Introduction: Generally, interspinal distractor fixation devices are used for severe low back pain associated with neurogenic claudication, and radiculopathy with central or lateral recess stenosis and/or foraminal narrowing. In this paper, the authors result in cases of severe low back pain and lumbar radiculopathy in whom this device was used with excellent results.Method: This is a retrospective study. Patients were contacted via phone call and their pain score and other data were recorded at different timelines. The final data presented in this paper are the data collected at the final follow-up that ranges from 14 months to 24 months. Surgeries were performed in the outpatient setting and although no identifiable patient information is included in this paper, yet, patients were asked for their verbal consent. The patient data are only included if verbal consent was obtained.Results: Over the past 24 months, 13 patients with disc protrusion and/or central and/or foraminal spinal stenosis were treated with this procedure. Follow-up ranges from 14 months to 24 months with a median of 19 months, male/female ratio of 6/7, and a median age of 68 years. There were no complications or reoperation. Statistical analysis showed significant improvement in the Numeric Pain Rating Scale (NPRS) for back and radicular leg pain .Conclusion: The system reported in this paper is a solid fixation system that works both as a distractor and internal decompressor of the spinal canal. It is simple to use and safe. Though the number of patients is small, statistically significant improvement was reported at a median follow-up of 19 months. The degenerative process of the spine can result in disc disease, spinal stenosis, facet arthropathy, and foraminal narrowing. Disc disease can result in radicular signs and symptoms; spinal stenosis can cause neural claudication, radicular symptoms, motor function loss; facet arthropathy can cause joint pain, and foraminal narrowing can cause radicular signs and symptoms. Traditionally, laminectomy, foraminotomy, discectomy, facet screws fixation, and fusion are the surgical procedures performed for these conditions. The interspinal distraction (ISD) or spacer devices were invented as distracting the spinous process widens the foramen, decreases the pressure on the disc and facets, and opens the spinal canal by stretching the ligamentum flavum. Though initial results on these devices were encouraging some studies cast doubts on their effectiveness -3. More Over the last 24 months, the authors have used the Inspan device  in 13 patients. The male-female ratios are 6/7; the age range is from 39 to 86 years with a median of 68 years. The following study covers 14 months to 24 months with a median of 19 months follow-up. All patients had a history of chronic pain syndrome and had extensive pain management treatment including epidural steroids injection and physical therapy. All patients had low back pain with shooting radiculopathy. Those with significant stenosis also had neurogenic claudication. Seven patients had moderate to severe or severe spinal stenosis, others had disc protrusion and/or foremen narrowing, one patient had grade 1 listhesis. Patients’ back pain and radicular leg pain were scored pre and post-operatively using the numeric pain rating scale (NPRS).Description of the systemThe device is an interspinous distraction fixation device Figure , is low Operative procedureThe procedures were done under general anesthesia or local anesthesia with heavy sedation in the prone position. Intra-operative fluoroscopy was used, as needed. A small incision 3.5-4 cm in length was made Figure .The para-laminar muscles were separated from the lamina and retracted laterally. The interspinous ligament was then removed deep down to the ligamentum flavum. Bony margins of the spinous processes in the interspace were roughened up. Distraction distance was measured using a temporary distractor under fluoroscopic control. Distraction was increased until the posterior disc space increased by 1.5 mm in height. An appropriate size device was then inserted and hammered down to the full depth Figures  and 4.Fluoroscopic images were obtained to confirm the intended distraction. The wings of the inspan interspinous distractor were then compressed into the spinous processes, and the system was locked in position. Then allograft bone putty was placed between the roughened surfaces of the spinous processes. The wound was then closed.Statistical analysisA sample of 13 patients was analyzed for pre-op and post-op back pain as well as radicular leg pain. The data were recorded using the NPRS, and data gathering was conducted for the back pain and radicular leg pain. Analysis for back and leg pain reduction was done via “t-test: paired two samples for mean” and the results were considered significant for p-value < 0.05. Statistical analysis was conducted via the Microsoft Excel data analysis tool.A sample of 13 patients was analyzed for pre-op and post-op back pain as well as leg pain. The data . None of the patients developed a spinous process fracture or needed reoperation. The blood loss was minimal, the length of the incisions was between 3.5 cm and 4 cm, and the operating time was between 45 minutes and 60 minutes. All patients were discharged on the day of the surgery. The follow-up is between 14 months and 24 months, with a median of 19 months.The conventional decompressive laminectomy with removal of lamina and ligamentum flavum is a logical procedure to decompress a spinal canal that is narrowed due to thickened bone and ligament. This procedure is often supplemented with spinal fusion. Though this does bring relief to a large percentage of people it has certain disadvantages. It is an invasive approach that may not be suitable for older people. Furthermore, because it is an intraspinal procedure it can result in injury to the nerve roots, formation of scar tissue around nerve roots resulting in chronic pain syndrome, adjacent segment instability, epidural hematoma formation, and dural tear resulting in a spinal fluid leak. On the other hand, spinal distraction fixation systems are minimally invasive and the spinal canal or the capsular ligaments around the facets are not violated. Therefore, the chance for instability, spinal fluid leak, post-operative scarring with resulting pain, post-operative intraspinal clot formation, and injury to nerve root(s) is unlikely.An interspinal distraction device can distract the interspinous space. This widens the foramen; widens the disc space resulting in a decrease in intradiscal pressure and disc bulge; straightens the interlaminar ligament which increases the diameter of the spinal canal, and decreases facet pain by decreasing pressure within the facet. Implanting this device is simple and minimally invasive with minimal risk for serious complications. Furthermore, since the procedure increases the height of the foramen and decreases intradiscal pressure, it reduces the risk of disc herniation at the treated level in the future. In addition, the procedure can be performed under general or local anesthesia, hospitalization is not required, and the patient can return to normal activity within a day or two. This system, therefore, gained some popularity in the last 10-15 years.The early distractor systems were spacers. They were used as the only procedure for spinal stenosis or and in combination with a laminotomy. Though early results were very encouraging  some of The newer types listed in the introduction section included interspinal dynamic distraction fixation (ISDDF), which is a distraction stabilization with preservation of motion; and ISDRF which is a distraction stabilization system with rigid fixation.In a cadaver study, the authors  observedThe ISDDF device implants -6 have rThere are several reports on the ISDRF devices. Daentzer et al.  in a 10 Goel et al.  reportedAccording to Inspan LLC, the manufacturers of Inspan interspinous fixation device , biomechIn the current paper, the authors report 13 consecutive patients who had Inspan implants. All patients had a history of chronic pain, and seven patients has moderate to severe spinal stenosis. The operative time was between 45 minutes and 60 minutes. Statistically, there was a significant improvement in low back pain and lumbar radiculopathy pain. Though the subject number in this series is small the median for follow-up is 19 months and there is a statistically significant improvement in back and radicular leg pain. This procedure therefore in selected cases can negate the need for laminectomy and major spinal fusion surgery. The Inspan interspinous distraction and stabilization system reported in this paper is a solid screwless fixation that works both as a distractor that decompresses the spinal canal and as a fusion device. It is a simple to use and safe system that eliminates the use of aggressive and invasive procedures such as pedicle screw and spinal cage type of fixation in the appropriate patient demographic. Though the number of test subjects is small, the follow-up timeframe is sufficiently long to showcase the effectiveness of ISP devices for back and leg pain reduction via decompression and stabilization. The results showing a statistically significant reduction in leg and back pain are encouraging. This procedure provides long-term benefit by leaving the level intact for future invasive procedures (should the need arises) like pedicle screw and cage type of spinal fusion. Furthermore, because it also involves posterior boney fusion, the effect should be good in the long term.


Background and Objectives: Notwithstanding patellofemoral pain syndrome (PFPS) being one of the most common causes of pain in the front of the knee in outpatients, few studies have shown the effects of radiofrequency on knee pain and function in this population. The aim of the present study was to determine whether outpatients diagnosed with PFPS obtained improvement in pain and function after treatment by dynamic application of monopolar dielectric diathermy by emission of radiofrequency (MDR). Materials and Methods: An experimental study was conducted with 27 subjects with PFPS. Subjects were treated with 10 sessions of MDR in dynamic application. The visual analogue scale (VAS), the Kujala scale, the DN4 questionnaire, the lower extremity function scale (LEFS), the range of movement (ROM) in knee flexion and extension and the daily drug intake were measured pre- and post-intervention and at the time of the follow-up (six months). Results: Statistically significant differences were found in pain perception , as well as improvements in functionality  and in ROM . No statistically significant changes in drug intake were found. Conclusions: The present study shows that the dynamic application of MDR seems effective in reducing pain and increasing functionality and knee flexion in patients with PFPS, after a follow-up of six months. Patellofemoral pain syndrome (PFPS) is a health condition of maximum topicality ,2,3. It Although the pain associated with PFPS is very characteristic, the causes of pain are as of yet unknown, traditionally being linked to cartilage damage. However, joint cartilage is known to have no nerve supply . As therThere is a large list of therapeutic approaches for the treatment of PFPS, likely due to a lack of understanding with regard to the etiology of the pain and dysfunction intrinsic to this condition. Physiotherapy is the most common approach within non-surgery-based treatments, particularly at the beginning of the pathology , includiHence, to accomplish the aim of the present study, among all the physiotherapy tools available, the electrotherapy treatment based on the application of monopolar dielectric diathermy by emission of radiofrequency (MDR) was selected. Few studies exist concerning its application in PFPS, despite being a frequently used physiotherapy technique. Non-statistically significant results were obtained in a 2012 study by Verma and Krishnan comparing the application of short-wave and strengthening vastus medialis exercises to McConell patellar taping and the same strengthening exercises . In addiFor all the above reasons, the aim of the present study was to assess the effects of MDR diathermy, after the follow-up of six months, in pain measured with VAS, in the neuropathic component of pain measured with DN4 ,17 and iThe design of this experimental study was a prospective uncontrolled trial. The study period was from May to December 2019. The research protocol was approved by the Andalusian Health Service Research Ethics Committee . Before inclusion, all participants signed an informed consent form agreeing to participate after being duly informed about the study and their rights.Patients over 18 years of age with PFPS were referred by a primary healthcare physician in the La Rinconada de Sevilla district . Only chronic patients who had undergone pharmacologic analgesic treatment and home exercise prescription, with a pain score of 30 mm and over in VAS and below 45 in the psychological apprehension scale (PPAS) , were inMeasurements were collected by a blinded researcher at baseline, post-intervention and at six months of follow-up after the last treatment. The treatment protocol consisted of a three-week intervention: the first week consisted of five treatment sessions (Monday to Friday); the second, three sessions ; and the third, only two treatment sessions (Monday and Thursday). Each session took 12 minutes and was performed by a physiotherapist with 15 years of experience using MDR. The whole study lasted for six months, which included three weeks of intervention and another six months of follow-up period without intervention.To assess the maximum pain experienced by the patients included in the study in the previous 24 h, the were asked to use VAS, which normally consists of a horizontal line, whereby a score of 0 mm would mean “absence of pain” and 100 mm would mean “the most insufferable pain” . The min®, a monopolar dielectric diathermy radiofrequency device . The applicator of this type of device must be used with dielectric substances instead of conductive ones, which is the most important differential point between the monopolar dielectric transmission and the bipolar capacitive-resistive one [MDR treatment was applied using ABD Modulartive one . The dietive one . Particitive one ,23  was chosen to calculate the effect size, considering it small when 0.01 ≤ ŋ2 ≤ 0.06, moderate when 0.06 ≤ ŋ2 > 0.14 and large when ŋ2 > 0.14. Statistical significance was determined at p < 0.05.The statistical analysis of the data was performed with PASW advanced statistics , version 24.0. Results were reported as mean (standard deviation) and confidence intervals (CI 95%). The normal distribution of the studied variables was verified by the Shapiro–Wilk test, after the appropriate descriptive analysis. Besides, the Levene test was used to assess the homogeneity of variances. To assess linearity, bivariate dispersion graphics of residual values were observed from the expected values. Differences in measurements were determined by analysis of variance of repeated measures within factors (ANOVA) to evaluate time interactions, including the effect of time . Eta square (ŋn = 27)  were selected for this experimental study. Although finally, 27 participants were enrolled in the study (n = 27) , comprisThe baseline, post-treatment and follow-up demographic characteristics  are shown in The clinical outcomes  are shown in Considering an improvement over the 20% in VAS as responding to the treatment, from the 27 participants, 14 (52%) improved after the three weeks of treatment, while 25 (93%) registered almost that improvement at the follow-up appointment.1,26 = 92.43, p< 0.000, ŋ2 = 0.78 and DN4: F1,26 = 124.15, p< 0.000, ŋ2 = 0.82), in knee disability  and in range of movement   . No statThe aim of this study was to investigate the clinical effects of the short- and long-term use of a popular electrotherapy technique such as MDR in the treatment of PFPS. Although there are many studies concerning PFPS, no strong evidence exists to support any specific treatment. As a non-surgical intervention, physiotherapy is widely used to treat PFPS: taping techniques and knee exercises seem to be the most effective treatment ,12,13,14The effects that diathermy devices based on emissions of radiofrequency have on knee pain have only been studied by few authors. In a recent study by Albornoz-Cabello et al., (2020), the addition of MDR to knee home exercises obtained greater pain improvements than exercise alone in participants with patellofemoral pain syndrome . In anotConsidering the results of Albornoz-Cabello et al., (2020) , the simn = 20).Another study carried out by Verma et al., (2012) revealed slightly better results for the treatment of PFPS with McConell taping plus exercises compared to short-wave diathermy plus exercises . It is iAs noted above, the most studied treatments for PFPS are taping and exercises. It can be seen from McConell’s study in patients with PFPS that taping for patellar alignment plus knee motor control and eccentric exercises represents a good a long-term solution, showing improvements in both pain and knee function . HoweverThus, regarding the previous information and the data generated by the present study, it can be considered that MDR could represent an effective treatment in managing knee functionality, range of motion and pain. However, the complex physiopathology of PFPS requires more studies in order to confirm whether or not improved clinical benefits can be achieved by combining this treatment with taping and knee exercises. Considering previous studies in patients with musculoskeletal conditions, such as supraspinatus tendinopathy  and loweThe present study has several limitations. First of all, a control group would be required to assess the possible interaction of time in outcomes. Secondly, the localization reduces the generalizability of the results; thus, future studies are needed with a multicenter design. Nevertheless, although participants were asked to avoid any change in their usual physical activity or treatment during the study, we cannot assure that all of them followed this. Further studies should consider higher cut-off values for clinical success and comparisons with other validated treatments.In the present study, participants with patellofemoral pain syndrome treated with monopolar dielectric diathermy by emission of radiofrequency obtained improvements in pain, the neuropathic pain component and functionality in the short term and at the six-month follow-up. Therefore, the application of MDR by a physiotherapist could be effective in pain reduction and function improvement. Further studies are needed to assume that improvements were due to intervention and not to time.


Temporomandibular disorders embrace a heterogeneous group of pathologies with manifestations in the orofacial region, head and neck. They are defined as a group of musculoskeletal and neuromuscular conditions that involve the temporomandibular joint, the masticatory muscles and the associated structures through interactions and reciprocal influences. They may present one or more signs or symptoms: orofacial pain, pain in the masticatory muscles or a combination of both . Accordia longitudinal quasi-experimental study with 26 patients with a diagnosis of temporomandibular muscle dysfunction (group I), on the masseter and temporal muscles, according to the Research Diagnostic Criteria for temporomandibular disorder. Patients were randomly picked up from the waiting list of the physiotherapy appointment at Clinica Egas Moniz (CEA) and randomised into two groups: 13 in the experimental group (G1) and 13 in the control group (G2). The groups were evaluated simultaneously but were not submitted to any intervention. The pain tolerance threshold was evaluated at pressure (2 kg), pain intensity measured with numeric pain rating scale (NPRS), before (T0) and after (T1) the intervention, and one week after (T2) the intervention. The intervention consisted of applying the dry needling technique to the painful points of the masseter. Statistical analysis performed in SPSS with a significance level of 5%. All the assumptions of the Helsinki Declaration have been fulfilled and a informed consent for clinical case of Clinica Dentária Egas Moniz approved by the ethic commission of Instituto Universitário Egas Moniz.p < .001) with averages and standard deviations respectively for: T0 8.34 ± 1.75; T1 79,886 ± 2.10; T2 1.78 ± 0.79. The pain intensity values decreased in T2 when compared to T0 in the G1 group (p < .001) with averages and standard deviations respectively for: T0 7.56 ± 1.36; T1 7.86 ± 1.52; T2 0.89 ± 0.72.G1 group was formed by 12 female and 1 male subjects with an average and standard deviation of 22.78 ± 3.75. G2 group was formed by 13 female with an average and standard deviation of 23.42 ± 2.45. Pain tolerance threshold at pressure values increased from T0 to T2 in G1 group (Dry needling promotes an increase in pain tolerance threshold values and a decrease in pain intensity values in patients with temporomandibular muscle disorder after a single session, reinforcing their importance in the treatment of themselves.


Introduction: Pneumatic tourniquets are used extensively in orthopedic hand/wrist surgery. Complications, while rare, are associated with elevated pressure and duration of tourniquet use. Limb occlusion pressure (LOP) is the minimum tourniquet pressure at which arterial blood flow is restricted. Therefore, we performed a cross-sectional double-blinded randomized control trial to assess if there is a difference in post-operative pain at the surgical and tourniquet site between LOP and standard tourniquet pressure and if there is a difference in post-operative opioid usage.Methods: A total of 44 patients  were randomized into two groups  of 22 patients controlling for gender . The primary outcome was a visual analog scale (VAS) for pain at the tourniquet and surgical sites, recorded for the first two weeks post-operative. Daily pain medication usage was recorded and quantified using oral morphine milligram equivalents (MME). A group-by-time generalized mixed-model ANOVA was used to detect within-group and between group (LOP vs STP) differences in VAS at the surgical and tourniquet sites as well as medication use. Results: LOP significantly decreased post-operative pain medication usage across the first week . Both groups had similar VAS pain at the surgery site, but the LOP group had 80% reduced pain at the tourniquet site when averaged across the first post-operative week (p<0.05). Conclusions: The use of LOP compared to STP elicits reduced post-operative pain at the tourniquet site and reduces post-operative pain medication use in the first post-operative week. Modern advances in tourniquet use include ease of use, numerous safety features, and the limb occlusion pressure (LOP) function -3. TournLOP is defined as the tourniquet pressure at which arterial blood flow is occluded . Modern Most existing tourniquet literature is based on lower extremity data; however, upper extremity surgeons rely on tourniquets to maintain visualization throughout surgical procedures. There have been recent attempts at minimizing tourniquet pressures in upper extremity surgery through multiple methods, including LOP, systolic blood pressure (SBP) measurements, and doppler ultrasound ,9,13. ThPostoperative pain control is fraught with many confounding factors, including psychosocial factors, patient perception, operative technique, and can also have an effect on surgical outcome and patient satisfaction -16. RelaThe primary purpose of this study was to determine if LOP causes less post-operative pain than STP at both the tourniquet and surgical sites following open carpal tunnel release. In conjunction with this aim, our secondary aim was to determine if potential reductions in post-operative pain translated into reduced opioid medication use for a period of two weeks following surgery. In light of previous literature, we hypothesized that LOP would decrease post-operative pain at the tourniquet site and overall narcotic usage. Additionally, we hypothesized that patient outcomes would be improved in the LOP group by decreasing complications and adverse side effects while having no effect on intraoperative blood loss or impairment of surgeon visibility.RecruitmentInclusion criteria consisted of all patients >18 years old undergoing open carpal tunnel release by one of two fellowship-trained orthopedic hand surgeons for mild, moderate, or severe carpal tunnel syndrome. The patient's diagnosis was confirmed via clinical assessment and/or electromyographic testing that failed non-operative treatment . PatientAll patients were randomized using a digital randomization function  to either the LOP or STP group. A total of 44 patients  completed all aspects of the study between January 1, 2019 - January 1, 2020 .Surgical procedure - open carpal tunnel releaseAll procedures were performed by two fellowship-trained orthopedic hand surgeons with standardized operative techniques. Surgeons and patients were blinded to the tourniquet technique using a cover over the pneumatic tourniquet controls and all necessary measurements were obtained prior to the surgeon entering the operating room. A tourniquet was placed on the operative extremity. The operative extremity was prepped and draped in a sterile fashion typical of standard surgical procedures. An Esmarch was used to exsanguinate the limb and the tourniquet was inflated to either STP (250 mm Hg) or LOP, which was premeasured, unique to each patient, and determined prior to surgery. Systolic blood pressure (SBP) and tourniquet pressure were recorded. Anesthesia was performed based on patient characteristics, preference, and anesthesiologist comfort. Patients had either general anesthesia or local/monitored anesthesia care (MAC) anesthesia.Both surgeons performed standard open carpal tunnel releases through a small volar incision. At the end of the case, all patients had 10cc of 0.5% bupivacaine injected at the surgical site. Wound closure was managed per surgeon preference with either interrupted 4-0 nylon or 4-0 subcuticular Monocryl. During surgery, intraoperative blood loss or impairment of surgeon visibility was rated on a scale of 0 (poor visibility) - 4 (excellent visibility) (Supplement) .Pre and post-operative measurementsPrior to participating, all patients were required to complete the disabilities of the arm, shoulder, and hand (DASH) questionnaire regarding functional disabilities of the hand . ThroughStatistical analysisPower and sample size: Previous literature  and prelA mixed-model analysis of covariance (ANCOVA) repeated on time, co-varied on baseline values was used to compare patient recorded VAS pain scores and medication usage  between groups (LOP and STP) for 14-days post-surgery. For all significant interactions indicated by type III tests of fixed effects, a Tukey’s post hoc adjustment was used for within and between group pairwise comparisons. Average pain medication usage and pain scores were compared using a two-tailed independent samples t-test for the first 48h post-op and across seven days post-op. A Mann-Whitney test for non-parametric data was used to compare the intra-operative visibility scores. Lastly, a Fisher’s exact test was used to compare the proportions of each subject group that reported taking any medication or having a VAS recorded pain for each day of the post-operative period. Type I error for all comparisons was set at α=0.05. For significant pairwise comparisons between groups, effect size was calculated using a Cohen’s D statistic. Effect sizes (ES) are interpreted as follows: 0-1 ; 1-3 ; 3-5 ; 5-7 ; >7 .Results for DASH scoring, intra-surgery measures, and post-operative blistering/bruising are as follows: no differences detected between groups other than tourniquet pressure used p<0.001), no differences were observed between groups for OTC medication use for any of the post-operative comparisons, and level of carpal tunnel severity did not differ between groups (STP: Mild (n=9), Moderate (n=12), Severe (n=9) | LOP: Mild (n=10), Moderate (n=9), Severe (n=10)) . This amounted to approximately an 80% reduction when pain scores were averaged across the first seven days post-surgery (p<0.05). Of note, post-operative VAS scores returned to being not significantly different from “0” by three days post-op in the LOP group compared to day 13 in the STP group. The proportion of patients logging a pain score greater than zero was observed to be significantly higher in the STP group at days 2-4,6,7, and 9-11 post-surgery (p<0.05) . This was observed at individual post-operative days (POD) 2 and 4 (p<0.05). This was also observed when looking at average consumption across the first 48 hours (p<0.001) post-operatively as well as the average for the first seven days post-operatively . Although no difference was detected for the proportion of patients taking pain medications each day, all patients in the LOP group were found to be finished taking medication by POD 7 whereas all patients in the STP group were observed to be finished by POD 9  for VAS can range from 1.2-5.4 depending on surgery type ,29. WhenLimitationsThis study is not without limitations. This investigation is a single surgery type with relatively short tourniquet times. However, patients were able to show a statistically significant difference in tourniquet site pain between LOP and STP despite such short tourniquet times, which is encouraging for future studies involving longer tourniquet times and higher post-operative pain levels. Patient pain tolerance variability is a limitation in any study analyzing pain medication usage post-operatively. Self-reporting also has inherent limitations affecting data interpretation . AdditioLOP can be applied to upper extremity orthopedic surgery, particularly carpal tunnel release, in a clinically impactful way that may decrease post-operative tourniquet site pain and opioid use. Most modern pneumatic tourniquet systems in operative centers have a LOP function and can be used with relative ease and minimal additional preparation time by operating room staff prior to incision. There is very little to no added risk or additional cost in the operating room when utilizing the LOP technology and is, therefore, an excellent candidate for becoming standard of care for reductions in post-operative pain and medication use. Further study is required to determine if LOP provides benefit in other surgical procedures where post-operative pain and narcotic use are common.


Patients with back pain are often in contact with 2–4 hospital departments when receiving a back pain diagnosis and treatment. This complicates the entire clinical course description. There is, currently, no model that describes the course across departments for patients with back pain. This study aims to construct an interdisciplinary clinical course using the central register’s information.All patients with back pain referred for diagnosis and treatment at the Spine Center of Southern Denmark from 1 January 2011 until 31 December 2017 were included. By means of information available in central registers, we described the interdisciplinary clinical course for the individual patient, including information on all contacts at different departments, and proposed three different models to define the index and final date. The index date was defined as the first visit without a previous contact to the Spine Center for 6 months for model I, 1 year for model II, and 2 years for model III. The final date was defined as the last visit without following contacts for 6 months, 1 year, and 2 years, respectively, for models I, II, and III.n = 30,976) with back pain diagnosis were identified. The three models all leave the information on the entire course at the hospital. In model I , the time span to a possible previous clinical course is too short to secure the start of a new course (14% had two or more). With at least 1 year between a possible previous contact, model II  fits the everyday clinical practice . In model III  it seems that two independent courses might be connected in the same course as only 5% had two or more clinical back pain courses.A total of 69,564 patients (male: Despite contact with different departments, the clinical course for back pain patients can be described by information from the central registers. A one-year time interval fits best the clinicians’ everyday observations. In 2010 the Danish National Health profile showed that about 20% of the Danish population reported low back pain in the preceding 14 days . DespitePatients with persistent disabling back pain may need a referral to specialized hospitals for diagnostics and treatment procedures such as surgery. Even though approximately 25% of the patients seen in the primary sector are referred to specialized hospital departments every year, due to back pain, we know very little about the clinical course and these patients’ characteristics . We know that patients are treated in different departments depending on the problem and the organization. Some patients are referred to one department, others to two or more, if needed.In order to be able to monitor national and international guidelines for the management of patients with back pain, there is a call for a nationwide monitoring system for back pain disorders. The objective of such a system is to use information from the national registries to establish a national back pain registry monitoring the clinical course for patients with back pain. This will provide patient-level relevant and comprehensive information to the health care personnel enabling them to optimize the delivery of evidence-based care (The Danish Spine Database). The secondary goal is to include information on pain, disability, and quality of health, but this information is not available in the registries and has to be included by means of questionnaires.In Denmark, all residents have free access to public health care, and all patients’ hospital services are collected centrally in national registries; it is thus possible to construct a database including information from different departments. The first step will be to develop a comprehensive database for patients with back pain using the Danish national central registries. The second step will be to assess the validity of the information given in the registry. However, patients seen in different departments are a challenge in register projects as the system xleaves no information on the linkage between visits related to the same clinical problem, and no information is given at the start and end of a course. Therefore, a model is needed for monitoring the management of patients with back pain, including details on the course across departments.The aim of this study is to describe the interdisciplinary course of patients with back pain referred for diagnosing and treatment at a specialized spine center. This is a means to assess the face validity of the information given in the registry, using the information available in the Danish central registries.This study is part of a large scale national study describing the course of back pain patients across sectors and specialties in the public health care system. To describe the individual course of the individual patient, algorithms are needed. This study describes the face validity of the individual course by information given in Danish central registries. The impact of such algorithms will provide the possibility to follow more than 50,000 incident patients seen in the hospital system each year.This is a retrospective register based cohort study. Since 1968, all Danish residents have been assigned a unique civil registration number, which allows record linkage among different Danish medical and administrative registries on an individual level, and it is mandatory by law to report to the Danish health registries . The DanThe Region of Southern Denmark comprises 1.2 M inhabitants. All non-emergency patients with back pain from this region, who need specialized diagnostics and treatment, are referred to the Spine Center of Southern Denmark (SCSD). We used the Danish National Patient Registry (DNPR) to identify our study population, which includes all patients referred to the SCSD with a cervical as well as low back pain diagnosis  between We chose the cohort from the SCSD because the authors have worked with this population clinically and for evaluation and have an in-depth knowledge of this group of patients, thus enabling assessment of face validity.We identified all back pain-related hospital visits and procedures using the DNPR including the following ICD10 classification codes: M41*, M503, M513, M53*, M54*, M62*, M998, M999. M43*, M45*, M46*, M47*, M480, M500–2, M510–2, M96*, M990–7. The information is stored in administrative courses linked to the hospitals’ departments. Patients who had contacts with more than one department during one clinical course will have more than one administrative course registered in the DNPR, which means that no information on the first and last visit in one continuous clinical course is registered in the DNPR. Therefore, to be able to follow the patient’s clinical course we have to define when a clinical course starts and ends using the information on the contacts during a certain time period, independently of the location for the contact. In our study, we defined the start of the patient’s first individual clinical course as the date of the first visit to the SCSD. The course ended when the patient had no contact during a specific time period after this date. Then a new individual clinical course can be initiated. In order to decide which time period without previous contact is most appropriate, we have constructed three models defined by the number of days that separate two individual clinical courses. In model I, we defined that a hospital contact with BPD starts with a new individual clinical course for the patient if the patient had no-hospital contact with BPD for at least 180 days, 365 days for model II, and 730 days for model III.We have described each population demographically to be able to choose the most appropriate model for further analyses. Figure Each of the three constructed models led to a number of courses. We calculated the length of each course and the time between courses. We defined the treatment and investigation procedures at SCSD and other hospitals by procedure codes including codes for MRI, surgery, and rehabilitation. We coded the surgical procedures in the spine by specific SKS codes  . ReferraWe used the Danish National Health Service Register to obtain information on contacts to chiropractor or physiotherapist treatment 3 months before the index date. The Danish National Health Service Register does not contain information on diagnoses. We believe that chiropractor or physiotherapist treatment carried out a few days before (or after) hospital contact is probably related to the back pain episode. Chiropractor or physiotherapist treatment was included in the clinical course if the visit was registered from 90 days before index the date. According to the Danish guidelines a GP may refer a non-acute back pain patient to a specialized spine center after the patient has been in chiropractor or physiotherapist treatment for 3 months.Age divided into two groups ≤60 and > 60, Sex , and somatic comorbidity – CCI, which was defined according to the Charlson comorbidity index (CCI) and classified into zero if CCI was equal to 0 and ≥ 1 if CCI was more than 0 [Moreover, we used the DNPR to define the following baseline variables: e than 0 , 16. TheThree models describing the interdisciplinary course are established by information in the DNPR. We calculated differences according to treatment procedures and demographics in order to describe whether the models performed as expected. Since referral practice and hospital care guidelines were changed numerous times during the study period, we performed all descriptive analyses separately for three cohorts: 2011–2013, 2014–2015, and 2016–2017 to evaluate whether the different models were stable over time. All statistical analyses were conducted in STATA version 16 on Statistics Denmark’s research computers via a remote server.In total, we identified 69,564 patients with at least one hospital contact with a back pain diagnosis from 1 January 2011 to 31 December 2017. Using model I, we identified 64,757 incident clinical back pain courses, 7842 patients (about 14%) had two clinical courses within the time period, 1474 had three or more, please refer to Table The distribution of performed clinical procedures is shown in Table The patients’ baseline characteristics at the start of a clinical back pain course are available in Table The aim of this study was, by use of information available in the central registers, to describe the face validity of a complex interdisciplinary clinical course for patients with back pain referred to a specialized spine center. We will use this model in future studies, evaluating the patients’ clinical course at different hospitals and departments. We proposed three models to define the index date and final date in a clinical back pain course by information given in DNPR. The models were applied in a cohort of patients who were referred to the SCSD with a back pain diagnosis from 1 January 2011 to 31 December 2017. We chose the SCSD as the population is well known to the authors and it is assumed that this knowledge will make it possible to assess the face validity of the model chosen to be used in future studies.Most patients from the study population (> 80%) had only one clinical course during the study period which corresponds to the information from the local PRO-database, Spinedata  and to oTo define the period used when indicating the start of a new clinical course we used three definitions: 6 months, 1 year, and 2 years where the patient had no contact to the SCSD. The number of patients seen in the three periods is as expected reduced from model I to III, and the number of previous clinical courses are higher for model I than for model III. To check whether the days of the clinical course change over time, the median time is measured for each model for each of the three time periods 2011–2013, 2014–2015, and 2016–2017. For all models the number of days is reduced according to organizational changes, the trend is the same for all three models and we concluded that all the models provide this information. For all models, the number of days in between the clinical courses increases during time, which also is in accordance with organizational changes. The difference between the three models is the number of clinical courses for each of the patients. If the period with no contact before the index-date is too short too many patients will have more than one course, if it is too long the risk of being referred twice because of different symptoms is too high. For all three models, we found that significantly fewer second and third clinical back pain courses start in the time period 2011–2013 than in 2016–2017. This is consistent with our expectation as the study’s observation time begins in 2011. Since most patients from the study population had only one clinical course during the study period, the similarity of the baseline characteristics in all three models is not surprising.The probability of starting the second and third clinical back pain courses in the period 2011–2013 is thus lower than starting the second and third clinical back pain courses in the period 2016–2017. This observation must be taken into consideration when identifying new cases by means of the central registers. From a clinical perspective model II is chosen as the most feasible and we concluded that future studies may include information on previous clinical courses and the diagnosis describing the cause of the visit to support the description of the population seen at a specialized spine center. Whether this assumption is valid in a national database, including the whole population of back pain patients, must be validated in the national database.To support the decision on using model II, the population in each of the three models was described by procedures performed during the clinical course and by baseline characteristics available in the registers. The MRI-rate declines a little through the time periods for all models. The surgical rate is stable and the referral-rate for rehabilitation increases for all models. Characteristics available in the registers were thereafter reported: age, sex, CCI, and prior treatment is stable in between the models, and changes during time is the same. It supports the conclusion that the models are rather stable when we look at demographics and treatment.The strengths of this method using central registers are multiple. All patients seen at defined locations will be included in the cohort, and it is possible to follow the patients treated at more than one department and hospital after the first visit. It is possible to include information on diagnostic procedures as well as treatment on the actual clinical course. The method can be used nationally while all departments report the same data on dates and procedures into the registers.The introduced model has some weaknesses. The validity of our model depends on the validity of the DNPR. Although it has been shown that DNPR has very high completeness according to the registration of clinical visits –19, to oThe described distribution of the patients’ baseline characteristics, as well as the clinical procedures, corresponds to what we observed on an everyday basis in the clinic . We founThe access to information registered in the DNPR leaves the opportunity to describe the population by sociodemographic information as the present. It also leaves additional opportunities for research and clinical control in the area of back pain disorders. Clinical back pain courses can be linked to other Danish central registries such as the Danish Prescription Registry –22, The Our model for generating interdisciplinary clinical back pain courses on patients referred to the SCSD can be applied to all patients with back pain in Denmark, leaving the possibility to compare back pain treatment quality across departments and hospitals in the country. A reduction in our algorithm’s broad usage could be differences in the classification of diagnoses across hospitals. The SCSD is a specialized spine center and thus more likely to use a standardized coding practice according to the ICD-10 classification of disease since the coding practice could be different; usage of the introduced model needs to be tested before applying it nationally.Patients solely seen in the primary sector are registered by diagnosis, therefore it is not possible to identify the first visit for patients seen by the GP, physiotherapist, or chiropractor. More than two thirds of the patients seen by health professionals are seen in the primary sector. The clinical course described in this paper is representative for the patients referred to a spine center, which has to be taken into consideration when register data is used to describe the clinical course for back pain patients. When patients seen in the primary sector are registered by diagnosis, the model described can be used for all patients seen by health professionals.The back pain course for the population of patients with back pain, referred for diagnosis and treatment at a specialized regional spine center, can be identified using the Danish central registers. The start and end of an interdisciplinary clinical course can be defined using time-intervals between clinical contacts. The one-year time interval fits best the clinicians’ everyday observations. Other clinically important information, such as intensity of pain, disability, and quality of life can be added to the back pain course by questionnaires, if needed.


Currently there is no recognized curative treatment for diabetic polyneuropathy (DPN). Strict glucose control and symptomatic pain relief are the first line management routes. DPN is a common complication of diabetes and has a major detrimental influence on the quality of life (QOL) for many patients. Due to the scope of the problem, it is imperative that treatment options which impede DPN's progression and restore sensorineural function should be researched comprehensively and made available to the masses at an economical cost. We reviewed a multitude of atypical treatment options for DPN including capsaicin, lidocaine, acupuncture, electrical nerve stimulation, alpha lipoic acid, benfotiamine, and acetyl-l-carnitine and explored the evidence to date regarding their safety and efficacy. Most of these options have been around for a long time and have promising pilot studies or small-scale trials focused on DPN treatment. Diabetes is the ninth major cause of death globally, and in the past three decades, the number of diabetic patients has quadrupled. Diabetes affects people of all ethnicities, ages, and genders . DiabeteThe diagnosis of DPN is through exclusion through a combination of focused investigations and the detailed clinical assessment of the neuropathic symptoms. Neuropathic symptoms could be commonly present with normal investigative results. Symptoms for DPN vary depending on the nerves affected and develop gradually over many years . Pain inThe prevention and management strategies of DPN traditionally focus on glycemic control, and hypoglycemics and dietary control play a significant role. Ideal management of factors such as hypertension, hypercholesterolemia, and hyperglycemia delay DPN development . NeverthCapsaicinFound primarily in chili peppers, capsaicin works by targeting the nociceptor to produce pain. However, high or repetitive doses of capsaicin induces an initial pain sensation that is followed by analgesia .Over the years, the idea of repetitive doses of capsaicin has been translated into higher concentration application. Early trials focused on low concentration capsaicin. A clinical trial from 1992 assessed the therapeutic benefits of topical 0.075% capsaicin in patients with chronic severe painful DPN, who were unresponsive to conventional treatment. Twenty-two patients were randomly assigned to be treated with capsaicin or a placebo cream over painful areas four times a day, over the course of eight weeks. Pain measures were assessed by baseline, two weeks and at eight weeks. The trial established that 0.075% capsaicin was more effective than placebo in decreasing pain intensity. During the follow-up open-label study, 50% of the patients reported improved pain control, whereas 25% reported that pain being unchanged or worse . More reThe evidence seems to be in favor of capsaicin’s therapeutic effect and safety but there is lack of active agent control trials for capsaicin and no consensus on the optimal concentration. Nevertheless, American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation consider capsaicin as a probably effective in lessening DPN symptoms and give it a level B recommendation . FurtherLidocaine patchesLidocaine was first manufactured in 1943. It functions through binding with sodium channels responsible for the generation of action potential, thereby preventing the transmission of impulses in the pain nerve fibers causing local anesthesia .An open-label, three-week trial was conducted to gauge the efficiency and tolerability of the 5% lidocaine patch in painful DPN. The dosing was flexible allowing up to four lidocaine patches for up to 18 hours daily. Patients showed significant improvements in pain and QOL measures during the three-week treatment period. A subgroup of patients treated for an additional five weeks retained the therapeutic benefits which allowed for the tapering of concomitant analgesic therapy. Systemic accumulation of lidocaine was not observed and the adverse effects were minimal .A two-week, open-label, nonrandomized, multicenter pilot trial was conducted to assess the efficacy and safety of the lidocaine patch 5% in patient with postherpetic neuralgia, DPN, and low back pain. Forty-nine of 107 included patients had DPN. Efficacy was assessed using the brief pain inventory (BPI). The trial concluded that with two weeks use of lidocaine patch treatment, all disease groups reported significant improvements of pain intensity and decrease in BPI scores. There were no reported side effects .Randomized controlled trials with placebo as well as other active agents are needed to rank its efficacy compared to first line agents.Electrical nerve stimulationTranscutaneous electrical nerve stimulation (TENS) was developed in 70s as a measure for pain tolerance in patient with chronic pain. Today it is used as a non-invasive method of pain relief through regulated electrical stimuli. It functions by sending an electrical pulse across intact skin to stimulate underlying nerves. TENS generates a non-painful electrical stimulus to elicit paresthesia .A randomized controlled trial involving 31 DPN patients was conducted to assess efficacy of TENS as a non-pharmacological treatment modality. Patients treated their lower extremities for 30 minutes each day for four weeks at home. Five patients from the placebo group and 15 patients from the active therapy group reported clinically significant reduction in pain scores. However, the active electrotherapy group reported substantial therapeutic effect far above the pain scores from the placebo group. The trial concluded that TENS reduced pain and discomfort of painful DPN . One plaIn a double blind, randomized study, 19 DPN patients received either treatment with a low frequency stimulation TENS device and placebo treatment with a duplicate but an inactive device. The patient’s symptoms were recorded at baseline, at six weeks and at 12 weeks of treatment using the new total symptom score (NTSS-6) and a visual analogue scale (VAS). Sensory nerve thresholds  and microvascular function were measured at baseline and after 12 weeks of treatment. The trial concluded that TENS significantly improved pain scores, numbness and allodynia. There were no changes recorded in the placebo arm [Trial results using TENS for pain control in DPN have yielded mixed results. TENS has also been studied for several other neuropathic pain syndromes like post-herpetic neuralgia, chronic low back pain, etc., and the results show equivocal to no benefit. For DPN, studies are small in size with no standard type of TENS studied. Bigger studies comparing TENS to other topical treatment options, systemic therapies and comparing different TENS device types are needed to prove its therapeutic effects. American Academy of Neurology considers it probably effective for treatment of DPN .AcupunctureOne of the oldest non-pharmacological treatments for pain is acupuncture, which dates back to 100 C.E. The first-time acupuncture was studied in US was in the 70s. Acupuncture has various possible mechanism of action, however, the most supported theory is the release endogenous opioids, causing an analgesic effect .There are handful of studies focusing on use of acupuncture for pain control in DPN. A small trial involving 46 DPN patient was carried to gauge the safety and efficacy of acupuncture. Patients were treated six times over 10 weeks. Thirty-four patients showed improvement in their symptom. The patients were followed for the next 18-52 weeks, 67% of the patients were able to either stop or significantly reduce their analgesic medication. A total of 77% reported clinically significant improvement in their symptoms, whereas 21% reported complete cessation of their symptoms. The trial concluded that acupuncture is a safe and effective treatment for the long-term management of painful DPN . AnotherA pilot study evaluated the therapeutic significance of two different methods of acupuncture: Traditional Chinese Medicine (TCM) and Japanese acupuncture in the treatment of painful DPN. The study lasted 10 weeks and consisted of seven patients only. Treatments were delivered once a week for trial duration. The trial concluded that patients assigned to Japanese acupuncture reported decreased pain intensity, whereas the group treated with TCM acupuncture reported minimal effects when measured using daily pain severity score. However, both methods reduced pain intensity per McGill Short Form Pain Score . A randoSimilar shortcomings are seen in evidence for efficacy of acupuncture in DPN as with other topical modalities. Studies are either very small in size or are just pilot studies without a follow-up larger study even if there is a signal of effect in smaller study. Moreover, the methodology in most trials is questionable. A meta-analysis consisting of 25 trials involving 1,649 participants although showed that acupuncture when compared to treatment with B12, B1, mecobalamin and no treatment had a better effect on general symptoms, the authors pointed out that clinically relevant conclusions cannot be drawn owing to poor design of most included trials and trials’ high risk of bias. For acupuncture to be considered as treatment option for DPN, better designed studies with relevant comparison arms are needed to show its benefits if any.Alpha-lipoic acidAlpha-lipoic acid (ALA) is a biological nutrient produced in minute quantities by plants and animals, including humans. ALA functions as an antioxidant and has a chemoprotective nature, as it oxidizes free radical and inhibits the degeneration of tissue cells. ALA concurrently plays the role of a cofactor for multiple mitochondrial enzyme interactions and can effectively regenerate other antioxidants such as vitamin C, vitamin E, and glutathione through redox cycling -28. MultA meta-analysis of four randomized, double blinded, placebo-controlled trials comprising of 1258 patients assessed the safety and the therapeutic value of intravenous (IV) ALA. The study concluded lipoic acid (600 mg daily) over three weeks as safe and quantitatively exhibited significant improvement in neuropathic symptoms . A multiBased on the current evidence, ALA use is associated with clinically significant improvement in neuropathic symptoms, with pain being the most improved symptom and can be considered as a treatment modality. Head-to-head studies comparing ALA to first-line pharmacotherapeutic agents such as gabapentin are needed.Acetyl-L-CarnitineAcetyl-L-Carnitine (ALCAR/ALC) is the derived amino acid form, produced by the acetylating carnitine . It servA randomized, double-blind, placebo-controlled clinical trial involving 333 patients was conducted over one year to assess ALC's therapeutic value. ALC was administered intramuscularly (1 g daily) for 10 days followed by oral dosage of 2 g daily for the remaining period of 355 days. Nerve conductions studies at conclusion compared to baseline showed significant electrophysiological as well as pain score improvement with ALC compared to the placebo group . An analA randomized, double-blind, multicenter clinical trial was conducted to demonstrate the safety and efficacy of ALC to methylcobalamin (MC) in the treatment of diabetic neuropathy. A total number of 232 diabetic patients were randomized to receive ALC or MC for 24 weeks. During the trial, clinical progress was assessed by the neuropathic symptom score, the neuropathy disability score, and the neurophysiological parameters. Each group at week 24 showed a noteworthy decline in both neuropathy symptom score and neuropathy disability score with no noted significant difference between the two groups .These clinical trials demonstrate safety and efficacy of ALC in treating DPN. The improvement in electrophysiological measures shows a more objective evidence of potential therapeutic benefit of ALC in DPN. There are no trials comparing ALC to standard-of-care treatment for DPN. Furthermore, the long-term data in placebo-controlled trials is restricted to one year only. Hence, the quality of evidence is still not considered high enough for it to be used for treatment of DPN as an alternative or adjunct to the pharmacologic agents.BenfotiamineDeveloped in late 1950s in Japan, benfotiamine is a synthetic lipid form of thiamin which is used as a treatment option for alcoholic neuropathy, sciatica, and other painful nerve disorders in alternative medicine. The mechanism for pain control is thought to be through increasing intracellular thiamine diphosphate levels, which serves as a cofactor of transketolase; this enzyme inhibits advanced glycation and lipid-oxidation end products, eventually preventing microvascular complications in diabetics .A randomized pilot study was conducted to evaluate the efficacy of benfotiamine in patients with DPN. The study included 40 patients with type 1 and type 2 diabetes with two or more years of neuropathic symptoms. One group received 50 mg of benfotiamine four times daily, and another group received a placebo. The study lasted for three weeks. A neuropathy pain score was used to assess symptoms of polyneuropathy and vibration threshold was used as electrophysiological baseline parameter. The trial concluded a significant improvement in the neuropathic score in the benfotiamine treated group compared to the placebo group. However, no changes were reported in regards to improvements in vibration perception threshold .Evidence for benfotiamine in treatment of DPN is still poor primarily due to few high-quality studies and short follow-up period. Moreover, there are no head-to-head trials with first line treatments for DPN. It is an economical and readily available product and could potentially serve as an adjuvant supplement for restoring normal physiological nerve function in diabetics. It may help with other chronic complications of diabetes due to its presumed mechanism of action.Treatment modalities other than the typical pharmacologic agents used for painful diabetic peripheral neuropathy have been around for a long time. Their use in general practice particularly for DPN is limited. Safety data for the use of these topical treatments (capsaicin and lidocaine), neuromodulation therapies (acupuncture and TENS) or nutritional supplements  is reasonably convincing. Efficacy data for some is more convincing than others. Almost all show significantly better symptom (primarily pain) control consistently in small to big studies. Those with better study designs  like capsaicin and ALA can be considered as an adjunct to DPN treatment. Most of these modalities lack evidence where they are compared to first-line therapeutic options. In absence of such evidence, despite their seemingly efficacious results from the pilot studies, they fail to make it into mainstream treatment guidelines.Further studies are needed to explore these potential treatment options. One or more of these options could potentially be equally good if not better than the typical pharmacologic agents used to treat DPN and may have more value because of their cost benefit and benign side effect profiles. Studies to identify optimal dosing and formulation of these therapies especially contrasting them to the typical agents with long-term follow-up data would help create better treatment alternatives for this globally ubiquitous problem.


Compression of the greater occipital nerve (GON) may contribute to chronic headache, neck pain, and migraine in a subset of patients. We aimed to evaluate whether GON decompression could reduce pain and improve quality of life in patients with occipital neuralgia and chronic headache and neck pain.In this retrospective cohort study, selected patients with neck pain and headache referred to a single neurosurgical center were analyzed. Patients (n = 22) with suspected GON neuralgia based on nerve block or clinical criteria were included. All patients presented with occipital pain spreading frontally and to the neck in various degree. Surgical decompression was performed under local anesthesia. Follow-up was made by an assessor not involved in the treatment of the patients, by telephone 2–5 years after the surgical procedure and an interview protocol was used to collect information. The data from the follow-up protocols were then analyzed and reported.When analyzing the follow-up protocols, decreased headache/migraine was reported in 77% and neck pain was reduced in 55% of the patients.Decompression of GON(s) may reduce neck pain and headache in selected patients with persistent headache, neck pain, and clinical signs of GON neuralgia. Based on the limitations of the present retrospective study, the results should be considered with caution. Mechanical needle stimulation of specific cervical roots can produce pain referred to the head . DiagnosEntrapment and compression of the greater occipital nerve (GON) can cause pain in the posterior part of the head, including the upper part of the cervical spine and migraine. Occipital nerve block is commonly used for the diagnosis and treatment of occipital neuralgia and primary headache conditions, as well as headache after head trauma , 30. PaiSurgical decompression of the GON has been used to treat GON neuralgia , migrainAll consecutive patients referred to a single neurosurgical unit  due to chronic neck-pain and headache between 2008 and 2012 and subjected to GON decompression were recruited to the present retrospective cohort study. The Regional Ethical Review Board in Lund, Sweden approved the study (Dnr 2016/324). All patients in the present study had undergone surgical decompression of the greater occipital nerve (GON) with the aim of reducing their symptoms. The follow-up was based on a telephone interview using a questionnaire and performed by an interviewer (A.E.) not involved in the treatment of the patients.Inclusion criteria were longstanding headache and neck pain not responding to conservative treatment  and clinical signs of uni- or bilateral neuralgia from the GON, treated with surgical decompression of the clinically symptomatic nerve(s). Exclusion criteria were cervical radiculopathy, other nerve entrapments in the neck and shoulder or other verified related diagnoses explaining the patient’s symptoms. The pre-operative medical records were analyzed in order to identify the most common symptoms reported by the patients to the treating neurosurgeon at the pre-operative visit and a follow-up protocol was designed.All patients were selected for the surgical procedure by an experienced neurosurgeon familiar with the diagnosis and its treatment (L.A.). At time of consultation, a clinical sign of entrapment of the GON(s) led to focused evaluation of this condition. Diagnosis was made by careful history and clinical examination. If palpation and percussion over the nerve caused severe pain in the occipital region and/or caused radiating pain cranially and frontally on the same side as the palpation, the diagnosis of GON entrapment was strongly considered. For differential diagnosis, a diagnostic GON block using local anesthesia (4–5 mL of 1% lidocaine) was used. If this block resulted in a marked relief of neck and headache, GON entrapment was also strongly considered. When other causes for the pain condition were excluded or considered unlikely, the patient was offered decompression of the GON.The surgery was performed under local anesthesia by a single neurosurgeon (L.A.) and the patient was fully awake during the procedure. The patient was placed in a prone position and a partial shaving of the surgical field was performed. After the area was sterilized, local anesthetics (mepivacaine (Carbocain) 10 mg/mL) were infiltrated in the subcutaneous tissue over the pain-producing nerve branch/es. A vertical incision of approximately 5 cm was made, and the nerve was identified by soft tissue dissection, released from constraining soft tissue and followed through the fascia and muscles. Microscope was used when needed, although not as a standard procedure.The nerve was released until it was considered to have a free passage. The wound was closed with resorbable subcutaneous sutures in two layers and nylon sutures in the skin. The duration of a unilateral surgical procedure was approximately 30 min. The patients were informed about wound tightness the first days after surgery, the risk of complications such as wound infections and potential loss or reduced sensation in the skin. The stitches were removed in a primary care unit after 12 days.Follow-up was performed at 2–5 years after surgery by an independent physiotherapist (A.E.) who had not been involved in the care or previous evaluation of the patients. Written information was sent home to the patients, and all patients signed an informed consent. The patients were then interviewed by telephone Fig. . The intFor the statistical analysis IBM SPSS Statistics version 22 for Mac was used . Age is presented as mean and standard deviations (SD) and range, for all other data descriptive statistical analysis was used.Nine men and 13 women with a mean age of 47 years (range 21–74) fulfilled the inclusion criteria and were enrolled in the present study  were negligible. However some patients reported deterioration of the pre-surgical, baseline symptoms Tables , 3, 4.TaThe results from the follow-up questionnaire are given in detail in Tables Intake of analgesics was decreased in 8/21 of the patients Table , and theThe present retrospective study describes a cohort of patients with chronic headache, neck-pain and a clinical diagnosis of neuralgia from the greater occipital nerve/s. The patients were clinically investigated by an experienced neurosurgeon who also diagnosed their occipital neuralgia. All patients presented with symptoms from the GON with occipital pain spreading over the skull and to the neck in various degree. This pain was reported as headache and/or migraine and neck-pain from the patients. In this paper, we only use the patients’ own description of their pain (headache or migraine). The same surgeon performed decompression of the symptomatic nerves and two to five years later, the cohort was followed up by a telephone interviewer using a customized protocol. The data from the follow-up protocols were analyzed, and the results presented in this paper, indicate that the surgical decompression reduced the perceived symptoms in this cohort of patients Table , 3.Interestingly, 20 of the 22 in the cohort had a history of trauma to the head and neck region.The majority of the patients had a cluster of symptoms difficult to incorporate into one diagnosis as facial pain, arm and shoulder pain coexisted in the cohort but none of the patients had radicular symptoms. However, headache may coexist with cervical radiculopathy  and fourUpper extremity nerve entrapment may cause symptoms such as pain, paresthesia, and muscle weakness . Nerve cWe used clinical signs, palpation and GON nerve block using a local anesthetic to establish the surgical indication. Occipital nerve block is commonly used not only for diagnosis but also for the treatment of occipital neuralgia, primary headache conditions, headache after head trauma  and whipPatients with longstanding pain in the head and neck region often present with secondary symptoms related to the pain. For that reason, our questionnaire was modified to also evaluate these secondary symptoms  and that the included patients had all failed prolonged conservative management, there are some important limitations. Since some baseline, i.e. pre-operative, information on patients’ symptoms specified in the questionnaire  was not available, we cannot exclude potential recall bias at follow-up. Furthermore, this retrospective study is not randomized and decompression was not compared to other treatments modalities. There was also a long period from the surgery to the follow-up, and we cannot exclude that the observed changes were due to the natural course of the condition. However, this explanation can be questioned since patient symptoms were chronic at inclusion and they were non-responders to conservative treatments before undergoing surgical GON decompression. Moreover, although an overall improvement was observed in the majority of patients, there were patients who reported more symptoms at follow-up.In selected patients with longstanding headache/migraine and neck pain, presenting with clinical signs of neuralgia from the greater occipital nerve(s), decompression of the nerve(s) appears to reduce patient-reported headache/migraine and neck-pain. Trauma to the head and neck region might precede the clinical condition. Due to the retrospective study design and the potential for recall bias the results have to be considered with care. Prospective studies might overcome these limitations.


Among all the prevalent painful conditions of the shoulder, frozen shoulder remains one of the most debated and ill-understood conditions. It is a condition often associated with diabetes and thyroid dysfunction, and which should always be investigated in patients with a primary stiff shoulder. Though the duration of ‘traditional clinicopathological staging’ of frozen shoulder is not constant and varies with the intervention(s), the classification certainly helps the clinician in planning the treatment of frozen shoulder at various stages. Most patients respond very well to combination of conservative treatment resulting in gradual resolution of symptoms in 12–18 months. However, the most effective treatment in isolation is uncertain. Currently, resistant cases that do not respond to conservative treatment for 6–9 months could be offered surgical treatment as either arthroscopic capsular release or manipulation under anaesthesia. Though both invasive options are not clinically superior to another, but manipulation could result in unwarranted complications like fractures of humerus or rotator cuff tear. Although the term FS and adhesive capsulitis have been used quite extensively, current ISAKOS guidelines favour use of the term er joint . The ISAer joint . FS or per joint , 3, and er joint . The peaer joint . 20% of er joint , 6. Bilaer joint .Associated conditions: Primary frozen shoulder is idiopathic, but two conditions are classically associated with FS; diabetes mellitus (DM) and thyroid dysfunction. The incidence of frozen shoulder in diabetic patients could vary from 10.8 to 30% [8 to 30%  with a t8 to 30% . Several8 to 30% , 13. Ano8 to 30% . Other a8 to 30% .Pathology: FS is characterized by intense inflammatory changes in capsule indicating a role of inflammatory mediators  and disturbance in local collagen translation, which result in global fibroplasia [, the capsule of the FS appears thick, congested and inflamed, particularly around the rotator interval and anteroinferior capsule along with thickened coracohumeral ligament (CHL) and superior–middle–inferior glenohumeral ligaments resulting in loss of flexion, abduction and rotations [roplasia –19. Macrotations , 21. Theotations , 23. An otations , 25. Incotations , 27. In Patients with FS complain of insidious onset of pain and stiffness without any preceding traumatic, infective, or inflammatory event. Pain is usually poorly localized, around the shoulder and is almost always troublesome in the night while the patient lies on the affected side. The index shoulder examination reveals global restriction of both active and passive range of movements (ROM) at least in two planes, and that is one of the critical findings. The loss of external rotation with arm by the side of the chest is one of the earliest signs. According to ISAKOS guidelines; if the range of movement is less than 100° in forward flexion, less than 10° in external rotation, and less than L5 vertebral level in internal rotation, it is defined as a global restriction of ROM . The strTraditionally, FS is described in ‘three clinico-pathological stages’ , which we find practical to understand and explain to the patients and decide the treatment plan –31. AnotFreezing stage (stage 1): It may last for 2–6 months. Clinically, stage 1 is predominantly characterized by moderate-severe pain and partial restriction of ROM. Pathologically, it is characterized by a slow onset of widespread inflammation involving capsule and synovium of the shoulder joint resulting in gradual onset of 'pain' as a principal symptom. Mere pain and only terminal loss of ROM in the early period of freezing stage of FS could be confused with rotator cuff tendinopathy as latter also presents with painful loss of terminal ROM. However, ROM does not progressively worsen in RC tendinopathy whereas it continues to worsen at every follow up in FS.Frozen stage (stage 2): It may last for 4–12 months. Clinically, this stage is characterized by both ‘pain and stiffness’ in varying proportions. Patients in the early phase of stage 2 have more pain while later phase of stage 2 comprises of more stiffness than pain. Pathologically, it is characterized by a gradual diminution in inflammation and onset of widespread fibrosis of capsule and ligaments which results in gross restriction of ROM.Thawing stage (stage 3): It may last for 6–26 months. Clinically, this stage is characterized by minimal pain and gradual resolution of stiffness. Pathologically, it is characterized by gradual resolution of inflammation and fibrosis, resulting in minimal pain and the progressive return of movements.The principal clinical characteristics of three stages are pain, pain and stiffness, and stiffness, respectively.The relationship between an established DM and thyroid dysfunction with FS is a known fact but the evidence to investigate an apparently ‘normoglycemic FS patient’ with fasting blood glucose level and haemoglobin A1C is mounting as several studies have confirmed that latter two investigations are often deranged in patients with FS , 33–35. Freezing stage: Since this stage is characterized by the presence of intense pain due to underlying capsule–ligament–synovium inflammation, the treatment strategy deployed in this stage should aim at minimizing pain. Many options are used to alleviate pain, such as NSAIDs, steroids , and pain-relieving physiotherapy (PT). A point needs to be stressed that none of these measures would relieve the pain entirely, and the entire exercise of pain minimization is aimed at enabling the patient to perform activities of daily living (ADL) with more ease, sleep better and gradually initiate the joint mobilisation PT. The mobilisation PT is principally aimed at ‘retaining’, and ‘slowly regaining’ the ROM. Of note-during the stage of intense pain, vigorous mobilization PT must be avoided as it can exacerbate the inflammation resulting in increased intensity of pain.Frozen stage: In this stage; pain is less, but the loss of ROM is profound due to fibrosis of capsulo-ligament complex. Hence the treatment strategy should be principally aimed to gradually ‘increase and regain’ the ROM by deploying a structured and well-sustained mobilisation PT program. Hydrodilatation (HD) could also be used as an adjunct in early frozen stage to break capsular fibrosis and accelerate the gain in ROM. Occasional analgesics keep the pain at bay. If sincere attempts of PT for several weeks–months and or HD fail to improve functional ROM and pain, MUA or ACR could be considered to accelerate the functional recovery in terms of regaining ROM and minimizing pain.Thawing stage: This stage is characterised by minimal or no pain and gradually improving ROM for past several weeks. Hence, sustained PT remains the mainstay of the treatment in this stage, which aims to gradually regain the ‘functional’ followed by total recovery of shoulder ROM. Any surgical interventions are hardly required in this stage.By and large, conservative treatment of frozen shoulder is successful in up to 90% patients –41. OnlyNSAIDs and other analgesics: NSAIDs remain one of the most common medical intervention in treating frozen shoulder . A shortCorticosteroid: Apart from NSAIDs, steroids are the second most commonly used drugs in the treatment of the frozen shoulder. Both oral steroid and local steroid injections are widely used. A paramount point to note that steroids in any form are beneficial only in early stages (freezing and early frozen) of frozen shoulder to control inflammation and ensuing pain, and there may not be any rationale to prescribe it in late stages of frozen shoulder with established fibrosis without much inflammation.Oral steroids: In several high-quality studies, moderate evidence was found in favour of oral steroid for improving pain, ROM and function when prescribed for ‘short term’ (6 weeks) in stage 1 , 47. HowLocal injectable steroids: Local injectable steroid is most frequently deployed medical method to provide relief from severe pain in freezing stage of FS. Systematic reviews and metanalysis have confirmed strong evidence in favour of steroid injections in improving pain and ROM as compared to placebo in the short term, and moderate evidence in the midterm , 49. TwoFurthermore, many issues regarding use of local injectable steroids such as optimal dose , 53, sinOf-note, steroid injections carry a risk of a transient increase in blood glucose levels (BGLs) occurring within 1–5 days in diabetic patients . HoweverAdverse events with injectable steroids: Minor complications such as facial flushing, chest or shoulder pain, dizziness and nausea are reported due to vasovagal reactions during injection [njection . Furthernjection .Physiotherapy (PT): Along with NSAIDs and steroids, PT remains one of the cornerstones in the treatment of the frozen shoulder. The arms of PT consist of ‘pain-relieving PT’, ‘mobilization PT’ and ‘strengthening PT’. In the freezing stage, it is better to use pain-relieving PT and avoid aggressive mobilization techniques as latter can exacerbate the pain. There are various modalities of ‘pain relieving PT’ such as Laser, short wave diathermy, ultrasound and hot packs , 63. PT,Once pain decreases, ‘mobilization PT’ can be started to retain and gradually regain ROM. The patients receiving PT must start with 3–4 sessions per day, with each session of 10–15 min, comprising of active-assisted ROM exercises, including forward elevation, abduction, rotations, and cross-body adduction. This must be combined with scapular and cuff rehabilitation along with core strengthening. Grigg’s et al. confirmed that patients in phase II of frozen shoulder report high satisfaction with four-direction stretching exercise . In the In comparison to PT vs. MUA in the frozen stage, a high-quality RCT confirmed the superiority of MUA compared to home exercise alone .Hydrodilatation (HD): In late freezing or early frozen stage, HD of the glenohumeral joint using saline, steroid, local anaesthetic agent is supposed to distend the capsule by breaking the ‘early intracapsular fibrosis’ which helps in improving ROM . A singlCalcitonin: Calcitonin decreases systemic inflammatory response and stimulate the release of endorphins . Yang etExtracorporeal shock wave therapy (ECSWT): An RCT involving 40 patients treated with ECSWT versus oral steroid confirmed that ECSWT significantly improves the functional outcome and ROM without any adverse events . In a syAcupuncture: Though few centres have tried using acupuncture in the treatment of FS and reported reasonable relief in pain and improved forward flexion , 77, theNerve block: Several authors report that single or multiple injections to block Suprascapular nerve in the treatment of frozen shoulder result in improved pain score and ROM , 80. HowManipulation under anaesthesia: MUA is a method wherein fibrosed capsulo-ligament complex of shoulder, which is a hindrance in regaining ROM, is forcibly broken by manoeuvring the shoulder across the ROM under anaesthesia. Krall et al. suggested that MUA is an effective method to improve function in patient with refractory FS in stage II, external rotation < 50% compared to opposite side and failure to respond to IA steroid infiltration . Of noteTechnique: Under anaesthesia, the arm of the patient is held with a short lever and shoulder is gently moved in flexion, abduction followed by external and internal rotation in 90° abduction  to improve function in patients with primary FS are recommended only when an extended conservative treatment for a period of 6–9 months fails to provide significant relief to the patient , 41, 81.Many studies have shown excellent short-, mid- and long-term results both in terms of lasting pain relief and ROM gains with ACR –101. ComTechnique: Under anaesthesia, diagnostic arthroscopy is performed from the posterior portal. The entry into the joint is often tricky, and care must be taken while inserting the trocar to avoid damage to the articular cartilage of humerus or glenoid. In case entry in the joint is not possible, force must be avoided, and gentle, controlled manipulation of joint should be done to break the extremely tight capsule, and that would enable the surgeon to insert the arthroscope. Lafosse et al. recommended lateral entry via rotator interval in tight shoulders to avoid damage to intraarticular structures during forcible entry [le entry . In almole entry . Literatle entry . Next, ale entry . Post MUle entry , 104–106Pain control and rehabilitation after MUA and ACR: Adequate pain control for 2–3 weeks using NSAIDs and local ice pack is quintessential for pain relief. Structured PT must follow immediately after the procedure, and continue for 4–6 months aiming to retain 'regained intra-operative' ROM. The PT program should consist of early passive and active-assisted ROM along with scapula stabilisation followed by active ROM combined with strengthening exercises for rotator cuff, scapular muscles, and core rehabilitation.MUA vs. ACR: Despite all said advantages of ACR over MUA, literature has failed to prove clinical superiority of ACR over MUA , 83, 97.While managing FS, clinician must investigate and manage the patient for any associated conditions especially diabetes and thyroid dysfunction alongside treating the FS. With the availability of trained musculoskeletal sonologist along with advanced sonographic machines, USG could be considered as a primary tool to confirm the diagnosis of FS and rule out secondary disorders rather than straightaway subjecting the patient to MRI. Largely, combination of conservative treatment works quite well in most patients of FS with good to excellent outcomes and must be tried for at least 6–9 months before embarking upon any invasive procedure. Nevertheless, no single conservative treatment option is found to be remarkably superior to others, and multimodal treatment comprising NSAIDs, steroid, and structured-sustained PT remain all-season favourites. Among the invasive procedures; both MUA and ACR seem to be equivocal in achieving functional improvement, but the latter is currently more preferred as it is largely devoid of most complications listed for MUA. Early and sustained PT along with good analgesia is quintessential postoperatively for a complete recovery. Considering overall recovery and achieving satisfactory functional outcomes, Diabetic patients continue to fare poorly as compared to non-diabetics.