Chronic pain treatment guidelines are unclear and conflicting, which contributes to inconsistent pain care. In order to improve pain care, it is important to understand the various factors that providers rely on to make treatment decisions. The purpose of this study was to examine factors that reportedly influence providers’ chronic pain treatment decisions. A secondary aim was to examine differences across participant training level.Eighty-five participants  made treatment decisions for 16 computer-simulated patients with chronic pain. Participants then selected from provided lists the information they used and the information they would have used (had it been available) to make their chronic pain treatment decisions for the patient vignettes.p < 0.05). A greater proportion of medical students wanted information on patients’ use of illicit drugs and alcohol to make treatment decisions; while a greater proportion of physicians reported using personal experience to inform their decisions.Frequency analyses indicated that most participants reported using patients’ pain histories (97.6 %) and pain description (95.3 %) when making treatment decisions, and they would have used information about patients’ previous treatments (97.6 %) and average and current pain ratings (96.5 %) had this information been available. Compared to physicians, medical students endorsed more frequently that they would have used patients’ employment and/or disability status (This study found providers use patients’ information and their own experiences and intuition to make chronic pain treatment decisions. Also, participants of different training levels report using different patient and personal factors to guide their treatment decisions.These results highlight the complexity of chronic pain care and suggest a need for more chronic pain education aimed at medical students and practicing providers. Chronic pain is a significant public health concern globally and in the United States, where it affects over 100 million Americans . ChronicInadequate chronic pain management may be related to the inherent challenges of treating chronic pain . OptimalGiven this ambiguous and challenging context, it is important to understand how providers make chronic pain treatment decisions. Medical decision-making is a complex process that involves synthesizing multiple sources of information . ChronicIn addition to better understanding pain decision-making, as a whole, it is unclear whether groups of providers use similar or different factors to guide their decisions. Training level may influence providers’ treatment decisions. For example, practicing physicians often rely on clinical experience to guide decisions, which is a source of information not yet available to medical trainees who are nevertheless involved in patient care .In this planned secondary data analysis of a recently completed study, we sought to explore the factors that providers reportedly use to guide their chronic pain treatment decisions, as well as the factors they would have used, had that information been available, to inform their decisions. We did not have any directional a priori hypotheses for this portion of the study. We also examined differences between medical students and physicians in their endorsement of factors that influence their decisions. For these analyses, we hypothesized that, compared to medical students, physicians would be more likely to endorse using their personal experience to inform their chronic pain treatment decisions.We sought to recruit approximately 100 practicing providers  and medical trainees  for the purposes of the primary study, of which the current paper is a secondary data analysis. We determined this sample size based on our previous work using a similar design –27. PartDetailed description of the virtual human patients and online study methods can be found in a previous paper (see ). ParticThe patients’ sex, race, and mental health status were systematically balanced across the 16 vignettes. The vignettes included information on the patients’ sex  and race  by showing a representative facial image that displayed a standardized and empirically-validated facial expression of pain . The texFor each patient, participants indicated their likelihood of using pharmacological  and non-pharmacological  treatment options; these ratings were made on separate 0  to 100 (extremely likely) visual analogue scales. After making chronic pain treatment decisions for all 16 vignettes, participants selected from a provided list the factors they used to make their treatment decisions and the factors they would have used to guide their treatment decisions had the information been provided see  below. TParticipants provided information about their sex, age, and race/ethnicity. They also indicated their training level . Medical students indicated their training year, and physicians indicated their years of professional experience and specialty area.Participants indicated which of the following factors informed their chronic pain treatment decisions for the 16 patient vignettes: (1) Pain history , (2) Patients’ description of the pain , (3) Patients’ facial expressions, (4) Patients’ demographic characteristics , 5) Patients’ vital sign values, (6) Patients’ mental health symptoms, (7) Your own personal experience in managing pain and/or interacting with patients with pain, and (8) Your intuition. These factors were included in the questionnaire based on prior research , 27, 29, PatientsParticipants indicated the factors they would have used to inform their chronic pain treatment decisions, had the information been provided. The following factors were listed: (1) Patients’ previous experience with the treatment options, (2) Patients’ rating of their average pain over the past week, (3) Patients’ rating of their current pain, (4) Patients’ social support, (5) Patients’ use of alcohol, (6) Patients’ use of illicit drugs, (7) Patients’ vocal expressions , (8) Patients’ description of pain complaint in his/her own words, (9) Patients’ history of treatment adherence, and (10) Patients’ employment and/or disability status. These items were selected as reflecting the different types of information providers may request from patients during a clinical encounter. Participants could select as many factors as applicable.Frequency analyses were conducted to characterize participants’ responses to the “Information used” and “Information would have used” questionnaires. Participants were coded as a medical student or physician based on the information they provided on the demographics questionnaire. Fisher’s exact tests were used to examine training level differences (student vs. physician) in participants’ responses to the questionnaires.For these analyses, we included the 85 participants who reported being a medical student or physician. Of these participants, 56 % were male and 44 % were female. The majority of participants were non-Hispanic (97 %). Approximately 66 % were White, 24 % were Asian, 4 % were Black, 1 % was Native American, and 5 % did not report their race/ethnicity.n = 1), second year (n = 17), third year (n = 12), and fourth year (n = 4); 2 participants did not report their training year. The average age of the physicians was 29 years (SD = 5.1 years). Physicians reported an average of 3 years (SD = 9.7 years) of professional experience and reported working in the following specialty areas: family/internal/primary care medicine (n = 23), combined internal medicine and pediatrics (n = 9), surgery (n = 3), pediatrics (n = 2), urology (n = 2), and infectious disease (n = 1); 10 participants did not report their specialty area. The sex, ethnic, and racial composition did not significantly differ between medical students and physicians .The sample included 35 medical students and 50 physicians. The average age of the medical students was 25 years (SD = 2.7 years). Medical students reported being in the following stage of medical education: first year (The majority of participants reported using the patients’ pain history (97.6 %) and patients’ pain description (95.3 %) to inform their chronic pain treatment decisions Table . ApproxiParticipants frequently endorsed wanting information on the patients’ use of illicit drugs (95.3 %) and alcohol  were examined in participants’ responses to the “Information used” and “Information would have used” questionnaires . While the differences were non-significant, there was a notably larger proportion of medical students (71 %) than physicians (56 %) who endorsed using patients’ demographics to inform their decisions, whereas a larger proportion of physicians (94 %) than medical students (83 %) reported using personal experience in their decision-making.p = .012; students = 97 %, physicians = 76 %). There was also a non-significant yet greater proportion of medical students who indicated they would have used patients’ illicit drug  and alcohol  use history had that information been available.Compared to physicians, significantly more medical students indicated that they would have used information on patients’ employment and/or disability status  before considering more aggressive treatments  . While pGiven providers’ concerns about opioid abuse and dependence, it is not surprising that the majority of participants reported wanting more information about patients’ illicit drug and alcohol use history. Bhamb, et al. , found pIndependent of concerns about opioid misuse, a large body of literature indicates that social support is an important factor in the functional status of patients with chronic pain . More geMedical students and physicians reported using similar factors to make their chronic pain treatment decisions, but there were a few noteworthy differences. Compared to physicians, medical students wanted significantly more information on patients’ employment and/or disability status. A greater proportion of medical students also wanted information on patients’ illicit drug and alcohol use. These results may reflect medical students’ desire for as much information as possible when making treatment decisions. Novice decision-makers tend to want more information and to use a deliberate decision-making approach, whereas experts are more likely to “size up” a situation quickly and to use their previous experiences to guide decision-making . Indeed,A notable strength of this investigation is our use of standardized patient images and clinical text vignettes to maximize experimental control and enhance realism. However, several limitations should be discussed. Participants self-reported the factors that influenced their chronic pain treatment decisions. Accurate self-report of these factors requires decision-making awareness, which likely varied across individual participants , 29, 59.This was one of the first investigations to examine the factors that medical students and physicians report using to make chronic pain treatment decisions. We found that providers prioritize patient information as well as personal experience and intuition when making chronic pain treatment decisions. Medical students were particularly interested in acquiring additional information on patients’ employment/disability status and to a certain extent substance use history, whereas a greater proportion of physicians reported using personal experiences to inform their decisions. This study highlights the complexity of chronic pain management and suggests a need for medical and continuing education efforts to more strongly focus on systematic, evidence-based clinical decision-making in this context.


Background. Enucleation is a psychologically and physically traumatic event associated with chronic pain. It would be desirable to better predict which patients will have pain after surgery. Methods. A cross-sectional postal questionnaire study of adults undergoing enucleation captured the demographic details, Pain Quality Assessment Scale (PQAS), Pain Catastrophizing Scale (PCS), and the Facial Pain Assessment questionnaire. Patients were classified as suffering from chronic pain if they reported a pain score of >1 out of 10 on the numerical pain score (NRS). Results. Seventeen of 60 adults participated in the study. 47% of patients reported chronic pain ; 25% experienced pain daily. No difference in age, surgical side, reason for surgery, or the duration of time since the surgery was noted. All patients had low PQAS scores and 50% of individuals with persistent pain were concerned about their facial appearance. There was no significant difference in the level of catastrophization noted in patients with or without pain or between the subgroups . Conclusions. Although persistent pain following enucleation affected a significant number of patients, the pain intensity was mild. Enucleation influenced the physical perception some individuals had of themselves. Enucleation is often the final step in a complicated series of eye disease treatments. It is indicated in the treatment of severe ocular trauma, ocular pain, and in the treatment of intraocular neoplasms. Ocular surgery has being shown to have a significant impact on the quality of life and function of affected individuals . It is uWe sought to evaluate the prevalence and character of persistent pain  following enucleation and examine the association between persistent pain and biopsychosocial profile of these adults. Greater insight into the relationship between degree of pain and the psychological impact of the diagnosis may assist in determining the preferred management and help refine postoperative routines for future patients with enucleation.A cross-sectional questionnaire study of all adults who had enucleation from 2005 to 2011 at our institution was performed. Individuals were identified using the hospital database code (ICD-10-AM) and Hospital In-Patient Enquiry Scheme. Medical records were then consulted to clarify the ophthalmic diagnosis and operative technique employed. A designated investigator (DC) then contacted the individuals by phone to invite them to participate in the study. Inclusion criteria were as follows: (i) greater than 18 years of age at the time of enucleation; (ii) English speaking; (iii) recovery of at least 12 months after surgery; (iv) no history of additional facial surgery or trigeminal neuralgia since the enucleation; and (v) consent to participate in the study. Ethical approval for this study was obtained from the Cork University Hospital Group Ethics Committee (reference number 232412).A questionnaire pack designed for ease of completion was prepared and tested in advance of its distribution to study participants. It was anticipated that completion would take 15 minutes. A cover letter to clearly explain the nature of the study and instructions for each individual was provided. Individuals were asked whether they would prefer large font questionnaires. A self-addressed envelope was included for return of the questionnaire. Three weeks after mailing the questionnaires, a follow-up telephone call was made to those individuals who had failed to return the pack. An additional questionnaire was reposted if the original was mislaid or if telephone contact was not achieved after repeated attempts. Each patient received a maximum of one telephone reminder and one postal reminder. Any incomplete or ambiguous information in the returned questionnaires was clarified by telephone, when possible.Demographic details were obtained from the hospital notes and updated to capture marital status, psychological profile, and employment records at the time of the study.Patients were asked to rate the average pain intensity in their orbit/face over the past week on a 0–10 numerical rating scale (where 0 = “no pain” and 10 = “the most intense pain sensation imaginable”). This indicated the presence or absence of persistent pain following enucleation. Patients were divided into two groups, those without pain (pain score = 0) and those with pain (pain score > 1).Clinical outcome was assessed using the Pain Quality Assessment Scale (PQAS) . Each PQInformation concerning facial appearance, distress related to perceived appearance, impaired occupational and/or social functioning, and frequency and character of facial pain was captured using a Facial Pain Assessment questionnaire presently being developed at Cork University Hospital. The assessment incorporated a facial drawing to capture the pattern of pain. A ptosis chart is a novel method that was used to measure a patient's perception of their facial image. The patient selected from 5 pairs of eye drawings with varying degrees of ptosis the drawing that most closely matched their appearance.The Pain Catastrophizing Scale (PCS) consists of 13 items rated on a 5-point scale ranging from 0  to 4 . Participants were instructed to indicate the degree to which they had specific thoughts and feelings when experiencing pain. The measure assesses three dimensions of catastrophizing: rumination, magnification, and helplessness. The PCS has been validated for both clinical and nonclinical samples . A totalt-test, Pearson's Chi-square testing, and other appropriate analyses were performed. P < 0.05 was considered statistically significant.All data recorded in the questionnaires was transferred to a secure Excel database. Statistical analyses were carried out using SPSS 16.0 software for windows. Data was expressed as the mean ± standard deviation (SD). Descriptive analysis, Student's Hospital records identified 60 adults with enucleation between 2005 and 2011. All were subsequently contacted. 12 patients declined to participate, 14 could not be reached, and 6 had died in the interim. Twenty-eight patients agreed by phone to participate in the study, but 11 of them failed to reply. In all patients, seventeen patients (28.4% of the patients undergoing enucleation) completed the questionnaire pack. Eight of the 17 responders (47.1%) reported the presence of persistent facial or orbital pain since their surgery. Their mean pain intensity score was low, 1.4 ± 0.7 (where 0 is no pain and 10 is the worst pain). Twenty-five percent (2/8) of these individuals experienced pain on a daily basis. Patients with and without chronic pain did not differ in age, surgical side, reason for surgery, or the duration of time since the surgery . PersistP = 0.5).Individuals with persistent pain consistently reported abnormal sensations in all domains with the exception of “cold” and “sensitivity” . The freχ2(1) = 0.9, P = 0.34 (odds ratio = 0.6)). 50% of individuals with persistent pain were concerned about their facial appearance and reported being “distressed” about it  of the patients who responded reported mild to moderate pain persistent up to 4.3 years after their enucleation surgery. The character of the pain was both neuropathic and nonneuropathic in nature. Most patients did not require oral analgesics to manage the pain. No demographic, psychological, or anatomical associations were useful in predicting those at risk of developing persistent pain.The development of persistent postsurgical pain (PPSP) in other surgical cohorts is well documented and ranges from 10 to 50% [Phantom pain is thought to be related to changes in the cortical representation of body parts adjacent to the amputated area  and is aDifferentiation of the character of the pain as neuropathic or nonneuropathic pain   is imporIt is noteworthy that the pain catastrophizing scores of affected patients in our study were low. In general, individuals with chronic pain have a tendency to focus on and exaggerate the threat of painful stimuli and therefore tend to negatively evaluate their ability to manage their pain, subsequently leading to higher catastrophizing scores. In addition, catastrophizing is preferentially associated with emotional responses to pain in younger adults (<65 years) and with a higher pain intensity rating in older adults (>65 years) . Our resThe loss of body parts can have distinct, but overlapping, psychological consequences. These include bodily changes—alterations in the way patients, their families, and others perceive their bodies—or changes of function—alterations in the activities and roles that they are able to carry out . The FacP = 0.34 , the reThis study was designed as a self-reporting postal questionnaire; therefore, we cannot remark on the potential cause of pain in each patient. Pain intensity greater than mild levels  is usually investigated. The low pain levels observed in our patients did not trigger further investigations.A significant limitation of our study was the small sample size. Several attempts were made to obtain a response. Assael and Keon asserted that while sampling error makes a minimal contribution to total survey error, nonsampling error, the error that includes a nonresponse component, is a major contributor .Nonresponse can be “technical” in nature, for example, a wrong address, lack of interest in the study, or a negative attitude to the health care system , 8. MayePatients with health problems may be more likely to respond to symptom-orientated questionnaires than those without problems . This fiAlthough persistent pain following enucleation affected a significant number of patients, the pain intensity was mild. Enucleation influenced the physical perception some individuals had of themselves. The impact on quality of life requires further exploration. Larger numbers of patients are needed to evaluate these preliminary findings.


Objective. The aim of this study was to examine the efficacy and safety of pulsed radiofrequency (PRF) in the treatment of chronic migraine (CM) on cervical 2-3 posterior medial branches. Methods. This randomized, double-blind, and controlled clinical trial included 40 subjects with CM, who were randomly divided into two groups: treatment (treated by PRF) and sham (treated by sham treatment). Pain intensity, headache duration (days), the Migraine Disability Assessment Questionnaire (MIDAS), and aspirin dose taken by patients were evaluated at 1, 2, and 6 months after the intervention. Side effects were observed from the time of treatment and throughout the follow-up period. Results. During the follow-up, pain intensity, headache duration (days), disability score, and the analgesic dose were significantly improved in the treatment group compared to the sham group (P < 0.001) and the baseline (P < 0.001) at all measured time points after intervention. No serious complications were reported. Conclusion. PRF on the cervical 2-3 posterior medial branches could provide satisfactory efficacy in the treatment of CM without obvious adverse effects. CM is diagnosed in patients who suffer from headache at least 15 days per month or who have at least 8 days per month in which the headaches are associated with symptoms that meet the diagnostic criteria for migraine. Migraine affects approximately 2% of patients worldwide . AlthougRecently, occipital nerve stimulation (ONS) has become a novel invasive treatment for primary headaches, including cervicogenic headache, occipital neuralgia, cluster, and migraine , 9. ONS PRF is a non neurodestructive therapy that has been widely used in treating numerous chronic pain conditions such as postherpetic neuralgia and chronic postoperative pain –18. PRF The protocol of this clinical trial was approved by the Human Ethics Committee of Xinhua Hospital. Patients at the Pain Center of Xinhua Hospital from Feb. 2012 to Feb. 2014 were considered for inclusion in this study. All patients had clear understanding of the trial and signed consent forms.Patients were considered eligible for the study if they met the following inclusion criteria: (1) the patient was older than 18 years of age, (2) the patient had suffered for more than 6 months from CM, (3) CM was diagnosed strictly according to the Third Edition of the International Classification of Headache Disorders (ICHD-III) , and (4)Among the 45 patients who met the criteria, 5 patients refused to sign the consent forms. 40 patients were divided into two equal groups by a random number table: a treatment group (treated by PRF) and a sham group (treated with sham treatment). Detailed information on study enrollment and design are shown in the flowchart and timeline . DoctorsAll procedures were performed within a sterile environment with the patient in a prone position. In the first phase, the C-arm machine was placed in the anteroposterior position. The C2 and C3 levels were confirmed by puncture needles through the C-arm. The first entry point was the intersection of the edge of the C2 vertebral bodies and the midline between the C2 and C3 levels. Lidocaine was injected hypodermically to provide local anesthesia. The C-arm machine was changed to the lateral position. A 21-gauge cannula with a 5 mm exposed tip was punctured vertically at C2, as had been marked by the C-arm previously.The cannula was inserted slowly until the tip reached the front bottom of the C2 inferior articular process, to align with the third ON under the monitoring of the C-arm . The canThe generator was turned to the PRF mode . During PRF, the healthcare provider ensured that the cannula did not move. The second entry point was the intersection of the edge of the C3 vertebral body and C3 level. After local anesthesia, the cannula was inserted slowly until the tip reached level of the zygapophyses, to align with the medial branch of C3. The cannula was connected with the generator and the steps were repeated as for the C2 PRF.In the sham group, the same procedures were applied except that no energy was used. All treatments in both groups were performed unilaterally. The generator was operated by an investigator who was not involved in the follow-up. Patients left the hospital after 1 day of observation. A second PRF or sham treatment was given after an interval of 2 weeks.Follow-up procedures were carried out in 1, 2, and 6 months after the intervention. Pain intensity, headache duration (days), analgesic dose, Migraine Disability Assessment Questionnaire (MIDAS) score, and adverse effects were the main outcome measures that were recorded during the follow-up.Pain intensity was defined as the average pain intensity during the migraine attack, as recorded on the visual analogue scale (VAS). Pain relief of more than 30% at the 6-month follow-up was defined as “effective.” The headache duration was defined as the number of days that patients suffered from migraine per month. MIDAS was assessed twice: before and 6 months after PRF or sham treatments. Aspirin was used as the routine analgesic, at a dose of 300 mg as needed. The total dose of aspirin used in a month was recorded.Adverse effects of patients were recorded immediately after the intervention and continued until study completion. In addition to the routine follow-up, patients were able to report the related symptoms to our investigators at the pain clinic. Adverse effects included infection, numbness, increased pain, and paresthesia.t-test. The difference at different time points in the same group was calculated by repeated-measures ANOVA. Differences of enumeration data were evaluated by χ2 test.Sample size was calculated by G-power 3.17. Statistical analysis was performed by SPSS19.0. Continuous data were presented as mean ± standard deviation or as the median (interquartile range) if the data were in a skewed distribution. The difference between two groups was calculated by A sample size calculation was performed to calculate the sample size needed to detect a statistically significant difference at the 0.05 level with a power of 80%. According to a pilot study, pain of patients in the treatment group was reduced by 30 to 40%, compared to 15% in the sham group. Therefore, the calculated minimum total sample size was 36.In this study, 40 patients were enrolled and 37 patients completed the follow-up. The demographic characteristics of the patients were similar in both groups. There were no significant differences in sex, age, migraine history, or baseline migraine conditions between the groups .F = 111.7, P < 0.001). The VAS differed significantly between the treatment and the sham groups at the 1-month , 2-month , and 6-month  follow-up periods. When “effective” was defined as a 30% reduction in pain at the 6-month follow-up, there was a significant difference in the numbers of patients with effective outcomes between the treatment and the sham group (P < 0.05). No patient in either group achieved a 50% reduction in pain intensity . There was a significant difference in the decrease of headache duration between the treatment and the sham groups at the 1-month , 2-month , and 6-month  follow-up time points , 2-month , and 6-month  follow-up periods  and between the two groups (t = 4.72, P < 0.001, The patients in the treatment group took a significantly lower aspirin dose compared to the patients in the sham group throughout the follow-up period. The aspirin dose differed significantly between these two groups at the 1-month ( periods . The meaNo patient experienced abnormal bleeding, infection, numbness, postoperative paresthesia, increased pain, or any other complication during the perioperative period. One patient in the treatment group reported mild pain at the injection site after the second round of PRF treatments and the pain subsided within 6 hours without any treatment. No complication was recorded at the follow-up.In this clinical trial, we have shown that using PRF on the cervical 2-3 posterior medial branches could result in satisfactory efficacy of CM. We chose the cervical 2-3 posterior medial branches as the target in this treatment because of their anatomy. The dorsal ramus of the C2 spinal nerve ultimately becomes the greater ON, which supplies the splenius capitis and semispinalis capitis. The deep branch of the dorsal ramus of the C3 spinal nerve, also known as the third ON, supplies the C2-C3 zygapophyseal joint and the skin over the suboccipital region . The ONsThe mechanism of ON-related treatments is mainly based on the trigeminal vascular system . Pain-seDuring migraine, the stimulation of pain-sensitive structures activates neurons of the trigeminal ganglion, which projects to the central nervous system and induces peripheral and central sensitization in migraine . SensitiBefore the PRF treatments, an ONB was applied to help predict the potential curative effect of the target nerves. Similar tests have been performed in former PRF studies , 28. In PRF is a minimally invasive neuromodulation approach that has been used to treat chronic pain of various origins , 17. A cNo obvious side effects were observed in this trial. PRF is an invasive procedure that provides reversible neuromodulation without tissue damage. The puncture was performed under C-arm monitoring to minimize the risks of injury to the carotid artery or spine. PRF on the cervical 2-3 posterior medial branches has not been reported previously. However, PRF on the greater ON has been used in the treatment of cervicogenic headache and no serious complications were reported . This fiThere were some limitations in this clinical trial. The trial was designed as a single-center study and had a small sample size. The follow-up period was only 6 months. Therefore, the long-term efficacy of this therapy could not be determined. Moreover, it remained unknown whether the efficacy of PRF on the cervical 2-3 posterior medial branches is superior to ONS. These limitations could be addressed with future studies.PRF on the cervical 2-3 posterior medial branches could provide a satisfactory treatment that can reduce pain intensity, headache duration, and disability scores. The procedure was relatively easy to perform and resulted in few side effects.


Chronic pelvic pain (CPP) is defined as pain in the pelvic organs and related structures of at least 6 months’ duration. The pathophysiology of CPP is uncertain, and its treatment presents challenges. Botulinum toxin A (BoNT-A), known for its antinociceptive, anti-inflammatory, and muscle relaxant activity, has been used recently to treat refractory CPP with promising results. In patients with interstitial cystitis/bladder pain syndrome, most studies suggest intravesical BoNT-A injection reduces bladder pain and increases bladder capacity. Repeated BoNT-A injection is also effective and reduces inflammation in the bladder. Intraprostatic BoNT-A injection could significantly improve prostate pain and urinary frequency in the patients with chronic prostatitis/chronic pelvic pain syndrome. Animal studies also suggest BoNT-A injection in the prostate decreases inflammation in the prostate. Patients with CPP due to pelvic muscle pain and spasm also benefit from localized BoNT-A injections. BoNT-A injection in the pelvic floor muscle improves dyspareunia and decreases pelvic floor pressure. Preliminary studies show intravesical BoNT-A injection is useful in inflammatory bladder diseases such as chemical cystitis, radiation cystitis, and ketamine related cystitis. Dysuria is the most common adverse effect after BoNT-A injection. Very few patients develop acute urinary retention after treatment. Chronic pelvic pain (CPP) is defined as chronic or persistent pain perceived in the structures related to all organs in the pelvis for at least 6 months’ duration, including prostate, scrotum, urethra, bladder, vagina, rectum, and anus .The diagnosis of CPP is based on a patient’s history and physical examination. Then, patients are classified according to organ-specific symptoms. The European Urology Association guidelines classify patients with CPP according to the region where pain occurs (with or without a particular disease), pain system , and end-organ. Pain syndrome as identified from the history or examination . Many well-known diseases involve different pelvic organs. Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), interstitial cystitis/bladder pain syndrome (IC/BPS), chemical cystitis, and pelvic floor muscle pain are categorized into CPP .The pathogenesis of CPP is unclear. The CPP mechanisms involve ongoing acute pain mechanisms (such as those associated with inflammation or infection) and chronic pain mechanisms  . The EAUClostridium botulinum, is one of the most powerful neurotoxins and inhibits the release of the neurotransmitter acetylcholine from nerve fibers, thereby inhibiting muscle contractions [Botulinum toxin (BoNT), which is produced by the bacterium ractions . Scott fractions . Since tractions ,5,6. Recractions ,8. In adractions . For patet al. reported his study of percutaneous or cystoscopic injection of the urethral sphincter in patients with spinal cord injury (SCI) and detrusor-sphincter dyssynergia in 1988 [et al. injected 200 U to 300 U of onabotulinumtoxinA  into the detrusor muscle during cystoscopy to treat detrusor hyperreflexia in SCI patients [The history of BoNT could be trace back to 18th century and it was first purified in 1928 ,11. Rese in 1988 . The urepatients . These ppatients ,15.et al. first treated female patients with IC/BPS, who received 100 U to 200 U of onabotulinumtoxinA with cystoscopic hydrodistention at the same time [United States Food and Drug Administration approved the use of intravesical injection of onabotulinumtoxinA for neurogenic urinary incontinence and non-neurogenic overactive bladder in 2011 and 2013, respectively ,17. Intrame time . For sucame time ,23,24.The possible mechanism of BoNT-A act on CPP is illustrated on BoNT-A relieves pelvic pain via three primary mechanisms acting on the muscles, central nervous system (CNS), and inflammation.Tenderness of pelvic muscles was highly prevalent among women with CPP, and spasm of the pelvic floor muscles is conventionally believed to be associated with CPP ,34. Perhet al. reported significant levels of BoNT-A-cleaved synaptosomal-associated protein appeared in retina after BoNT-A injection in rat eye [Central sensitization is a process of the CNS in which the responsiveness of the central neurons to input from peripheral receptors is increased . Recent  rat eye . When Bo rat eye .Neurogenic chronic inflammation of the pelvic organs is also a possible mechanism of CPP. Current evidence suggested persisted chronic inflammation contributes to IC/BPS, CP/CPPS, and pelvic floor muscle pain ,50,51. IThe mechanisms of BoNT-A acted on neurogenic detrusor overactivity and CPP have some similarity and some difference. BoNT-A injection normalized the neurotransmitters release such as acetylcholine, ATP, substance P and CGRP. Patients with neurogenic detrusor overactivity could decrease abnormal detrusor contraction by BoNT-A direct action of the blocking acetylcholine and ATP. In contrast, the CPP patients might have benefit from more complicated mechanisms which involving more neurotransmitters as mentioned above.p < 0.05). Urinary frequency, nocturia, and bladder pain  also showed significant improvements. The onset of symptom relief was 5–7 days after treatment, and it persisted for an average of 3.7 months. In 2006, Giannantoni reported on 20 IC/BPS patients who received 200 U of onabotulinumtoxinA injected into the trigone and bladder floor [p < 0.05).IC/BPS is a distressing syndrome of chronic bladder pain and is diagnosed on the basis of chronic (>6 months) pelvic pain, pressure or discomfort perceived to be related to the bladder, and at least one other urinary symptom such as persistent urge to void or urinary frequency . The pater floor . Of themp < 0.01). In a recent prospective, randomized, double-blind, placebo-controlled study of 60 refractory IC/BPS patients, intravesical supratrigone injection of 100 U of onabotulinumtoxinA at 20 sites was compared with normal saline injection at 20 sites with cystoscopic hydrodistention. Both groups showed improvements in ICPI and ICSI, but only the onabotulinumtoxinA group had a decrease of pain on the VAS pain scale and an increase in FBC. The improvement in the VAS pain scale was significantly better in the onabotulinumtoxinA group than in the normal saline group [In a prospective, randomized, and controlled study, suburothelial injection with 100 U or 200 U of onabotulinumtoxinA and cystoscopic hydrodistention was compared with cystoscopic hydrodistention alone in patients with refractory IC/BPS . In the ne group .The long-term therapeutic effects of onabotulinumtoxinA are not achieved after a single injection. In a study of 15 IC/BPS patients receiving an injection with onabotulinumtoxinA 200 U, 13 patients (86.6%) reported symptom improvement at the 1 and 3-month follow-up evaluations . HoweverThe therapeutic effect of onabotulinumtoxinA injection on the ulcerative type of IC/BPS is controversial. OnabotulinumtoxinA injection in 15 patients with ulcerative IC/BPS showed no significant change in any clinical or urodynamic variable after four sets of injections . HoweverAlthough early studies also used 200 U of onabotulinumtoxinA in IC/BPS patients, most recent studies only used 100 U and had good therapeutic effects. Clinical studies of onabotulinumtoxinA for IC/BPS are summarized in Laboratory evidence shows the peripheral desensitization and anti- inflammatory effects of onabotulinumtoxin Ainjections in IC/BPS patients. In 19 IC/BPS patients who received intravesical onabotulinumtoxinA injections compared with 12 healthy controls , the basIn summary, many different clinical and laboratory studies show the effectiveness of onabotulinumtoxinA injections for the treatment of IC/BPS. However, the therapeutic duration and long-term follow-up results need to be investigated in larger, prospective studies. The long-term follow-up investigation of immunochemical staining of bladder specimens is also necessary.Chronic pain in the region of the prostate is linked to the term “prostatitis” in male patients. However, only 10% of such cases have a proven bacterial infection . The UniOnabotulinumtoxinA has been reported to use in treating prostatitis since 1998, in that report, four male patients had improved voiding dysfunction after onabotulinumtoxinA injection . In an aRecently, a prospective, double-blind and randomized placebo- controlled study enrolled 60 male patients with refractory CP/CPPS to receive transurethral intraprostatic injection of 100 U of onabotulinumtoxinA or normal saline . The ChrThe pelvic floor is made up of muscles and fascia, and CPP could be simply a form of myalgia. Studies show that some patients with CPP have more muscle spasm and increased muscle tone; muscle relaxation could diminish spasm and pain ,89. Diagp < 0.001). In the placebo group, only dyspareunia improved significantly. The magnitude of the reduction of the pelvic floor pressure was significantly higher in the onabotulinumtoxinA group than in the placebo group. No intergroup differences for VAS pain score were found. Repeated onabotulinumtoxinA injections in female patients with pelvic floor muscle pain are reported to be as effective as the first set of injections [OnabotulinumtoxinA was first used to treat pelvic floor spasm and pain in women in 2004. Jarvis enrolled 12 women with objective pelvic floor muscle hypertonicity and chronic pelvic pain to receive 40 U of onabotulinumtoxinA injected into the puborectalis and pubococcygeus muscles . The VASjections .A systematic review of five studies suggested onabotulinumtoxinA injections were beneficial in relieving CPP related to pelvic floor spasm . HoweverSubstance induced cystitis and radiation cystitis usually induced bladder pain in these patients, and generally definite effective treatment of these diseases did not exist. Recently, onabotulinumtoxinA has also been used for the treatment of inflammatory bladder pain diseases and showed some promise results.es. Cayan injected onabotulinumtoxin Ainto the bladders of rats with chemically induced cystitis . The maxKetamine-induced cystitis is a relatively new urological disease characterized by severe urinary frequency and bladder pain . OnabotuThe therapeutic effect of onabotulinumtoxinA injection in these inflammatory bladder diseases might be resulted from, as above-mentioned, blocking release of noxious neurotransmitters and reducing neurogenic inflammation in bladder. However, removing the subtances which induced bladder inflammation is always the first step of treatment . Complication of BoNT-A injection such as hematuria and urinary tract infection might be more severe in the bladder with active inflammation. We suggested BoNT-A injection must be performed after subsiding of active inflammation. Furthermore, in the late stage of these inflammatory bladder disease, a contracted bladder with severe fibrosis is a common presentation. BoNT-A injection should not be effective in such bladders.et al. reported that two of 13 IC/BPS patients developed a slow urinary stream after onabotulinumtoxinA injection [et al. also reported decreased maximal urinary flow rate and detrusor pressure [The commonest adverse event of onabotulinumtoxinA injection is urinary tract is de novo intermittent catheterization, urinary retention and asymptomatic urinary tract infection . A phasenjection . Giannanpressure . In a sepressure . Urinarypressure . In termpressure . A smallpressure . AlthougCPP originates from different pelvic organs, and its treatment is usually challenging. Onabotulinumtoxin A injection provides promising results in treating refractory CPP due to various pelvic organs. Current evidence suggests onabotulinumtoxin Ainjection in CPP provides effects in pain relief, and repeat injection improves inflammation in the bladder. Preliminary studies of onabotulinumtoxin Ainjection in men with CP/CPPS and pelvic floor muscle pain also showed encouraging results. Using BoNT-A to treat CPP is safe and has few self-limiting adverse effects. More randomized, placebo controlled studies in patients with IC/BPS, CP/CPPS and other conditions are necessary in order to well establish the efficacy of onabotulinumtoxinA injections in these diseases.


Ultrasound (US)-guided percutaneous ethanol injection (PEI) has been proposed for treatment of benign thyroid nodules (TNs). However, there is no consensus for the optimal amount of ethanol injection, number of applications, and time to re-evaluation in order to achieve maximum volume reduction with minimum adverse effects.The purpose of the present study was to analyze the effectiveness of an US-guided PEI protocol to treat solid and mixed TNs based on a new target outcome.We performed a prospective study evaluating the results of PEI in 52 patients with benign solid and mixed TNs. The ethanol dose was fixed in 30% of the nodular volume per session. Patients returned 1 month after each session for US re-evaluation. Therapeutic success was defined as volume reduction of at least 30% associated with disappearance of clinical symptoms and a complete esthetic satisfaction reported by the patient.We performed a mean of 2.8 ± 1.9 PEI sessions, with an average total volume of ethanol injected of 9.1 ± 10.3 ml, and a follow-up time of 10.0 ± 8.7 months. There was a reduction of at least 50% of the initial nodular volume in 33 patients (63.5%). In 11 patients (21.2%), the reduction did not reach 50% (mean reduction of 31 ± 11%), but 6 of them reported esthetically satisfactory results and treatment was stopped. Our therapeutic success rate considering the patients with esthetic improvement was 75%. There were no severe complications.Our protocol is effective and safe to treat solid and mixed benign TNs based on our established outcome. Thyroid nodules (TNs) are common entities, often detected in clinical practice, with a largely variable prevalence, depending on the diagnostic method , 2. EpidMost TNs are benign (94–96%) , 11 smalThis method has been suggested to be an effective, safe, and inexpensive outpatient procedure for the treatment of benign TNs, leading to reduction of nodular volume, with a low rate of early and late clinical complications , 17–29. Most articles in literature have considered a nodule volume reduction of at least 50% as a partial success and more than 90% as a complete outcome . It is wTherefore, the purpose of the present study was to analyze the effectiveness of an US-guided PEI protocol to treat solid and mixed TNs based on that concept of treatment outcome.We performed a prospective study evaluating the results of an original US-guided PEI protocol in patients with solid and mixed TNs at Endocrinology Department of Federal University of Pará, from January 2011 to January 2016. We included 52 patients diagnosed with TNs and normal thyroid function, confirmed to be benign by fine-needle aspiration biopsy (FNAB). Mixed TNs were only included when the solid component was >50% of the nodular volume. All patients presented compressive local symptoms and/or esthetic complaints. Exclusion criteria were the presence of malignancy or suspected malignancy detected by FNAB. Cystics and autonomous TNs were not included. The study was approved by the local ethics committee-University Hospital João de Barros Barreto, Federal University of Pará.Patients were placed in a supine position with mild neck extension. After skin sterilization, a 22 gage needle (Becton Dickinson 30 × 7) was inserted through the epidermis to the thyroid pericapsular space under US guidance, reaching the center of the target lesion. Then, 99% ethanol was slowly instilled into the nodule, respecting the patient’s tolerance. Ethanol diffusion through the lesion was monitored as intense echogenicity in real-time observation by US. The procedure was stopped if ethanol leaked out of the nodule or if the patient complained of severe pain. None of 52 patients were dropped out through this procedure, and no cases of severe pain were reported. The procedure was carried out without local anesthesia at the puncture site.The amount of ethanol injected was equivalent to approximately 30% of the nodule volume, estimated by ultrasonography before each application. The nodular volume (milliliter) was obtained by multiplying the product of the longitudinal, lateral, and anteroposterior axes (centimeter) by the constant 0.52.In mixed nodules, we removed the liquid portion guided for the US, and the nodular volume was calculated. In cases of septated nodules, the greatest possible liquid part was removed. If patients had a multinodular goiter, treatment was only performed in the dominant nodule. In all alcoholization sessions, the amount of injected ethanol did not exceed 5 ml.Nodular volume reduction was calculated according to the following formula: [Pretreatment volume (milliliter) − Post-treatment volume (milliliter)] × 100%/Pretreatment volume (milliliter). The PEI sessions were followed by monthly assessments of nodular volume by US, and clinical evaluation.Therapeutic success was defined as volume reduction of at least 30% associated with disappearance of clinical symptoms and a complete esthetic satisfaction reported by the patient. The procedure was considered ineffective when the nodule did not show significant volume reduction (30%) and the patient did not refer esthetic improvement after at least three sessions of PEI and a follow-up period of at least 6 months.The new information of our study is a protocol that used ethanol fixed doses, but with shorter periods of re-evaluation by US and consequently more frequent applications based not just in nodule volume. We have also taking in consideration the disappearance of clinical symptoms and a complete esthetic satisfaction to stop PEI applications.p < 0.05 was considered statistically significant. Data were analyzed using Sigma Stat version 3.5  and Statistical Package for the Social Sciences version 21.0 .Categorical variables were presented as frequency (percentage). All normally distributed values were given as mean ± SD and all other values were given as median (range). The Wilcoxon test was applied to compare thyroid nodules initial and final volumes. A two-sided Our study group consisted of 51 women (98%) and 1 man, with a mean age of 45.2 ± 16.6 years. Among TNs, 19  were mixed and 33  solid.We performed a mean of 2.8 ± 1.9 PEI sessions, with an average total volume of ethanol injected of 9.1 ± 10.3 ml, and a follow-up time of 10.0 ± 8.7 months. Data regarding the US evaluation of the TNs before and after treatment are described in Table n = 33) and those who reported esthetic improvement with reduction of 30–50% (n = 6), the therapeutic success rate of our PEI protocol increases to 75% (39/52). We compared our results with other series using PEI for treating TNs  were less likely to completely respond compared to the others nodules. They have found a global satisfactory response in 70% of cases. Nevertheless, it was not reported the success rate specifically in solid TNs. Furthermore, Lee et al. (Perez et al. , using Pe et al. , in a lae et al. . In our When compared to other methods of treatment, PEI has shown more effective results and fewer complications. Four controlled studies demonstrated a 75–85% success rate after an average of two PEI sessions, compared with a 7–38% success rate in controls treated by simple cyst evacuation or saline injection –49. AddiThe highly variable success rate reported in different series might be related to the heterogeneous nature of thyroid nodules evaluated, ranging from purely cystic to purely solid nodules . The besPercutaneous ethanol injection is a safe procedure without serious complications . The mosIn conclusion, our US-guided PEI protocol is safe and effective for mixed and solid thyroid nodules when compared with other methodologies described, with a 75% success rate, in a short follow-up period and no major complications based on that new target idea. In addition, we need to increase the number of patients to confirm the effectiveness of this approach.JF wrote, reviewed and edited the final version, and was responsible for submitting the manuscript. AS and KM are university professors and helped writing the paper. CK, JN, CC, TA, AJ, HB, MJ, FR, FS, MS, FB, FM, AP and AC who have contributed by creating the database and contacting patients. All authors read and approved the final manuscript, and agreed to its submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The aim of this study was to investigate the long-term efficacy and safety of paresthesia-free high-frequency spinal cord stimulation (HF10 SCS) for the treatment of chronic, intractable pain of the low back and legs.Prospective, multicenter, observational study.Patients with significant chronic low back pain underwent implantation of a spinal cord stimulator capable of HF10 SCS. Patients' pain ratings, disability, sleep disturbances, opioid use, satisfaction, and adverse events were assessed for 24 months.P < 0.001), and mean leg pain from 5.4 ± 0.4 to 2.3 ± 0.3 (P < 0.001). Concomitantly to the pain relief, there were significant decreases in opioid use, Oswestry Disability Index score, and sleep disturbances. Patients' satisfaction and recommendation ratings were high. Adverse Events were similar in type and frequency to those observed with traditional SCS systems.After a trial period, 88% (72 of 82) of patients reported a significant improvement in pain scores and underwent the permanent implantation of the system. Ninety percent (65 of 72) of patients attended a 24-month follow-up visit. Mean back pain was reduced from 8.4 ± 0.1 at baseline to 3.3 ± 0.3 at 24 months (In patients with chronic low back pain, HF10 SCS resulted in clinically significant and sustained back and leg pain relief, functional and sleep improvements, opioid use reduction, and high patient satisfaction. These results support the long-term safety and sustained efficacy of HF10 SCS. Spinal cord stimulation (SCS) is an accepted treatment for failed back surgery syndrome (FBSS)—the presence of persistent or recurrent back and/or leg pain following spinal surgery High-frequency spinal cord stimulation (HF10 SCS) therapy is a form of SCS that delivers high frequency stimulation to the spinal cord by a system of leads and implantable pulse generator (IPG) that resembles standard systems. Our group previously published the 6-month results from a prospective, multicenter trial of HF10 SCS for chronic low back pain The study was conducted at two European centers . Both centers obtained ethics committee approvals, and all patients provided informed consent. The study was conducted in accordance with local clinical research and data protection regulations, good clinical practice guidelines (ISO 14155), and the Declaration of Helsinki.The rechargeable Senza® SCS system  received European regulatory approval (CE Mark) in May 2010 for use in the management of chronic intractable pain of the trunk and/or limbs. Similar to other commercially available SCS systems in design, this SCS system delivers electrical stimulation to the spinal cord via a pulse generator and epidural leads. However, unlike traditional systems, this HF10 SCS system is capable of delivering stimulation frequencies up to 10 kHz. At this frequency, the resulting stimulation is paresthesia-free.For this prospective, multicenter, open-label study, patients had to meet the following criteria: be candidate for commercial SCS device  After baseline evaluation, patients underwent a percutaneous trial for 14–30 days based on the center's standard practice. An external trial stimulator delivered bipolar stimulation at 10 kHz and current amplitude in the range of 1–5 mA. A programming algorithm defined during a previous study was used to optimize the HF10 SCS stimulation according to each patient's report of pain relief After a successful trial, an IPG was implanted. Patients were assessed at 1, 3, 6, 12, and 24 months following permanent implant. Changes in pain medications based on clinical judgment and adjustment of stimulation parameters were permitted throughout the follow-up period. Also, patients were allowed to adjust the amplitude of the therapy, within a predefined range, using a patient remote control.The trial and permanent implantation procedures were based on each center's established method for conventional SCS. The HF10 SCS surgical procedures differed from that used for traditional stimulation in three key ways: 1) the two leads were sited solely anatomically—in the midline spanning T8 to T11 , and neurological examinations. Additionally, patients used a 5-point scale to rate their satisfaction with their therapy and whether they would recommend it to others. The study personnel at each center directed the administration/collection of the data.t-test was used to analyze continuous variables, such as VAS. Adverse events (AEs) are reported descriptively for all patients. A P value less than or equal to 5% (P < 0.05) was considered to be statistically significant.Descriptive statistics were calculated for each analyzed variable. These include the number of observations, mean, median, and standard deviation. Two-tailed paired Of the 83 patients enrolled, 82 completed the trial phase and 72 of them had a successful trial of the HF10 SCS system and proceeded to implantation of an IPG . Sixty-five of the 72 patients (90%) were available for data collection at 24 months . Mean leg pain VAS score was 2.3 ± 0.3 at 24 months, compared with 5.4 ± 0.4 at baseline and 1.4 ± 0.3 at 6 months . At 24 months, 60% of the implanted patients had at least 50% back pain relief and 71% had at least 50% leg pain relief. ODI and sleep disturbances at 24 months post-IPG implant were significantly lower compared with baseline. Mean ODI values decreased from 55 ± 1 at baseline to 40 ± 2 at 24 months (P < 0.001). Mean subjective sleep disturbances per night decreased from 3.7 ± 0.4 at baseline to 1.4 ± 0.2 at 24 month follow-up (P < 0.001).At 24 months, the mean reported VAS score for back pain was 3.3 ± 0.3, compared with 8.4 ± 0.1 at baseline and 2.7 ± 0.3 at 6 months. Back pain relief was significant and sustained to 24 months (P < 0.001). The mean dosage of oral morphine equivalents per patient decreased from 84 mg/day at baseline to 27 mg/day at 24 months (P < 0.001).Eighty-six percent of patients were taking some form of opioid at baseline, and this reduced to 57% at 24 months  and a very high follow-up percentage of 90% (65 of 72) at 24 months.After 24 months of HF10 SCS, 60% of patients reported reductions from baseline back pain of greater than 50%, and 71% of patients reported reductions in leg pain of more than 50%. Published 24-month data with traditional SCS is available in the Prospective Randomized Controlled Multicenter Trial of the Effectiveness of Spinal Cord Stimulation (PROCESS) and North et al. studies Furthermore, the North and PROCESS studies did not demonstrate a significant reduction in opioid use, whereas in this HF10 SCS group, pain reduction was accompanied by concomitant reductions in opioid use and dosage. Thirty-eight percent of patients stopped taking opioids during follow-up, and the mean dosage of morphine per patient decreased from 84 mg at baseline down to 27 mg at 24 months.This study shows that the pain relief afforded by HF10 SCS is maintained for at least 24 months. The mean VAS baseline back pain score of 8.4 ± 0.1 was markedly reduced at 24 months with a score of 3.3 ± 0.3, and the small increase from a back pain score of 2.7 ± 0.3 at 6 months of therapy was not statistically significant. Similarly, the relief in leg pain was well maintained at 24 months with the baseline score of 5.4 ± 0.4 reduced to 2.3 ± 0.3 at 24 months. The rise in leg pain score between 6-month therapy and 24-month therapy (1.4 ± 0.3 to 2.3 ± 0.3) was statistically significant, but was small compared with the reduction from baseline. This observation is not unusual, considering that the benefits of traditional SCS will also diminish with time. This is exemplified in the landmark work by Kemler et al., reporting reduction in the efficacy of SCS in complex regional pain syndrome over time The improvement in ODI at 24 months is both statistically and clinically significant, with a baseline ODI of 55 ± 1 reduced to 40 ± 2 at 24 months. The improvement in patient function is illustrated in Figure P < 0.001) and was 3.2 ± 0.4 at 24 months (P < 0.001). FBSS group's mean baseline leg pain VAS was 5.3 ± 0.4, and this dropped to 1.5 ± 0.4 at 6 months (P < 0.001) and was 2.1 ± 0.3 at 24 months (P < 0.001). In the group without prior back surgery, patients with predominantly degenerative disc disease, 15 of the 16 patients had a successful trial . The mean VAS back pain at baseline was 8.1 ± 0.2, which was reduced to 2.6 ± 0.7 at 6 months (P < 0.001) and 3.4 ± 0.7 at 24 months (P < 0.001). The mean VAS leg pain score in this group was 5.9 ± 0.8 at baseline, 1.2 ± 0.6 at 6 months (P < 0.001), and 2.8 ± 0.7 at 24 months (P < 0.05). The positive 24-month results in this group of patients indicate that HF10 SCS may be an effective treatment for many patients with severe chronic back pain in whom surgery is not indicated. Further studies are warranted in this group to demonstrate effectiveness definitively.Our study cohort includes two main subgroups who warrant individual discussion Figure . Sixty-sP < 0.001) and 4.2 ± 0.9 at 24 months (P < 0.05). Mean leg pain VAS was 7.7 ± 0.8 at baseline, 1.9 ± 0.9 at 6 months (P < 0.05), and 2.5 ± 0.6 at 24 months (P < 0.05). The success of HF10 SCS at 24 months in this population who had failed traditional SCS suggests that spinal stimulation might still be a useful therapy if HF10 SCS is employed. This is particularly important for the many patients with current SCS systems that are not getting optimal results.Another group of special interest in this study population is patients who have previously failed traditional SCS (N = 14). These patients had either failed an SCS trial due to the lack of back paresthesia coverage (N = 10), or failed after permanent IPG implant due to the loss of back pain relief. Eleven (79%) of these patients had a successful trial. Baseline mean VAS back pain score was 8.9 ± 0.3, reduced to 2.0 ± 0.6 at 6 months  reduce the chance of overestimating the magnitude of the treatment effect In this study, patients with chronic low back pain have shown a marked and sustained response to HF10 SCS treatment. After 24 months of treatment, both back pain and leg pains were significantly reduced. Patient function, opioid utilization, and sleep were markedly improved. No AEs related to the high-frequency stimulation itself were observed. The positive results of this large prospective trial are encouraging and should inspire further investigation of the role that HF10 SCS may play in treating chronic spinal pain and other chronic pain states.


Objective. To compare ultrasound-guided miniscalpel-needle (UG-MSN) release versus ultrasound-guided dry needling (UG-DN) for chronic neck pain. Methods. A total of 169 patients with chronic neck pain were randomized to receive either UG-MSN release or UG-DN. Before treatment and at 3 and 6 months posttreatment, pain was measured using a 10-point visual analogue scale (VAS). Neck function was examined using the neck disability index. Health-related quality of life was examined using the physical component score (PCS) and mental component score (MCS) of the SF-36 health status scale. Results. Patients in the UG-MSN release had greater improvement on the VAS (by 2 points at 3 months and 0.9 points at 6 months) versus in the UG-DN arm; (both P < 0.0001). Patients receiving UG-MSN release also showed significantly lower scores on the adjusted neck disability index, as well as significantly lower PCS. No severe complications were observed. Conclusion. UG-MSN release was superior to UG-DN in reducing pain intensity and neck disability in patients with chronic neck pain and was not associated with severe complications. The procedural aspects in the two arms were identical; however, we did not verify the blinding success. As such, the results need to be interpreted with caution. Chronic neck pain is a common and disabling condition , 2. It uMiniscalpel-needle (MSN) release is a promising treatment for chronic neck pain –11. In tA major concern of the conventional MSN release is the potential damage to nerves and blood vessels , 13. LimThe current study is a randomized controlled trial (RCT) that compared MSN release and dry needling in patients with chronic neck pain.ChiCTR-TRC-10001609). Data collection, analysis, and reporting were performed in compliance with the CONSORT guidelines . By. By16]. One author (YJZ) performed the treatment (either MSN release or DN under ultrasound guidance). For MSN release, when the pinpoint needle reached the trigger point, the MSN was moved up and down 2-3 times longitudinally around the vertebral lamina and the posterior tubercle of the transverse processes of C6 . The minThe primary outcome was pain intensity. Secondary outcomes included pain disability and health-related quality of life. Pain intensity was measured using the 10-point VAS . Pain diThe survey instruments were administered by a pain management specialist blinded to the treatment (even whether a patient was in the study or not). Outcomes were assessed before the treatment and at 3 and 6 months after the treatment.n) was calculated according to the following equation for repeated measures at a significance level of 0.05 and power of 80%: n = 2 × (μα/2+μβ)2 × δ2 × (1 − ρ)/(m × s2 × (βA1−βB1)2)   [δ2) was 3.08; the symmetric correlation coefficient (ρ) was 0.38; the number of repetitions (m) was 3; s2 = ∑(tj−t)2/m = 8.25, where tj is the time when repeated measures are performed and t is the average time of repeated measures; and βA1 − βB1 = 0.137, where βA1 and βB1 are the slopes (change in measurement over time) for the UG-MSN and UG-DN groups, respectively. This equation indicated the need for 64 participants per arm, so we recruited 80 patients for each arm to take into account a 20% dropout rate.Sample size was calculated based on a preliminary RCT involving 60 patients with chronic neck pain, 30 of whom were treated by UG-MSN release and 30 by UG-DN. None of the 60 subjects in this preliminary study was included in the current study. Sample size (= 0.842) . Based on = 8). Allocation concealment was carried out using the SNOSE method . The next envelope in the sequence was opened after the participant had given informed consent.Subjects were randomly allocated into UG-MSN or UG-DN group based on a computer-generated allocation sequence using a block design  performed UG-MSN and UG-DN procedures on all participants. Data were analyzed by an independent statistician.t-test for normally distributed data and the Mann-Whitney test for nonnormally distributed data. Intergroup differences in categorical variables were assessed for significance using the χ2 test or Fisher's exact test. Analysis of covariance was also used to assess differences between the two groups based on F-statistics. The baseline served as a covariate. The significance level for all tests was set at 0.05.All data were analyzed using SPSS 13.0 . Data for continuous variables showing a normal distribution were reported as means and standard deviations (SD); otherwise, data were reported as median. Intergroup differences were assessed for statistical significance using independent Student's P = 0.5801, χ2 test). In the UG-MSN group, 4 patients were lost to follow-up by 3 months posttreatment and 6 were lost by 6 months. In the UG-DN group, 4 patients were lost by 3 months and 8 were lost by 6 months.From January 2009 to February 2010, 250 participants were approached, of which 81 were excluded, leaving 169 who were randomized into UG-MSN or UG-DN group . Each grP > 0.05, Mann-Whitney nonparametric tests). This suggests that losses to follow-up did not significantly affect the outcomes measured for the patients who completed the trial.Scores on the VAS, NDI, SF-36 PCS, and SF-36 MCS were measured immediately prior to the start of treatment and again at 3 and 6 months posttreatment. VAS scores at baseline were similar for the patients lost to follow-up from either group at 3 months and 6 months  in the UG-MSN release group and for 73 of 81 patients (90.1%) in the UG-DN group. Analyses of covariance were performed in which the score on the VAS, NDI, SF-36 PCS, or SF-36 MCS at 3 and 6 months served as the response variable (outcome) and treatment served as the explanatory variable; results were adjusted for baseline differences in the response variable.β = 0.9, SD = 0.2, P < 0.0001); at 6 months, this difference had grown to 2.0 points ; at 6 months, this difference had grown to 5.3 points ; at 6 months, this difference had grown to 7.5 points .Treatment adherence rates were similar between the two treatment groups: 82 of 88 subjects (93.2%) in the UG-MSN release group completed the study protocol, compared to 73 of 81 (90.1%) in the UG-DN group (Six participants in the UG-MSN release group (7.3%) and 7 in the UG-DN group (9.6%) reported mild reactions during treatment, mainly slight pain and somatic reactions such as sweating. However, all these participants agreed to continue the treatment. No serious adverse complications, such as spinal injury or nerve injury, were recorded.The results of this randomized trial suggest that UG-MSN release is more effective than UG-DN in reducing pain intensity and neck disability and in increasing health-related quality of life in patients with chronic neck pain. Both treatments appear to be associated with similarly low rates of mild adverse events, similar dropout rates, and no severe side effects. These findings should be confirmed in larger cohorts. To our knowledge, this is the first report using ultrasound to guide MSN release.The greater efficacy of UG-MSN may reflect the fact that it combines the therapeutic action of DN and minimally invasive surgery. MSN release can cut and detach the taut band in myofascial pain syndrome as well as relaxing the compressed blood vessels and trapped nerves at the primary and second foci . MSN relDN and MSN have been shown to relieve chronic neck pain , 26, butOur finding that UG-MSN release is superior to UG-DN is reminiscent of a previous study showing MSN release to be superior to acupuncture in managing myofascial pain syndrome . Our resIn addition to its randomized and controlled nature, our study fulfills the essential requirement of using well-validated outcome measures. While outcomes based on self-report inherently carry some risk of bias, we believe that outcomes like pain, functional ability, and quality of life can be more accurately assessed by listening to patients rather than physicians.All treatments were conducted by a single physician in the current study. Such a design helped to ensure consistency between the two treatment groups but decreased the generalizability of the results. Another concern is the completeness of the blinding: patient experience during the procedure may help them to identify which treatment they received. We included only “naïve” subjects in the current study: those who received acupuncture or miniscalpel-needle release previously were not included. Nonetheless, we did not take solid measures to verify the blinding success. As such, the results of the current study need to be interpreted with caution.Supplementary Figure 1. A. A schematic diagram of a miniscalpel-needle (MSN). B. A photohragph of a MSN. C. The high-frequency liner array transducer (upper) and disposal sterilizing medical ultrasonic coupling agent (subjacent). D. Ultrasound device.Supplementary Figure 2. A. The procedure of UG-MSN release. B. The procedure of UG-DN.


Objectives: The study had twin objectives: to assess the incidence of flare-ups (a severe problem requiring an unscheduled visit and treatment) among patients who received endodontic treatment in the Department of Conservative Dentistry and Endodontics in Vyas Dental college and hospital, Jodhpur during a period of one year, and also to examine the correlation with pre-operative and operative variables.Material and Methods: Data was collected from 1023 teeth from 916 patients who had received endodontic treatment over a 12- month period. Information was obtained for each patient treated, including pulp and peri-radicular diagnosis for the tooth, presence of pre-operatory pain, type of medication being used, type of instrumentation technique used and number of appointments needed to complete the root canal treatment.Results: The results showed an incidence of 2.35% for flare-ups from 1023 endodontically treated teeth. Statistical analysis was done using the chi-square test.Conclusions: Flare-ups were found to be affected significantly by gender of patient, presence of radiolucent lesions, patients taking pre-operative analgesic or anti-inflammatory drugs and on type of instrumentation technique. In contrast, there was no correlation between flare-ups and age, different arch/tooth groups and single or multiple visit endodontics. Key words:Anti-inflammatory, flare-ups, instrumentation, prospective. Flare-up is a commonly used term with the characteristic symptoms of pain and swelling arising following endodontic treatment with its best treatment solution being its prevention of occurrence . MechaniA flare-up may be defined as the occurence of severe pain and/or swelling following an endodontic treatment appointment, requiring an unscheduled visit for treatment. It is a well-known complication that disturbs both patients and dentists . EndodonFlare-ups prevalence is reported as low as 0.39% , to as hData was collected from 1049 teeth from 936 patients who had received endodontic treatment over a 12- month period in the Department of Conservative and Endodontics in Vyas Dental College and Hospital, Jodhpur by three different operators. Informed consent was taken from all the participants and approval from institutional ethical committee was taken. Information was obtained for each patient treated, including pulp and peri-radicular diagnosis for the tooth, presence of pre-operatory pain, type of medication being used, type of instrumentation technique used and number of appointments needed to complete the root canal treatment.Inclusion critera included patients aged between 15 to 66 years, average age of 42 years, teeth with fully formed roots, teeth with non-calcified canals, teeth with normal pulp for intentional endodontic treatment, teeth with irreversible pulpitis, teeth with apical periodontitis with and without any periapical lesion.Exclusion criteria included retreatment cases, acute pain with swelling cases, teeth with mobility, pregnant patients.Under rubber dam isolation, conventional straight-line access preparations were made and a step-back instrumentation technique was used as the routine procedure in teeth treated using hand filling in which the coronal two-thirds of the root canal was enlarged with Gates Glidden burs , sizes 070 and 090, The working length was established 1 mm from the radiographic apex. The apical third was then prepared using K files  with step-back increments of 0.5 mm until a final file size 30 to 45 could be placed at the working length. The criteria used to determine the end of the preparation were:  a fine fOut of total 936 patients, twenty patients did not participated in the study as they did not turn up after first appointment and so total 916 patients were included in the study from which 1023 teeth were examined and twenty four required emergency treatment, resulting in an overall incidence of flare-ups of 2.35%. No statistically significant difference was found for age or for different arch and tooth groups but a significant difference was found for gender  with higThis study showed a low incidence of flare-ups following endodontic treatment 2.35%]. These results can be compared to studies who also reported similar findings .35%. The,10. To eAn analysis of the influence of patient age or tooth/arch groups with flare-up occurrence, showed no statistical significant difference. These findings are in agreement with several authors ,10. StudIn contrast, other studies have found that treatment outcome levels significantly decreases with increasing age  as well Gender differences in pain states that women reports more pain than men and also the reduction in pain thres-holds . FemalesStudies determining the prevalence of persistent pain following endodontic treatment, concludes that females are more associated with persistent pain after successful endodontic treatment . Higher Higher levels of post-endodontic pain have been reportedly associated significantly with posterior teeth in the mandibular arch . IncisorThe incidence of flare-up is having direct relationship with the severity of the patient’s preoperative diagnosis and signs and symptoms. The incidence of flare-ups is higher with necrotic pulp tooth than in vital tooth. Studies have found the incidence of flare-ups in tooth with necrotic pulp being 7.17% . EstabliAntibiotic usage generally shows low incidence of flare up. Majority of cases of pain showed its resolution within 48 hours. Hence it can be concluded that most of the postoperative pain can be easily controlled by an-ti-inflammatory medication . AntibioPresent study reported no significant difference in flare ups between single visit and multiple visit treatment. Another unusual finding was that postoperative pain frequency for patients treated in one appointment was higher [16%] than patients treated in two appointments [9.6%] . Most otRoot canal instrumentation using step-back technique with hand files produced significantly more pain perception than rotary files. The engine driven techniques extrude smaller amounts of debris and irrigants, presumably due to the rotary motion, which tends to direct debris toward the orifice, avoiding its compactation in the root canal . HoweverFlare-up can be prevented by selection of an instrumentation technique that extrude less amount of debris apically, which usually is the crown down technique with rotary action combined with copious and frequent irrigation. Intracanal medication is a preventive measure that is used to reduce the incidence of inter-appointment flare-ups. But still more comparative studies are required, to find out the best treatment option available for the prevention of flare-up.In this study it was concluded that flare-ups were found to be positively correlated with gender of patient, presence of radiolucent lesions, patients taking analgesic or anti-inflammatory drugs and on type of instrumentation technique. In contrast, there was no correlation between flare-up, and age, different arch/tooth groups and single or multiple visit endodontics.


People using opioids, painkillers and sedatives regularly and in large doses and patients with a history of lung or liver problems did not participate in this project. The parameters of the severity of pain and nausea (VAS), hemodynamic changes (BP and HR), pruritus, arterial oxygen desaturation and patient satisfaction (VAS) of both groups were measured by a third party (trained colleague). The data was analyzed using SPSS 16 statistical software then descriptive results were extracted and ultimately the groups were compared using the following statistical tests: student’s T-test, chi 2 and Fisher’s exact test (P<0.05).The mean age of the participants was 45±12.5 years. Women constituted 24.3% of the patients and men 75.7%. The average pain severity for morphine and paracetamol groups (VAS) was 5.3±2.2and 6.37±1.7 after2 hours and reached 1.91±1.3 and 2.49±1.3 after 8 hours (after the operation) respectively. There was a significant difference between the groups after 2 and 4 hours in terms of pain severity (after 2 hours P=0.007 and after 4 hours P=0.047). However there was no significant difference between the average pain severity of the studied groups (after 6 hours P=0.4 and 8 hours P=0.08).After 8 hours, the average nausea severity was the minimum in both groups being 1.71±1.6 and 1.43±1.1 in morphine and paracetamol groups respectively. Nausea severity was higher after 2 hours in paracetamol group. In morphine group, it was higher after 4, 6 and 8 hours. Difference between the groups was not significant. The average satisfaction level (VAS) for morphine and paracetamol groups reached from 5.29±2.3 and 4.2±2.4 after 2 hours, to 7.94±1.8 and 7.69±2.1 after 8 hours (after the operation), respectively. The average satisfaction level of patients was higher in morphine group in 2,4,6 and 8 hours and except for, after 4 hours (P=0.01), the satisfaction difference between both groups was not significant in other hours Morphine seems to be more effective at 2 and 4 hours, but after 4 hours they have similar effects, the satisfaction difference between both groups was not significant in the patients. Reducing postoperative pain, especially with some specific analgesic regimens, reduces perioperative mortality .Transmission of painful stimuli to the CNS  creates neuro-endocrine stress responses and increases local and systemic inflammatory substances. Neuroendocrine responses to pain include increase in the secretion of catecholamines and catabolic hormones such as cortisol, glucagon, aldosterone, morphine, angiotensin, ACTH (Adreno-corticotropic hormone) and ADH (antidiuretic hormone), and decrease in anabolic hormones which results in salt and water retention, blood glucose, free fatty acids, ketone bodies and lactate increase. The responses ultimately create a hyper-metabolic and catabolic state. Stress response increases postoperative coagulability caused by the decrease in anticoagulant levels, and increases pro-coagulants and ultimately increases DVT (Deep Vein Thrombosis) incidence and vascular and myocardial ischemia graft rejection .On the other hand, stress response causes immune-suppression relative to the severity of surgical trauma which leads to hyperglycemia and reduced wound healing. Increase in catecholamines, due to uncontrolled pain, results in increased myocardial oxygen consumption, coronary artery disease, ischemia and myocardial infarction. Also stimulation of the sympathetic system delays the return of gastrointestinal motility and causes ileuses .Pain reduces deep breath and cough which causes respiratory complications. Depending on the type of surgery, postoperative chronic pain can be seen in 10% to 65% of the patients. Uncontrolled acute postoperative pain is an important prognostic factor for the development of respiratory complications. Various drugs are used to control postoperative pain, among which narcotics, NSAID , ketamine, topical anesthetics and paracetamol can be named. Side effects of narcotics include respiratory depression, nausea, drowsiness and drug tolerance and dependence .NSAID drugs, due to platelet dysfunction and the inhibition of thromboxane A2, reduce homeostasis. Additionally, they result in impaired renal function and side effects on bone repair and spinal fusion. Ketamines reduces central sensitization and prevent chronic pain. It also reduces 24-hour morphine usage with PCA  method and has side effects such as nausea .Topical anesthesics are used for nerve blocks . ParacetPCA does not reduce the duration of hospitalization but provides shorter nursing time, higher satisfaction in the patients and improved pain and reduces lower respiratory depression. It is both as IV (intra venous) and epidural .With this technique receive of drug delay is prevented. It provides the highest flexibility for drug regulation and the best compatibility with the patients’ physiological differences. It is suitable for adults and children and is preferred to IM injection for postoperative pain control . It can Morphine is the drug chosen for this method. Although morphine is standardized, it doesn’t seem preferable to other narcotics such as hydromorphone. It is also shown in some studies that infusion dose of narcotics causes nausea, drowsiness and hypoxemia and due to respiratory events it is necessary to monitor the patients . Due to This research was done using double blind randomized clinical trial. This research was registered in IRCT  with number 2013012712298N1. The studied community includes 15 to 65 year-old patients with the ASA (American Society of Anesthesiologists) of 1 or 2, who had undergone laparotomy surgery. It was conducted in Shahid Rajaee Center and Velayat Hospital, on patients who underwent laparotomy surgery from February 2012 to October 2012. Seventy patients aging from 15 to 65 with the ASA of 1 and 2 underwent laparotomy surgery. The length of the operation was less than 2.5 hours, surgery time more than 2.5 hours was our exclusion criteria in our study. There was not significant difference between two groups (P>0.05). After being admitted, the patients were randomly divided into two groups with white and black cards. The morphine group received morphine with the dose of 0.02 mg/kg of their body weight. The maximum dose of paracetamol in a day was 3 grams. In our study we gave paracetamol 1.4mg/kg/hr. Two groups equal with regard to anesthesia methods. Men constituted 75.7% of the patients and women 24.3%. No significant gender difference was observed between the groups (P>0.05). Pain severity and side effects such as nausea, hemodynamic changes, pruritus, desaturation of arterial oxygen and patient satisfaction all using VAS, are measured by third party (trained colleague) for 8 hours, with 2 hour intervals. VAS is a scoring range system which is divided to 10 points and the patients rate their situation. One represents asymptomatic  and the People using opioids, painkillers and sedatives regularly and in large doses and patients with a history of lung or liver problems did not participate in this project.Ultimately the obtained data was statistically analyzed. The data obtained from both groups were inserted into the forms and the data such as pain (VAS), patient satisfaction (VAS), nausea (VAS), HR and BP changes, pruritus and respiratory complications of the patients using morphine and paracetamol were collected. Then the data was transferred to the computer using SPSS 16 software, descriptive findings were extracted and the groups were compared using chi-square, T-test and Fisher’s exact test with P<0.05.Men constituted 75.7% of the patients and women 24.3%. Mean age of the patients of morphine and paracetamol groups were respectively 48±10.4 and 42±14.5 years old on average. No significant difference was observed in the age groups (P: 0.05).There was a significant difference between the groups after 2 and 4 hours after surgery in terms of pain severity (after 2 hour P=0.007 and 4 hours P=0.047)  Figure .Based on VAS scale, the highest and lowest pain severity in morphine and paracetamol groups was 9 and 1, respectively. The findings show that after the surgery the average pain severity in both groups decreases with the passage of time.However there was no significant difference between the average pain severity of the studied groups (after 6 hours P=0.4 and 8 hours p=0.08).After 2 hours, the average nausea was 3.2±3.0 and 3.17±3 in morphine and paracetamol groups, respectively .Nausea difference between the groups was not significant and the P value was higher than 0.05 in all cases. The average satisfaction level in both groups increased with the passage of time. The average satisfaction level of patients was higher in morphine group in all four data collection hours and except for four hours after (P=0.01) the satisfaction difference between both groups was not significant in other hours  .The highest and lowest satisfaction levels in morphine and paracetamol groups were 10 and 1, respectively. Throughout the study, HR change was not recorded higher than 40% in all patients .After 2 hours, the HR change in the patients of paracetamol group was mostly between 20% to 40% (57.1%). This number for the most of morphine group was less than 20% (77.1%). The difference between morphine and paracetamol groups was significant (P=0.003).After 4 hours, the HR change in more than 90% of the patients of both groups was less than 20% and the difference was not significant (P=0.5). In both groups the HR change was less than 20% at 6 and 8 hours. Throughout the study BP change was not more than 40% in all patients .After 2 hours, the BP change in the patients of paracetamol group was mostly between 20% to 40% (54.3%). In morphine group, the BP change experienced by most patients was less than 20% (82.9%). The difference between the groups was significant (P<0.001 after 2 hours).After 4 hours, the BP change in most patients in paracetamol group (97.1%) and all the patients in morphine group was less than 20%. The difference between the groups was not significant (P<0.5 after 4 hours). After 6 and 8 hours, the BP change was less than 20% for all the patients in both groups.In this research the patients were studied after 2, 4, 6 and 8 hours in terms of pruritus and only one patient (2.9%) from the morphine group complained about pruritus after 2 hours, but it was not significant (P<0.5). There were no complaints about pruritus after 4, 6 and 8 hours.The groups were also analyzed by pulse oximeter in terms of arterial oxygen desaturation and only 2 patients (5.7%) experienced arterial oxygen desaturation under 90% after 2 hours but the difference was not significant (P=0.2). After 4, 6 and 8 hours there was no report of arterial oxygen desaturation under 90%.There are many studies conducted on postoperative analgesia using various drugs and methods in the past years. In the present study we compared morphine and paqracetamol analgesic effect.Morphine had a stronger analgesic effect compared to paracetamol in the final results after 2 and 4 hours after surgery, but there was no significant different between them after 6 and 8 hours. There was no significant difference between the side effects of the drugs except for HR and BP after 2 hours and there was no significant difference in the satisfaction level of the patients after 2, 6 and 8 hours except for 4 hours which was higher in morphine group. In many studies researchers have found that 1g iv paracetamol used alone is just as effective as 30 mg ketorolac, 75 mg diclofenac or 10 mg morphine . In thisIn the research by In the research by In the research by In another research conducted in Verbal Rating Scale) for 4 hours. It was similar in both groups but the severity of side effects such as nausea and dizziness were reported higher in morphine group.Another research was conducted by Probably, the reason for the difference in side effects is the whole injection of narcotics compared to our research in which narcotics were administered to the patient gradually and within 24 hours. In the other hands many predictors of postoperative pain intensity or analgesic Consumption may be effect on pain after surgery such as gender, predictors of postoperative pain intensity and/or analgesic consumption.Although In our study the distribution of gender was not equally but this different was not significant and therefore could not have a confounding effect. In systematic review that was conducted by Hui and et al was found that many studies could not show a significant correlation between gender and postoperative pain .Other demographic factors, such as body mass, weight, American Society of Anesthesiologists status, and education level were evaluated in only a few studies and were found to be related to postoperative pain and/or analgesic consumption only in isolated studies .Due to the importance of postoperative analgesia and also because morphine is the standard index for the effectiveness of drugs in pain control, this research tries to compare the analgesic effect and the side effects of paracetamol and morphine using PCA method. Paracetamol could be as successful as morphine in pain control and analgesia in the first postoperative hours and its effect increases with the passage of time. Although morphine seems to be more effective at 2 and 4 hours, but after 4 hours they have similar effects. With due attention to this and similarity of patient satisfaction in both groups Paracetamol could be considered as an alternative drug.