Most vulvodynia patients receive combinations of several treatment modalities for their chronic painful condition. If conservative treatments fail, vestibulectomy is considered to be the ultimate treatment option for localized provoked vulvodynia (LPV). The aim of this descriptive study was to analyze relief of pain, quality of life (QoL), and complications associated with combining surgery with conservative treatments among LPV patients, both in short term and after 3 years of follow-up.n = 16) and only conservatively (n = 50) treated LPV patients. QoL data were assessed by a validated questionnaire (RAND-36). Data were collected by reviewing patient records and by aid of postal questionnaires. Efficacy of treatments in relief of pain was measured by numerical rating scale (NRS). Two months after surgery, the NRS scores assessed by a physician were lower in the surgery group than in patients treated only conservatively (p = 0.008). However, after a median of 36 months of follow-up, self-reported NRS scores and QoL showed no difference between the two patient cohorts. Complication rate after vestibulectomy was 18.8%. The findings suggest that combining surgery with conservative treatments may result in a more effective short-term reduction of pain. However, the effect seemed to be only temporary, as no long-term benefit was achieved.The study population consisted of a retrospective patient cohort of surgically ( The 2015 Consensus and Terminology and Classification of Persistent Vulvar Pain and Vulvodynia3 divides vulvar pain into two categories. The first category includes vulvar pain that is caused by a specific clearly identifiable disorder . The second category includes vulvar pain that is at least 3 months in duration and cannot be clearly identified or linked to a specific cause. However, it may have potential associated factors. The descriptors of the pain are location , type , onset (primary and secondary), and temporal pattern . Symptoms can overlap and co-occur. Vulvodynia may be associated with a history of yeast infection, hormonal factors, genetic factors, pelvic floor dysfunction, and psychological factors.3Vulvodynia is a chronic pain syndrome of unknown etiology affecting 7–8% of women in population-based epidemiological studies.4 LPV is also considered to be the most common form of sexual pain in women <30 years of age.5 Chronic pain is known to have a negative impact on a woman's quality of life (QoL).7The most common clinical subtype of vulvar pain in premenopausal women is localized provoked vulvodynia (LPV).9 it is actually not evidence based.10 Surgery (vestibulectomy) for LPV is recommended as the ultimate treatment option, if conservative treatments fail or are insufficient in terms of pain reduction.Different medical treatment modalities for LPV consist of local, topical, or oral medications. Patients treated by a multidisciplinary team are usually offered physiotherapy , sexual counseling and therapy, and psychotherapy. Although a multidisciplinary approach to LPV is recommended,11 even though the comparison of different studies is difficult as the term “success,” the surgical technique used and the length of follow-up show considerable variation.11 There is no definitive consensus as to which surgical technique is the superior one. In a review by Tommola et al.,12 which was based on 33 studies on surgical treatment for LPV (or vulvar vestibulitis), it was concluded that the experience of individual surgeons plays an important role, and that the aim of surgery should be to remove all painful tissues while avoiding unnecessary risks. The review also found surgery to be effective and safe.12Based on studies concerning surgical treatment for LPV, reported success rates vary between 60% and 90%,13 which showed that vestibulectomy was more successful than surface electromyographic feedback and group cognitive-behavioral therapy in pain reduction. As the authors stated, there is a concern in interpreting these results, due to a higher pretreatment drop-out rate in the vestibulectomy group.13 However, the psychological and sexual functions remained equally positive in all three groups after 6 months of follow-up. Another study that included randomization to the surgical  and nonsurgical  groups, by Weijmar Schultz et al.,14 found no difference in the outcomes between these two treatment modalities after a mean of 2.5–3 years of follow-up. In the review of Goldstein et al.,11 surgery was recommended for LPV after failure of conservative treatments (level B evidence).Most studies on surgical treatment for LPV lack randomization and/or controls. One of the few randomized controlled studies on vestibulectomy is that by Bergeron et al.,15 dyspareunia,16 sexual functioning,13 psychological distress,15 and patient satisfaction16 have been measured using questionnaires; moreover, findings of physical examination and self-reported symptoms have also been reported. Psychological well-being,17 quality of sexual life,17 and sexual and partnership satisfaction have all been reported to improve18 after vestibulectomy.In previous studies concerning surgery for LPV, the measured outcomes have varied. At least pain reduction,The aim of this study was to evaluate the safety and effectiveness of LPV treatments with or without surgery in both short and long terms. Pain was measured by numerical rating scale (NRS) assessed by both a physician and the patient. QoL was evaluated after a combination of treatments with or without surgery, using a questionnaire (RAND-36) validated in the Finnish population.19 or severe pain on vestibular touch or attempted vaginal entry, and tenderness on localized pressure within the vulvar vestibule, were considered eligible (n = 66). Among these eligible patients, 16 patients operated on for LPV (vestibulectomy) were identified. Patients with generalized or continuous vulvar pain were excluded. Other exclusion criteria included malignant tumors of vulva and ongoing inflammatory or dermatological diseases of vulva. The flow chart of study patients is shown in This retrospective cohort study on LPV patients was carried out at the Department of Obstetrics and Gynecology of Tampere University Hospital (TAUH), Tampere, Finland. All at least 18-year-old women diagnosed with vulvodynia at TAUH from January 2003 to May 2016 were screened for the study. Potential vulvodynia patients were identified from the hospital records (computer database) by using the appropriate ICD-10 codes: N90.9 ; N90.8 (other specified noninflammatory disorders of vulva and perineum); N94.1 (dyspareunia); and N94.2 (vaginismus). Only LPV patients who fulfilled the strict criteria by Friedrich,Information on parity, menopausal status, age, different treatment modalities, and complications after surgery was collected from the hospital's medical records. The baseline pain before any treatments for LPV was assessed by a physician with a cotton swab test and rated on an NRS from 0 to 10. If the rating was not found in the patient record, the information was reported as “no data.” As a part of the treatment protocol, every patient had a checkup appointment at 2 months after the surgical treatment with the operating surgeon. Patients treated with conservative methods only were assessed by a physician usually after 2 or 3 months after commencing the treatments. The conservative treatment modalities used for LPV are described in 16 with the aim to surgically remove the painful vulvar area. The operations were performed under general anesthesia, and all operations were carried out by three senior gynecological surgeons. First, 0.01% lidocain cum adrenalin solution was injected into the vulvar vestibulum for bleeding control and prevention of postoperative pain. To excise vestibular mucosa, 2-mm deep incisions using electrocautery were made from 10 to 2 o'clock in the posterior vulvar vestibulum to a width of ∼1–2 cm. The inner incision was made just inside the hymenal ring, and the outer margin followed the Hart's line. The vaginal mucosa was liberated from underlying tissue and subsequently opposed to distal vulvar margin with absorbable sutures without tension.The surgical technique used was the modified posterior vestibulectomy described by Tommola et al.,A seven-page postal questionnaire on demographic data, self-reported pain, and RAND-36 was sent to the 66 eligible LPV patients. The questionnaire was resent to the patients who did not return the questionnaire within 2 months after the first mailing.21The validated Finnish version of the RAND-36-item health survey includes eight multi-item dimensions: general health, physical functioning, mental health, social functioning, vitality, pain, and physical and emotional role functioning.Participants of the study were moreover asked to assess vulvar pain intensity upon touch on the NRS before and after treatments. NRS was used to quantify the intensity of vulvar pain by rating the pain using a 0-to-10 scale, where 0 indicates “no pain” and 10 indicates “the worst pain imaginable.”The study protocol was approved by TAUH Ethical Committee , and a written informed consent was obtained from the patients participating in this study.U-test was used for statistical comparisons. A probability value of p < 0.05 was considered as statistically significant.Version 23 of IBM SPSS statistics software was used in statistical analyses . Mann–Whitney p = 0.020). Demographic data and pain before and after the treatments are shown in p = 0.048). The median follow-up time at the data analysis point 2 was 36 months (interquartile range [IQR] = 24–36). The most frequent (received by >50% of the patients) combination of conservative treatments consisted of local treatments (lidocaine and/or gabapentin), physiotherapy, and sexual counseling in both patient cohorts. The treatment modalities used for both patient groups are summarized in p = 0.03).Thirty-six patients (55%) returned the questionnaire during the study period (August 2016–November 2016). Twenty-eight patients returned the questionnaire after the first mailing and eight patients after the second mailing. The patient flow chart is shown in p = 0.11, p = 0.008). After median of 36 months of follow-up, self-reported NRS scores before or after treatments did not differ significantly between the groups . Similarly, post-treatment NRS score assessed by a physician was 7 and 2, respectively (p = 0.005). Among the LPV patients who did not respond to postal questionnaires (n = 30), the median pretreatment NRS score collected from the patient records was 9 , and the median 2-month post-treatment NRS score was 5 . When nonresponders were compared with all LPV patients who returned the questionnaire , the pre- and post-treatment NRS scores derived from the medical records were similar .At data analysis point 1, median pretreatment NRS scores were similar between nonsurgical  and surgical groups , it being a randomized study strengthens the perception that individual tailoring of treatment is one of the key factors in a successful treatment for LPV.Vestibulectomy seems to be a safe treatment modality for LPV with an acceptable complication rate. This is in line with the previous review by Tommola et al. concerning surgery for LPV.17 However, another long-term follow-up study on LPV patients treated conservatively versus treated surgically failed to show any difference in long-term well-being between the treatment groups.18 Even if there are previous valuable reports on QoL and overall well-being among vestibulectomy patients,18 to our knowledge this is the first report using a validated QoL questionnaire when assessing QoL among vestibulectomy patients.We report here QoL data obtained with a validated questionnaire among surgically and nonsurgically treated vulvodynia patients. There was no difference in QoL between these two patient groups after a median of 3 years of follow-up. Previously, Bohm-Starke and Rylander have reported that vestibulectomy improves QoL measured by VAS from median 0.5 to 6.5, during a median 41 months of follow-up.p = 0.35) and QoL measured corresponded to present moment . A longitudinal QoL evaluation, done before and after treatments, would have been of additional value.There are some limitations to our study. The study is a retrospective nonrandomized cross-sectional study. An ideal study setting would have been a comparison between only surgically and nonsurgically treated patients preferably as a randomized controlled study. A confounding factor is that the study patients in the surgical group had also received various conservative treatments before surgery, that is, the comparison between the groups is in fact a comparison between combination of treatments with and without surgery. Because both groups received various conservative treatment modalities it is not possible to conclude fully the effectiveness of surgery. However, this setting is clinically unavoidable since vestibulectomy is the treatment modality offered to patients only after failure of all noninvasive treatments. The fact that patients were asked to report pain retrospectively after a median of 36 months after treatments contains also a risk of bias. However, the median follow-up time after treatments did not differ significantly between surgically and nonsurgically treated patients (Although the total number of patients is relatively low, with the surgically treated group being even smaller, it reflects the fact that vulvodynia is a rather rare condition. The response rate after follow-up was only satisfactory, 55%. The response rate to postal questionnaires of surgically treated patients was higher and this may lead to a false accentuation of positive effect of the intervention, that is, to a type I error. However, pain rated on the NRS and QoL did not differ significantly between the groups after the longer follow-up. The amount of missing data was unfortunately also quite high and this may cause bias. The study patients had received slightly different conservative treatment entities before surgery or during the treatment period that might have an effect on outcome, too.22 prospective sufficiently powered controlled trials are truly warranted.Measuring QoL with a validated questionnaire in the Finnish population can be considered as strength of the study. Bearing in mind the limitations, as discussed earlier, we conclude that even if surgery seems to be associated with more effective pain management in the short term, it showed no additional benefit with respect to QoL or pain after extended follow-up. In contrast, it may be concluded that performing vestibulectomy after conservative treatments is safe and does not seem to be harmful. However, long-term patient-reported outcomes in terms of QoL and pain after surgery do not seem to differ from those achieved conservatively. Considering recent evidence of a strong placebo effect concerning medical treatments,


Temporomandibular disorders (TMD) are observed in a number of autoimmune diseases but limited studies have assessed the effect of autoimmune diseases on TMD. Therefore, the present review article was conducted to determine the effect of autoimmune diseases on TMD.International databases, including Web of Sciences, PubMed and Scopus, were searched in order to find related articles. The search key words were; temporomandibular joint (TMJ) autoimmune disorders, TMJ, TMD, medical therapy and non-invasive, local and systemic management. Published articles from June, 2010 to June, 2019 were included in the review.A total of 11 related articles including rheumatoid arthritis (RA), lupus erythematosus and systemic sclerosis were found. All articles noted that TMJ has unique features that distinguishes it from other human body joints. Cases of TMJ injury and TMD require specific treatments. Therefore, early diagnosis of TMD is essential. It was also mentioned in the articles that the collagen-induced arthritis (CIA) method is a suitable method for investigating TMD and its relationship with RA. Treatment methods included oral steroids, Disease-modifying antirheumatic drugs, nonsteroidal anti-inflammatory drugs, methotrexate 75 mg, and combination therapy with methotrexate.Based on the results of this study, TMD exists in some autoimmune diseases, including RA, lupus erythematosus and systemic sclerosis. Therefore, there should be an interdisciplinary collaboration between physicians and dentists in order to choose the best conservative treatment and medication therapy for TMD to reduce the progression and pain associated with this type of disorder. The chronological changes in TMJ are important issues in surgery and radiology 2This narrative review was performed to determine the effect of autoimmune diseases on TMD. Various key words, including temporomandibular joint autoimmune disorders, TMJ, TMD, Systemic management, medical therapy and non-invasive local and systemic management, were used to identify related articles. Articles that were published from June, 2010 to June, 2019 in international databases, including Web of Sciences, PubMed and Scopus, were included in the search. At first, the titles of the identified articles were investigated based on thematic communication. In the next phase, the abstracts were evaluated regarding the relevance to the intended purpose. Then identified articles were included in this study. Articles without thematic connection, method, full text and articles presented at conferences, duplicate articles and articles published in a language other than English were excluded from this study.The information of the articles was reviewed based on the inclusion and exclusion criteria by two reviewers independently. Finally, both reviewers summarized the information. At first the collected data was summarized into categories, including definitions of TMJ, TMD related factors, signs and symptoms of TMD, TMD diagnostic methods, systemic management and effect of autoimmune diseases on TMD. Finally, the results were summarized in 3.A total of 78 articles were found in the literature search, among which 11 articles were found to be related to the effect of autoimmune diseases on TMD.3.1.TMJ acts like a sliding hinge and attaches the jaw bone to the skull In most people, in the maximal mouth opening, Condyle goes down and forward to the prominent peaks and when the mandibul is closed, the disc returns to the mandibular cavity with condyle 3.2.Based on the attitude of many researchers, TMD is multifactorial and complex 3.3.In order to identify signs and symptoms of TMD, a complete medical and dentistry history should be primarily obtained from the patient to detect any inherited or acquired disorder. furthermore, history of trauma and pain should be considered. Then, the clinical examination of the patients begins with the palpation of Temporal muscle, superficial and deep part of masseter muscle, lateral pterygoid, sternocleidomastoid and upper trapezius muscles, occipital bone and cervical muscles 3.4.The initial evaluation of TMD is based on a clinical examination of the masticatory muscles. However, several studies have shown that clinical examination is unreliable in many cases 3.5.Treatment for TMD is implemented in two distinct phases. The first phase involves patient training for reducing anxiety, behavioral changes, pharmacotherapy, physiotherapy and splint therapy. The second phase involves performing occlusal adjustment, fixed prosthetics, restorative treatments, dental restoration, orthodontics or orthognathic surgeries. A topic called Biofeedback has been suggested in the non-pharmacological treatments to reduce anxiety through behavioral and Biofeedback treatments in both short and long-term. Biofeedback is also more effective in pain management in patients with TMD compared to conventional treatments Behavioral modifications, including stress reduction, sleep hygiene and avoiding abnormal habits  and avoiding severe jaw movements  are advised to patients with TMD Physiotherapy involves the use of TENS, ultrasound and hot pack. Arthroscopy is sometimes helpful to remove intruder connectors inside the joints and cleaning joint through arthrocentesis. On the other hand, there are evidence based researches regarding the effects of occlusal splints. Short-term studies have also shown that the use of the appliance has been effective in reducing signs and symptoms of TMD disorders Only 5% to 10% of patients with TMD need treatment and TMD symptoms reduce spontaneously in 40% of patients. In a long follow up study, 50% to 90% of patients reported a period of pain relief during the course of follow up The first treatment goal is to manage, reduce and eliminate pain. At first, conservative treatments are prescribed. Conservative treatment may lead to the resolution of symptoms in over 80% of patients. Conservative interventions include resting the jaw by using a soft diet, avoiding excessive opening of the mouth, physiotherapy and the use of NSAIDs, that can be administered topically, and use of soft occlusal appliances made by the dentists. Effective management of the disease with disease-modifying anti rheumatic drugs (DMARDs) is vital for patients There is no evidence that long-term physiotherapy is beneficial, but due to the safety of physiotherapy, it can be used in short-term management of patients, post arthroscopy or after open surgery. Topical NSAIDs can have similar effects and fewer side effects compared to oral NSAIDs. These topical agents should be used 4 times a day for 4 weeks. In addition to the findings of clinic trials on the use of NSAIDs in osteoarthritis, these drugs are also effective in the treatment of TMJ inflammation due to orthopathy. The other medications that are used in the management of TMD are tricyclic anti-depressants that can relieve facial joints pain caused by TMJ TMJ pain can be blocked temporarily by local infusion of anesthetic agents including lidocaine (1% or 2%) in the joint space. The pain resolves after 10 minutes. This is more effective in improving intra-articular pain. Injection site is in the upper joint space and below the straight line from the tragus to the canthus of the eye Intra-articular steroid injection can be effective in TMJ synovitis. This method is not recommended, unless joint inflammation is confirmed by MRI scan or during arthroscopy. The excessive use of intra-articular steroids may lead to irreversible removal of cartilage. Myofascial pain and spasm can be temporarily relieved by injection of a local anesthetic like bupivacaine 0.5% or botulinum toxin, into the temporalis muscle mass. Measuring pain using a visual analog scale shows that this treatment reduces at least 25% in 79% of the pain. In recent years, Methotrexate and other agents like Hyaluronate have also been considered in the management of TMD in addition to NSAIDs and local anesthetics. In the next sections, the findings of studies that used these agents for treating TMDs will be discussed Anticonvulsants have been used in some studies for the treatment of TMJ. In the study by Kimos et al., daily administration of 300 mg Gabapentin significantly decreased pain compared to control group 3.6.Autoimmune disease occurs when the immune system erroneously attacks body organs 3.7.Rupareila et al. published a short report describing an Indian woman who was diagnosed with TMD and RA. They found that early diagnosis of TMD could help in early diagnosis of other conditions including RA. The reported case received NSAIDs and corticosteroids Sodhi et al. published a case report describing a 22-year-old patient with the complaint of pain in the left side of the jaw. The patient was diagnosed with RA. TMD was observed in TMJ examinations. They reported that TMD was present in RA with a common radiographic injury in hand and foot joints. Treatment was performed by administration of 75 mg methotrexate Chebbi et al. reported a case of systemic sclerosis, an autoimmune disease, with hip joint involvement in a 45-year-old woman. The patient was also diagnosed to have TMD. They mentioned that TMD should be suspected by physicians in systemic sclerosis patients. Patients should be thoroughly examined since the effect and discomfort might be limited to jaw, which will result in pain. Furthermore, the treatment is harder if the TMD complications were diagnosed at later stages Cordeiro et al. assessed the TMD in TMJ of patients with RA. They performed physical assessment of TMJ to categorize TMD in 49 patients of both genders in all age groups. The findings revealed that 75% of patients complained from orofacial pain, and one or both of the following symptoms; arthralgia and myalgia. Degenerative changes were observed in 90% of patients. In order to reduce functional and structural damage, early diagnosis of TMD was recommended for RA patients Crincoli et al. assessed that prevalence of signs and symptoms of TMD and TMJ and their complications in 52 patients with RA. They found that TMD was present in RA patients. Significant reduction in the saliva production was observed in patients with ERA. Pain in palpation of MP joints was more prevalent and sever in the control group compared to the case group. Treatment was performed by administration of corticosteroids, DMARDs and biologic DMARDs Shi et al. performed a review study to compare the therapeutic effects of hyaluronate with corticosteroids in TMD. They reported no significant difference in terms of reduction in pain and other symptoms between the two treatments. They reported heterogeneity in the comparison of arthroscopy with arthrocentesis with or without hyaluronate. Hyaluronate was reported to have potential effects in the improvement of arthroscopy assessment scores. Complications were mild and transient and included pain or discomfort in injection site in hyaluronate group. No significant improvement in quality of life was observed in hyaluronate group Didem O. Ince et al. assessed the effectiveness of methotrexate treatment on TMD and facial morphology in patients with juvenile rheumatoid arthritis. They found that methotrexate administration might minimize destruction in TMD in patients with juvenile rheumatoid arthritis. They also reported that the extent of TMJ involvement in patients with polyarticular form of juvenile rheumatoid arthritis was significantly reduced in methotrexate group compared to control group, who did not receive methotrexate Beside the studies that assessed the administration of methotrexate in improving TMD symptoms, further studies assessed the combination of methotrexate and other medications in order to improve treatment outcomes.Sigvard Kopp et al. assessed the effect of administration of methotrexate and infliximab in reduction of temporomandibular joint pain in patients with RA. They assessed the changes in synovial and plasma cytokines. They found that the combination of systemic infliximab and methotrexate resulted in reduction in TMJ pain in patients with RA, which was correlated with increased cytokines and antidepressant receptors in the synovial fluid and plasma. Infliximab has a very specific inhibitory effect on TNF-α. The binding of infliximab to TNF-α results in the degradation of TNF-α 4.The current study included 11 studies comprising of 9 studies on the relationship between RA and TMD and 2 studies on the effects of systemic sclerosis on TMD. In the point of view of physicians, several systemic disorders including lupus erythematosus, RA and systemic sclerosis commonly occur with TMD In the study by Aliko et al. TMD was assessed in patients with lupus erythematosus and systemic sclerosis Chebbi et al. assessed the effect of systemic sclerosis on TMD. They reported that early diagnosis of TMD in systemic sclerosis patients is necessary The mentioned treatments for TMD in the studied articles included oral steroids, DMARDs and NSAIDs, 75 mg methotrexate and combination therapy with methotrexate and administration of hyaluronate. Aiko et al. 5.The findings of this review revealed that TMD exists in some autoimmune diseases, including RA, lupus erythematosus and systemic sclerosis. Based on majority of the studied articles early diagnosis of TMD results in the prevention of progression in the primary stages and reduce treatment costs. Therefore, it is necessary to identify the prevalence of TMD in different regions and to identify the influencing factors related to TMD. Furthermore, medications including oral steroids, DMARDs, NSAIDs and methotrexate (75 mg) were used in the studied articles in this review. Combination therapy, including combination of methotrexate and other anti-inflammatory medications, is being used recently in the management of TMD. It seems that multiple treatments that implement the combination of different medications and physical methods, including physiotherapy and etc., can improve treatment outcomes. Regarding the findings of this review, as the prevalence of TMD in autoimmune diseases was not identified, it is recommended to conduct further research regarding the prevalence of TMD and its relationship with autoimmune diseases, geographical regions, lifestyle and nutritional habits. Furthermore, there is a need to assess TMD in different age groups especially among adolescents, as this age group is susceptible to TMD. Lack of knowledge on the risk factors and prevalence of TMD is due to the absence of a clear definition, and lack of clinical and history criteria for TMD. Due to the complications of TMD, there is a need to establish a data base by the ministry of health regarding patients with TMD in order to improve patient follow up by dentists and to be able to assess the effectiveness of primary treatment and TMD medications in order to choose a more suitable treatment modality. It is also recommended for physicians to have interdisciplinary collaboration with dentists to assess autoimmune diseases to prevent the pain caused by these conditions.


Objective: Thoracic neuralgia (TN) is a chronic pain syndrome that can be refractory to pharmacologic intervention and management by pain specialists. Dorsal root ganglion (DRG) stimulation has shown promise as a targeted and effective modality compared to traditional therapies for several indications but has not yet been applied in the thoracic region. This study aims to report the outcomes of off-label thoracic DRG stimulation in patients with refractory TN.Methods: A retrospective chart review was performed at Emory University Hospital for patients who underwent thoracic DRG stimulation in a two-year period. Relevant outcomes for safety and efficacy were evaluated.Results: Six patients were identified that underwent thoracic DRG stimulation for various etiologies of TN, including post-mastectomy, post-herpetic, and post-abdominoplasty neuralgia. All patients initially underwent trial DRG stimulation with a mean pre-operative visual analogue scale (VAS) (0-10) of 6.8 ± 1.6 (range: 4-8). Four of six patients (67%) were non-responders and did not pursue permanent implantation; two experienced pain with stimulation during the trial, and two patients experienced no significant benefit. In addition, all three patients with post-herpetic neuralgia did not respond to treatment. Two of six patients (33%) responded well to stimulation, elected to receive permanent leads, and reported significant pain relief with VAS scores of 0/10 and 1/10, and 100% reduction in morphine equivalent use. Complications included lead migration and need to reset stimulator programming.Conclusions: DRG stimulation may be an effective therapy for patients experiencing chronic TN as a result of peripheral nerve injury; however, post-herpetic neuralgia may be unresponsive to this treatment. Future prospective studies are warranted to evaluate the feasibility of this procedure in patients with refractory TN. Thoracic neuralgia (TN) is a chronic pain syndrome with various causes, including thoracotomy, mastectomy, and herpes zoster infection. While the true incidence is difficult to define, 3%-22% of pain clinic patients are referred for thoracic pain, and these etiologies are associated with a high risk of severe chronic postoperative or post-infection pain . For insIn the last ten years, dorsal root ganglion (DRG) stimulation has become available for treating neuralgia and has shown promise to provide a more targeted and effective modality compared to SCS for pain relief. The DRG resides in the foramen in close proximity to the pedicle. It plays a key role in the development of neuropathic pain, so stimulation can allow a more focused, and effective therapy. Studies have shown that electrical stimulation of the DRG modulates neuropathic pain signals with root specificity and minimal effect with postural changes -8. A triOperative techniqueAbbot Axium Neurostimulator System SlimTip  and Patient Programmer  were used for these procedures. Patients are brought to the operative suite and prepared in a standard fashion in a prone position. Intraoperative fluoroscopy is used to identify the appropriate vertebral body and spinous process and the overlying skin is marked with indelible ink. A stab incision is made at this site with a #15-blade. A 14-gauge Tuohy needle is inserted towards the pedicle of the appropriate spinal level and side using intraoperative fluoroscopy for guidance. The needle is advanced to the inferior margin of the lamina into the intralaminar space, then through the ligamentum flavum into the epidural space. A guidewire is passed through the needle into the epidural space adjacent to the pedicle to confirm proper location. Once this is confirmed, the guidewire is then removed and the introducer cannula is advanced into the epidural space. The introducer is maneuvered inferior to the pedicle. The electrode is then advanced such that the four electrode contacts are positioned within and beyond the pedicle, with the most proximal contact no more medial than the inner border of the pedicle. The introducer is retracted over the wire, and the wire is advanced to form a loop superiorly in the canal to serve as an anchor. The introducer and Tuohy needle are then removed. This is repeated for each of the levels indicated. For trial electrode placement, the distal wires exiting from the skin are connected to an external stimulator. Patients are admitted for observation, then discharged for the trial period lasting seven to 14 days. After a successful trial, a subcutaneous pocket was used for implantation of the implanted pulse generator (IPG) at the buttock or flank.Chart reviewA retrospective chart review was performed to identify all patients at the Emory University Hospital who underwent thoracic DRG stimulation for thoracic neuralgia over a two-year period. Demographic variables were collected, including indication, comorbidities, age, and prior treatments. Pre- and post-operative visual analogue scale (VAS) pain scores, post-operative complications, and narcotic medication doses were also collected. Narcotic medications were converted to morphine equivalents (ME) to provide consistency. Data are represented with descriptive statistics.Statistical analysisCategorical variables were summarized as frequencies and percentages, while continuous variables were reported as means, standard deviations (SD) and range using Microsoft Excel. Box plots were used to graphically display continuous variables and the non-parametric Wilcoxon sign rank test was used to compare pre- and post-operative VAS scores using Stata version 14 .Six patients were identified who underwent thoracic DRG stimulation for indications including post-mastectomy, post-herpetic, and post-abdominoplasty neuralgia Table .All patients received trial DRG stimulation with a mean pre-operative VAS of 6.8 ± 1.6 and range of 4-8. Mean post-operative VAS score was 4.9 ± 3.6 showing no statistically significant pain reduction as compared to the pre-operative VAS score baseline (p=0.58) .The first patient with permanent stimulator implantation had post-abdominoplasty pain in the lower left extremity and groin that began six weeks post-operatively and continued for one year before the stimulation trial. The patient reported a VAS change from 4 to 0/10 after trial stimulation, and permanent leads were placed T12-L2 on the left side with similar pain reduction at eight months follow-up. Following permanent placement, there was a 100% reduction in ME, from 30 to 0. The only reported complication was the migration of leads causing pain, which was relieved by realignment. The second patient with permanent stimulator implantation had post-bilateral mastectomy pain around the ribcage that developed eight months post-operatively and underwent trial stimulation three years later. The patient reported a VAS improvement from 8 to 1/10, and permanent leads were placed T4-T7 on the right and left sides. After permanent implants were placed, similar pain relief was reported at two weeks follow-up. The patient reported acute pain at the electrode site, which was relieved by program resetting. There was a 100% reduction in prescribed ME, from 25 to 0 ME.Four patients elected not to receive permanent lead implants after trial stimulation. One patient with severe right-sided flank pain due to post-herpetic neuralgia received trial stimulation T12-L2 on the right side three years after onset. The patient reported some initial pain relief, but the leads were removed 14 days after placement due to subsequent pain from the leads. A patient with chronic pain on the left chest and back for four years post-mastectomy received trial stimulation T2-T4 on the left side. Electrodes were eventually removed after 12 days due to intense pain from the leads. Two post-herpetic neuralgia patients experiencing burning pain on the chest for four to seven years received trial stimulation at T4-T7 or T1-T3 on the left side. Both reported no pain improvement with the trial and elected to have the leads removed and not pursue permanent implantation.The current study demonstrates that 33% of patients responded well to DRG stimulation, with notably thorough pain relief, 100% reduction in ME use, and minimal complications at one to 1.5 years follow-up. Both responders had developed TN due to a history of thoracic surgical intervention, while the etiology of TN of three of the four non-responders was post-herpetic. Of the 67% of non-responders, two experienced pain with trial stimulation, while one experienced transient pain relief followed by no significant benefit based on their VAS scores. Given that thoracic neuralgia due to trauma or iatrogenic injury has been historically difficult to treat , DRG stiFailure of stimulation to provide pain relief could be due to a number of different causes. Because thoracic DRG stimulation is still a new avenue for treatment, lead programming and positioning are not standardized, and improper placement could lead to unchanged or increased pain. In addition, patient willingness to make adjustments to find the best position and setting while in pain may limit the opportunity to optimize the settings. These patients could also represent a population not responsive to this approach. Notably, patients with herpetic neuralgia did not benefit from treatment, while both successful implants were with patients with post-operative pain. Many neuromodulatory strategies for herpetic neuralgia fail because the underlying source of pain in herpetic neuralgia is still unclear and likely multifaceted involving both central and peripheral neurons and neuroplasticity in the dorsal horn . Time frWhile this study provides insight into the potential use for DRG stimulation in TN, there are a number of limitations. This was a single-center analysis analyzing outcomes from one provider and approach. While this may help limit discrepancies in methodology, patient environments and previous treatments were not standardized. In addition, since this was a retrospective report of six cases, data relied on accurate patient information and record keeping. Lastly, this was a limited patient pool with only six individuals who met the criteria for the analysis.This report of six cases demonstrates the potential success of DRG stimulation as an effective therapy for medically refractory patients experiencing chronic TN. DRG stimulation may be efficacious in patients with thoracic neuralgia due to post-surgical iatrogenic injury. Our cases of post-herpetic neuralgia did not experience pain relief from stimulation. Further studies are warranted to determine the safety and efficacy of this approach and identify accurate patient selection criteria for this treatment strategy.


The effects were evaluated immediately and 7 days after treatment through pain, cervical range, and electromyographic activity of the UT muscle. Significant effects were confirmed immediately after treatment (OVMG and PVMG) for numeric rating scale scores (p < 0.001) and pain area (p < 0.001). Significant increases in EMG amplitude were identified immediately and 7 days after treatment for the OVMG (p < 0.001). No differences were identified between the OVMG and the PVMG for cervical range of motion (p > 0.05). This study demonstrated that a single visceral mobilisation session for the stomach and liver reduces cervical pain and increases the amplitude of the EMG signal of the UT muscle immediately and 7 days after treatment in patients with nonspecific neck pain and functional dyspepsia.Previous studies have reported that visceral disturbances can lead to increased musculoskeletal tension and pain in structures innervated from the corresponding spinal level through viscerosomatic reflexes. We designed a pilot randomised placebo-controlled study using placebo visceral manipulation as the control to evaluate the effect of osteopathic visceral manipulation (OVM) of the stomach and liver on pain, cervical mobility, and electromyographic activity of the upper trapezius (UT) muscle in individuals with nonspecific neck pain (NS-NP) and functional dyspepsia. Twenty-eight NS-NP patients were randomly assigned into two groups: treated with OVM (OVMG; Nonspecific neck pain (NS-NP) is a musculoskeletal disorder characterised by pain in the structures located between the superior nuchal line and the spinous process of the first thoracic vertebra , which iThe specific diagnosis of NS-NP is not clear in the literature or in clinical practice, as several different therapeutic modalities  techniques is to improve the mobility  and funcThese neurofunctional relationships and the effects of OVM are currently unclear. Therefore, considering the possibility that viscerosomatic reflexes may be found in patients with NS-NP who exhibit dyspepsia  , we testThis pilot randomised placebo-controlled study was designed to evaluate the effect of OVM (stomach and liver) on pain, cervical mobility, and electromyographic activity of the upper trapezius (UT) muscle in individuals with NS-NP and dyspepsia.NCT03043625). All subjects were informed about the procedures of the study and signed a consent form before any procedure.The present study was a double-blind, placebo-controlled trial with balanced randomization (1:1), approved by the Ethics Committee of the University Nove de Julho (process n°: 02290412.0.0000.5511) and registered in Clinical Trials   between Individuals were allocated to different groups based on numbers randomly generated by a randomization site . NumbersIndependent evaluators performed the following procedures: Evaluator 1: triage, random draw of treatments to be performed; Evaluator 2: treatment application; Evaluator 3: EMG data collection; Evaluator 4: EMG signal processing and statistical analysis. Evaluators 3 and 4 were blinded in relation to the groups.NRS scores for pain and pain area after a single session of OVM were considered the primary outcome and cervical range of movement (ROM) and surface electromyographic (sEMG) activity of the upper trapezius muscle as the secondary outcomes of the study.The NPRS, translated and cross-culturally adapted for the Brazilian population, was used to assess pain intensity  , 24. PaiCervical ROM (degree) was measured using a fleximeter , in a standardized sitting position, to remove errors and movement compensation, except for the movements of rotation, in which they had to stay in the supine position. The equipment was fixed by means of a Velcro strap around the head, with the gauge positioned on the lateral side of the head for the flexion-extension movements, in the frontal region of the head for the right and left lateral inclination movements and at the top for the right and left lateral rotation movements. The reproducibility of the measurements has been verified in a previous study that had intra- and interexaminer reliabilities that ranged from moderate to excellent, which proved its potential for use in clinical practice .The sEMG signals were recorded by an acquisition system with 16 channels . Two channels were set for the use of the force transducer. The data were recorded with a sample frequency of 2000 Hz and digitalized using analog-digital (A/D) conversion plates, with a 16-bit resolution.A linear electrode array composed of 10 silver bar electrodes distributed in two columns  was positioned on the UT muscle, 2 cm lateral to the medium point of the line traced between the posterior edge of the acromion and the seventh cervical vertebra . A gel cSubjects in the osteopathic visceral manipulation group (OVMG) were submitted to treatment with a single intervention, which involved application of a manipulation technique to the stomach followed by the liver. After an initial evaluation, each participant was instructed to lie down comfortably on an examination table in the supine position, with their lower limbs flexed and abdomen exposed. The therapist was positioned to the right side of the patient. The therapeutic intervention began with the therapist's left hand in contact with the lower region of the stomach. The therapist applied force to this region to move the organ in an upper and lateral left direction while their right hand controlled and directed the subject's knees to the right side, until the therapist noticed an increase in tension in the stomach region . The samSubjects in the placebo visceral manipulation group (PVMG) were treated with a single intervention involving a placebo mobilisation technique, as described by McSweeney . After aThe sequence of experimental events is summarized in After electrode fixation in the UT muscle that presented greater area of pain, the subjects were instructed to perform three shoulder elevations in maximal isometric voluntary contraction (MIVC) against the resistance of the force transducers for 5 s during verbal encouragement, with an interval of 1 minute between collections. The maximum peak force between force collections (Newtons) was considered as 100% of MIVC. A 30% MIVC training line was established as feedback on the computer screen and subjects were instructed to maintain shoulder elevation over this training line for 60s (EMG-1). After 1 minute rest interval, data on pain was collected (E2). Subsequently, treatment with visceral mobilization or placebo was started. After a ten minute rest interval, new evaluations of NPRS and cervical ROM were performed (E3), followed by a new sEMG signal collection (EMG-2) in the same manner as performed during EMG-1 and data collected on pain after 1 minute rest interval (E4). After a period of 7 days, a further evaluation of pain and cervical ROM (E5) was performed, followed by sEMG signal collection as performed during EMG-1  (EMG-3). After 1 minute rest interval, data on pain was collected (E6). All participants received training prior to shoulder elevations based on the previously determined force levels.The data were analyzed offline using specific routines carried out in the Mathlab program .The amplitude of sEMG was defined as the RMS (root mean square) value of the sig-placebo manipulation on UT muscle activity was verified by the overall RMS value (gRMS) obtained from the mean RMS of the eight channels, since averaging across multiple electrodes increases the stability of the RMS estimates .Muscle fiber conduction velocity (MFCV) was calculated for each force level, using a cross-correlation based algorithm that calculated the time delay corresponding to the maximum of the cross-correlation function, using its time derivative . t tests.The Shapiro-Wilk test was used to test the normality of the data distribution. Data in relation to pain area were log-transformed prior to analyses to negate the effects of heteroscedasticity. Mean age, body mass index and height were compared between groups using independent-sample p < 0.05. The data were analyzed using the StatSoft software SPSS 20.0 .The two-way repeated-measures analysis of variance (ANOVA) design was used to analyze the influence of OVM treatment on the pain considering with factors: treatment (OVM vs. PVM) and intervention (pre- vs. immediate posttreatment vs. 7 days after termination of OVM). Specific differences were determined based on post hoc analysis, using Bonferroni correction. The significance level wasAnthropometric data  and clinical characteristics assessed by NDI did not differ between the groups treated with visceral manipulation (OVMG) and placebo manipulation (PVMG) .For NPRS, we considered the mean of the data obtained in the evaluations in E1 and E2 as pretreatment values, the mean values of the E3 and E4 evaluations as immediate posttreatment, and the mean E5 and E6 values as post-7 days values. p< 0.004, ηp2 = 0.21) and the pain area  (Significant interaction (treatment vs. groups: ANOVA test) was identified between groups after the treatment for NPRS scores  . p <0.001; PVMG: p <0.001) and pain area  (p <0.001) and pain area (p <0.001) in relation to data collected preintervention (baseline).In intra group analysis (post hoc test), significant effects were confirmed for the data collected immediately after treatment in both groups to NPRS (OVMG: <0.001) . For thep <0.001) and left side flexion after 7 days of treatment (p <0.001) (No significant interaction (treatment vs. groups: ANOVA test) was identified between groups after the treatment for cervical ROM. In intra-group analysis, only OVMG presented a significant increase of the cervical ROM for extension and right side flexion movements after immediate treatment ( <0.001) . p=0.94; ηp2=0.002) and treatment vs. group . However, significant differences were observed in the EMG signal amplitude analysis for treatment interactions  and treatment vs. group .The results of this study verified our hypothesis that possible nociceptive inhibition provided by OVM of the stomach and liver reflects an improvement in the clinical status of patients with NS-NP associated with dyspepsia. The significant decrease in pain, measured by NPRS and the area of pain, together with a significant increase in the amplitude of the EMG signal of the UT muscle in the OVMG immediately after the intervention and after 7 days suggests that viscerosomatic reflexes may be present in NS-NP patients with dyspepsia. The mechanisms underlying this reflex are not yet understood and require further investigation; however, these results strengthen the possibility that OVM of the stomach and liver could contribute to the treatment of these patients.β afferents fibres, thereby inhibiting pain [There was a significant decrease in pain symptoms immediately after the intervention for the groups treated with OVM and the placebo. Similar results have been reported for patients with NS-NP who were treated with acupuncture for pain control , as welling pain . In addiing pain .In relation to EMG of UT muscle activity, previous studies have found that pain promotes a decrease in the electromyographic activity of this muscle during isometric contraction , 36. ThuThe results observed for the cervical ROM in this study did not contribute to a better understanding of the physiological mechanisms of OVM. The differences observed in the OVMG post-intervention were heterogeneous, with significant differences in the movements of extension and right-side flexion immediately after OVM and for left-side flexion 7 days after the intervention. There was no significant improvement in the PVMG, so we are unable to conclude that these differences are related to treatment with OVM. Thus, these results must be interpreted with caution.Although explanation of these findings is not straightforward, the responses observed for pain and EMG activity of the UT muscle after OVM indicate that the visceral stimulus provided by the manipulation techniques applied in this study may be related to some physiological mechanism (not yet reported clearly in the literature) that inhibited pain and muscle activity. This physiological effect could be due to muscle relaxation and a consequent clinical improvement, evidenced by the decrease in pain reported by individuals in the OVMG 7 days after treatment. These observations reinforce our initial hypothesis that visceral changes can produce a nociceptive input that can promote alterations in the muscular activation threshold at the spinal level and, consequently, changes in the activation pattern of the muscles corresponding to the affected spinal level as previously suggested , 16, 39.The results of this study reinforce the possibility that spinal facilitation of the internuncial neurons occurred in the OVMG at the level of the neural roots of the phrenic nerve (C3-C5) that innervates the diaphragm muscle, the subdiaphragmatic peritoneum , coronarThe results of this study can be considered promising for a better understanding of mechanisms involving viscerosomatic reflexes; however, they should be interpreted with caution given the important methodological limitations of the current study. These include the lack of calculation of sample size ratio , presentation of the effects observed after only a single treatment session, and absence of prior evaluation of visceral mobility, which is usually performed subjectively by the therapist, which makes scientific reproduction difficult. Another limitation was that we did not assess clinical variables related to fibromyalgia , which is a common comorbidity in these patients . This haTo our knowledge, there has been no randomised controlled trial assessing the effectiveness of OVM as a complementary therapy for the relief of acute pain or for improving cervical function in NS-NP patients. Therefore, the present study provides the basis for future studies to assess the efficiency of treating NS-NP with OVM, as previously suggested , 14.The results of this pilot study indicate that a single session of osteopathic visceral manipulation for the stomach and liver reduces cervical pain and increases the amplitude of the upper trapezius muscle EMG signal immediately and 7 days after treatment in patients with nonspecific neck pain and functional dyspepsia. Patients treated with placebo visceral mobilisation reported a significant decrease in pain immediately after treatment. The effect of this intervention on the cervical range of motion was inconclusive. The results of this study suggest that further investigation is necessary.


Electrical cardioversion (ECV) is a short but painful procedure for treating cardiac dysrhythmias. There is a wide variation regarding the medication strategy to facilitate this procedure. Many different sedative techniques for ECV are described. Currently, the optimal medication strategy to prevent pain in ECV has yet to be established. The role for additional analgesic agents to prevent pain during the procedure remains controversial, and evidence is limited.  We conducted a prospective multicenter study to determine the incidence of painful recall in ECV with propofol as a sole agent for sedation, in order to assess the indication for additional opioids. In all patients, sedation was induced with propofol titrated till loss of eyelash reflex and nonresponsiveness to stimuli, corresponding to Ramsay Sedation Score level 5-6. ECV was performed with extracardiac biphasic electrical shocks. The primary outcome was painful recall of the procedure, defined as numeric pain rating scale (NRS) ≥ 1. NRS ≥ 4 is considered inadequately treated pain. Secondary outcome parameters were pain at the side of the defipads and muscle pain after ECV.  A total of 232 patients were enrolled in this study. Six patients were excluded due to missing data or violation of study protocol. Three patients reported recall of the procedure, and one patient (0.4%) reported recall of severe pain during the procedure with NRS 7. Two patients (0.9%) reported recall of mild pain with NRS 1–3. Complete amnesia was observed in 223 patients (98.7%), with NRS 0. The mean of the total dose of propofol was 1.1 mg/kg. Fifteen patients (6.6%) experienced pain at the side of the defipads, and six patients (2.7%) complained of muscle pain after the procedure.  In this prospective multicenter study, propofol as a sole agent provided good conditions for ECV with a low incidence of recall. Effective sedation and complete amnesia was achieved in 98.7% of the patients, 0.4% of patients reported recall of severe pain during the procedure, and 0.9% of patients experienced mild pain during the ECV. External electrical cardioversion (ECV) is a short and painful procedure for treating cardiac dysrhythmias. There is a wide diversity regarding the medication strategy to facilitate ECV. Cardioversion can be performed using a variety of hypnotic agents, sedative agents, and additional analgesics . The agePropofol is frequently used for ECV because of its ease of titration, rapid onset of action, brief duration of sedation, and amnestic properties , 2, 3. ACurrently, the optimal medication strategy to prevent pain in ECV has yet to be established. The evidence for the use of analgesic agents such as opioids in conjunction with sedatives to prevent pain is limited and controversial. The aim of this study was to determine the incidence of painful recall in ECV using propofol as the sole agent for sedation and to assess the need for additional analgesia.This was a prospective multicenter study that took place from December 2014 to November 2016 at the Intensive Care Unit (ICU) of Haaglanden Medical Centre and the Cardiac Care Unit (CCU) of Reinier de Graaf Hospital, the Netherlands. In these departments, sedation is performed at the discretion of the attending intensive care specialist or anesthesiologists. Propofol is the sedative agent of choice in ECV. Additional opioids are not given.The primary outcome was the incidence of painful recall of the ECV after sedation with propofol. Secondary outcomes were pain at the side of the defipads and muscle pain after the procedure.http://www.trialregister.nl.All patients (aged 18 years or older) scheduled for cardioversion for arrhythmias such as atrial fibrillation, atrial flutter, or supraventricular tachycardia with an indication for ECV were eligible for study participation. Patients were excluded in case of hypersensitivity to propofol. The regional Medical Ethics Committee Zuidwest Holland, in the Netherlands, exempted this study for formal ethical approval and patient consent. However, verbal consent was asked to all potential study participants before participation in the study. The trial is registered at Depending on the clinical practice of the treating specialist, some patients received a small dose of lidocaine to prevent pain due to injection of propofol. No additional analgesics were given. Anesthesia for ECV was induced with propofol. Propofol was titrated by the attending ICU specialist or anesthesiologist until adequate sedation was achieved. Adequate sedation was defined as a state of unconsciousness with nonresponsiveness to stimuli and loss of eyelash reflex, corresponding with Ramsay Sedation Scale level 5 or 6. In case of inadequate sedation, additional boluses of propofol were given as often as necessary. The dose of additional bolus and the speed of drug injection were not predetermined.ECV was performed by the cardiologist with extracardiac biphasic electrical shocks ranging from 50 to 200 Joules. If sinus rhythm was not restored, more shocks were delivered. Patients were questioned after the procedure at the moment basal mental status was restored. They were asked to report any pain perception or recall using the Numeric Rating Scale (NRS). The NRS score is a validated score to express the intensity of pain by choosing a number, from 0 (no pain) to 10 (worst pain imaginable). NRS ≥ 4 is used to refer to inadequately treated pain . In thisRecords were kept of the pain scores, age, sex, weight, dose of propofol, the use of lidocaine, the number of shocks, and total amount of energy delivered. Data were collected by the ICU specialist, the ICU resident, or the CCU nurse on a preformatted data sheet during the procedure.All patients were preoxygenated with 100% oxygen via a nonrebreathing facemask while breathing spontaneously before induction of anesthesia. Noninvasive blood pressures were measured every 3–5 minutes. Oxygen saturation and heart rate were monitored continuously during and after the procedure until patients had returned to their baseline mental status, corresponding with Ramsay Sedation Scale level 2.In case of apnea, 100% oxygen was administered using bag-valve-mask ventilation. If the patient showed signs of upper airway obstruction, simple airway maneuvers like chin lift and jaw thrust were performed. Adverse events and complications were recorded in the patient files but are not described in this study as they fall beyond the scope of this present study.As this was a descriptive study, no power calculation was undertaken. Statistical analysis was performed using SPSS Statistics version 17.0. Standard descriptives were obtained. Outcomes in this study included dichotomous outcomes , discrete data (NRS and number of shocks), and continuous data (age and propofol dose). Values were expressed as mean ± standard deviation or percentages of patients, as appropriate.A total of 232 patients who underwent ECV facilitated with propofol as the sedating agent were enrolled in the study. Six patients were excluded because of missing data. The mean age was 68.7 years, and 65.5% (148) of the patients were male. The baseline characteristics of the patients are shown in Sixty-two (27.4%) patients received a single dose of lidocaine of 5 to 20 mg to numb the blood vessel before administration of propofol. The mean propofol dose required was 1.1 mg/kg (± 0.3).Complete amnesia was observed in 223 patients (98.7%) with NRS 0. One patient (0.4%) had reported painful recall of the procedure with NRS 7 and recollection of the two shocks with 150 Joule. This patient received 10 mg lidocaine to numb the blood vessel and 90 mg propofol (0.83 mg/kg). The patient was adequately sedated with loss of eyelash reflex and nonresponsiveness to auditory stimulus. Two patients (0.9%) reported recall of mild pain with NRS 1 and NRS 3, respectively. The patient with NRS 1 received 10 mg lidocaine and 80 mg propofol (0.95 mg/kg), and the patient with NRS 3 received no lidocaine and 90 mg propofol (1.25 mg/kg). In both patients, one shock with 200 Joule was given.We also studied the need for simple analgesics after ECV. Fifteen patients experienced a burning sensation or pain at the side of the defipads, and six patients complained from muscle pain after the ECV. One, two, or three shocks were needed in respectively 178, 34, and 14 patients. The patients who received 3 shocks reported no pain with NRS 0 after the procedure. Findings of the procedure are presented in The aim of this study was to determine the incidence of painful recall in ECV using propofol as the sole agent for sedation. In this multicenter study, painful recall of the ECV was found in 0.4% of the patients.As far as we know, this is the first study that evaluates the amnesic properties of propofol in ECV as a primary outcome measure in a large group of consecutive patient group.The previous studies that addressed painful recall after sedation with propofol described incidences of recall varying from 0 to 23% in a variety of short painful procedures . These sThe evidence for the use of opioids in conjunction with propofol to prevent pain is limited and controversial. The studies that added opioids to propofol in short painful procedures showed similar incidences of recall compared to studies in which procedures were performed with propofol as a sole agent –14. MineMoreover, it can be debated whether pain experienced during a procedure, without recalling it afterwards, is clinically relevant .Furthermore, studies have demonstrated that administering opioids in addition to propofol may even contribute to increased rates of respiratory depression and clinical interventions , 19–22. In our study, complete amnesia of the ECV was observed in 98.7% of the patients sedated with propofol, and 0.9% did recall a feeling of mild pain (NRS 1–3) during the procedure. Previous literature on the Numeric Rating Scale determined NRS ≥ 4 as inadequate treated pain . In thisThe secondary outcomes of this study were pain at the time of propofol injection and pain at the site of the defipads. The literature describes injection pain in 2–33% of the patients , 22. TheThe variance to the dosage of propofol can be seen as a limitation of this study. However, our aim was to determine the incidence of painful recall in propofol sedation in current clinical practice. In current clinical practice, careful titration of propofol until adequate sedation is achieved is preferred above the large boluses. Titration of propofol is known to prevent profound hypotension and oxygen desaturation , 5, 11. Conversely, the dosage of propofol in this study can also be called rather ‘high' for this study population with a mean age of 68.7. In the elderly population, 1 mg/kg propofol is generally recommended to induce general anesthesia. This relative overdose of propofol might have contributed to the low incidence of reported recall.Furthermore, speed of drug injection and time between additional boluses can be a confounding factor since this was not standardized. In this cardiologic population, slow drug distribution causes a longer time to achieve adequate sedation. Also, additional boluses of propofol were not predetermined. This might have led to high doses of propofol in some patients depending on the personal preference of the attending specialist. Nevertheless, these unpredictable factors contribute to the aim of our study, to evaluate recall in current clinical practice. Variety is part of clinical practice and despite that variety propofol proves to be providing sufficient sedation to prevent recall of the ECV.Another limitation of this study is the missing data regarding the amount of electricity delivered to achieve cardioversion. Although the Joules used in the patients with recall are known, data is missing for 20/223 patients without recall. It is possible that the height of energy might be related to a painful recall, but given the small number of patients with recall, a subset analysis of these patients with regard to this factor will have minimal impact on the study outcomes.In this prospective multicenter study, propofol as a sole agent provided good conditions for ECV with a low incidence of recall. Effective sedation and complete amnesia were achieved in 98.7% of the patients. 0.4% of patients reported severe painful recall of the procedure and 0.9% of patients experienced mild pain during the ECV.


Despite the widespread existence of guidelines regarding undernutrition monitoring and reporting, there is scarce information whether they are followed. We aimed to evaluate the adherence to guidelines regarding undernutrition monitoring and reporting as well as their determinants in a university hospital.Retrospective analysis of discharged patients with data on Nutritional Risk Screening score (NRS-2002) from the department of internal medicine of the Lausanne University Hospital for years 2013–14. Adherence to the hospital monitoring guidelines, i.e.: 1) discharged patients with NRS-2002 score≥3 should have prealbumin levels measured, and 2) discharged patients with prealbumin levels<0.20 g/l should be rechecked 7 days afterwards, was assessed. Reporting of nutritionally ‘at-risk’ status in the discharge letter was also assessed. Multivariable logistic regression was used to examine potential determinants of adherence to guidelines.Of the 2,539 discharged patients with NRS-2002 data, 1,605 (63.0%) were nutritionally ‘at-risk’. Complete adherence to the monitoring guideline was observed in 238 (14.8%) of ‘at-risk’ patients. After multivariable analysis, adherence to the first step of monitoring guideline was associated with older age (≥ 80 years) [OR (95% CI): 2.03 (1.29–3.18)], high comorbidity index [1.36 (1.05–1.77)], and nutritional management [5.57 (4.38–7.07)]. Nutritional management was also associated with adherence to the second step of monitoring [3.98 (2.33–6.78)]. Adherence to the reporting guideline was observed in 343 (21.4%) of ‘at-risk’ patients. Multivariable analysis showed that adherence to the reporting guideline was associated with NRS-2002 score>4 [1.97 (1.47–2.64)], nutritional management [3.80 (2.85–5.07)], and adherence to the monitoring guideline [3.33 (2.35–4.71)].Our results show a poor adherence to guidelines regarding undernutrition monitoring and reporting, possibly due to lack of training, staff, and time. Undernutrition is a common condition among hospitalized patients, varying between 20 and 60% depending on study population and definition applied ,2. UnderSwitzerland has one of the best health systems in the world , but thewww.chuv.ch) and the Internal medicine unit of the CHUV is the largest in Switzerland, with over 4,000 admissions per year.This is a retrospective study using medical information from of the department of internal medicine of the Lausanne University Hospital (CHUV). The CHUV is one of the Swiss university hospitals  score in 2013. Data collection, merging, and coding was performed by the Lausanne university hospital team; investigators were blinded to patients’ identifiers.For the present analyses, we used hospitalized patients’ data from January 1S1 Fig”. Thus, the final sample consisted of 1,605 hospital discharges.All hospital discharges of adult patients (>18 years old) with NRS-2002 score data were considered as eligible. Of the 8,541 hospital discharges that occurred during the study period, 2,539 (29.7%) were considered as eligible, of whom 934 (36.8%) were excluded due to an NRS-2002 score <3 “S2 Fig”. The CHUV monitoring guidelines have a two-step approach: 1) all nutritionally ‘at risk’ patients should have their prealbumin levels measured, and 2) patients with prealbumin levels <0.20 g/l should have a second prealbumin measurement performed 7 days after the first one to monitor their nutritional status. Adherence to the CHUV monitoring guideline was assessed at those two steps; for step 2) the analysis period was extended to 10 days because of possible delays due to weekends or holidays.The procedure regarding undernutrition screening and monitoring in the department of internal medicine is summarized in “th revision (ICD-10). We systematically searched for all ICD-10 codes related to undernutrition and adherence to the reporting guideline was defined by presence of at least one undernutrition related codes “S1 Table”. If both criteria were not met, adherence to the reporting guideline were considered as not implemented.The CHUV reporting guideline states that all nutritionally ‘at-risk’ patients should be reported as such in the discharge letter. This condition is then coded using the International Classification of Diseases 10S2 Table”. The cores are added and scores ≥3 indicate that the patient is nutritionally ‘at-risk’. In this study, NRS-2002 scores were further categorized into medium (NRS-2002 score: 3–4) and high (NRS-2002 score >4) risk [Nutrition risk screening was defined by the presence of NRS-2002 scores in patients’ electronic medical record. The NRS-2002 is one of the most commonly used validated nutrition screening tools ,19. BrieS3 Table”. Severity of disease was assessed using the Swiss version of the Charlson Comorbidity Index (CCI) [We extracted the following explanatory variables from the patients discharge files: gender, age , and main diagnosis “ex (CCI)  and dichex (CCI) . Height Statistical analyses were performed using Stata version 14.1 for Windows . Statistical significance was assessed for a two-sided test with p-value <0.05. Descriptive results were expressed as average ± standard deviation for continuous data and as number of participants (percentage) for categorical data. Bivariate analysis was performed using logistic regression to identify potential determinants of adherence to guidelines. In this model, adherence to the guideline (yes or no) was the outcome and each socio- demographic or clinical characteristic was the predictor. Results were expressed as odds ratio (OR) and 95% confidence interval. Multivariable analysis was then performed using logistic regression to identify the factors significantly and independently associated with adherence to guidelines. Model fit for the multivariable analysis was tested using the Hosmer-Lemeshow goodness-of-fit test for each outcome. The p-value for the tests were not significant (>0.05), suggesting adequate model fit. The linear relationship with age with adherence to guidelines was evaluated categorically using orthogonal polynomial contrasts (command contrast p. of Stata) and continuously by calculating the odds ratio of a 10-year increase.2, which are the criteria suggested by the European Society of Parenteral and Enteral Nutrition (ESPEN) for definite undernutrition status [To investigate the potential effect of in-hospital mortality on adherence to the reporting guideline, analyses were performed after excluding patients who died during hospitalization. Further, in January 2014, the Swiss society of clinical nutrition issued a recommendation regarding undernutrition coding . We thusn status .www.cer-vd.ch, decision 428–14, of Dec. 2, 2014) and the CHUV board of directors  approved this study. Only routinely collected data was used. All information was extracted and anonymized by the hospital clinical research staff before being handled for analysis.The Ethics Committee of the Canton Vaud  had their prealbumin levels measured. In bivariate analysis (Table 1), adherence to the first step of the monitoring guideline was positively associated with older age, having circulatory system disease, mental and behavioral disorder, NRS-2002 score>4, high CCI, and nutritional management. Except for circulatory system disease, the associations remained significant on multivariable analysis, which also showed a positive association with year of admission and a negative association with cancer and digestive system diseases.Of the 1,605 nutritionally ‘at-risk’ cases  “S5 Table”.Among the 530 cases with prealbumin measurement, 439 (82.8%) had levels below 0.20 g/l. No associations were found between low prealbumin levels and their socio-demographic and clinical characteristics; similarly, no association was found between low prealbumin levels and nutritional management “Table 2), adherence to the second step of monitoring guideline was positively associated with having NRS-2002 score>4, high CCI, and nutritional management. In multivariable analysis  had a hospital stay ≥10 days and were thus eligible for a second measurement of prealbumin levels. Of the 346 eligible cases, 189 (54.6%) had a second prealbumin measurement. In bivariate analysis , adherenTable 3), adherence to reporting guideline was positively associated with having infectious disease, NRS-2002 score>4, nutritional management, and adherence to the monitoring guideline. In multivariable analysis  had undernutrition-related ICD-10 codes in the discharge data “2 led to comparable results, although the associations of NRS-2002, cancer, and diseases of the respiratory system with undernutrition reporting were no longer significant “S6 Table”.Exclusion of those who died during hospitalization (n = 119) did not appreciably change the adherence to the reporting guideline (21.6%). Sensitivity analysis restricted to 193 patients with both NRS-2002 ≥3 and BMI <18.5 kg/mLess than one sixth of patients ‘at-risk’ of undernutrition was adequately monitored, and only one fifth was reported as such in the discharge letter. Our results indicate that adherence to guidelines regarding undernutrition monitoring and reporting is low in a Swiss hospital setting.nutrition programs in hospitals’ [Inadequate recognition and proper treatment of hospital undernutrition has prompted the issuing of guidelines for screening, management, monitoring, and documentation . Still, spitals’ , and thespitals’ . Pre-albspitals’ . Prealbuspitals’ .The CHUV guidelines state that all nutritionally ‘at-risk’ patients (NRS-2002 score ≥3) should have their prealbumin levels measured. Still, our results indicate that this measurement is performed in only one third of them. Possible explanations for this low adherence rate are lack of manpower, excessive workload, inadequate nutrition knowledge, and no defined responsibilities , but no Adherence rate to the second step of the guidelines  was higher than to the first one. Nevertheless, it only concerned half of the patients, leading to a full adherence rate (i.e. to the first and the second steps) of only 13%. This value is lower than in Italy (21.6%) among 24 medical and surgical departments  or Cuba,‘nutrition programs in hospital’ [Only one out of five patients nutritionally ‘at-risk’ was reported as such in the discharge data. Our results agree with one study conducted in one university medical center in Amsterdam, where nutritional status was documented in only 15.5% of referral letters by the general practitioner . Conversospital’ ,33,34.Cancer patients who were nutritionally ‘at-risk’ had a lower likelihood of being reported as such. This finding is in agreement with a previous study which reported that undernutrition is underestimated among cancer patients  or to thIn January 2014, the Swiss society of clinical nutrition issued several recommendations regarding undernutrition reporting . Still, Overall, our results highlight that adherence to the reporting guideline is inadequate.Monitoring patient’s nutritional status is imperative to check the effectiveness of the nutritional care plans and medical treatments, especially among patients who are ‘at-risk’ of undernutrition ,37. UndeThe strength of this study is its large sample size of ‘at-risk’ or undernourished patients. The main limitations are that it was restricted to a single department of one university hospital in Switzerland; as there is no consensus regarding undernutrition monitoring guidelines, generalizability is thus limited. Still, our results provide the first evaluation of adherence to guidelines on monitoring and reporting of undernutrition status, and its methodology could be replicated in other health care settings. Second, it is possible that the hospital staff unconsciously selected the most nutritionally ‘at-risk’ patients for screening, thus leading to a higher prevalence of the condition. Still, we were interested in the implementation of the monitoring and the reporting guidelines rather than the screening itself. Hence, even in the presence of a selection bias, our results indicate that adherence to the guidelines regarding nutrition monitoring and reporting is far from optimal.In a Swiss hospital setting, less than one sixth of patients ‘at-risk’ of undernutrition was adequately monitored, and only one fifth was reported as such in the discharge letter. Adherence to guidelines regarding undernutrition monitoring and reporting varies according to the patients’ characteristics and could be due to lack of training, staff, and time. Implementation measures are urgently required to improve management of undernourished patients and to estimate prevalence of undernutrition using hospital discharge data.S1 FigAbbreviations: NRS-2002, nutrition risk screening.(TIF)Click here for additional data file.S2 Figth revision; LOS, length of hospital stay.Abbreviations: NRS-2002, nutrition risk screening 2002; ICD-10, International Classification of Diseases, 10(TIF)Click here for additional data file.S3 Figth revision.Abbreviations: NRS-2002, nutrition risk screening 2002; ICD-10, International Classification of Diseases, 10(TIF)Click here for additional data file.S1 TableAbbreviation: ICD-10, International Classification of Diseases 10th revision.(DOCX)Click here for additional data file.S2 Table10.1177/0884533617692527.Adopted from Kondrup et al., 2002, doi: (DOCX)Click here for additional data file.S3 TableAbbreviation: ICD-10, International Classification of Diseases 10th revision.(DOCX)Click here for additional data file.S4 Tablea where prevalence is expressed as number of patients (row %) or as average ± standard deviation. P-value for comparisons between groups performed using chi-square for categorical variables and student’s t-test for continuous variables.Abbreviation: CCI, Charlson comorbidity index. Analyses were performed among patients with NRS-2002 score in their medical file . Results are expressed as number of participants (column %) except for (DOCX)Click here for additional data file.S5 TableAbbreviations: ref., reference category; CCI, Charlson comorbidity index; NRS-2002, nutrition risk screening 2002. Analyses were performed among patients with NRS-2002≥3 and first prealbumin measurement (n = 530). Results for bivariate analysis are presented as number of patients (column %) and for multivariate analysis as OR (95% CI). Bivariate analysis performed using chi-square or Fisher’s exact test (ⱡ); multivariable analysis performed using logistic regression adjusting for all variables in the table.(DOCX)Click here for additional data file.S6 Table2 (n = 193). Results are presented as OR (95% CI). Bivariate analysis performed using logistic regression analysis in which adherence to the guideline (yes or no) was an outcome and each characteristic was a predictor; multivariable analysis performed using logistic regression adjusting for all variables in the table. * P-values for trend are presented, for which an ordinal variable was included as a continuous term in a logistic regression model.Abbreviations: ref., reference category; CCI, Charlson comorbidity index; NRS-2002, nutrition risk screening 2002. Analyses were performed among patients with NRS-2002≥3 and body mass index<18.5 kg/m(DOCX)Click here for additional data file.S1 Filehttp://www.plosmedicine.org/, Annals of Internal Medicine at http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.* Give information separately for exposed and unexposed groups. Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at (DOC)Click here for additional data file.


To compare parasagittal interlaminar cervical epidural steroid injection (PSIL-CESI) and the classic midline interlaminar cervical epidural steroid injection (MIL-CESI) in terms of pain relief and functional improvement in patients with unilateral upper extremity radicular pain.This was a randomized clinical trial being conducted in a single pain center in Tehran. Twenty-six patients were allocated into two groups of 13, undergoing either PSIL-CESI or MIL-CESI. After confirmation of radiocontrast spread in the epidural space by fluoroscopic guidance, dexamethasone 8 mg and bupivacaine 0.125% in a volume of 5 ml were delivered to the epidural space. Evaluation of functional state and pain intensity before and 1 month after the procedure was accomplished using the neck disability index (NDI) and the numeric rating scale (NRS) respectively.Demographic and baseline characteristics of the cases showed no significant statistical difference. Improvements in the NDI and the NRS were observed in both groups; meanwhile, improvements were more pronounced in the PSIL-CESI group as compared to the MIL-CESI group (P<0.001). With the PSIL approach the ventral spread of radiocontrast was significantly higher (38%) than with the MIL approach (0.7%) (P<0.001). All patients in PSIL group showed radiocontrast spread ipsilateral to the painful side and all patients in the MIL group showed a midline distribution of radiocontrast.PSIL-CESI provides superior pain relief and improvement of functional disability in patients with unilateral upper extremity radicular pain in comparison to the classic MIL-CESI. IRCT20180524039816N1  Cervical epidural steroid injection (CESI) has been used in treatment of radicular upper extremity pain -3. SeverThe TF approach may be associated with devastating complications and it is strongly recommended that this procedure be performed under continuous fluoroscopic imaging and with the help of digital subtraction angiography. It is also recommended that in the cervical region only non-particulate steroid be used , 10. HazStudy population   This study was a double-blind, parallel-group, randomized controlled clinical trial. The institutional ethics committee approved the trial (IR.SBMU.RETECH.1397.163). The study protocol also was registered by the Iranian registry for clinical trials . All patients were thoroughly informed regarding the study procedure and written informed consent was acquired from all participating patients. The following inclusion criteria were met: unilateral radicular pain in an upper extremity, age between 18 and 65 years, pain duration of at least 3 months, failure to respond to at least 6 weeks of conservative management , MRI findings consistent with a herniated disc correlating with patient’s signs and symptoms, minimum pain intensity score of 4 on the NRS. Patients with any of the following were excluded from the study: refusal to provide an informed consent, clinical or imaging evidence of cervical cord compression, psychological disorders, unstable medical conditions, prior cervical spine surgery, presence of contraindications for epidural access , CESI within the past 6 months, and pregnancy.Randomization and blinding Twenty-six patients with unilateral radicular upper extremity pain were selected. Using a random allocation software, patients were randomly allocated into one of the two groups; MIL-CESI (n=13) and PSIL-CESI (n=13). Random numbers were kept in sealed envelopes. Both the patients and the physicians in charge of recording the data were blind to the groups to which the patients were allocated. The envelopes were opened by the physician performing the procedure at the time of procedure. Inevitably the proceduralists were aware of the routes they would choose to access the epidural space according to the number they drew out of the envelops. Proceduralists had no role in data collection, recording and analysis.CESI Procedures Procedures were performed in two academic medical centers. Proceduralists were either faculties certified in pain management subspecialty or senior in-training fellows of pain management subspecialty. Upon arriving to the pain OR, intravenous access was established for each patient. Patients assumed prone position on a fluoroscopy table. Monitoring included noninvasive blood pressure measurement, pulse oximetry and electrocardiography. The posterior cervical region was prepared with povidone-iodine 10% and draped in a sterile manner. Using fluoroscopic imaging needle entry points either at the C7-T1, C6-C7 or C5-C6 levels were selected. C5-C6 interspace was avoided and only chosen if visualization of other more inferior interspaces was unsatisfactory. Lidocaine 1%, 3-4 mL was used for local anesthesia. Using a saline loss-of-resistance technique a 17-gauge 3.5 inch Tuohy needle was advanced to the epidural space. Anteroposterior fluoroscopic images were used to guide the needle in a midline or parasagittal trajectory in a coaxial manner. A parasagittal trajectory was defined as a needle course passing between the lateral edge of the cervical spinous process and the medial border of the lamina in an anteroposterior (AP) fluoroscopic view  and 2. AData Collection The primary measured outcomes were changes in neck disability as measured by the NDI, and changes in pain intensity as measured by the NRS. Physicians who recorded the data had no role in performing the procedures. Data were gathered before the procedure (baseline) and one month after the procedure. The secondary measured outcome was the pattern of radiocontrast spread which was judged by the two physicians one of which, was the performing physician.Statistical analysiset al., [  Referring to the study conducted by Hashemi et al.,  the follP-value less than 0.05 was considered to be statistically significant. The calculated sample size was 11 for each group. Considering attrition, we reached a sample size of 13 patients per group. Data analysis was performed using SPSS 20.0 software . Chi-Square and Independent-Sample-T tests were used, and measurement outcomes were compared through the Repeated-Measurement ANOVA.  All the patients finished the study and the flow diagram is summarized in p=0.082)  .Functional Improvement Improvement in the NDI was seen in both groups one month after the procedures. Meanwhile, this improvement was significantly more pronounced in the PSIL-CESI group as compared to the MIL-CESI group .Effective Pain Relief No significant difference in pain intensity was observed between the two groups before the interventions. Both groups experiences significant alleviation of pain. Reduction of pain intensity was more pronounced in patients in the PSIL-CESI group in comparison to patients in the MIL-CESI group .Patterns of radio-contrast Spread In all 13 patients of the MIL-CESI group, the pattern of radiocontrast spread was predominantly midline. Among patients in the PSIL-CESI group, in 7 cases (53.8%) radiocontrast spread was predominantly ipsilateral right-sided and in 6 cases (46.1%) predominantly ipsilateral left-sided. With the PSIL-CESI approach in 38% (5/13) of instances a ventral spread of radiocontrast was observed as opposed to 0.7% (1/13) with the MIL-CESI approach .Cervical epidural steroid injections are among the most prevalent interventions used in the management of cervical radicular pain due to disc herniation. This procedure is especially valuable in those who are poor candidates for surgery -5. We coet al., [ Targeted approach to the delivery of medications into the epidural space has been investigated in the lumbar region. The rationale behind taking a TF approach to access the epidural space has been the hypothesis that ventral spread of the injectate addresses the pathology site more thoroughly , 14-16. et al.,  observedet al., [et al., [ Recently two groups of investigators have introduced alternative techniques; E. Choi et al.,  introduc[et al.,  comparedet al., [et al., [Although we observed clinically significant improvements in the scores of the NDI and the NRS in both groups, those improvements were significantly more pronounced in the PSIL-CESI group. Radiocontrast distribution (2 mL) to the ventral epidural space was seen in 38% 5/13) of patients in the PSIL-CESI group and only in 0.7% (1/13) in the MIL-CESI group. Reports of radiocontrast spread to the ventral epidural space in the cervical region are highly variable; Jatindar Gill et al.,  performe3 of patiDue to the incidence of devastating complications attributed to the TF approach, this route of access to the cervical epidural space cannot be advocated. Considering the fact that the depth of the cervical epidural space at C7 is as little as 1.5-2 mm, the previously mentioned modified paramedian interlaminar approach seems technically demanding and potentially unsafe . We propThe authors declared that there was no conflict of interest in this study.