. We found that esteem/emotional support provision by spouses was associated with subsequent decreases in pain across the day. In contrast, solicitous support provision by spouses and negative support receipt by patients were associated with subsequent increases in pain across the day. This study provides evidence that examining only total support may mask important differences in the effects of specific types. In the past studies of social support, even when differentiating types of support, have tended to lump solicitous and esteem support together, treating both as emotional support. However, consistent with operant models of pain, our study suggests that the effects of these two types of support on patient pain outcomes may be quite different. This study also provides evidence that assessing both partners’ perceptions of partner responses provides complementary information that would be missed if only one partners’ perceptions were assessed.Our primary goal was to examine a model in which spouse responses are expected to lead to changes in patient adjustment. However, a competing model is that patient pain is independent of social influences, and that associations that have been observed in previous cross-sectional studies between patient pain and spouse responses are simply due to spouses reacting to patient disability. Previously, Our study replicates and extends the work of We found that within-couple increases in spouse reports of solicitous support provision were associated with subsequent increases in patient pain. In reverse causation analyses, we found that higher levels of patient pain were associated with subsequent increases in solicitous spouse responses as reported by both partners. These results suggest a vicious cycle of patient pain and spouse solicitousness: not only may solicitous support lead to increases in patient pain, but also increases in patient pain may lead spouses to be more solicitous.Together, these findings point to a potential target for interventions for couples coping with chronic pain. One way that spouses could become better support providers might be to learn to change the way they respond to the patient, especially when the patient is in pain. Spouses could be taught to express love, admiration, acceptance, and confidence in the patient instead of expressing concern or worry. Changing the way that spouses react to patient pain might pave the way for better pain management. The potential vicious cycle of solicitous support and pain should be examined in future research because of potential applicability for interventions in couples coping with chronic pain.In this study, most of the patients were female and most of the spouses were male. Previous studies have found gender differences in the extent to which individuals benefit from support . AlthougThis study focused on the within-couple relations between partner responses and pain using a small sample of RA patients and their partners. We caution readers that although this study provides initial evidence on the role of support in patient outcomes, more work is needed with larger samples to replicate these results. As is often the case in samples of non-distressed couples, there were relatively few instances of negative support. This low frequency of may have limited our power to detect some of the effects of spouse negative responses. Because of the small sample and consequently limited power for between subject analyses, we were not able to test more complex models, such as models examining aggregated averages of spouse responses on average change in patient pain from morning to evening, the unique effects of morning and evening reports of spouse responses on patient pain, or interactive effects among different spouse response variables. Future research could examine these more complex and potentially more informative models. Additionally, it was not possible to examine stable factors that might influence the extent to which partner responses were associated with changes in pain. For example, patients who are more satisfied with their relationship partner in general may not be as impacted by negative support receipt compared to those who are less satisfied with their relationship partner . Additiohow spouse responses influence well-being. Our findings here suggest that solicitous and negative spouse responses lead to increases in patient pain, and esteem/emotional spouse support leads to decreases in patient pain. We propose two potential mediators to examine in future research. The first is self-esteem. Associations have previously been found between receiving support and reduced self-esteem in recipients , the International Conference on Harmonization Good Clinical Practice Guidelines (ICH-GCP) and the requirements of the U.S. Department of Health and Human Services, as set out in the Federal Policy for the Protection of Human Subjects, 45 CFR Part 46, sub-part A.AD designed and directed the project, developed the theoretical framework, and supervised all work. JP and ES conducted the data analyses and drafted the manuscript. MH contributed to the writing of the manuscript. All authors discussed the results and contributed to the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The analgesic effects of dexamethasone have been reported previously, and the present study determined the effects of preoperative dexamethasone on postoperative pain in patients who received thoracotomy.Forty patients participated in this randomized, double-blind study. All patients received either dexamethasone via a 0.1 mg/kg intravenous bolus before anesthetic induction or an equal volume of saline. Postoperative analgesia was provided to both groups via epidural patient-controlled analgesia (PCA), which consisted of 250 μg of sufentanil in 250 mL of ropivacaine (0.18%) for 72 h. The primary outcome was the cumulative consumption of epidural PCA at postoperative 24 and 72 h. The secondary outcomes were the pain intensity scores during resting and coughing at postoperative 24 and 72 h, quality of recovery, total amount of rescue analgesics required, and length of hospital stay.P = 0.281) and 72 h . Moreover, there was no significant difference in the pain intensity scores during resting and coughing at postoperative 24 and 72 h, quality of recovery, total amount of rescue analgesics required, and length of hospital stay.No significant differences was observed in the consumption of epidural PCA between the control and dexamethasone infusion groups at 24 h  and was conducted from December 2011 to October 2012.The study was registered at http://cris.nih.go.kr ( Many patients experience intense pain following thoracotomy. Although thoracic epidural analgesia (TEA) is believed to be the most effective single technique for controlling post-thoracotomy pain , it ofteRecent studies have suggested that glucocorticoids are beneficial as postoperative analgesic agents because of their anti-inflammatory property in various surgeries –6. MoreoOur hypothesis is that the preoperative administration of dexamethasone may be an effective adjuvant treatment for post-thoracotomy pain like other surgeries. Thus, in this randomized, controlled double-blind study, we investigated whether the preoperative administration of this drug reduces post-thoracotomy pain during the recovery period.http://cris.nih.go.kr (KCT0000359) and conducted between December 2011 and October 2012.After obtaining approval from our institutional review board (2011–0812) and written informed consent from each patient, 40 patients with American Society of Anesthesiologists physical status I–II for more than 20 years, who were scheduled for thoracotomy under general anesthesia, were enrolled in this prospective study. Exclusion criteria included an emergent infection for < 1 month before surgery; contraindications for dexamethasone or opioid use; severe cardiac, renal, or hepatic diseases; psychiatric disorder; uncontrolled diabetes mellitus; and the preoperative use of analgesics or steroids. The study was registered at Patients were randomly allocated to two groups using computer-generated codes that were maintained in sequentially numbered opaque envelopes. On the morning of the surgery and before the induction of anesthesia, the envelopes were opened by a blinded nurse or anesthesiologist who subsequently prepared either dexamethasone or saline in coded 5-mL syringes. All other anesthesiologists involved in patient management or data collection were blinded to the group assignment. Just before the induction of anesthesia, each patient was administered an intravenous (IV) bolus injection of 0.1 mg/kg dexamethasone or an equal volume of saline.Before the anesthetic induction, all patients underwent thoracic epidural catheterization at the T6–7 intervertebral space using the loss-of-resistance technique. General anesthesia was induced using a bolus IV injection of 0.2 mg/kg etomidate and the continuous infusion of propofol and remifentanil using a target-controlled infusion pump. Furthermore, a bolus IV injection of 0.8 mg/kg rocuronium was administered to perform orotracheal intubation. After the intubation, patients were ventilated to normocapnia using 50% oxygen and air. The effect-site concentration of propofol was adjusted to maintain the bispectral index value between 40 and 60 (using 0.1–0.2 μg/mL steps), and remifentanil was administered to maintain the heart rate within 15% of the pre-induction value and systolic arterial blood pressure within 20% of the baseline value (using 0.5 ng/mL steps). If the mean arterial blood pressure and cardiac index showed a more than 20% decrease from the preoperative values, vasoconstrictors or inotropics, such as phenylephrine, dopamine, or norepinephrine, were administered. All patients underwent standard posterolateral thoracotomy by the same surgical team. The serratus anterior muscle was preserved, and the sixth rib was removed. During thoracotomy, all patients received one-lung ventilation using a double-lumen endotracheal tube. Postoperative analgesia was administered to both groups via epidural patient-controlled analgesia (PCA), consisting of 250 μg of sufentanil in 250 mL of ropivacaine (0.18%) administered as a 2-mL bolus dose with a 15-min lockout period; a maximum of 10 mL was administered over 1 h, and 2 mL of background infusion was maintained for 72 h postoperatively. Epidural PCA was started during the closure of the muscle layer. The administration of all drugs was stopped 5 min before the end of surgery, and extubation was performed in case of a response to verbal commands, spontaneous respiratory rate > 12 breaths/minutes, and end-tidal carbon dioxide partial pressure < 45 mmHg. Patients were admitted to the intensive care unit within 5 min of tracheal extubation. Both groups received rescue analgesics, if needed, during the postoperative period, and the total amount of rescue medication was recorded.The primary outcome was the cumulative consumption of epidural PCA at postoperative 24 and 72 h. We believe that the cumulative consumption of epidural PCA is more objective than the pain score in assessing postoperative pain; therefore, we determined epidural PCA consumption as the primary outcome. The secondary outcomes included the pain intensity scores during resting and coughing, incidence of shoulder pain, total amount of rescue analgesics administered, and incidence of nausea and vomiting at postoperative 24 and 72 h, as well as the quality of recovery, duration of intensive care unit (ICU) stay and length of hospital stay. Moreover, we determined the incidence of postoperative complications, such as vocal cord palsy, wound infection, subcutaneous emphysema, pneumothorax, chylothorax, new onset of atrial fibrillation, and in-hospital death. Pain was assessed using the numeric rating scale, by asking patients to rate their pain on a scale of 0 (no pain) to 10 (disabling pain). The quality of postoperative recovery was assessed using the global Quality of Recovery-40 (QoR-40) questionnaire at postoperative 24 and 72 h. This questionnaire consisted of 40 questions that examined 5 domains of patient recovery, namely physical comfort, physical independence, psychological support, emotional state, and pain. The global QoR-40 scores range from 40 to 200, representing very poor to outstanding recovery. Poor recovery is defined as < 1 standard deviation below the group mean in ≥2 dimensions or a global QoR-40 score of < 1 standard deviation of the group mean. The postoperative consumption of rescue analgesics was converted to the equianalgesic dose of IV morphine .t test or Mann–Whitney rank-sum U test. Categorical variables such as the incidence of shoulder pain, nausea, vomiting, vocal cord palsy, wound infection, respiratory complication, subcutaneous emphysema, pneumonia, chylothorax, in-hospital death and poor recovery profile at POD 1 and 3, and new onset of atrial fibrillation were presented as frequencies and percentages and assessed using the Pearson’s χ2 or Fisher’s exact test. Repeatedly measured data, such as QoR-40 and perioperative hemodynamics, were analyzed using 2-way analysis of variance. Statistical analyses were conducted using SPSS . In all comparisons, P < 0.05 was considered statistically significant.Based on 5 preliminary patients, we identified that the epidural PCA requirement during the first 24 h of surgery was 68.7 ± 20.2 ml. With a sample size of 17 patients in each group, a total of 34 patients were calculated to obtain a statistical power of 80% at a significance level of 0.05 (2-tailed) to reduce 30% of epidural PCA requirement. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) II consensus recommended that a 30% reduction in pain from baseline can be considered significant in chronic pain clinical trial . Thus, rBetween December 2011 and October 2012, 40 patients were enrolled in this prospective, randomized, double-blind study. All patients were randomly allocated to the control (group C) or dexamethasone (group D) groups. Among the enrolled patients, 2 were excluded because they did not want to participate (1 patient each in both groups). Therefore, 38 patients were included in the final analysis  and 72 h . Other outcomes, such as the pain intensity score during resting and coughing, shoulder pain, postoperative consumption of rescue analgesics, and incidence of nausea and vomiting, were also not significantly different  does not reduce the cumulative epidural PCA consumption during postoperative period.To treat post-thoracotomy pain, we believe that the multimodal approach is important because pain after thoracotomy is caused by a multifactorial pathophysiology. The mechanisms underlying post-thoracotomy pain include nociceptive somatic and visceral mechanisms, neuropathic mechanisms, and referred pain. Somatic tissue injuries are caused by factors such as skin incision; rib retraction; muscle splitting; and injury of parietal pleura afferent through intercostal nerves and ipsilateral dorsal horn of the spinal cord and are transmitted to the limbic system and somatosensory cortex of the contralateral anterolateral system of the spinal cord. Injury to visceral tissues, such as bronchi, visceral pleura, and pericardium, are transmitted via phrenic and vagus nerves. These nociceptive stimuli increase inflammatory mediators, which is directly activate and enhance the nociceptor activity. This mechanism is called primary sensitization and causes acute pain after thoracotomy , 13. TheIn our knowledge, to date, no study has reported the effect of the combination of epidural analgesia and IV steroids on post-thoracotomy pain. The pain relief properties of steroids are well established in metastatic bone, neuropathic, and visceral pain. Glucocorticoids confer anti-inflammatory effects by inhibiting prostaglandin synthesis and reduce tissue edema by modulating vascular permeability. Moreover, steroids reduce the spontaneous discharge of injured nerves , 17. DexHowever, dexamethasone showed no analgesic effects in the present study. These results may be explained by the doses of dexamethasone. We used a relatively small dose of the drug (0.1 mg/kg) because corticosteroids may have various side effects, such as weight gain, muscle weakness, insomnia, and infection . A recenThe present study has some limitations. First, we did not perform a dose-dependent analysis and did not examine the effects of multiple doses. Second, we did not measure the pain intensity score during the immediate postoperative period. Because patients are unstable immediately after thoracotomy, the measurement of the pain intensity score might not be feasible. Furthermore, we administered epidural PCA during the closure of the muscle layer because the pain-reducing effects of epidural PCA are so effective that the combination effects of dexamethasone are often masked. Third, we did not examine chronic, neuropathic pain. Nociceptive stimuli occur continuously during the perioperative period; it leads to the hyperexcitability of the dorsal horn and may develop progress chronic, neuropathic pain. Dexamethasone reduces the spontaneous discharge of injured nerves. Our finding reflects that dexamethasone may be more effective against chronic, neuropathic pain than against acute pain. Finally, we only included 40 patients and acknowledged that additional, larger, dose-dependent, and time-dependent studies are required to elucidate the effects of dexamethasone on post-thoracotomy pain. To overcome these limitations, we think that dose-dependent, long-term outcome study should be needed to evaluate the effects of dexamethasone on post-thoracotomy pain.The single administration of dexamethasone during the preoperative period does not reduce post-thoracotomy pain during the recovery period.