The purposes of this study were to determine whether patients with mild biceps tendonitis required revision surgery after the biceps tendon was not surgically treated, while addressing concomitant pathology, and to evaluate whether preoperative groove pain affected patient-reported outcomes.t-tests compared postoperative patient-reported outcomes based on the presence or absence of preoperative bicipital groove tenderness.Patients who underwent shoulder arthroscopy between 2015 and 2018 by a single surgeon for rotator cuff pathology, debridement, and distal clavicular excision (DCE), with or without subacromial decompression (SAD), and where the biceps tendon was not surgically addressed were retrospectively identified. Inclusion criteria were mild LS , and a minimum 2-year follow-up. The primary outcome measure was the incidence of revision surgery. Secondary outcomes included American Shoulder and Elbow Surgeons (ASES) score, simple shoulder test (SST), pain level, and satisfaction scores. Two sample P = .62), SST (P = .83) scores, and postoperative pain (P = .65). Patients without bicipital groove pain had average respective ASES and SST scores of 93.70 ± 11.84 and 10.66 ± 2.47; those with bicipital groove pain averaged 92.00 ± 15.31 and 10.78 ± 1.87. There was no significant difference in overall satisfaction scores between patients with groove pain (9.42 ± 1.40) and those without .Sixty-four of 69 eligible subjects (93%) were evaluated at a minimum of 2 years postoperatively. One out of 64 subjects underwent revision to perform a biceps tenodesis. Overall, patients had high patient-reported outcome measures (PROMs) postoperatively. Ninety-seven percent of patients reported they would have the surgery again. The presence of preoperative bicipital groove tenderness had no effect on ASES (Patients with mild biceps tendonitis showed favorable outcomes with low revision rates and high patient satisfaction when the biceps tendon was not surgically addressed when the primary shoulder pathology was treated during arthroscopy, independent of preoperative groove pain.Level III, retrospective cohort study. This has led many surgeons to surgically address the biceps unless it looks completely normal. Two decades ago, many treatment algorithms favored addressing the biceps only for structural tears greater than 50%, or if unstable.,There is little argument that surgical intervention of the LHB tendon is indicated when severe tendinitis, structural tearing, or instability is present during shoulder arthroscopy.Following Institutional Review Board approval, patients who underwent shoulder arthroscopy by a single surgeon (K.F.B.) between 2015 and 2018 for rotator cuff pathology, debridement, and distal clavicular excision (DCE), with or without subacromial decompression (SAD), and where the biceps tendon was left alone were retrospectively identified. Inclusion criteria were mild LS (defined as a biceps tendon with less than 50% of its surface area and that was hyperemic in appearance by arthroscopic examination), age between 18 and 89 years at the time of surgery, and a minimum two-year follow-up. The exclusion criteria were patients with any structural tearing or instability of the LHB, unstable significant superior labrum anterior-posterior (SLAP) tears, diagnosis of adhesive capsulitis, treatment with a tenodesis, or less than a 2-year follow-up. We classified the LS into mild or moderate to severe when assessing the biceps intraoperatively. Examples of tendons from this cohort that were considered mild and not surgically addressed during arthroscopy are seen in Potential participants were mailed a letter or called to explain the purpose of the study, PROMs, and a return envelope. PROMs included American Shoulder and Elbow Surgeons standardized shoulder Assessment (ASES), simple shoulder test (SST), pain visual analog scale (VAS), and three site-specific questionnaires addressing surgical expectations. Once patients returned their consent form and PROMs, electronic medical records were used to obtain general demographics, comorbidities, concomitant surgical procedures, physical examination information from preoperative and postoperative clinic visits, and clinical outcomes. Data and PROMs were recorded on a data collection tool and scored.The patients were separated into two groups. Group 1 consisted of those who reported bicipital groove tenderness presurgery, and Group 2 reported no bicipital groove tenderness presurgery. These two groups created the independent variables. The dependent variables were the standardized PROMs of the ASES, self-reported outcomes of the SST, and results from the VAS pain scale and site-specific questions regarding surgical expectations. Further data collected included demographic, baseline variables, and surgical outcomes.P value for significance was set to <.05. The site-specific questionnaire, which contained "Yes/ No" questions, required nonparametric testing using the Kruskal-Wallis test with the P value for significance set to <.017. Because of the nature of the nonparametric tests, the P value was set at <.017 to show no significant differences between the groups for their responses.SPSS Statistics for Windows, version 27.0  was used to perform a multivariate analysis of variance (MANOVA) to analyze descriptive statistics and determine the main effect of bicipital groove pain on parametric outcome measures. The A total of 69 subjects were identified and sent the questionnaire. Sixty-four subjects responded (93% response rate). There were 36 subjects who experienced preoperative bicipital groove tenderness and 28 subjects with no preoperative bicipital groove tenderness. Demographic data are summarized in All patients had either rotator cuff repair (RCR), RC debridement with subacromial decompression (SAD), distal clavicle excision (DCE), or a combination of the 3 procedures. The most common procedures done in sequential order from greatest to least were SAD and RCR (41%), debridement/SAD for impingement syndrome/bursitis (22%), SAD and DCE (20%), and SAD with RCR and DCE (17%). A breakdown of the number of patients receiving each procedure, the number of patients in each group that exhibited bicipital groove tenderness in each group, and the postoperative satisfaction in each group can be found in V = 0.04, F = 0.49; P = .87. For the ASES scores, there was no significant difference in the scores of participants who had no bicipital groove pain (93.70 ± 11.83) and those who did . The SST scores showed no significant difference between those with no bicipital groove tenderness (10.66 ± 2.45) and those with groove tenderness . Patients with no tenderness (0.71 ± 1.74) and those with tenderness (0.93 ± 1.92) showed no significant differences for the subjective 0-10 VAS pain scale (P = .65). Similarly, patients with no tenderness (9.51 ± 1.27) and patients with tenderness (9.33 ± 1.75) demonstrated no significant difference in patient expectation scores (P = .64), with 10 being the highest level of postoperative expectation and 0 being the least. Lastly, patients reported their satisfaction on a scale of 0-10, whereas 10 indicated the most satisfaction with the procedure and 0 was the least. Patients with no tenderness (9.46 ± 1.38) and those with tenderness (9.44 ± 1.40) showed no significant difference in satisfaction scores (P = .92). All outcome measures had a low effect size of <.005. There was no significant effect of whether a patient experienced bicipital groove pain or on PROMs: P = .38. Only 1 of the 64 subjects enrolled required additional surgery to address persistent anterior shoulder pain felt to be potentially related to her biceps. Following injections, which seemed to provide temporary relief, a revision arthroscopy and biceps tenodesis were performed. However, the patient's anterior shoulder pain persisted at the latest follow-up.For all nonparametric data, to analyze the site-specific “Yes/No” questions, a Kruskal-Wallis test was completed. In regard to needing additional surgeries, there was no significant difference between Groups 1 and 2; P = .96; 57/64; 89%) of subjects enrolled perceived making a full recovery after surgical intervention. Additionally, there was no significant difference between Groups 1 and 2 regarding whether the patient would undergo surgery again  of the subjects enrolled stated that if they could go back in time, they would choose to have the same procedure.There was no significant difference between Groups 1 and 2 for the responses of perceived recovery , and SST scores  were comparable no matter if they had preoperative “groove pain” or not. Patients with groove tenderness (0.93 ± 1.92) and no tenderness (0.71 ± 1.74) also showed no significant difference for the subjective 0-10 VAS pain scale (P = .65). Although evaluation for anterior shoulder pain or groove pain is important in the preoperative evaluation, our results indicate that it may be reasonable to leave the biceps alone in the setting of mild inflammation whether the patient has preoperative bicipital groove tenderness or not. However, this ultimate decision-making by the surgeon should be done in the context of other underlying pathology. Although we did not evaluate on exam at 2 years postoperation if the subjects enrolled had postoperative bicipital groove tenderness after addressing their primary pathology, our results revealed that their pain levels were reported to be quite good, and patients were quite satisfied with their outcomes. Understandably, however, one could still argue that pain levels could still be improved, and they perhaps could have been better if a tenodesis had been performed.Preoperative bicipital groove pain or what we should probably term anterior shoulder pain in this group did not affect ultimate outcomes, which confirms sentiments that groove pain is not always helpful in the setting of concomitant shoulder pathology, such as rotator cuff tears. In this study, both ASES  was assessed to be mild. There is little consensus on when to address the biceps when the inflammatory pathology is mild. A potentially limiting factor to extrapolating these results is that different surgeons may still have varied subjective opinions on what constitutes a mild LS that may not require intervention.Our study has several limitations. There is little consensus regarding the clinical distinction between grades of pathology when it comes to the lipstick sign. Therefore, interobserver and intraobserver reliability may not be consistent. Surgeon bias may have been present when deciding to leave the biceps alone, as many other patients received tenodesis throughout the study period. Additionally, assessing the biceps in the groove with the elbow flexed does not assess more distal biceps pathology, which, if missed, may negatively influence postoperative pain scores and PROMs.Patients with mild biceps tendonitis showed favorable outcomes with low revision rates and high patient satisfaction when the biceps tendon was not surgically addressed when the primary shoulder pathology was treated during arthroscopy. Outcomes were not affected by the presence of preoperative groove pain.


BackgroundHemorrhoids refer to the abnormal enlargement of the anal cushions. They are a common anorectal problem with a prevalence of 5% in the general population aged greater than 40 years. The objective of this study was to compare Milligan-Morgan open hemorrhoidectomy with pedicle ligation with LigaSure  in terms of postoperative pain on day 1 and day 7. It is important to assess the technique that is associated with lower postoperative pain because both of these techniques are still practiced in the developing world.MethodsIt was a randomized controlled trial conducted in the Department of Surgery, Rawalpindi, Pakistan. A total of 100 patients were selected and were allotted into the two groups by lottery method. Patients aged from 15 to 60 years who presented with symptomatic third and fourth-degree hemorrhoids were included after taking informed consent. Patients who had a previous or concomitant anorectal disease, patients who had undergone previous surgery for hemorrhoids, and those who were anesthetically unfit for surgery (American Society of Anesthesiologists (ASA) class 3 or above) were excluded from the study. Pain was assessed using the Visual Analogue scale (VAS). Data was entered and analyzed using SPSS v. 23.0 . Chi-square tests were applied. P-value <0.05 was taken as statistically significant.ResultsOut of 100 patients, 68 (68%) were males while 32 (32%) were females. The mean age was 40.56±9.24 years. Postoperative pain at day 1 was 9.24±0.51 in the Milligan-Morgan group while that in the LigaSure group was 8.44±0.64 (p<0.0001). Postoperative pain at day 7 was 5.00±0.85 in the Milligan-Morgan group while it was 3.04±1.08 in the LigaSure group (p<0.0001).ConclusionLigaSure is a newer technique that helps to reduce complications as compared to other traditional hemorrhoidectomy procedures. Many patients avoid hemorrhoidectomy as it is associated with painful postoperative recovery. Pedicle coagulation with LigaSure was better than conventional Milligan-Morgan hemorrhoidectomy in terms of reducing the mean postoperative pain on 1st day and 7th day. Reducing the postoperative pain helps in greater patient satisfaction and lesser requirement of analgesia among patients of 3rd and 4th-degree hemorrhoids undergoing hemorrhoidectomy.  Hemorrhoids are normally found in the human body -3. InterSymptoms of hemorrhoids include bright red painless per rectal bleed, mucus discharge, and prolapsed anal mucosa. If left untreated, they may lead to complications like strangulation, thrombosis, ulceration, gangrene, fibrosis, or portal pyemia . A hemorThe LigaSure  is a novel device consisting of a bipolar electro-thermal device with an optimized combination of pressure and radiofrequency, with the ability to seal blood vessels up to 7mm in diameter and associated with a collateral thermal injury confined to 2mm over the surgical field. This confined spread decreases reflex anal spasm and a bloodless hemorrhoidectomy is possible with reduced postoperative pain and rapid healing. Thus, this operation can be advocated as the ideal technique because of the potentially decreased collateral tissue trauma . Among tThe aim of this study is to evaluate the LigaSure pedicle coagulation in comparison with conventional Milligan-Morgan hemorrhoidectomy pedicle ligation and if proven effective it will result in less postoperative pain, more patient satisfaction, and less requirement of analgesia.Study setting and durationThis study was a randomized controlled trial conducted at the Department of Surgery Holy Family Hospital, Rawalpindi from 10th October 2021 to 10th April 2022.Ethical approvalThis randomized controlled trial was approved by the Ethical Review Board of Rawalpindi Medical University. The reference number is SUR-96-46-23.RandomizationA total of 100 patients were divided into two groups of 50 each and were randomly allotted into one of the two groups by lottery method. Group A comprised of patients undergoing Milligan-Morgan open hemorrhoidectomy and group B comprised of patients who underwent pedicle coagulation by LigaSure. Randomization was single-blinded meaning that the patient did not know about the one procedure that was going to be used among the two procedures.Eligibility criteriaBoth male and female patients aged 15 to 60 years, who presented with symptomatic third, and fourth-degree hemorrhoids were included after taking informed consent. Patients who had a previous or concomitant anorectal disease, patients who had undergone previous surgery for hemorrhoids, and those who were anaesthetically unfit for surgery (ASA class 3 or above) were excluded from the study.The procedure of pedicle coagulation hemorrhoidectomyAfter administering standardized spinal or general anesthesia the procedure was carried out with the patient in the lithotomy position. After examination under anesthesia, hemorrhoids were delivered with the help of artery forceps. One of the artery forceps was applied at the mucocutaneous junction of the hemorrhoid and the other at the apex of the hemorrhoidal tissue. A skin incision was given at the base of the hemorrhoids and dissection was done to separate the hemorrhoidal tissue from the internal anal sphincters. After this, in Milligan-Morgan’s open technique, the hemorrhoid pedicle was transfixed with zero number Vicryl suture while in the other group, the hemorrhoid pedicle was coagulated with the help of LigaSure.Postoperative procedurePostoperatively patient was given a ketorolac injection of 30 mg 8 hourly and pain was recorded on a visual analog pain score ranging from 0 to 10 after 24 hours. Follow-up was done on the seventh postoperative day in the surgical outpatient department. Mean post-operative pain was calculated. This randomized controlled trial was done in accordance with Consolidated Standards of Reporting Trials (CONSORT) guidelines as shown in Figure Data analysis150 subjects were initially enrolled in the study. 50 patients were excluded and a total of 100 patients were divided into two groups of 50 each. The collected data was entered in the SPSS Statistics v. 20.0 . Qualitative variables like gender, ASA grade, and grade of hemorrhoids were measured as frequencies and percentages. The quantitative variables like age and postoperative pain were measured as mean ± SD. Independent samples t-test was used to compare postoperative pain in both groups. Effect modifiers like age, gender ASA class, and grade of hemorrhoids were controlled by stratification. Post-stratification chi-square test was applied. P-value ≤ 0.05 was significant.A total of 100 patients were included in the study out of which 68 (68%) were males whereas 32 (32%) were females. Both genders were equally distributed within the study groups. There were 34 males and 16 females in each of the two groups. The mean age of the study participants was 40.56±9.24 years. The mean age of the patients in group A (Milligan-Morgan open hemorrhoidectomy) was 43.84±9.98 years and that in group B (pedicle coagulation by LigaSure) was 37.28±7.15 years. Out of 100 patients, 82 (82%) belonged to ASA class I while the rest 18 (18%) were of ASA class II. Thirty-six out of 82 (43.9%) in ASA class I and 14/18 (77.78%) in class II were in study group A. Forty-six out of 82 (56.1%) in class I and 4/18 (22.22%) in class II were in study group B.Eighty-four out of 100 (84%) patients had grade 3 hemorrhoids while 16/100 (16%) had grade 4 hemorrhoids. Out of 84 patients with grade 3 hemorrhoids, 38 45.24%) were in study group A while 46 (54.76%) were in study group B. Similarly, out of 16 patients with grade 4 hemorrhoids 12 (75%) were in group A while 4 (25%) were in group B. postoperative pain on day 1 was 9.24±0.51 in the Milligan-Morgan group while that in the LigaSure group was 8.44±0.64. This difference in mean postoperative pain at day 1 was statistically significant between the two groups (p<0.0001). postoperative pain on day 7 was 5.00±0.85 in the Milligan-Morgan group while it was 3.04±1.08 in the LigaSure group. Mean postoperative pain at day 7 was also statistically significant between the two groups (p<0.0001). postoperative pain on both day 1 and day 7 was significantly lesser in the LigaSure group which means that the LigaSure procedure is associated with better postoperative clinical outcomes as compared to the Milligan-Morgan procedure. A comparison of mean postoperative pain in both study groups is shown in Figure 4% were iThe results of stratification for postoperative pain at day 1 and day 7 with regards to age, gender, ASA class, and hemorrhoids grades are shown in Table Hemorrhoidectomy is an effective treatment for 3rd and 4th-degree hemorrhoids . HoweverIn our study, the mean age of the patients with hemorrhoids was 40.56 years. This is consistent with the study by Ravindranath and Rahul, where the mean age was below 40 years of age . Ali andThe results of stratification showed that postoperative pain at day 1 was higher in the age group 26-60 years (8.88) as compared to the age group 15-25 years (8.00) in the Milligan-Morgan group. Similarly, postoperative pain at day 7 was also higher in the age group 26-60 years as compared to 15-25 years in both the study groups Postoperative pain at day 1 was higher in grade 4 hemorrhoids (9.25) as compared to grade 3 hemorrhoids (8.76) in the Milligan-Morgan group. Whereas postoperative pain at day 7 was more in grade 3 (7.12) as compared to grade 4 hemorrhoids (6.02) in the LigaSure group. LigaSure is a newer technique that helps to reduce complications as compared to other traditional hemorrhoidectomy procedures. Many patients avoid hemorrhoidectomy as it is associated with painful postoperative recovery. This study concluded that pedicle coagulation with LigaSure was better than conventional Milligan-Morgan hemorrhoidectomy in terms of reducing the mean postoperative pain on 1st day and 7th day. Reducing the postoperative pain helps in greater patient satisfaction and lesser requirement of analgesia among patients of 3rd and 4th-degree hemorrhoids undergoing hemorrhoidectomy.


Background: Trigeminal neuralgia (TN) is defined as a spontaneous painful sensation in the trigeminal nerve territory. The pain intensity of TN is classified into different grades of suffering that affect a patient’s quality of life. Percutaneous balloon compression of the ganglion is a neurosurgical option that is easy, reproducible, and can reduce the morbidity of TN.Methods: We retrospectively analyzed all patients treated with trigeminal nerve percutaneous balloon compression at the Clinical Hospital of the University of Chile between January 2012 and May 2022. Data collected from electronic records included demographic information, medical and surgical history, type of anesthesia and drugs used during surgery, balloon inflation time, surgery time, operative room time, intraoperative events, postoperative complications, duration of hospitalization, and duration of follow-up. Results: We identified 63 patients who met our inclusion criteria. The median patient age was 62 years (interquartile range [IQR] 57-69 years). Sixty-five percent of the patients were female. The simultaneous involvement of the second and third branches of the trigeminal nerve was the most frequent symptom. Before surgery, the patients experienced an average of 6.6 years of pain (IQR 2-10 years). Right neuralgia was the most frequent laterality type (69%). Forty percent of the patients had a previous surgical procedure for neuralgia, with treatment failure being the most frequent surgical indication (63%). According to the procedure, the mean balloon insufflation volume was 0.89±0.12 mL with a median compression time of 2.5 min (IQR 2.1-4.0 min). No hemorrhagic complications were observed. Furthermore, during follow-up, there were no surgical complications among any of the patients; however, 6.4% of patients required a second intervention. The pain-free period was two years in 60% of patients and five years in 23% of patients.Conclusions: TN is a painful condition. Although there are multiple surgical approaches, we believe that percutaneous balloon compression is an excellent alternative treatment option that offers high effectiveness, low morbidity, and low hospital stay.  Trigeminal neuralgia (TN) is defined as a spontaneous painful sensation in the trigeminal nerve territory. Pain intensity involves different grades of suffering that affect the quality of life. The main criteria for diagnosis are brief, intense, and sudden paroxysms of pain triggered by innocuous stimuli such as talking, chewing, or light touch of the overlying skin, and is restricted to one or more branches of the trigeminal nerves . AlthougTreatment options include medications and surgery. The initial management of choice for TN is medical pharmacotherapy. Patients who do not tolerate or fail medical management may benefit from surgery ,4. The oIn general, all techniques have an initial response of more than 80% at five years, and MVD has a superior response compared to the other techniques. Significant risks associated with MVD occur at rates of less than 2% and include stroke, meningitis, and death .Percutaneous balloon compression (PBC) of the Gasserian ganglion (GG) is an alternative neurosurgical treatment option. The technique involves needle insertion through the foramen ovale under the GG. With the needle tip placed in Meckel's cave, a Fogarty catheter is inserted, and balloon insufflation with contrast material is performed under direct radioscopic vision. The balloon is loaded with up to 1 mL of the solution, compressing the ganglion for 1.3-3 minutes (Mullan technique). Compression of trigeminal fibers allows for immediate pain relief in 80-90%. Advantages of this technique include high effectiveness, a low hospital stay, and minimal morbidity and mortality .In 1991, we started treating TN using PBC of the GG. Here, we present the results of a 10-year retrospective review (2012-2022) at the Clinical Hospital of the University of Chile.This article was presented as a poster at our Chilean neurosurgical meeting in September 2022.Study design and settingA retrospective study was conducted using digitized records of patients who underwent PBC of the trigeminal nerve at the Clinical Hospital of the University of Chile between January 2012 and May 2022. The study received approval from the ethics committee (Ref: OAIC:33/2022). All personal information was handled confidentially.A search was conducted within the electronic clinical records of all surgeries identified using the terms "Percutaneous balloon compression" and "Neurolysis with microsurgical technique." Patients who underwent alternative procedures, including peripheral neurectomies, percutaneous glycerol rhizotomy, percutaneous radiofrequency rhizotomy, radiosurgery, and MVD, were excluded from the analysis.Data collected from electronic records included demographic information, medical and surgical history, type of anesthesia and drugs used during surgery, balloon inflation time, surgery time, operative room time, intraoperative events, postoperative complications, duration of hospitalization, and follow-up time of patients Table .Quantitative variables and statistical methodsCategorical variables are summarized as relative frequencies. Continuous variables were expressed as means (and standard deviations) or medians (and interquartile ranges [IQR]). We found 63 patients treated with PBC within the 10-year lookback period  was the most frequent symptom, followed by the independent involvement of each of the territories. Patients were treated after 6.6 years of pain (IQR 2-10 years), with right neuralgia as the most common laterality (69%). Medical treatment failure was the most frequent surgical indication (63%), and in the 10-year study period, the recurrence rate was 25%.All procedures were performed under general anesthesia. Propofol/remifentanil site-based target control infusion was the most frequent technical procedure for the administration and delivery of anesthesia.All surgeons performed the same procedure Table , 2. DuriAfter surgery, only one patient presented with pain and 16 (25%) had hypoesthesia or paresthesia of the V2-V3 territory. The mean postoperative stay was one day. No hemorrhagic complications were observed in our case series.Based on our records, during a median follow-up period of four months, no patient experienced any surgical complications; however, 10 patients presented with pain recurrence that required a second PBC procedure after 2.7 years.Finally, a phone interview with the entire cohort was performed. Of the 42 patients who had their first surgery at our center, 29 responded to the telephone evaluation. Of these, 18 patients showed evolution to mild facial hypoesthesia. Additionally, three patients required a new surgery. Of these, one patient was pain-free for three months, one patient for one year, and one patient for two years before requiring a second surgery.TN is a benign disease that does not modify a patient's life expectancy but has a meaningful impact on daily living activities. In this study, we reported our 10-year single-center experience with PBC of the GG for the treatment of TN.Although TN is a rare condition, affecting 4-13 people per 100,000 annually, it is the most common facial neuralgia. It is more common in women 2:1), with an incidence that increases with age and is more frequent in the fifth or sixth decade of life [:1, with Neurological examination and neuroimaging should exclude secondary causes, such as vascular malformations, multiple sclerosis, or expansive processes (secondary TN). Angio-magnetic resonance allows anatomical structure visualization of the trigeminal nerve and its relationships and is especially useful for ruling out neurovascular compression that may lead to posterior fossa surgical exploration, particularly in younger patients ,6-8.The pathophysiological origin of classic and secondary TN is nerve damage at its entry into the pons, and the trigeminal nerve  loses its Schwann cell myelin sheath, which is replaced by central myelin generated by oligodendrocytes. This transition zone is vulnerable to damage, particularly demyelination. Demyelination at these sites has been demonstrated by neurophysiological, neuroimaging, and histological studies . When thPharmacological and surgical management are used as TN treatment modalities Table . MedicalSurgical intervention for TN patients is necessary whenever adverse effects or symptoms are not abated with medical treatment. These options include MVD, PBC, percutaneous radiofrequency rhizotomy, percutaneous glycerol rhizotomy, and stereotactic radiosurgery. The most used techniques are MVD and PBC, which are strong, viable alternative options due to the low morbidity associated with these techniques. In general, all techniques have an initial response of more than 80% at five years .MVD is a suboccipital craniotomy. It is the most invasive technique but has a superior response at a 10-year follow-up compared with the other percutaneous techniques. Significant risks associated with MVD occur at rates of less than 2% and include stroke, meningitis, and death, but in experienced hands, the complication rate is relatively low .Radiofrequency rhizotomy provides a high initial success rate of 90%, though recurrence occurs in 25% of cases, with a long-term response rate of 57.7% at five years. PBC provides immediate pain relief in 80-90% of patients, with a long-term response rate of 69-80% at five years ,2,16-18.An interesting finding was that patients underwent surgery with 6.6 years of symptoms, probably due to low suspicion and low referral to specialists (neurologist or neurosurgeon). Furthermore, in the 10 years reviewed, we recorded a recurrence rate of 25%, which is compatible with the literature. These patients underwent a second surgery in an average of 2.7 years. PBC of the GG damages the thick myelinated fibers (which trigger pain by ephaptic-type contact with nociceptive fibers), usually leaving the thin and unmyelinated myelinated fibers unharmed ,9,10. FiDuring compression, pear-shaped balloon insufflation indicates adequate balloon pressure in the cavity. An hourglass image denotes balloon protrusion into the prepontine cistern. In such cases, the catheter is deflated, removed a few millimeters, and again insufflated. Exaggerated balloon insufflation compresses the upper inner wall of the cavum, with cranial nerve VI involvement. In our series, we observed a first-attempt, pear-shaped image in more than 90% of the patients.Although percutaneous techniques are "less invasive," they also carry a risk of loss of sensitivity in the trigeminal territory, dysesthesia, loss of corneal reflex, painful anesthesia, meningitis, subdural hematoma, and a very low risk of mortality ,21-24.If a patient's pain is refractory to PBC performed using the proper technique, it is necessary for the practitioner to review the patient’s diagnosis. Patients with long-standing neuralgia and treatment-resistant trigeminal naturopathy can develop atypical facial pain.TN is a severely painful and disabling condition. Our 10-year experience with GG PBC highlights its efficacy after medical treatment failure. We observed high effectiveness and low morbidity, as evidenced by the absence of surgical complications and minimal symptomatic recurrence. While MVD remains the gold standard, our analysis suggests that PBC presents a compelling and easily implementable alternative for neurosurgical teams.As a team, it seems interesting for future studies to protocolize the postoperative management of patients based on pain scales and local protocols in order to offer different surgical options depending on each patient. Even so, sufficient data have not yet been obtained and further studies are needed.


Pharmacological therapy for acute pain carries the risk of opioid misuse, with opioid use disorder (OUD) reaching epidemic proportions worldwide in recent years. This narrative review covers the latest research on patient risk factors for opioid misuse in the treatment of acute pain. In particular, we emphasize newer findings and evidence-based strategies to reduce the prevalence of OUD.This narrative review captures a subset of recent advances in the field targeting the literature on patients’ risk factors for OUD in the treatment for acute pain. Besides well-recognized risk factors such as younger age, male sex, lower socioeconomic status, White race, psychiatric comorbidities, and prior substance use, additional challenges such as COVID-19 further aggravated the opioid crisis due to associated stress, unemployment, loneliness, or depression.To reduce OUD, providers should evaluate both the individual patient’s risk factors and preferences for adequate timing and dosing of opioid prescriptions. Short-term prescription should be considered and patients at-risk closely monitored. The integration of non-opioid analgesics and regional anesthesia to create multimodal, personalized analgesic plans is important. In the management of acute pain, routine prescription of long-acting opioids should be avoided, with implementation of a close monitoring and cessation plan. Opioid use disorder (OUD) is a pattern of harmful opioid use that leads to clinically significant distress or impairment with physical or mental impairments and/or legal consequences ••. OUD iSince the 1990s, increased prescribing of opioids in high-income countries has led to iatrogenic dependence and later to illicit opioid use. Since 2010, several interventions to reduce the supply and extra-medical use of prescribed opioids, such as prescription monitoring programs and “pill mill” laws, have been introduced. These interventions led to a transition from opioid to heroin use from the late 2000s, followed by a third wave starting around 2013 as highly potent synthetic opioids like illicitly manufactured fentanyl entered the market –7.Opioids are used to treat acute and chronic pain, such as post-injury pain, or chronic diseases such as cancer ••. In suOpioids remain an important and potent measure when treating acute postoperative pain, although recent findings showed that excessive and/or prolonged prescribing, both in-hospital and at discharge, contributes to the current opioid crisis and increase patient harm ••.In 2017, the global age-standardized rate of opioid dependence per 100,000 people was 510, with the highest estimated prevalence in the USA at 1347 per 100,000 people .Several risk factors for OUD have been identified, including younger age, male sex, lower education level, lower socioeconomic status, race/ethnicity, psychiatric comorbidities , 13, andIn order to reduce OUD, opioid prescriptions should be made after evaluating both, the patient’s risk factors and individual preferences, and short-term prescribing should be considered. In addition, the opioid use should be monitored and followed closely in those patients at risk for persistent or new chronic opioid use ••. To miThe main risk factors for the development of OUD, such as younger age, male sex, lower education level, lower socioeconomic status, race/ethnicity, psychiatric comorbidities ••, and pIn this narrative review, we capture a subset of recent advances in the field targeting the literature on patients’ risk factors for OUD in the treatment for acute pain.A major risk factor for OUD is the duration of patients’ misuse following initial therapy for acute pain, with no fewer than 6–19 days of opioid intake increasing dependency by 3.5-fold, and 20–30 days by 5.5-fold •, 29, 30Another patient-related risk factor for OUD development in the treatment of acute pain is a history of mental illness such as anxiety disorders, or depression ••, incluAdequate pain management is crucial in preventing the development of OUD in the perioperative setting . Pain trCurrent evidence confirms increased risk of developing OUD in patients exposed to opioids following trauma, as early as 3 months after initial exposure . Also, pMost opioids prescribed for adults are also used by children and are generally well-tolerated, except for codeine ••. The lIn the elderly population , problematic opioid use and OUD have been increasingly observed, with both illicit and prescription opioids . Risk faRegardless of age, however, opioid misusage has been linked to psychological factors and single social determinants of pain rather than somatic factors .In the management of pain and of OUD, there are significant demographic disparities encountered ••. PreveAs of 2019, the COVID-19 pandemic posed new challenges to the global consequences of the opioid crisis: in the USA, patients with OUD were at a higher risk of COVID-19 hospitalization and subsequent worse course of disease, including death, sepsis, kidney failure, and an increased risk of intubation . Beside,In general, OUD patients suffering from COVID-19 were older, more likely to be Black or Hispanic with an increased likelihood of having other medical comorbidities like hypertension, cardiovascular disease, chronic pain disorder, diabetes, substance disorders, or mental health issues . HoweverIn the COVID-19 era, approximately 22% of opioid-naïve patients were treated with opioids during hospitalization, with 8% of them receiving a new opioid prescription upon discharge . In contAppropriate discharge prescriptions are vital and should be consistent with the current practice guidelines of safe opioid stewardship, with close follow‐up to reduce their availability in the community .The trend of increasing opioid prescriptions for acute pain has also been noted in patients with headache disorders, despite a lack of evidence of benefit from its use –66. OpioGiven the significant drawbacks of opioids, referral to a neurological center with headache specialists is key for patients to ensure correct diagnosis and adequate treatment planning depending on the type of headache . In addiMembers of the US military are at particularly high risk of OUD or use of other sedatives –74. A 53In summary, in the acute setting, the use of short-acting opioids is pivotal in members of the military suffering from more severe injuries, additional mental health conditions, lower socioeconomic status, or known previous opioid exposure. Moreover, these patients experience particular benefits from multimodal pain management and regular follow-up visits , 75••.Prevention strategies for OUD development imply proper assessment and identification of patients at risk for opioid misuse or addiction. However, most screening tools were either based on low-quality studies or were hardly efficient to adequately identify patients at risk for opioid misuse . In addiIn order to reduce the prevalence of OUD, opioid prescriptions should be made after evaluating both individual patients’ risk factors and preferences. In addition, short-term prescription should be considered and patients at high risk for dependence closely monitored. A shift of standards and protocols towards non-opioid analgesics and regional anesthesia as the basis for multimodal analgesic treatment plans is urgently required. In the management of acute pain, routine prescription of long-acting opioids should be avoided, with implementation of a close monitoring and cessation plan supported by pain specialists.


Previous studies have shown that malnutrition before hematopoietic stem cell transplantation (HSCT) is associated with poor patient prognoses. There is inconsistency among studies on which nutritional status screening tool is appropriate for malnutrition diagnosis before allo-HSCT. The present study aimed to compare nutritional screening tools in patients with leukemia before allo-HSCT.An observational, cross-sectional, and single-center study was conducted in Tehran, Iran. One hundred four adults allo-HSCT candidates aged 18-55 years with leukemia were selected sequentially. Malnutrition assessment was done using three tools, the Global Leadership Initiative on Malnutrition (GLIM), nutritional risk screening 2002 (NRS-2002) and European Society for Clinical Nutrition and Metabolism (ESPEN) criteria. The agreement between malnutrition assessment tools was evaluated with Cohen’s kappa.p < 0.001), while the agreement between GLIM and ESPEN was fair . The agreement between NRS-2002 and ESPEN was fair . We also found a moderate agreement for all tools .The agreement between GLIM and NRS-2002 was perfect (κ = 0.817, NRS-2002 is an accepted tool for screening malnutrition in hospitalized patients. In the current study, the GLIM criterion perfectly agreed with the NRS-2002. Further studies in the HSCT setting are needed to introduce a valid tool. Allogeneic hematopoietic stem cell transplantation  is a usual treatment for hematological diseases like leukemia . Even thFew studies demonstrated nutritional screening tools to diagnose malnutrition in patients with hematological malignancies prior to HSCT, and none has presented conclusive evidence that verified which tool is obviously superior , 11. AmoNotably, the Global Leadership Initiative on Malnutrition (GLIM) criteria were suggested by nutritional scientific societies in 2019 for diagnosing malnutrition . It consUntil now, no study evaluates the malnutrition status of patients with leukemia who are candidates for allo-HSCT with GLIM criteria. A few studies compare the GLIM criteria with other previously utilized criteria, including NRS-2002 and ESPEN. We explained that NRS-2002 offers a holistic assessment, ESPEN’s evidence-based nature ensures a comprehensive framework, and GLIM criteria incorporate the latest advancements. This comparison enables us to identify the most appropriate criteria in the clinical setting. Therefore, this study aimed to compare the diagnostic test accuracy of the GLIM, NRS-2002, and ESPEN criteria for malnutrition diagnosis before allo-HSCT in patients with leukemia. This combination of tools ensures a thorough evaluation of nutritional risk in the context of allo-HSCT.An observational, cross-sectional, and single-center study was conducted in the Hematology Center of Shariati Hospital, Tehran, Iran. One hundred four adult allo-HSCT candidates aged 18–55 years with leukemia hospitalized in bone marrow transplant wards from November 2021 to December 2022 were selected sequentially. Patients with leukemia were eligible for inclusion if they were aged between 18 and 55 and candidates for allo-HSCT.The exclusion criteria were refusal to be involved in this study, and patients who were candidates for autologous transplantation.Demographic variables such as age, sex , and clinical variables of the patients, which included the type of malignancy (acute myeloid leukemia (AML) or acute lymphoblastic leukemia (ALL)), complete remission (CR) status , and risk status  were extracted from the patient’s medical records.The functional status of patients was assessed based on the Karnofsky functional status index, which includes a score from 0 (dead) to 100  with 10-point intervals . A score2).Body weight was measured using a digital scale  with an accuracy of 0.1 kg. Height was assessed using a tape measure attached to the wall and an accuracy of 0.5 cm. BMI was calculated by dividing weight (kg) by the square of height (mThe Tanita (BC-418’s) device was used to evaluate body composition during fasting conditions, with minimal water consumption and little exercise before the test and after defecation. This device offers independent analysis for various organs (right and left hand and right and left foot) and the trunk due to employing eight electrodes (two beneath the right foot and two in the right and left hand). Before the assessment, all the anthropometric devices were calibrated.Daily calorie intake and consumption of macronutrients  of all patients was checked by a trained dietitian with 3-day 24-h dietary recalls . The recorded amount of each food using the scale guide for Iranian households was converted to grams , and ana2 for <70 years and < 22 kg/m2 for ≥70 years) and reduced muscle mass. In the current study, the reduction of muscle mass was considered based on Appendicular Skeletal Muscle Index  <7 for men and ASMI <5.7 for women. Etiological criteria include reduced energy expenditure, chronic gastrointestinal status, disease burden, and inflammatory conditions. According to the definition of GLIM criteria, disease burden, and inflammation were considered positive in all patients in the current study.Nutritional assessment was conducted by a trained evaluator who remained blinded during the initial 48 h of hospitalization. Three tools were utilized for this purpose: the NRS-2002 for nutritional screening to identify patients at risk, and the GLIM and ESPEN criteria for diagnosing malnutrition. The GLIM criteria requires at least one phenotypic and etiological criteria for malnutrition diagnosis . PhenotyAssessment of nutritional status based on NRS-2002 is done using a questionnaire. The main components of this questionnaire were: 1) the severity of the impact of the primary disease on the nutritional status; 2) recent changes in body weight (during the last one to 3 months); 3) Change in food intake during the last week; 4) BMI; If the evaluated person is 70 years old or more, one point will be added to the sum of her points. NRS score equal to 3 and more than 3 is defined as a nutritional risk .2 for patients ≥70 years old and < 20 kg/m2 for <70 years) or low fat-free mass index (FFMI) (<15 kg/m2 in women and < 17 kg/m2 in men)  along with low BMI (<22 kg/m in men) .ncss.com/software/pass. Therefore, taking into account 10% drop-out rate, the sample size was finally determined to be 104 patients .The Kolmogorov–Smirnov test was used to evaluate the normality of continuous variables. Demographic, clinical, and anthropometric variables, as well as dietary intakes of patients in accordance with malnutrition status , were evaluated by independent sample t-test or Mann–Whitney test and Chi-squared or Fisher’s exact test for continuous and categorical variables, respectively. The agreement between the two malnutrition assessment tools was evaluated with Cohen’s kappa . Fleiss’The ethics committee of Tehran University of Medical Sciences evaluated and approved this project (Ethics code: IR.TUMS.MEDICINE.REC.1400.1089). A signed consent form was obtained from all the participants.n = 67, 64.4%). The GLIM and NRS-2002 indicated the highest percentage of patients with malnutrition (26 and 33.6%), and the ESPEN criteria indicated the lowest percentage of patients with malnutrition (8.65%). Patients without malnutrition were more prone to be in the first CR for all tools . The NRS-2002 showed that patients without malnutrition were more prone to AML than ALL (p = 0.049); however, the adverse risk of disease was higher (p = 0.012).p < 0.05). Although GLIM and ESPEN criteria indicated that FM was significantly higher in patients without malnutrition, this relation was insignificant based on NRN-2002. No significant difference was observed between malnourished and well-nourished groups for all tools regarding BF .Anthropometric variables of patients according to the GLIM, NRS-2002, and ESPEN criteria are summarized in The detailed results of the sensitivity, specificity, positive and negative predictive values for all patients and according to sex, type of leukemia, CR, and risk of disease are available in p < 0.001), while the agreement between GLIM and ESPEN was fair . Moreover, when comparing the ESPEN with NRS-2002 as a reference tool, ESPEN showed a sensitivity of 93.55%, while the specificity was 22.86%. The agreement between these two instruments was fair . We also found a moderate agreement between GLIM, NRS-2002, and ESPEN   .p < 0.001); however, the agreement between GLIM and ESPEN , and between ESPEN and NRS-2002  were fair. We also found a moderate agreement between GLIM, NRS-2002, and ESPEN . In female patients, the agreement between GLIM and NRS-2002 was substantial , and the agreement between GLIM and ESPEN was moderate . However, the agreement between ESPEN and NRS-2002 was fair . We also found a moderate agreement between GLIM, NRS-2002, and ESPEN   .p < 0.001), while the agreement between GLIM and ESPEN was slight . There was no significant agreement between ESPEN and NRS-2002. We observed a fair deal between these three tools . In ALL patients, our results indicated substantial agreement between GLIM and NRS-2002  and moderate agreement between GLIM and ESPEN . Nevertheless, there was a fair agreement between ESPEN and NRS-2002 . Also, the agreement between these three tools was moderate   .p < 0.001), while the agreement between GLIM and ESPEN  and between ESPEN and NRS-2002  were fair. We found a moderate agreement between all three mentioned tools . In patients who achieved a second CR, the agreement between GLIM and NRS-2002 was substantial . The agreement between GLIM, ESPEN, and NRS-2002 was not significant. In patients in the third CR, the agreement between GLIM and NRS-2002 was perfect , while the agreement between GLIM and ESPEN and between ESPEN and NRS-2002 were insignificant. We found a substantial agreement between these three tools   .p = 0.003). In patients with adverse risk of disease, the agreement between GLIM and NRS-2002 was substantial ; however, the agreement between GLIM and ESPEN  and ESPEN and NRS-2002  were fair and slight, respectively. We also found a moderate agreement between these three tools   .This study is one of the first to compare different tools for evaluating malnutrition in patients with leukemia who are also candidates for allo-HSCT. According to NRS-2002, GLIM, and ESPEN criteria, the results showed that 33.6, 26, and 8.6% of the patients were malnourished, respectively. Regardless of gender, type of leukemia, CR status, and risk status, GLIM and NRS-2002 instruments had a perfect agreement in diagnosing malnutrition; however, the ESPEN criterion showed fair agreement with the other two instruments (GLIM and NRS-2002). In all patients, we obtained a moderate agreement for all tools. In general, these results were maintained in subgroup analyses.Although malnutrition caused by disease is known as a serious problem, a gold standard for its diagnosis has not been introduced so far. While Peng et al. introduced the NRS-2002 as the first choice for assessing malnutrition before HSCT , studiesMost previous studies evaluated malnutrition in patients with solid tumors, and studies in HSCT candidate patients are limited. However, the nutritional status of patients with hematologic malignancies is not vastly different from general oncology patients . VariousThe prevalence of malnutrition in this study based on the GLIM criteria was 26%, which was in line with previous studies in cancer patients. Previous studies have reported that the rate of malnutrition was 32% in head and neck cancer , 24% in In this study, our choice of comparing these tools stemmed from a prior investigation that pitted the NRS-2002 against the SGA. The findings revealed a high degree of concordance, with NRS-2002 exhibiting a specificity of 94.81% in identifying severe malnutrition. This strong agreement might be attributed to NRS-2002’s balanced consideration of both nutritional status and disease severity. It implies that NRS-2002 could categorize patients as high-risk primarily due to the severity of their illness .Hence, the primary objective of our study was to assess NRS-2002 against alternative tools like the GLIM criteria, focusing on their specificity and sensitivity. While the PG-SGA is widely regarded as the gold standard for cancer patients, our study specifically aimed to compare screening and assessment tools commonly used in the pre-transplant setting. The choice of which method to employ depends on factors such as available infrastructure, resources, automation feasibility, and the healthcare environment .Moreover, previous research has indicated that GLIM criteria demonstrate ‘moderate agreement’ (kappa = 0.426) when compared to SGA. This suggests that GLIM criteria can effectively assess the nutritional status of cancer patients even without considering SGA, a recommendation supported by existing literature , 39. AddThe results of our study determined that the GLIM and ESPEN criteria have a fair agreement in diagnosing malnutrition in leukemia patients who are candidates for HSCT. In the subgroup analysis, the agreement ranged from weak to moderate; however, in the group of patients with favorable risk at the beginning of transplantation, a perfect agreement was shown, but because only three patients were in that group, the clinical significance of the result is reduced, and further studies are needed. The results of our study were consistent with previous studies; for example, Ruiz et al. determined the prevalence of malnutrition in outpatient cancer patients based on the GLIM criteria, 46.7%, and based on the ESPEN criteria, 17.6% . The kapOne of the important reasons for the difference in the prevalence of malnutrition obtained with the above two tools is the reduction of the BMI cut-off required to diagnose malnutrition in the ESPEN criteria. In addition to all the parameters for diagnosing malnutrition based on ESPEN, the GLIM criterion also has a series of etiological criteria that can be effective in the high prevalence of malnutrition compared to the ESPEN criterion.The NRS-2002 and GLIM criteria perfectly agreed in diagnosing malnutrition in this study. In the subgroup analysis, the agreement ranged from substantial to perfect. 33.6% of patients in the current research based on NRS-2002 were recognized as being at nutritional risk, comparable to previous studies in patients with cancer and candidates for HSCT , 20. AmoMalnutrition assessment is important because its early diagnosis leads to better and more effective interventions in the hospital. Early intervention prevents the progression of malnutrition to cancer cachexia . VariousOne of the strengths of this study was that the total population was patients with leukemia who were candidates for allo-HSCT, which had low heterogeneity. The number of participants in the project was greater than in similar studies because other hematological malignancies and autologous HSCT candidates were omitted. Additionally, three separate days were used for the collection of dietary data. As a result, individual variation could more effectively be detected. Despite the strengths, there were also limitations. The cross-sectional design makes the cause-and-effect relationship between the diagnosis of malnutrition and post-transplant outcomes unclear. Considering the differences in ethnicity within other studies and its effect on some parameters for determining malnutrition, such as BMI, FFMI and ASMI, it is necessary to conduct similar studies in different populations in different countries to obtain results with higher clinical significance. While our study aimed to compare the performance of three tools, namely NRS-2002, ESPEN criteria, and GLIM criteria, it is important to acknowledge that these tools serve distinct roles in the nutritional assessment process. NRS-2002 is a recognized screening tool designed to identify patients at risk of malnutrition , whereasThis study demonstrates that the GLIM criterion perfectly agreed with the NRS-2002. The ESPEN criterion had a fair agreement with other two instruments, and it has problems in early diagnosis of malnutrition, especially in the pre-cachexia stage. The agreement of the three tools with each other was also moderate. In the future, it is imperative to undertake rigorous scientific investigations focused on discerning the optimal diagnostic modality for malnutrition and fostering consensus in this regard.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by Tehran University of Medical Sciences ethics committee. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.RK and HM designed the study. SM, MB, and AR did data collection. ES did the analysis. HI, SZ-M, and RK wrote the article. SW provided additional scientific analysis and reviewed and edited the manuscript. Finally, HM and SW carefully read the text and tables and made the necessary edits. All authors contributed to the article and approved the submitted version.


BackgroundPostoperative rehabilitation protocols, including weightbearing restrictions following hip arthroscopy (HA) for femoracetabular impingement syndrome (FAIS), vary widely among surgeons, from complete non-weightbearing to immediate weightbearing as tolerated; it is unclear if weightbearing restrictions affect short-term outcomes in patients undergoing HA. The purpose of this study is to evaluate patients undergoing hip arthroscopy for FAIS before and after a change in weightbearing protocol, from partial weightbearing with crutches for three weeks to weightbearing and weaning from crutches as tolerated, by examining postoperative outcomes. We hypothesize that the change in weightbearing protocol will have no significant effect on patient outcomes.MethodsA retrospective review was conducted of 211 patients undergoing hip arthroscopy by a single high-volume surgeon. The change in weightbearing was implemented in February 2022; previously, all patients were toe-touch weightbearing with crutches for the first three weeks postoperatively. Following this change, patients were allowed to weightbear as tolerated with crutches immediately and wean from crutches as tolerated. The patients were divided into two groups: 119 patients pre-implementation (January 2021 to January 2022) and 92 patients post-implementation (February 2022 to December 2022). The primary endpoint was any complication in the first six weeks postoperatively, divided into complications at two and six weeks, emergency department returns in the first 90 days, reoperations in the first 30 days, and pain at six weeks. We also compared patient-reported outcomes at six weeks.ResultsThere were no significant differences in demographics between groups. There were no significant differences in postoperative outcomes between patients that had weightbearing restrictions and those that did not when looking at 30 day return to operating room , 90-day return to emergency department , two-week complications , six-week complications , pain score at six weeks postoperatively , any pain at six weeks postoperatively 37.8 vs. 32.6%, p=0.523), and six-week Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) score .ConclusionPatients undergoing HA after the discontinuation of a mandatory period of protected weightbearing did not experience any significant increase in complications or continued pain, and patient-reported outcomes were similar. Routine postoperative weightbearing restrictions may not be necessary for patients undergoing hip arthroscopy for femoroacetabular impingement syndrome. Further study is required to validate these findings and determine the optimal postoperative protocol for this patient population. Femoroacetabular impingement syndrome (FAIS) is a relatively recently recognized source of hip pain and has been implicated in the development of osteoarthritis of the hip as well as damage to the acetabular labrum ,2. The uRehabilitation protocols, including weightbearing restrictions following hip arthroscopy, vary widely among surgeons, and there isn’t significant evidence to support one protocol over another . Even amStudy population and settingThis study was performed at Anne Arundel Medical Center in Annapolis, Maryland, USA. This study was deemed institutional review board-exempt by the institution’s clinical research committee. A retrospective observational study of patients undergoing hip arthroscopy for FAIS was performed to assess whether the shift from a toe-touch weightbearing with crutches for three weeks postoperatively to an immediate weightbearing as tolerated protocol adversely affected patient outcomes. All surgeries were performed by a single surgeon in a single hospital-based outpatient surgery center from January 2021 through December 2022. All patients underwent arthroscopic surgery for a cam or pincer lesion and were surgically treated with bony resection and repair or reconstruction of the labrum and primary repair of the capsulotomy, along with any other necessary procedures including iliotibial band release or lengthening, gluteus medius repair, trochanteric bursectomy, psoas debridement or lengthening, and synovectomy.Perioperative protocolAll surgeries were performed on an outpatient basis under general anesthesia; regional anesthesia for postoperative pain control was used at the discretion of the surgeon and anesthesiologist. All patients used the same rehabilitation protocols, with the exception of weightbearing restrictions. Prior to February 2022, all patients were toe-touch weightbearing with crutches from weeks zero to three, progressing to weightbearing as tolerated thereafter. Starting February 2022, patients were instructed to weightbear as tolerated with crutches starting postop day zero and wean from crutches as tolerated. Prior to the study period, routine postoperative bracing was discontinued at our institution. Any patient using a postoperative brace was excluded from the analysis. All patients began a supervised rehabilitation program during postoperative week one. Initial range of motion (ROM) restrictions during physical therapy were hip flexion from 0-120 degrees weeks zero to three, abduction from 0-45 degrees weeks zero to three, and no external rotation for two weeks. Strength and ROM with restrictions were progressed per protocol.Power analysisAn a priori power analysis was conducted to determine that this study had adequate sample sizes to detect medium and large effect sizes for continuous and categorical endpoints, respectively, with 80% power. Cohen’s d was defined as the difference between two means divided by the standard deviation of the data. Cohen described a "d" of 0.20 to be a small effect size, 0.50 to be a medium effect size, and 0.80 to be a large effect size for continuous endpoints. Cohen’s w was defined as a measure of effect size used for chi-squared tests. Cohen described a "w" of 0.10 to be a small effect size, 0.30 to be a medium effect size, and 0.50 to be a large effect size for categorical endpoints. The sample sizes necessary to detect large effect sizes were 52 and 64 for continuous and categorical endpoints, respectively; 128 and 176 for medium effect sizes; and 788 and 1,570 for small effect sizes . The primary endpoint of the study was complications within the first six weeks postoperatively. This was broken down into any complication at two weeks postoperatively, any complication at six weeks postoperatively, and continued pain at six weeks postoperatively. Continued pain at six weeks postoperatively was defined as patient-reported pain at the six-week postoperative visit that was documented in the provider's note. Patient-reported outcomes were collected six weeks postoperatively using the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function score. Univariate statistics  were performed to evaluate differences in demographics, comorbidities, and operative characteristics between patients who had weight-bearing restrictions and those that did not. All statistical analyses were performed using R Studio . Statistical significance was assessed at p<0.05.Two hundred and eleven patients were included in this study: 119 prior to February 2022 who had initial weightbearing restrictions and 92 from February 2022 who had no weightbearing restrictions postoperatively. One hundred thirty-nine (65.9%) patients were female, 148 (70.1%) patients were white, and 189 (89.6%) patients had an American Society of Anesthesiologists (ASA) score less than three, a mean age of 38.9 years old, and a mean body mass index (BMI) of 27.3 kg/m2. Table There were no significant differences between groups in patients that had weightbearing restrictions postoperatively and those that didn’t in age, BMI, sex, race and ASA score.Table Twenty-two (10.4%) patients experienced an emergency department (ED) visit in the first 90 days after surgery, although only seven (31.8%) visits were related to surgery and primarily those involved pain or medication issues; the ED returns unrelated to surgery included unrelated medical issues, psychological issues, and traumatic injuries. Twelve (5.7%) patients experienced a complication in the first six weeks following surgery; complications were overall minor, including superficial wound complications (two patients), pain (seven patients), and medication issues (three patients). One patient experienced a deep vein thrombosis, and one patient required postoperative admission for pain control. There were no significant differences between groups when examining 30-day operating room returns, 90-day emergency department (ED) visits, two-week complications, six-week complications, pain score at six weeks postoperatively, any pain reported at six weeks postoperatively, and the six-week PROMIS physical function score.In this study, there were no significant differences in demographics or postoperative outcomes between patients that had initial weightbearing restrictions and those that were able to weightbear and wean from assistive devices as tolerated. Approximately 10% of patients experienced an ED visit in the first 90 days after surgery, although fewer than one-third of these visits were related to surgery. The most common surgery-related ED visits were for pain or medication issues. Only 5.6% of patients experienced complications within the first six weeks, and most of these were relatively minor, including superficial wound complications, pain, and medication issues. The findings in this study are similar to the findings by Avnieli et al., who found no difference between patients before and after changing the weightbearing protocol after hip arthroscopy, although their study differed in that they moved from non-weightbearing to weightbearing as tolerated, whereas we moved from partial weightbearing to weightbearing as tolerated [Protected weightbearing or non-weightbearing protocols after hip arthroscopy were established for two primary reasons: to protect against hip fracture following osteochondroplasty and to protect the labral and capsular healing . Hip fraIn light of the unclear need for protected weightbearing after hip arthroscopy, the variability in weightbearing protocols is unsurprising. In a study by Cvetanovich et al. that surveyed 31 hip arthroscopy surgeons in North America, most surgeons prescribed a period of protected weightbearing, most commonly partial weightbearing with 20 pounds of foot flat . In a stThis study does have a number of limitations. Firstly, it is a single institution, single surgeon observational cohort study, and it is possible that our population of patients is not representative of the broader population. This study is also subject to the inherent limitations of a retrospective study, including selection bias and the potential for confounding variables. Secondly, this study had a short follow-up period, which may not be sufficient to identify all possible complications resulting from discontinuing weightbearing restrictions, although one significant complication, a hip fracture, is likely to occur early in the postoperative period . The resPatients undergoing hip arthroscopy after the discontinuation of a mandatory period of protected weightbearing did not experience any significant increase in complications or continued pain, and patient-reported outcomes were similar. Routine postoperative weightbearing restrictions may not be necessary for patients undergoing hip arthroscopy for femoroacetabular impingement syndrome. Further study is required to validate these findings and determine the optimal postoperative rehabilitation protocol for this patient population.


Background and Objective: Wide-Awake Local Anesthesia No Tourniquet (WALANT) is a technique of local anesthesia commonly used in the surgical treatment of a wide variety of conditions affecting the upper extremity, including Carpal Tunnel Syndrome (CTS). The recent retrospective studies investigated patient experiences in a wide variety of hand disorder-related cases. The aim of our study is to evaluate patient satisfaction regarding open surgical treatment for CTS using the WALANT technique. Material and Methods: we enrolled 82 patients with CTS without medical record of surgical treatment for CTS. For WALANT, a hand surgeon used a combination of 1:200,000 epinephrine, 1% lidocaine, and 1 mL 8.4% sodium bicarbonate solution without tourniquet application and sedating the patient. All patients were treated in a day-care setting. For assessment of patient experience, Lalonde’s questionnaire was adapted. Participants completed survey twice: one month and six months after the surgical treatment was performed. Results: the median pre-operative pain score for all patients was 4 (range 0–8) after one month and 3 (range 1–8) after six months. The median intraoperative pain score for all patients was 1 (range 0–8) after one month and 1 (range 1–7) after six months. The median post-operative pain score for all patients was 3 (range 0–9) after one month and 1 (range 0–8) after six months. More than half (61% after one month and 73% after six months) of the patients responded by stating that their real experience of WALANT was better than their initial expectations. An absolute majority of patients (95% after one month and 90% after six months) would recommend WALANT treatment to their relatives. Conclusions: overall, patient satisfaction with treatment for CTS using WALANT is high. Furthermore, complications related to the performed treatment and persistent post-operative pain could be associated with more reliable patient recall of this healthcare intervention. A longer period of time between intervention and assessment of patient experience could possibly be a reason for recall bias. Carpal Tunnel Syndrome is the most prevalent entrapment neuropathy worldwide and causes numbness, pain, and tingling sensations in the hand and arm ,2. The ip < 0.05 was chosen.A retrospective study was conducted on patients with Carpal Tunnel Syndrome. Ethical approval for this study was obtained from Kaunas Regional Biomedical Research Ethics Committee . Patients were only included if they met all of the study’s inclusion criteria: they were older than 18 years old during inclusion in the study, diagnosed with CTS without a medical record of surgical treatment, and signed an informed consent form for participation in the research. Exclusion criteria excluded the following individuals: pregnant patients; patients with a history of systemic connective tissue diseases, diabetes mellitus, and ischemic heart disease; and patients with a known allergy to lidocaine or epinephrine. All patients were treated in the plastic and reconstructive surgery department of Kaunas clinics in a day-care setting. Surgeries were performed by two senior hand surgeons using the same surgical technique. For wide awake local anesthesia, surgeons used a combination of 1:200,000 epinephrine, 1% lidocaine, and 1 mL of 8.4% sodium bicarbonate solution without tourniquet application. Moreover, surgical field anesthesia in carpal tunnel release was achieved with 10–20 mL of combined solution. With permission, we adapted Lalonde’s questionnaire to evaluate participant satisfaction and experience of Wide-Awake Local Anesthesia No Tourniquet surgery. The survey consisted of two parts. The first part contained numerical rating scale (NRS)-type questions to assess pre-operative, intraoperative, and post-operative pain and anxiety levels. Scales were scored from 0–10 (0 meaning no pain or anxiety and 10 meaning the worst pain or anxiety imaginable). The second part of the survey contained questions related to overall patient experience and satisfaction before, during, and after the surgical treatment was performed. Participants completed the survey twice: one month and six months after the surgical treatment was performed. We ensured that the same participant completed the survey twice due to the opportunity to assess recall bias of patient. Furthermore, we decided to evaluate possible causes that may influence recall bias in patients through adding more direct questions about patients’ hand function during their follow-up visits six months after the treatment. Results after one month are considered a short-term outcome, while results after six months are considered a long-term outcome. The data were analyzed using Statistical Package for Social Sciences (SPSS). Pain and anxiety scores were not normally distributed; thus, they were presented as medians and intervals of values. The Wilcoxon test was applied for comparison of results after one and six months. Distribution of answers to the questions was presented in counts and percentages. The comparison of answers after one and six months was made using the McNemar and McNemar–Bowker tests. For hypothesis testing, a significance level of Eighty-two patients participated in our study. Approximately one quarter (26.8%) of all patients were male and remaining approximately three quarters (73.2%) were female; the mean age was 56 years old (range 39–89). All patients were treated in a day-care setting.The median pre-operative pain score  for all patients was 4 (range 0–8) after one month and 3 (range 1–8) after six months. The median intraoperative pain score  for all patients was 1 (range 0–8) after one month and 1 (range 1–7) after six months. The median post-operative pain score  for all patients was 3 (range 0–9) after one month and 1 (range 0–8) after six months .p < 0.05). Furthermore, one-third of all patients did not take post-operative pain treatment at all. An absolute majority of patients (97% after one month and 96% after six months) responded that post-operative pain treatment with drugs was successful. Approximately half (49% after one month and 59% after six months) of all patients responded that the first signs of post-operative pain were noticed during three to six hours following the surgery  answered that WALANT was less painful or there was no difference compared with dental treatment after one and six months. Approximately two-thirds (70% after one month and 61% after six months) of all patients responded that they took post-operative pain treatment after the surgery was performed. The difference was statistically significant regarding post-operative pain treatment comparing one- and six-month results ( surgery . The med surgery .p < 0.05)  of all patients responded that their real experience of WALANT was better than their initial expectations one month after surgical treatment was performed. Approximately one-third (34%) of all patients responded that their real experience during WALANT matched their expectations one month after surgical treatment was performed. The difference in results between the real experience of WALANT and expectations was statistically significant both one and six months after surgical treatment was performed ( < 0.05) . An absoTo evaluate the possible causal factors that could affect how patients recall their surgery experience, three additional questions were added to the questionnaire during follow-up after 6 months. Roughly one-fifth (17%) of all patients suffered persistent hand pain six months after surgery. Four patients (5%) responded that they had minor complications related to surgical treatment that did not require surgical intervention six months after the initial surgery was performed. Sixty-six respondents (81%) were satisfied with the outcome of the surgery . PatientThe WALANT technique was proven to be successful for common procedures, including surgical treatment for CTS. In a recent paper, a literature review was conducted with the purpose of evaluating the advantages and disadvantages of WALANT . AccordiThat study’s results regarding pre- and intra-operative pain evaluation are similar to our findings. However, pre-operative anxiety levels were significantly higher. We made a hypothesis that proposed that day-care setting surgery is less stressful because patients usually have time to prepare for upcoming surgery. In the case of trauma, patients experience much more stress because surgical treatment is unexpected. Similar to our results, 80% of their patients described WALANT as similar to or less painful than dental treatment. Moreover, 95% of patients responded that their overall experience was better than expected. This result is significantly higher compared with the results of our study (61% after one month and 73% after six months). Inequality in results can be explained through different levels of satisfaction among patients. In the case of trauma patients, the main objective is to restore integrity and essential function of the hand. After surgical treatment of trauma, the patients’ hand integrity and capability to perform essential functions are mostly restored within a couple months. Patients with CTS have only partial disruption of hand function, while manipulations of essential hand movements in daily activities are restricted only to a certain degree.In a previously mentioned study  and in oIn our research, we recorded complications related to surgical treatment during an assessment conducted six months after the treatment was performed. Based on the data from our survey, four patients had minor complications related to surgical treatment that did not necessitate surgical intervention. Patients considered persistent tingling, numbness, and loss of strength in hand as complications related to surgical treatment. None of our patients suffered from post-operative infections.In a contemporary article, a retrospective study was conducted to evaluate post-operative complications and infection rates in a group of patients undergoing CTS surgical treatment . SimilarCurrently, there is no consensus on the association between patient experiences and clinical outcomes. Some studies demonstrate that lower rates of complications and mortality are related to a better patient experience ,27. HoweIn our study, we only involved patients with a diagnosis of CTS. For future studies, we recommend including a broader spectrum of diseases (such as Trigger finger or Dupuytren’s contracture) that are treated in a day-care setting. Furthermore, we recommend comparing patient satisfaction with the WALANT procedure with other methods of regional anesthesia. Moreover, further prospective randomized studies evaluating patient experience during WALANT are required to confirm our findings.The findings of this study should be interpreted with caution and verified through further research; however, they indicate that WALANT does not seem to cause significant pain or stress for patients with CTS. The patients in this study expressed satisfaction with their pre-, intra-, and post-operative care in a day-care setting. Moreover, complications related to the treatment and persistent post-operative pain could be linked to more accurate patient recall of healthcare intervention. A long interval between intervention and assessment of patient experience could potentially be a reason for recall bias. Patient-reported experience surveys are emerging as one of the main indicators of healthcare quality; however, the relationship between patient experiences and clinical outcomes remains unclear. Our study supports the claim that WALANT is a safe, effective, and well-accepted method for hand surgery. Further prospective randomized studies are needed to confirm our findings.


Postoperative pain management is an important aspect of anesthesia care and multimodal analgesic techniques are generally recommended.To compare the effect of spinal anesthesia + transversus abdominis plane (TAP) block application on postoperative analgesia quality and patient satisfaction with spinal anesthesia + intrathecal morphine (ITM) application.A total of 70 patients were randomly separated into 2 groups as spinal anesthesia + TAP block  and spinal anesthesia + ITM group . The groups were compared in respect of age, body mass index values, and visual analog scale (VAS) values at 0 h, 2 h, 6 h, 12 h, and 18 h, and patient satisfaction was scored by Quality Improvement in Postoperative Pain Management at 24 h.P = 0.001) and postoperative complications such as nausea, vomiting, and itching  were found to have a negative effect on patient satisfaction.The mean age of the patients was 32.52 ± 6.50 years in the TAP block group and 30.11 ± 5.62 years in the ITM group, with no statistically significant difference determined. There was no statistically significant difference in terms of VAS values at 0 h, 2 h, 6 h, 12 h, and 18 h. When the factors affecting postoperative patient satisfaction were evaluated, feeling fatigue after the surgery (r = −0.811, Due to low complication rates, TAP block is an effective application for postoperative analgesia management in varicocele operations that increases patient satisfaction postoperatively. Although there is still controversy on the issue of whether or not optimal pain control with minimal side effects affects postoperative surgical outcomes, there is a general consensus that optimal control of pain is associated with a shorter hospital stay and increased patient satisfaction , 2. PostMultimodal analgesia may include systemic or neuraxial opioids, centrally acting drugs such as anti-inflammatory agents, and paracetamol. Another method that can be used for this purpose is intrathecal (IT) morphine administration, which is known to provide excellent analgesia for the treatment of postoperative pain. However, there are some adverse effects that reduce patient satisfaction, such as nausea, vomiting, and itching in addition to delayed respiratory depression due to rostral expansion, which limits the use of this method , 5.Recently, attention has been focused on the local anesthesia technique, known as transversus abdominis plane (TAP) block, which was first described by Kuppuvelumani et al.  and has The study's primary aim was to determine the effect of spinal anesthesia + TAP block application on the reduction in the need for postoperative pain relief, and the secondary aim was to compare the effect of the increase in analgesia quality on patient satisfaction.Approval for the study was granted by the Kahramanmaras Sutcu Imam University Faculty of Medicine Clinical Research Ethical Committee , and all procedures were drafted in accordance with principles of the Helsinki Declaration. This blind, randomized, prospective, and controlled study was conducted in the urology and anesthesiology departments of Kahramanmaras Sutcu Imam University Hospital, between October 2016 and July 2018. The patients comprised in the study were informed about the methods before the procedure and written consent forms were obtained. A Clinical Trials number  was also obtained before the study.The study included a total of 70 consecutive patients, aged 18–45 years, evaluated as American Society of Anesthesiologists (ASA) I–II who underwent elective varicocele operations. Patients with a psychiatric disorder, usage of opioid analgesics, tricyclic antidepressants, or corticosteroids, hypersensitivity, severe systemic disorders such as cardiovascular, liver, and kidney disease, a drug and chronic pain killer addiction, anesthetic substance usage, alcohol addiction, pain syndrome, coagulopathy, infection in the surgical site, or recurrent varicocele were excluded from the study. The patients were randomly separated with the lottery method  into two groups, as the spinal anesthesia + TAP block group  and the spinal anesthesia + intrathecal morphine (ITM) group .All patients who received regional anesthesia were administered 0.02 mg/kg of midazolam IV sedation prior to the process. For spinal anesthesia, while the patients were sitting on the operating table, the area to be anesthetized was cleaned under sterile conditions and covered with a sterile perforated green cloth. With a median approach from the L4–L5 distance, the subarachnoid space was entered with a 26 G spinal needle. After the cerebrospinal fluid (CSF) flow was observed, the aperture of the needle was turned toward the sacral. By applying 10 mg of 0.5% hyperbaric bupivacaine, the head was lifted 30° when the patients were placed in the supine position after the patients were left in this position for 10 min.In the ITM group, 0.05 mg/kg was applied. In the TAP block group, the procedure was performed under ultrasound (US) guidance using the method defined by the experienced anesthesiologists, Hebbart et al., and theThe patients were evaluated for nausea, vomiting, itching, and respiratory depression at 0 h, 2 h, 6 h, 12 h, and 18 h, respectively.Pain at rest and in motion  were measured with a 10 cm visual analog scale (VAS) pain score, from 0 = the absence of pain to 10 = the worst pain. Nausea severity was rated between 1–4 points, as 1 = absent, 2 = mild, 3 = moderate, and 4 = severe and vomiting.Itching was rated between 1–4 points, as 1 = no pruritus, 2 = mild itching with no treatment required, 3 = moderate itching requiring treatment, and 4 = severe itching requiring treatment. A 24 h general evaluation was assessed at 24 h postoperatively using the QUIPS test.A patient IV controlled pain monitoring device was used to control pain. The PCA protocol was a 25 mg tradamol bolus, with a locked time of 30 min, with no continuous infusion. The 4 h limit was 100 mg. The amount of analgesia and number of analgesic boluses used were recorded. Power analysis was applied to the study based on the results of previous studies.Evaluation was made of all the patients in respect of age, gender, body mass index (BMI), duration of operation, ASA values, 0 h, 2 h, 6 h, 12 h, and 18 h VAS values, operated side, patient satisfaction, and anesthesia complications causing patient dissatisfaction such as nausea, vomiting, and itching, and the amount and time of first analgesic use.Figure 1).The approximate sample size was calculated using the G*Power 3.1.9.4 analysis program (Heinrich-Heine-Universitat). We sought to investigate the analgesic efficiency of the USG-TAP block used for varicocele surgeries. The power analysis was based on the mean postoperative analgesia consumption. The sample size estimation was based on the postoperative tradamol requirements  of a similar study performed by Kupiec et al. . The samU test was used with the Monte Carlo simulation technique, and the independent-samples T test was used with bootstrap results. In the comparisons of categorical data, the Spearman's rank correlation and Fisher's exact tests were applied with the Monte Carlo simulation technique. Quantitative data were expressed as mean ± standard deviation (SD) values and median  values in the tables. Categorical data were expressed as number (n) and percentage (%). The VAS values were analyzed by a repeated measure ANOVA followed by the Bonferroni test for between-group comparisons. The data were analyzed at 95% confidence interval level and a P < 0.05 was accepted as statistically significant.Data obtained in the study were analyzed statistically using SPSS 17.0 software (SPSS Inc.). Conformity of the data to normal distribution was tested using the Shapiro–Wilk test and variance homogeneity with the Levene's test. In the comparisons of two independent groups, the Mann–Whitney P = 0.174; Table 1). One patient in both groups avoided movement due to pain (P = 0.731), 4 patients in the TAP block group responded negatively, and 3 patients in the ITM group felt pain (P = 0.450). Tiredness after surgery was reported by 3 patients in the TAP block group and in 10 patients in the ITM group (P = 0.045). In our study, it was observed that VAS scores increased significantly in both groups over time , but the difference between the groups was not significant  (.The mean age of the patients was 32.5 ± 6.5 years in the TAP block group (n = 34), and 30.1 ± 5.6 years (n = 36) in the spinal anesthesia group, and mean BMI values were 26.7 ± 3.9 and 23.1 ± 2.7, respectively. There was no statistical difference between the groups in respect of these parameters. Although the operation time in the spinal anesthesia group was shorter, the difference was not statistically significant (P = 0.019). The results were significantly different in the spinal anesthesia group in terms of anesthesia complications .There was a statistically significant difference between the groups in terms of patient satisfaction scores . When the patients were assessed in terms of factors affecting postoperative patient satisfaction, it was seen that feeling fatigue after surgery  and complications such as nausea, vomiting, and itching in the postoperative period  were found to have a negative effect on patient satisfaction. In the subgroup analysis, especially nausea  and vomiting  were found to have a greater effect than itching  on patient satisfaction.In the TAP block group, 1 patient who underwent bilateral varicocelectomy and bilateral TAP block first needed analgesia of 150 mg tramadol at 4 h postoperatively. The patient stated that he felt unilateral pain, which suggested unilateral unsuccessful block implementation. In the ITM group, analgesia requirement was found to be 75 mg tramadol at 10 h postoperatively. There was no statistically significant difference between the groups in terms of postoperative analgesic requirement . Patient satisfaction was found to be statistically significantly lower in patients with complications  (P = 0.001). The VAS scores and patient satisfaction are shown in Figure 3.When the patients were evaluated as patients with and without complications, there was no statistically significant difference in terms of VAS values at 0 h, 2 h, 6 h, 12 h, and 18 h , and patient satisfaction was significantly higher in patients without drowsiness-fatigue .When the patients were grouped as patients with and without drowsiness-fatigue associated with patient satisfaction, the VAS values were lower in patients with drowsiness-fatigue, which was not statistically significant . In addition, the pain values obtained throughout the first 24 h postoperative period were evaluated as mean pain value throughout 24 h, and maximum and minimum pain values. There were no statistically significant differences between the groups in terms of these values. It is known that respiratory functions are affected and the cough reflex is suppressed due to severe postoperative pain, which is particularly prone to complications such as atelectasis. As some authors have stated, optimal pain control is not only a factor that may shorten hospital stay but also affects surgical outcomes in the postoperative period by preventing some lung complications such as atelectasis [P = 0.450). In addition, none of the patients in the present study developed AC complication, postoperatively. Nevertheless, considering that the operation site chosen in the present study was the lower abdominal region, we infer that further studies are needed to evaluate the effect of TAP block on respiratory complications in abdominal surgery.In the present study, the QUIPS test was applied at 24 h postoperatively. The most important limitation of this test is that it provides only one measurement for pain and does not include the whole 24 h period . To overlectasis , 24. PaiP = 0.001). When the patients were separated as those with and without fatigue-drowsiness, the mean pain, maximum pain, and minimum pain values in patients with fatigue-drowsiness were lower than those of the patients without fatigue-drowsiness, but this difference was not statistically significant .Although the ITM application is known to have highly effective analgesic efficacy, it has severe potential side effects ,26,27. TP = 0.483, P = 0.175, P = 0.714). Despite the lack of a statistically significant difference, the feeling of drowsiness was seen to be more disturbing to the patients in terms of satisfaction. Similar results were found for nausea, vomiting, and itching. In the subgroup analysis, especially nausea  and vomiting  had a greater effect on patient satisfaction than itching . Since we could not access data on this issue from the literature, we could not compare our study results with those of any previous study.Although there were fewer patients who did not feel fatigue-drowsiness postoperatively, the difference was not statistically significant (No vascular complications related to the TAP block developed in the current study. Therefore, the main limitation of the study was that no evaluation was made of the effect of such complications on patient satisfaction.In conclusion, due to low complication rates, TAP block is an effective application for postoperative analgesia management in varicocele operations that increases patient satisfaction postoperatively.