We aimed to prospectively evaluate and compare the effectiveness of Alvogyl and Cutanplast as intra-alveolar dressings for managing pain associated with extraction and incidence of dry socket. All patients who underwent maxillary and mandibular teeth extraction and fulfilled our inclusion and exclusion criteria from Feb 2021 to Oct 2021 were included in our study. Patients who were diagnosed with postoperative pain after tooth extraction were randomly allocated to three groups: Group A (Alvogyl), Group B (Cutanplast), and Group C (placebo). Pain relief and healing of the socket were compared between these groups. The collected data were analyzed using the Chi-square test and Z test of proportionality. Alvogyl was superior to the other medication for providing initial pain relief, and the incidence of dry socket was significantly lower than in the Cutanplast and placebo groups (p<0.05). However, wound healing was statistically non-significant among groups A, B, and C (p>0.05). Alvogyl is still the material of choice in terms of pain relief, wound healing, and low incidence of dry socket. Furthermore, no statistically significant difference was detected between the groups in the biographic information, location, and condition of the extracted tooth, presence of a radiologic pathology, or type of extraction procedure. Moreover, whether it is the first extraction or not, Alvogyl and Cutanpast are comparable in postoperative pain management as intra-alveolar dressing materials. Dry socket is a common post-extraction issue following the extraction of permanent teeth, particularly mandibular third molars . Dry socThe inconsistency in the documentation of aetiology, risk factors, prevention, and treatment modalities represent a serious clinical problem. Dry socket is thought to have a multifactorial aetiology, with general factors like age and gender, decreased body resistance from systemic disease, nutritional deficiency, as well as local factors like anatomical location, traumatic surgery, smoking, clot fibrinolysis, local circulation, local anaesthesia, and vasoconstrictors –6. Severet al. [Streptococcus mutans and this condition in animal models by demonstrating delayed socket repair following organism injection.Bacteria have long been suspected of playing a role in the development of dry sockets in people with poor oral hygiene and pre-existing infections . In a coet al.  showed tMany researchers tried to find a suitable technique for preventing dry sockets, the most common post-extraction issue. Systemic antibiotics, topical antibiotics, chlorhexidine, para-hydroxybenzoic acid, tranexamic acid, polylactic acid, steroids, eugenol-containing dressings, lavage, 9-aminoacridine, and others have been proposed to help avoid dry socket. However, there is still disagreement because no technique has gained widespread approval .The therapy of dry sockets is as disputed as its cause and prevention. Any “treatment” advice is likely deceptive because the illness cannot be treated until the cause is identified. According to Fazakerlev and Field , the priAO treatment is typically centered on soothing the patient and providing immediate pain relief until natural healing occurs. Alvogyl is a palliative drug that contains analgesic and anti-inflammatory Eugenol, antibacterial iodoform, and butamben (anesthetic) .Absorbable gelatin sponges contain hemostatic material and can be utilized in surgical procedures where typical hemostasis is difficult to establish. The use of Alvogyl or an absorbable gelatin sponge (Cutanplast) can minimize postoperative pain severity, painkiller consumption, postoperative hemorrhage, and wound re-epithelialization . Aside fversus those who received Cutanplast after molar tooth extraction.A prospective randomized experiment was necessary to objectively examine the relative efficacy of various dressings for the management of pain and promotion of healing in AO. The purpose of this study was to examine socket healing, the incidence of acute alveolar osteitis (AO), and related discomfort in people who had direct intra-alveolar Alvogyl injections A prospective randomized clinical trial single-blind was conducted on eighty-four patients in Riyadh Elm university hospitals and private clinics from February 2021 to October 2021.All patients who reported to the department for dental extraction from February 1, 2021, to October 31, 2021, were included in the study after receiving approval from the research and ethics council. Pregnancy, radiation history, chemotherapy, hematologic diseases, bone diseases, acute infections or cystic lesions, allergies to Lidocaine, Ibuprofen, Alvogyl, and gelatin, and concomitant cellulitis/facial space infections were all considered exclusion factors. Traumatic extractions with fragmented alveolar bone, extractions requiring bone reduction, and extractions lasting more than 30 minutes were also excluded. In the standardized proforma created to collect the numerous criteria essential for accomplishing the study's objectives, all patients provided a complete case history.Extractions were performed by a general practitioner and a dental intern. All participants' information about the objectives of the study and consent forms were signed. All the required information was documented in the questionnaire paper regarding name, age, gender, nationality, date, file number, mobile number, smoking, medical history, tooth number indicated for extraction, time of tooth extraction, and whether it was a first-time extraction. Preoperative clinical tooth evaluation  and radiographic tooth evaluation . Postoperative assessment of tooth extraction according to extraction procedure: simple extraction (with elevator and forceps only) or surgical extraction including flap and suture  and according to time consumed during extraction .Teeth extractions were carried out using 2% Lidocaine and 1:100,000 epinephrine. Infiltration was used to anesthetize the upper molars, while a combination of inferior alveolar nerve block and buccal infiltration was used to anesthetize the lower molars. Elevators and forceps were used for simple extractions, while a surgical handpiece and burs with standard saline irrigation were used for root separations.Patients who complained of pain following tooth extraction were assessed to determine the source of the problem. A blinded assessor made a clinical diagnosis of AO based on the following characteristics: pain in and around the extraction socket that worsens with time, with or without radiation, between 1 and 3 days following the extraction.To receive therapy for their ailment, patients were randomly assigned to one of three groups: A, B, or C, using a randomization table. Within these groups, patients were treated as follows:® was used on extraction sockets manufactured by Septodont India Pvt. Ltd. 15.8 gm iodoform, 13.7 gm eugenol B.P., and 25.7 gm butamben).Group A: Alveogyl® 10×10×10 mm gelatin sponge  soaked in 2% Lidocaine with 1:100,000 epinephrine was placed.Group B: In the extraction sockets, a CutanplastGroup C: Extraction sockets received no medication and acted as a control group.A warm sterile saline solution was used to irrigate the socket. Curettage was avoided at all costs. Loose debris was removed with special care not to dislodge any remaining clots in the socket.With the use of a sterile device, a few fibers of Alvogyl were put deep into the socket, ensuring that the denuded bone was entirely covered, followed by the installation of sterile gauze. After 5 minutes, the gauze was removed.Inside the socket, a single roll of Cutanplast was put in, followed by a sterile gauze piece to cover the socket. After 5 minutes, the gauze was removed.Postoperative instructions were given to all participants. In addition, a prescription of Ibuprofen 400 mg  every 8 hours for the first 3 days was also given to the patients.The participants recorded their pain intensity on the Wong-Baker Visual Analogue Scale (VAS) (0–10). A score of 0 indicates no pain, while a score of 10 indicates severe pain. Pain intensity was recorded after 3, 6, 12, and 24 hours of tooth extraction and on the second and third day. At each follow-up appointment, the dressings were assessed by a blinded assessor.The data was assessed using the SPSS software package (Version 20). Descriptive statistics such as frequency distribution, mean, standard deviation, and percentages were analyzed. Analysis of pain statistics amongst the three groups was done using One Way Analysis of Variance. Post hoc analysis was done using Tukey's HSD. The proportions of dry socket incidence and healing signs at the follow-up periods compared to baseline were tested using the Chi-Square test and the Z test of proportionality, respectively. In all tests, a P value of less than 0.05 was considered significant.In this study, a total of 84 subjects participated. These subjects were allocated to Group A (N=27), Group B (N=35), and Group C (N=22). The majority of participants were between 26 and 45 years old . Most ofDry sockets were present in 48.1% of cases in Group A, 63% of cases in Group B, and 91% of cases in Group C. A comparison of the three groups showed that the difference in proportions was statistically significant, indicating a significantly higher incidence of dry socket in Group C compared to Groups A and B (p=0.006).The mean time for initial pain relief in Group A was 6.75±1.43 minutes, 10.20±2.78 minutes in Group B, and 22.34±3.03 minutes in Group C. These differences in mean values amongst the three groups were statistically significant, indicating significantly lower initial pain relief time in group A and significantly higher initial pain relief time in group C. Concerning time for complete resolution of pain, the mean was lowest in group A at 4.85±2.07 days, higher in group B at 7.35±2.96 days and highest in group C at 9.54±3.42. These differences in mean values amongst the three groups were statistically significant, indicating significantly low complete pain resolution time in group A and significantly high complete pain relief time in group C. Thus, overall pain management was better in Group A .th, indicating complete healing. The reductions in empty socket cases from baseline to the third day, the fifth day, the seventh day, and the tenth day were statistically significant. Concerning exposed bone, at baseline, there were 6 cases, which were reduced to 3 on the third day, 2 on the fifth day, 1 on the seventh day, and no empty socket cases on the tenth, indicating complete healing. The reductions in exposed bone cases from baseline to the 3rd day, the 5th day, the 7th day, and the 10th day were statistically significant. Concerning redness around the socket, at baseline, there were 5 cases, which were reduced to 3 on the third day, 2 on the fifth day, 1 on the seventh day, and no redness around the socket on the tenth, indicating complete healing. The reductions in redness cases from baseline to the third, fifth, seventh, and tenth day were statistically significant . Larsen , Nusair The capacity to effectively control pain is a critical skill in dental practice . For botThe use of intra-alveolar dressing materials for postoperative pain control is recommended . Alvogylet al. [The participants were mainly between the ages of 26 and 45, with an average age of 35.50. Other investigations produced similar results . In thiset al. , establiThe female-to-male ratio in this study was 1.2:1, with 45 (54%) of the 84 patients being female and 38 (46%) being male . Other set al. [Females have a higher incidence of dry sockets than males, according to a study by MacGregor , which iet al.  and Sweeet al. , oral coet al. [et al. [Despite delayed healing in this study, groups A and B had uneventful healing after the seventh day compared to group C. Another study by Supe NB et al.  discover [et al.  conducteIn circumstances where more postoperative discomfort is expected, Alvogyl is indicated . FurtherThe results of this study revealed a statistically significant difference in postoperative pain control between Alvegy and Cutanpast. In a study by Ehab, Karim, and colleagues , there wNusair and Abu Younis  and AmarFor controlling postoperative pain, several intra-alveolar dressings and laser therapies were investigated. During the 7-day treatment period, no statistically significant difference in VAS pain scores was seen between patients treated with Alvogyl (Eugenol) and SaliCept (acemannan), demonstrating that SaliCept is a potent palliative treatment for dry socket . AccordiTo our knowledge, no comparative study between Alvogyl and Cutanplast has been published. Subsequently, multiple publications in the literature extolling the benefits of individual drugs can be bewildering as a result. A comparative analysis is essential to make an informed decision. In this study, the efficacy of drugs was determined by their ability to provide pain relief and clinical evidence of socket healing.There were statistically significant differences in pain scores between Alvogyl and Cutanplast patients. When comparing Alvogyl to Cutanplast, Alvogyl had a faster onset of analgesia. Alvogyl was also able to provide pain relief that was both rapid and long-lasting. Additionally, Alvogyl required fewer dressing changes than the others.According to an examination of the improvement in signs of dry socket after dressings with the two drugs under consideration, the signs of an empty socket and exposed bare bone in the Alvogyl treatment group completely disappeared by the seventh day. After the seventh day, just one (3.7%) socket in this group experienced persistent redness surrounding the afflicted area. On the other hand, two sockets in group B remained empty after the seventh day. In group B, two sockets had exposed bone more than seven days after treatment began. Redness around the socket remained for more than seven days in two Cutanplast-treated sockets and one Alvogyl-treated socket.These findings show a statistically significant difference in results between the two groups, with Alvogyl showing higher pain relief and healing capability, as evidenced by clinical signs of improvement. Clinical criteria, on the other hand, cannot be used to evaluate the healing feature. Histologic validation is therefore essential.One of the limitations of the study is the small sample size and that there are not enough surgical extraction instances. However, larger sample size is needed to verify that there is no statistically significant difference in postoperative pain between Alvogyl and Cutanpast. Patients with systemic disorders, acute infections, and cystic lesions should also be included in future studies.The present study concludes that there is a statistically significant difference between using Alvogyl or Cutanpast in postoperative pain management. Furthermore, no statistically significant difference was detected between the groups in the biographic information, location, and condition of the extracted tooth; the presence of a radiologic pathology, type of extraction procedure; and whether it was the first extraction or not Alvogyl and Cutanpast are comparable in postoperative pain management as intra-alveolar dressing materials.


In this case series, we describe a novel ultrasound (US)-guided cervical interlaminar epidural steroid injections (CILESIs) procedure that does not depend on the loss-of-resistance method for epidural space identification. A needle is introduced into three US-identified structures (triple bar sign), the interspinal ligament, ligamentum flavum, and dura mater. The injectants are monitored using superb microvascular imaging during injection. Here, we demonstrate the use of US-guided CILESIs in nine cases and propose the use of sonography, rather than conventional methods, for easier and safer cervical epidural injections. Sonography for direct visualization of cervical epidural injection may allow for outpatient injections. A major concern for cervical epidural injection (CEDI) in patients with neck pain and cervical radiculopathy is the safety and effectiveness of the procedure. Reports of serious complications such as spinal cord injury have led to concerns regarding this procedure’s safety ,2,3. FluIt is also important to examine the placement of the needle tip and the spread of the injectant to ensure its effectiveness . The losSonography offers an alternative method for performing cervical interlaminar epidural steroid injections (CILESIs). It could help reduce the risk of injury, avoid the pitfall of false-positive LOR, and avoid radiation exposure or the use of contrast media by allowing direct visualization of the location of the needle tip during the procedure with cross-sectional imaging .However, the technique for ultrasound (US)-guided CILESIs has not been reported, and no case series has described the safety of this technique in cervical lesions. Herein, we report cases of US-guided CILESIs without fluoroscopy.This study was performed at the Maeda Orthopedic Clinic and was approved by its institutional review board .Patients provided written informed consent for the cervical epidural block and the publication of this report. Overall, nine patients presented to the Maeda Orthopedic Clinic between August 2021 and January 2022. All patients underwent US-guided CEDI for the treatment of neck pain or interscapular radicular pain due to cervical disc herniation, cervical discopathy, cervical canal stenosis, or thoracic disc herniation.This novel US-guided CILESIs was performed as follows. First, the axial image of the interspinal ligament, ligamentum flavum, and dura mater as a triple bar sign was identified using a posterolateral with transverse scan approach by a PVI-475BX convex probe  . To optiWhile being inserted and removed, the needle is translocated from the caudal  side to the correct plane where a triple bar sign is seen clearly A. Next, Using a posterolateral approach, the needle is visible from the insertion point to the epidural space between the ligamentum flavum and dura matter. At first, while being inserted and removed (indicated by blue arrows in the figure), the needle is translocated from the caudal  side to the correct plane where a triple bar sign  is seen clearly  . Lastly,To confirm the accuracy of US-guided CEDI, we chose one patient (case 4) and two other patients . All patients were instructed on how to use the VAS prior to the cervical epidural block . Before the procedure, an interventional orthopedic doctor questioned the patients regarding their baseline VAS scores for pain. The patients were discharged on the day of the procedure and asked to revisit 1 week and 2 months later for evaluation of side effects and pain scores, respectively. If the pain persisted, we treated patients with an additional block and rechecked their pain scores.Functional ability was evaluated using the neck disability index (NDI). The NDI is a 10-item self-administered disease-specific questionnaire that evaluates the impact of neck pain on a patient’s daily life and the corresponding disability. The questionnaire scores range from 0 to 50; the higher the score, the greater the disability. The validity and reliability of this scale have been previously established .Symptom improvement was assessed before and 2 months after the injection using the VAS and the Japanese version of the NDI. Any potential complications, including headache, increased neck pain, or stiffness, were monitored. Moreover, functional ability was rechecked in patients treated with an additional block.Patients were asked about their opioid consumption, any additional cervical spine injections, and progression to surgery during the follow up period, and the answers were documented in their profile.2 . At the 2-month follow-up, there were significant reductions in NDI from 44.4 to 15.6 points in During the study period, nine participants with radicular pain underwent US-guided CEDI. The radicular pain in one, two, three, and three patients was caused by thoracic disc herniation, cervical disc herniation, cervical discopathy, and cervical canal stenosis, respectively. These patients were followed up from 60 to 348 days after the procedure. Their baseline data are presented in Vascular or subdural injections were not confirmed in any of the patients during the procedure. Furthermore, we did not encounter any significant complications, including stroke or persistent neurological deficits, during the procedure or 2-month follow-up. Nausea and general fatigue were observed after epidurography using a contrast media (case 4); however, the symptoms resolved within a day.CT epidurograms revealed that the procedure was technically successful in all three patients from whom they were obtained, including case 4. The spread of contrast was confirmed from the C2 vertebra level to the Th5 vertebra level according to the axial CT epidurogram.SMI was performed with a small injection. An appropriate epidural space was detected using SMI after the needle was advanced. The epidural space was then enlarged by means of an additional injection directed to the area where the SMI signal was detected .A 73-year-old woman presented with severe posterior cervical pain and right shoulder pain. The pain did not resolve with the use of medications . Magnetic resonance imaging revealed cervical canal stenosis. Her pain persisted for 3 weeks; therefore, US-guided C3/4 interlaminar CEDI of 1 mL dexamethasone (4 mg) and 6 mL 0.25% lidocaine was administered. In the examination room, SMI was used to confirm that the parenteral solution had spread throughout the epidural space. Subsequently, the VAS score decreased from 10 to 5. An additional four blocks were performed for 2 months, and the VAS decreased from 5 to 2. After 2 months, she experienced exacerbations and remission of symptoms. She received US-guided epidural blocks 20 times in total. We confirmed the 20th US-guided injection using CT epidurography .A 73-year-old man presented with severe pain in his right shoulder and arm. Radiographs revealed that the patient had severe cervical spondylosis. Considering that severe night pain and insomnia had persisted for 2 weeks, US-guided C5/6 interlaminar CEDI of 1 mL dexamethasone (4 mg) and 6 mL 0.25% lidocaine was administered. Subsequently, the VAS score decreased from 10 to 1. No additional blocks were administered. No recurrence of pain was observed at the 8-month follow-up.A 23-year-old man presented with severe pain in his right neck and interscapular region. The pain persisted despite diagnostic facet joint blocks . Magnetic resonance imaging revealed no vertebral bone injury; however, damage to the C3/4 and C4/5 discs was observed. The pain persisted for 3 months; therefore, US-guided C5/6 interlaminar CEDI of 1 mL dexamethasone (4 mg) and 6 mL 0.25% lidocaine was administered. In the examination room, SMI was used to confirm that the parenteral solution had spread throughout the epidural space. Subsequently, the VAS score decreased from 10 to 1. Two additional blocks were administered over 7 weeks, leading to the resolution of his pain. No recurrence of pain was observed at the 3-month follow-up.Reports of serious complications such as spinal cord injury have led to concerns regarding the safety of CEDI ,2,3. EpiIn the interlaminar approach, a guide is used to advance the needle tip just before the epidural space .CT guidance in interlaminar ESI improves the evaluation of the proper positioning of the needle owing to its high resolution and cross-sectional imaging . HoweverCEDI is based on the LOR method ,7. The eThe needle tip position must be visualized throughout the procedure to ensure accurate injection into the epidural space. Clinical practice guidelines recommend fluoroscopic guidance in all CEDIs . HoweverFor the accurate insertion of the needle, the US monitor, the affected area, and the practitioner should be in a straight line. However, this is not always possible during outpatient examinations because the size of the examination room is limited. Furthermore, since the needle is inserted deeply, needle orbit correction is often needed. As there are no critical arteries or nerves beyond the ligamentum flavum through this approach, the needle orbit correction can be repeated just before the needle tip reaches the ligamentum flavum. As a result, accurate injection is possible with our US guided method.The LOR technique relies on penetration of the ligamentum flavum. However, up to 74% of the ligamenta flava are discontinuous in the midline of the cervical region . Dural pIf the needle is advanced deeply, dural puncture or spinal injury can be avoided because the needle is tangentially advanced with respect to the dura. Even in cases of inappropriate injection, the practitioner could use the US image to confirm and terminate the inappropriate injection from the beginning, if necessary. Therefore, serious complications, such as total spine anesthesia or spinal injury, could be avoided. The direction of the needle has two advantages. The first is improved needle visibility by bringing the needle closer to the probe in parallel. The second is the avoidance of dural puncture and spinal cord injury.Unlike US guidance, fluoroscopy and CT guidance  cannot aThe LOR method can also be used to precisely detect the epidural space using SMI signals. However, the LOR method is associated with false-positive LOR before the needle enters the epidural space. False-positive LOR occurs in 29.4% of patients who undergo CEDI under conventional fluoroscopic guidance . The retUS guidance allows better positional relationships between the needle tip and anatomical structures  in cross-sectional imaging such as CT guidance. A previous investigation examining conventional fluoroscopy-guided lumbar interlaminar ESI demonstrated that many non-target injections in the retrodural space of Okada are likely to go unnoticed at the time of the procedure . This maRiveros-Perez et al. introduced color Doppler imaging to confirm the correct position of the epidural needle in the lumbar spine . HoweverIn conclusion, we propose the possible use of US for easier and safer CILESIs compared with conventional methods. US for the direct visualization of CILESIs may allow for safer outpatient injections.


An internal validation cohort (n = 64) was applied to validate the model.This study aimed to develop and validate a nomogram for predicting the risk of severe pain in patients with knee osteoarthritis. A total of 150 patients with knee osteoarthritis were enrolled from our hospital, and nomogram was established through a validation cohort (Eight important variables were identified using the Least absolute shrinkage and selection operator (LASSO) and then a nomogram was developed by Logistics regression analysis. The accuracy of the nomogram was determined based on the C-index, calibration plots, and Receiver Operating Characteristic (ROC) curves. Decision curves were plotted to assess the benefits of the nomogram in clinical decision-making. Several variables were employed to predict severe pain in knee osteoarthritis, including sex, age, height, body mass index (BMI), affected side, Kellgren—Lawrance (K–L) degree, pain during walking, pain going up and down stairs, pain sitting or lying down, pain standing, pain sleeping, cartilage score, Bone marrow lesion (BML) score, synovitis score, patellofemoral synovitis, bone wear score, patellofemoral bone wear, and bone wear scores. The LASSO regression results showed that BMI, affected side, duration of knee osteoarthritis, meniscus score, meniscus displacement, BML score, synovitis score, and bone wear score were the most significant risk factors predicting severe pain.Based on the eight factors, a nomogram model was developed. The C-index of the model was 0.892 (95% CI: 0.839–0.945), and the C-index of the internal validation was 0.822 (95% CI: 0.722–0.922). Analysis of the ROC curve of the nomogram showed that the nomogram had high accuracy in predicting the occurrence of severe pain [Area Under the Curve (AUC) = 0.892] in patients with knee osteoarthritis (KOA). The calibration curves showed that the prediction model was highly consistent. Decision curve analysis (DCA) showed a higher net benefit for decision-making using the developed nomogram, especially in the >0.1 and <0.86 threshold probability intervals. These findings demonstrate that the nomogram can predict patient prognosis and guide personalized treatment. Osteoarthritis (OA) is one of the most important causes of pain and disability in the elderly in recent years . It mainAccording to clinical guidelines, the focus of osteoarthritis of the knee treatments is to relieve pain . Severe There is a need to investigate the pathology of knee osteoarthritis in terms of pain development and the factors influencing it. It was generally believed that the onset of KOA pain was due to mechanical loading or aging injury , but recIdentification of factors associated with severe pain may promote timely detection and early intervention. This will reduce the pain and burden on the patient. Therefore, we aimed to develop a model for predicting the risk of severe pain.A total of 150 KOA patients treated at the Third Hospital of Shanxi Medical University from 2018 to 2020 were retrospectively enrolled in this study. An additional 64 internal validation patients were collected based on the following inclusion criteria.Inclusion criteria (1). Patients who underwent TKA at the Department of Orthopedics, Third Hospital of Shanxi Medical University; (2). Patients with complete medical records; (3). Underwent first unilateral total knee arthroplasty.Exclusion criteria (1). Patients with severe heart, liver, lung, and kidney organ dysfunction; (2). Patients with incomplete data; (3). Patients who were unable to cooperate, unwilling to participate, or lost to follow-up.The study of this columnar graph prediction model was reviewed and approved by the Ethics Committee of the Third Affiliated Hospital of Shanxi Medical University. This study was conducted following the Declaration of Helsinki.General information about the patient, clinical presentation, and, most importantly, some critical information about the patient′s MRI were collected and counted.The K–L grading scale which is extensively used in KOA studies as adopted to assess x-Ray results. We have standardized the method of x-ray examination of the patient to the frontal and lateral knee position, and the patient′s position during the examination to the standing position. The severity of bone wear in the knee joint in KOA was scored on x-ray as follows, Grade 0: Normal; Grade 1: Suspicious narrowing of the joint space with possible bone piles; Grade 2: Mild narrowing of the joint space with significant small bone piles; Grade 3. Significant narrowing of the joint space, as well as a moderate amount of bone stumps, mild sclerosis of the subchondral bone, and possible knee deformity; Grade 4: Severe narrowing of the joint space, extensive bone stump formation, as well as significant sclerosis of the subchondral bone and significant knee deformity.Patients received a Philips 3.0 T knee MRI scan of the affected knee. Image sequences included: (1) T1-weighted 3D fat-suppressed gradient echo sequence with 90° flip angle, TR: minimum500 ms, maximun 700 ms, FOV: 170 × 170 mm, TE: 20 ms, matrix: 380 × 305. Layer thickness: 4.0 mm, 19 layers scanned. (2) T2-weighted 3D fat-suppressed fast spin-echo sequence, flip angle 90°, FOV: 170 × 170 mm, TR: 500 ms, TE: 20 ms, matrix 340 × 265, layer thickness 4.0 mm, 19 layers scanned. The MRI images of the knee were evaluated observationally using the StartWebclient software.In 1957, Kellgren and Lawrence (KL) first established and used the imaging classification scheme for OA, the K–L grading scoring system that was later used with our present study . Whole-OSynovitis score rating is based on the maximum expansion of the synovial cavity, with grade 0 typical , grade 1 less than 33% of the total potential increase, grade 2 accounting for 33%–66% of the maximum possible expansion, and grade 3 more significant than 66% of the maximum potential growth.To record T1 image, measuring the distance between the plumb line of the largest section of the meniscus and the plumb line over the edge of the tibial plateau was recorded. Meniscus displacement was measured on T1 images in the coronal MRI position, with two vertical lines drawn in the image, one over the largest section of the medial or lateral meniscal volume and the other over the edge of the medial or lateral tibial plateau (excluding the osteophyte), and the distance between the two vertical lines was defined as a measure of Meniscus displacement, as shown in Bone marrow lesion (BML) was histologically defined as bone marrow necrosis, trabecular bone abnormalities, bone marrow fibrosis, edema, cellular infiltration, and vascular hyperplasia. Magnetic Resonance Imaging (MRI) presents as a T1-weighted image with low signal and a T2-weighted image with high signal short-time inversion recovery sequence (STIR) high signal images in a punctate, map-like, or diffuse irregular pattern. Bone marrow lesions (BML) are measured in T2 images on MRI and are graded as follows, grade 0: normal; grade 1:≤33% of the area; grade 2: 33%–66% of the area; grade 3:≥66% of the area.Observations and diagnostic scores were assigned by two attending physicians who do not know each other, and if the results deviated significantly from the values, further assessments were made by a more senior and highly qualified chief physician with many years of experience.Pain was expressed based on the McMaster Universities Osteoarthritis Index (WOMAC) pain score, using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the degree of pain in the patient′s knee was determined , 36. TheThe knee was divided into 15 observation areas according to the WORMS scale as shown in The remaining variables, except BMI, were converted to binary variables. Patients’ outcome times were divided into two groups: the severe pain group and the non-severe pain group. The score for pain was determined by averaging the scores of two senior doctors in our department. The imaging assessment was conducted jointly by two experienced senior physicians from our imaging department.http://www.r-project.org/). Firstly, Lasso regression was used to select significant variables, logistics regression analysis was used to display risk factors, and a nomogram chart was constructed according to the RMS package′s univariate and multivariate analysis results. The accuracy of the nomogram was tested using the modeling cohort and the internal validation cohort through identification and calibration. Finally, C-index, calibration curve, and ROC curve were constructed to evaluate the accuracy of the prediction model. The DCA curve was also employed to assess the effectiveness of the nomogram in clinical applications.Statistical analysis was performed by SPSS 25.0  and R for windows  had a BMI >24.0. Moreover, 35.3% (53) patients had severe pain. Other clinical data of patients are presented in Among the 14 characteristics screened, 8 were considered potential predictors in 150 patients (∼2:1 ratio) and had non-zero coefficients in the LASSO regression model. These factors included BMI, affected side, duration of knee osteoarthritis, meniscus score, meniscus displacement, BML score, synovitis score, and bone wear score. The specific content is shown in .Logistic univariate regression showed that BML score, synovitis score, bone wear score, and meniscus displacement were more predictive and were independent risk factors for severe pain in patients with KOA. The regression coefficients of 8 variables and other analysis results are shown in P-value for BMI was more than 0.05 in our logistic univariate and multivariate regressions, we concluded that the BMI was a clinically significant risk factor for pain in osteoarthritis of the knee. Therefore, we included the BMI in the nomogram.The LASSO regression analysis results revealed that the BMI was a significant variable. Although the A nomogram for predicting the risk of severe pain in patients with KOA was constructed using eight variables: BMI, affected side, duration of knee osteoarthritis, meniscal score, meniscal displacement, BML score, synovitis score, and bone wear score. See Analysis of the calibration curve of the nomogram showed good agreement in this cohort. The C-index of the cohort prediction nomogram was 0.892 (95% CI:0.839–0.945), and for the internal validation it was 0.822 (95%: CI 0.722–0.922), indicating good discriminatory performance of the model. The nomogram showed good predictive power in predicting the occurrence of severe pain in KOA patients. The specific data of patients are shown in .The area under the ROC curve (AUC) analysis was used to assess the accuracy of the model. The higher the AUC value, the better the model accuracy. The results showed that the model for predicting the risk rate of severe pain in KOA patients had better accuracy, as seen in the modeling cohort (AUC = 0.892). The final result are present in Decision curve analysis of a nomogram predicting the risk of severe pain in KOA patients. The decision curves showed that the nomogram could effectively predict the risk of developing severe pain in KOA patients if the threshold probabilities for patients and physicians were >0.1 and <0.86, respectively. In this range, it showed excellent clinical effect based on the predicted risk of developing severe pain in KOA patients. The details are presented in Due to the increasing prevalence of global obesity and the growing aging population, the number of KOA patients has increased tremendously worldwide. Pain is one of the most important clinical manifestations in patients with KOA and is often a key factor influencing surgical treatment of TKA patients. The mechanisms of pain associated with knee OA are complex, and local structural changes in the knee, such as synovitis, degree of bone marrow pathology, and deformity changes in the kneecap, are postulated to cause or induce different kinds of pain .To our knowledge, this is the first study to develop and validate a risk probability model for predicting the occurrence of severe pain in KOA patients. In both the training and validation cohorts, the nomogram showed satisfactory agreement, and DCA revealed that it had good clinical applicability. Nomograms are widely used for various diseases, primarily because of their ability to reduce statistical predictive models to a single numerical representation of the probability of an event  tailored to an individual patient′s profile. The user-friendly and easy-to-understand graphical interface used to generate these estimates allows the use of nomograms in clinical practice to inform clinical decision making . In our Research has revealed a strong link between BMI and KOA. It has been shown that obesity can increase the occurrence of KOA and the progression of pain , 41. HigOur study found that KOA patients with a longer duration of disease, meniscal damage or higher meniscal scores, high synovitis scores, and right-sided KOA had a higher probability of severe pain. In addition, the more influential the bone wear, the greater the relative likelihood of obtaining severe pain. In the constructed nomogram we developed, the severity of bone wear was one of the most important factors influencing the occurrence of severe pain in KOA patients, followed by the synovitis score and whether the meniscus was displaced. These factors can be used to predict the risk of severe pain in KOA patients.There are some limitations to our study. First, this was a retrospective study, and therefore, there is some inherent bias. Moreover, many factors such as MRI and x-ray imaging data, were not available. Therefore, further studies are needed to validate our findings through multicenter internal validation.In this study, higher BMI, synovitis score, BML score, bone wear score, meniscus score, in addition to right-sided KOA or presence of meniscal displacement and longer duration of KOA were found to be risk factors for the development of severe pain in patients with KOA. A nomogram comprising eight predictors showed good ability to predict the risk of severe pain in patients with KOA more accurately.


Higher late (3 and 6 months) postoperative pain was associated with intercostal incisions in both groups, as previously reported, whereas higher early  postoperative pain was more associated with subxiphoid incisions than intercostal incisions in the bilateral VATS group.There is a lack of data comparing postoperative pain after subxiphoid and intercostal video-assisted thoracoscopic surgery (VATS). Pain is an individual’s subjective experience and, therefore, difficult to compare between different individuals subjected to either procedure. This study assessed reported pain at six postoperative time points in the same patients receiving both subxiphoid and intercostal incisions for thoracic disease. Data from 44 patients who received simultaneous combined intercostal and subxiphoid VATS were retrospectively analyzed from August 2019 to July 2021. All patients received the same length of subxiphoid and intercostal incisions with or without drain placements. A numerical pain rating scale was administered on postoperative days (POD)-1, POD-2, POD-Discharge, POD-30, POD-90, and POD-180. Bilateral uniportal VATS was performed in 11 patients, and unilateral multiportal VATS was performed in 33 patients. In the unilateral VATS group, there were no differences in pain reported for both incisions in the early postoperative period. However, in the bilateral VATS group, subxiphoid wounds resulted in significantly higher pain scores on POD-1, POD-2, and POD-Discharge ( Recent data comparing open thoracotomy to video-assisted thoracoscopic surgery (VATS) suggests a predilection for the latter. Randomized and non-randomized studies have associated VATS procedures with less trauma, decreased postoperative pain, fewer postoperative complications and faster recovery. Findings such as these have led to wider usage of VATS among thoracic surgeons ,2,3. ConIt has been suggested that uniportal VATS is less painful than multiportal VATS based on the assumption that one incision is less painful than two or more. However, questions have arisen regarding the relative degree of postoperative pain and chest wall neuralgia among patients receiving uniportal VATS compared with those who receive multiportal VATS ,6,7,8. W2 insufflation [In 2012, Suda et al. reported their first concomitant use of subxiphoid single-port thymectomy and COfflation . In 2014fflation . Subsequfflation ,14,15,16fflation . Moreovefflation ,14,15,16While theoretically there should be less pain, is there actually less pain? Pain is a subjective and multidimensional experience. One of the most challenging aspects of any pain research is the objective evaluation of pain. Although several studies have been performed to investigate the incidence and intensity of pain after thoracic surgery ,21,22,23Therefore, this study accessed reported pain associated with both subxiphoid and intercostal incisions of the same lengths on the same thoracic disease patients. Pain was rated numerically at six different postoperative time points, three early and three late.2. Five patients whose subxiphoid and intercostal incisions were not the same length, three whose postoperative drains were not the same size, and four who received intraoperative thoracic epidural anesthesia were excluded. After exclusion, the remaining 44 patients were divided into two groups, (1) eleven patients receiving simultaneous bilateral uniportal VATS (n = 11) with ipsilateral subxiphoid incisions on one side and contralateral intercostal incisions on the other and (2) thirty-three patients receiving unilateral multiportal VATS (n = 33) with both surgical approaches used on the same side -20200228). The requirement for written informed consent was waived. Fifty-six patients receiving combined subxiphoid and intercostal VATS for thoracic procedures at a single medical center from August 2019 to July 2021 were consecutively enrolled. All incisions were equal in length. None of the patients had preoperative analgesic requirements, previous thoracic surgeries, impaired cardiac functioning, or body mass indices (BMI) >30 kg/mame side .All procedures were performed by one surgical team following the same perioperative protocols. Patient data, including age, gender, BMI, smoking habits, lung function tests, perioperative data, postoperative complications, and follow-up pain scores were collected from digital medical records. Under general anesthesia via a double-lumen endotracheal tube, nine of the simultaneous bilateral uniportal VATS patients received right side subxiphoid VATS pulmonary wedge resections and left side intercostal VATS pulmonary wedge resections. The other two patients received right side intercostal VATS upper lobectomies and left side subxiphoid VATS lower lobe wedge resections See .Surgical equipment included Echelon Flex endoscopic articulating linear cutters , long curved dissector and grasping forceps with double articulations, and curved suction , and a 10 mm 30° thoracoscope . Patients were placed in a supine position on a tilted operating table (30 to 45 degrees) for easy access and performance of subxiphoid VATS surgery. A single incision 2–5 cm long was made below the xiphoid process and slightly slanted along the costal arch. The skin, subcutaneous tissue, and rectus abdominis were cut, blunt dissection was performed using a finger applied to the deep surface of the costal arch, and the pleural cavity was accessed. A plastic wound protector  was placed in the incision. Throughout the procedure, the xiphoid process was not excised and no sternal elevator was used. After uniportal subxiphoid VATS pulmonary wedge resection, a chest drain was inserted through the same incision. For the other side, the patient was changed to a decubitus position to access the contralateral lung. A single incision with the same length as the subxiphoid incision was made over the intercostal space, and a wound protector was inserted. A chest drain the same size as used on the other side was placed through the intercostal incision A.Following similar anesthetic procedures and positioning for the optimized subxiphoid approach, multiportal combined subxiphoid and intercostal VATS were performed depending on surgical procedure type See .n = 3) receiving two equal but separate drains via the subxiphoid and intercostal incisions. In total, 15 patients received no chest drain.Incisions equal in length were made over the subxiphoid and intercostal regions. For patients with pulmonary or mediastinal tumors, specimens were retrieved through the subxiphoid incision without enlarging the wound. A total of 15 of the 33 patients received an additional small third port (0.5–1 cm) for intraoperative manipulation and placement of postoperative chest drains B. The otChest radiography was performed immediately after the operation or the following morning. Chest drains were removed in both groups if there were no air leaks and if the drainage was < 200 mL within 24 h. A total of 15 of the 44 patients received intravenous patient-controlled anesthesia upon request. Acetaminophen, diclofenac, and tramadol were regularly administered once patients resumed normal oral intake until discharge. Additional doses of intravenous parecoxib were used for intolerable pain during the postoperative hospital stay. Pain scores for both subxiphoid and intercostal wounds were simultaneously assessed separately by a surgical team member using a numerical rating scale (NRS), 0 (no pain) to 10 (excruciating pain), every eight hours with patient at rest on postoperative day 1 (POD-1) and then on subsequent postoperative days until discharge. The mean of the three daily NRS scores for both incisions were recorded for the three early time points. Pain scores at the three late time points were followed up either by a consultation in the outpatient clinic or a phone call.t-test (paired t-test) was used to compare subxiphoid and intercostal NRS scores from time point to time point among the same patients. All statistical operations were performed using SPSS 20  for Windows. All statistical tests were two-tailed, and a p-value <0.05 was considered significant.Descriptive data were expressed as numbers with percentages and continuous variables expressed as either means with standard deviation or medians with interquartile range (IQR). The Student’s 2. Other perioperative variables such as operative time, blood loss, complications, and postoperative hospital length-of-stay were comparable and similar to our own experience with transthoracic VATS.Of the 44 patients receiving subxiphoid VATS for the surgical treatment of thoracic conditions between August 2019 and July 2021, 11 simultaneously received uniportal ipsilateral subxiphoid VATS on one side and contralateral intercostal VATS on the other side, while 33 received multiportal subxiphoid and intercostal VATS on one side only. As can be seen in As can be seen in p = 0.0003, 0.001, and 0.03, respectively)) but lower mean pain scores on POD-90 and POD-180 (p = 0.03 and 0.16) (p = 0.03 and 0.08) (nd 0.16) A. Interend 0.08) B. ComparPain is usually assessed subjectively by means of verbal or visual intensity scales and questionnaires ,21. MostIn contrast to the literature’s overwhelming opinion that subxiphoid VATS causes much less early postoperative pain than intercostal VATS following thoracic surgery ,15,16,18Although the findings of this study were in contrast to findings in the literature , the present study did find higher pain intensity associated with intercostal incisions in the late follow-up period (POD-90 and 180), consistent with the literature ,23. ReceThe use of subxiphoid VATS incisions avoids intercostal nerve damage, which has often been cited as a major source of postoperative pain and paresthesia after thoracotomy and intercostal VATS. From a surgical standpoint, this approach allows easier access to the anterior mediastinum when performing thymectomy as well as better access to both sides of the chest with only a single incision. However, this approach, particularly when there is posterior mediastinum and left thorax involvement, can be challenging even for experienced thoracic surgeons. Whether the potential advantages outweigh the potential disadvantages remains to be determined by future studies.Reviewing the literature, we found it took a long time for the field to draw a firm conclusion regarding relative reported pain associated with thoracotomy versus VATS ,2,3,9,19This study has a number of limitations. Our sample size was small. The difficulty in recruiting patients who required receiving two procedures in the same locations at the same time made this limitation unavoidable. Another limitation is that all the procedures in this study were performed by one surgeon at one institute, and so the learning curve for the performance of subxiphoid VATS has not been taken into consideration. In addition, when considering our results, the non-constant confounding posed by the use of different types of anaesthesia and analgesics with variable doses in different groups should be considered. Therefore, further studies, including well-controlled prospective studies and multi-center studies, are needed to further verify our findings.Our study found that patients who received simultaneous uniportal ipsilateral subxiphoid VATS and contralateral intercostal VATS reported more pain associated with subxiphoid incisions than intercostal incisions. Thus, the use of subxiphoid VATS may not always result in greater pain reduction than intercostal incisions in the early postoperative period. Additionally, the higher pain intensity in the intercostal incisions reported in the late postoperative period may not be indicative of pain caused by merely nerve damage during surgery, as there were other potential multifactorial pain-causing or pain-worsening mechanisms such as adjunctive chemotherapy and/or radiotherapy involved. More research is needed to better understand the cause of pain in a surgical area previously not thought to be prone to pain.


To analyse if postoperative complications constitute a predictor for the risk of developing long-term groin pain.Population-based prospective cohort study of 30,659 patients operated for inguinal hernia 2015–2017 included in the Swedish Hernia Register. Registered post-operative complications were categorised into hematomas, surgical site infections, seromas, urinary tract complications, and acute post-operative pain. A questionnaire enquiring about groin pain was distributed to all patients 1 year after surgery. Multivariable logistic regression analysis was used to find any association between postoperative complications and reported level of pain 1 year after surgery.The response rate was 64.5%. In total 19,773 eligible participants responded to the questionnaire, whereof 73.4% had undergone open anterior mesh repair and 26.6% had undergone endo-laparoscopic mesh repair.Registered postoperative complications were: 750 hematomas (2.3%), 516 surgical site infections (1.6%), 395 seromas (1.2%), 1216 urinary tract complications (3.7%), and 520 hernia repairs with acute post-operative pain (1.6%).Among patients who had undergone open anterior mesh repair, an association between persistent pain and hematomas , surgical site infections  and acute post-operative pain  was seen. Analysis of patients with endo-laparoscopic repair showed an association between persistent pain and acute post-operative pain .Acute postoperative pain was a strong predictor for persistent pain following both open anterior and endo-laparoscopic hernia repair. Surgical site infection and hematoma were predictors for persistent pain following open anterior hernia repair, although the rate of reported postoperative complications was low. Approximately 20 million hernia repairs are performed annually worldwide . The lifCPIP is associated with disability, dissatisfaction, impaired productivity, and decreased quality of life . StudiesEfforts to identify and reduce risks for persisting pain is crucial. Risk factors for chronic pain after inguinal hernia repair can be divided in patient-related risk factors, such as young age, female sex, preoperative pain, significant pain in other locations, and specific genotypes –11; and Previous studies from our research group have suggested that postoperative complications are also risk factors for CPIP . PatientSince patient satisfaction has become an important measure of successful outcome, a Patient Report Outcome Measure (PROM) questionnaire has been developed by the SHR. The PROM was automatically sent 1 year after surgery to all registered patients that had undergone hernia repair . The SHRIn this study we investigated the impact of specific postoperative complications on CPIP in a population-based material, using data from the extended SHR form and corresponding PROM answers.The hypothesis in this study was that some postoperative complications increase the risk for chronic pain after inguinal hernia repair. The aim of this study was to clarify the association between specific postoperative complications and CPIP in the operated groin with the primary endpoint patient-reported persistent pain 1 year after surgery.This study was designed as a population-based prospective cohort study. Collection of data was performed in accordance with the RECORD statement extended from the STROBE statement for observational studies . Data wePatients who had undergone inguinal hernia repair between 27th August 2015 and 31st August 2017 and were registered in the SHR were eligible for inclusion. The starting date of the study was chosen since that was when the SHR began more detailed registration of postoperative complications.Inclusion criteria were registered hernia repair and a completed PROM. Exclusion criteria were hernia repair techniques other than open anterior mesh repair and endo-laparoscopic repair with preperitoneal mesh placement. “Other repairs” were excluded due to the heterogeneity of that category. Open and endo-laparoscopic repairs were analysed as two separate groups.The primary outcome was reported level of pain during the past week reported in the PROM questionnaire. The PROM included a seven-grade ordinal scale rating of persistent pain in the operated groin, derived from the former Inguinal Pain Questionnaire (IPQ) , 19. GraDefinitions of the postoperative complications included in the SHR during the study period are listed in Table Postoperative complications occurring in the operated groin, and thus theoretically having some association with the risk for persisting pain, were considered, while systemic complications  were not investigated. Postoperatively diagnosed iatrogenic injury to the testis, bladder or intestine were not included in the analyses as these events were very rare. The postoperative complications registered were grouped into five categories: hematoma, surgical site infection, seroma, urinary tract complication and acute postoperative pain Table .Since the rates of complications vary according to hernia repair technique, the study cohort was divided into two groups based on the surgical approach: open anterior mesh repair and endo-laparoscopic repair with preperitoneal mesh placement.2). Separate analyses were performed for the two surgical method groups, open anterior mesh repair and endo-laparoscopic repair, respectively.Descriptive statistics and statistical analyses were performed using SPSS 22.0 . Ordered logistic regression analyses were performed with self-reported pain at 1 year, according to the PROM seven-grade scale, as dependent variable. The postoperative complication categories  were assessed as potential risk factors and entered as independent variables, along with age at surgery , sex , smoking habit (yes/no), and BMI  consisted of 91.4% males and 8.6% females. Mean age at surgery was 62.3 years. There were 4.1% smokers and mean BMI was 25.2 kg/m2. Hernia repair was performed with open anterior mesh repair in 73.4% cases and with endo-laparoscopic repair in 26.6% cases. Sex distribution in the two surgical method groups is presented in Table The study group  or endo-laparoscopic repair , response rates stratified for sex were 1,694/2,809 (60.3%) for females and 18,079/27,850  for males. Mean age at surgery was 64.2 years (SD 13.5) in the study group and 58.0 years (SD 16.5) in the non-responder group (p < 0.001).In the groups of patients undergoing open anterior mesh repair (p = 0.450); 287/19,773 (1.5%) vs 169/10,886 (1.6%) for surgical site infection (p = 0.485); 224/19,773 (1.1%) vs 129/10,886 (1.2%) for seroma (p = 0.682); 737/19,773 (3.7%) vs 396/10,886 (3.6%) for urinary tract complication (p = 0.691); and 242/19,773 (1.2%) vs 243/10,886 (2.2%) for acute postoperative pain (p < 0.001).In the groups of patients undergoing open anterior mesh repair or laparoscopic repair the complication rates among responders and non-responders were as follows: 442/19,773 (2.2%) vs 258/10886 (2.4%) for hematoma , 843 grade 2 (16.0%), 602 grade 3 (11.4%), 268 grade 4 (5.1%), 209 grade 5 (4.0%), 69 grade 6 (1.3%), and 223 grade 7 (4.2%).Uni- and multivariable ordered log-odds regression analyses in the open anterior mesh repair group showed that hematoma, surgical site infection and acute postoperative pain were associated with CPIP 1 year after hernia repair, while urinary tract complication and seroma were not. Age was inversely related to persistent pain; the odds ratio for CPIP decreased for every 1-year increase in age at the time of surgery. BMI was associated with persistent pain; the odds ratio for CPIP increased for every step increase in BMI. Females, who had an open anterior repair, also had an increased odds ratio for developing CPIP Table .Table 3RIn the endo-laparoscopic repair group, acute postoperative pain was associated with CPIP 1 year after surgery, while the other postoperative complications were not. Older age was associated with a decreased odds ratio for CPIP, while females, smokers, and patients with a higher BMI had increased odds ratios for persistent pain Table .Table 4RIn this large population-based cohort study, we found an increased risk for CPIP among patients suffering from acute post-operative pain after groin hernia repair. With open anterior mesh repair the risk for CPIP was also increased in patients with postoperative hematoma or surgical site infection. There was an apparent difference in patient characteristics between the group who had endo-laparoscopic repair, who were younger and more often female, and the group who had open repair.Acute postoperative pain was a strong risk factor for CPIP after open anterior as well as after endo-laparoscopic repair. The definition of acute postoperative pain in the SHR is “severe pain resulting in prolonged pharmacologic treatment, readmission or reoperation” . Acute pIn a previous study we showed that patient-reported “early severe postoperative pain in the groin” was associated with “chronic groin pain” 8 years after open hernia repair . The preSeveral habitual risk factors for acute postoperative pain are known including history of chronic pain, preoperative groin pain, and younger age , 8, 24. To minimise the risk for acute postoperative pain, previous history should be carefully considered before planning for surgery. The use of a less traumatic surgical method, such as endo-laparoscopic repair has been reported to minimise the risk for postoperative complications . In caseSurgical site infection was a significant risk factor for persistent pain after open anterior mesh repair, but not after endo-laparoscopic repair. This category of complications includes superficial infection and deep infection. Open anterior mesh repair is associated with a higher rate of surgical site infection compared to endo-laparoscopic repair , and thiPerioperative antibiotic prophylaxis is seldom used today as part of the campaign to reduce the prevalence of resistant pathogens . ProphylThe hematoma category in this study included both deep and superficial hematoma. Hematoma was associated with CPIP after open anterior mesh repair, but not after endo-laparoscopic repair. The risk for hematoma is generally higher after open anterior mesh repair than after endo-laparoscopic repair . IntraopLocal surgical wound complications, such as surgical site infection and hematoma in the surgical area were associated with CPIP after open anterior mesh repair in this study, even though the complication rates were low.One hypothesis, not possible to evaluate from the present material, is that the increased odds ratios presented may be a result from confounding, where, for example, traumatic dissection causes local postoperative complications as well as persisting postoperative pain. The extent of tissue trauma inflicted by the surgical technique is not registered in the SHR, but the potential association between traumatic technique, postoperative complications and persisting pain gives indirect support for recommending careful technique to reduce the risk of persisting pain.The results of this study are statistically significant but since the analyses are based on relatively rare events in a large cohort, the clinical importance must be evaluated with this in mind. The absolute risk for one of these events occurring is low and accordingly a moderate increase in the incidence of a specific complication will have limited impact on the rate of CPIP. Nevertheless, this study provides detailed information regarding the association between specific postoperative complications and CPIP as well as confirming findings from previous smaller studies.The postoperative complication categories urinary tract complication and seroma were not significant risk factors for CPIP regardless of technique used. In contrast to hematoma, surgical site infection and acute postoperative pain, urinary tract complications are not obviously associated with a surgical dissection technique causing tissue damage and nerve injuries. This could explain the lack of association with CPIP. Postoperative seroma may be associated with surgical technique but there might be predisposing factors which are not associated with surgical technique, such as coagulopathy, congestive liver disease and cardiac insufficiency .Younger age and female sex are well-established predictors of CPIP and were independent risk factors in this study too , 8, 12. CPIP is one of the most significant long-term complications after inguinal hernia repair. It must be considered when planning and optimizing groin hernia surgery. In patients with an asymptomatic hernia, the risk for intestinal strangulation should be weighed against the risk for CPIP. In some cases, the strategy “watchful waiting” could be preferred –39.The main strength of this study is the large population of almost 20,000 individuals. The Swedish national register with its high coverage and verified validity, further underlines the strength of the study, and increases its external validity. Use of the PROM questionnaire for reporting pain 1 year after surgery combined with data on specific postoperative complications in the SHR provide a deeper understanding of the association between postoperative complications and CPIP that previous smaller studies have suggested , 14.The study also has limitations. Preoperative pain could not be included as an independent variable in the analyses of this study, even though it is a known predisposing factor for chronic pain, since that information is presently not included in the SHR. The response rate was 64.5% which was lower than desired. Since the PROM is sent to all hernia patients rather than to a selection of patients who have accepted inclusion in a study involving a specific follow-up regime, 64.5% may be considered reasonable and may not even be lower than expected. Furthermore, this study was not designed as a controlled study. The non-responder group was investigated to examine any selection bias. It differed from the responder group in distribution of method of repair, age, and sex, although the differences were not large, and it is possible that the postoperative outcome regarding pain between non-responders and responders differed. On the other hand, the non-responder group did not differ substantially from the responder group regarding reported postoperative complications in the register. Together, these facts suggest that the results of the present study are applicable to a large population.Acute postoperative pain was a strong predictor for CPIP 1 year after surgery after both open anterior mesh repair and endo-laparoscopic repair. Hematoma and surgical site infections also moderately increased the risk for persisting groin pain after open anterior mesh repair. Considering the moderate influence and the relatively low rates of these specific complications, their role in the pathogenesis of CPIP is probably limited. Our findings suggest that other strategies are required to reduce the problem of CPIP, in particular improvement of surgical technique during inguinal hernia surgery.


Enhanced recovery after surgery (ERAS) protocols are the current standard of care when it comes to improving post-surgical outcomes in breast cancer patients. Compliance with all protocol items is required in order for patients to experience significant benefits. Given that the ERAS protocols involve numerous medications which each have unique side effect profiles and medication interactions, this is often difficult to accomplish. Additionally, breast cancer patients are often left with a large psychological burden, which ERAS protocols fail to address. This review aims to determine the role that alternative therapies can play in improving both the emotional and physical strains patients experience during the post-operative stage of recovery. A PubMed search was conducted using the following search terms  and (“surgery”) and (“pain”). Studies selected for this review include articles published or translated in English that addressed alternative medical interventions affecting pre-, peri-, or post-operative outcomes in breast biopsies, surgeries, or breast-related procedures. Eighteen articles fit the inclusion criteria, with seven addressing music, five addressing meditation, yoga, and guided imagery, five addressing massage, one addressing myofascial release, four addressing aromatherapy, two addressing acupuncture, and three addressing hypnosis. Most forms of alternative therapies offered some benefit to patients following breast-related procedures, many resulting in improvements in post-operative outcomes including pain, fatigue, energy, stress, anxiety, mood, and depression. The reviewed studies demonstrated numerous benefits to integrating alternative medicine into standardized therapy to improve postoperative outcomes. Most studies analyzed did not include placebo controls as including proper placebos was often not feasible. Future studies with larger sample sizes are needed to better quantify the benefits patients receive from these noninvasive, low-risk complementary therapies. Breast cancer is one of the most common cancers amongst women in the United States, second only to skin cancer . Each yeThe American Society of Breast Surgeons (ASBrS) has compiled a workgroup to encourage breast surgeons to consider the use of non-opioid alternatives to combat post-operative pain control and mitigate the current opioid crisis. This workgroup has recommended the use of a multidisciplinary approach in combination with standardized quantities of narcotics. It also strongly supports the use of the enhanced recovery after surgery (ERAS) protocol . ERAS prGillis et al. conducted a patient-led narrative style study assessing the ERAS protocol patient experience, which brought to light several unaddressed patient needs. The success of ERAS protocols lies in the physical components of surgical recovery; however, these protocols lack to address patients’ emotional needs. In Gillis et al.’s study, patients felt ill-equipped to resolve stressors on their own during the pre-surgical phase and they were not informed of available community resources by their healthcare providers . ImportaSome women with breast cancer occasionally desire to utilize alternative remedies as a complement to traditional medications . Many woMethodsA systematic literature review was conducted in order to determine what non-pharmacologic treatments could be used to optimize breast cancer patient care pre-, peri-, or post-operatively. The search terms were as follows:  and (“surgery”) and (“pain”). All articles were uploaded from PubMed into COVIDENCE, an online software program used for the production of systematic reviews. Once imported into COVIDENCE, all abstracts underwent initial screening by members of the review team. Studies included in this review required at least one alternative medicine intervention and a description of a pre-, post-, or peri-operative surgical outcome . All systematic reviews, literature reviews, meta-analyses, opinion pieces, non-English, non-human, chronic pain studies, and studies on non-surgical screening techniques  were excluded. Articles with a focus on medications including vitamins, herbs, and supplements were also excluded from this study. Following abstract screenings, the full text of each article was screened using the predetermined inclusion/exclusion criteria, and qualitative data was extracted from all articles which met this criterion. Additionally, the references of select articles were screened in order to identify and include any additional relevant studies.ResultsThe original search identified 1,645 total papers related to surgery and holistic medical interventions. Of that, 1,625 studies were excluded because they lacked a surgical intervention on the breast. Of the 20 remaining papers, two were excluded from being non-English studies. Thus, 18 met the criteria for review  to determine pain, mood, energy, relaxation, insomnia, stress, anxiety, alertness, fatigue, and tension after massage alone or with the addition of acupuncture. The massage techniques utilized included foot reflexology and Swedish massage. Using the VAS scores, Dilaveri et al. determined that stress and anxiety decreased significantly, while relaxation increased in both treatment groups. Although both groups showed improvement, the massage-only group experienced a greater effect in all metrics . SimilarThus, the use of massage alone as an adjunctive therapy to patients following breast procedures has shown to be beneficial and can reduce numerous post-operative symptoms including pain and anxiety.Myofascial ReleaseFascia is the connective tissue that encases various structures in the human body. It has tremendous tensile strength and any disruption in the fascial planes can cause dysfunction, pain, and discomfort. Myofascial release is the practice of placing direct pressure on the restricted fascia until a moment of release is felt. Serra-Ano et al. studied the effectiveness of myofascial release compared to placebo manual lymphatic drainage in patients who underwent breast cancer surgery. Fascial manipulation improved the range of motion in the shoulder determined by measuring the active angular reach via a goniometer. Pain severity, measured with VAS scores, was also decreased in patients undergoing myofascial manipulation with greater significance than those undergoing placebo manual lymphatic drainage .MusicMusic was first reported to aid in surgical procedures in 1914 . Music cSix studies evaluated the effect of music on breast-related surgical procedures. Tellez et al. aimed to determine the effect of music on breast biopsies. By analyzing VAS scores, the study concluded that when compared to a standard breast biopsy, the pre- or post-operative addition of music reduced stress, pain, and anxiety .Deng et al. compared the effects of music and the combination of music and aromatherapy in the peri-operative treatment of breast cancer. Patients treated with music therapy demonstrated a reduction in pain intensity and anxiety when compared to standard therapy alone and the combination of music and aromatherapy demonstrated an even greater decrease in pain intensity and anxiety .Soo et al. investigated the impact of relaxing music played during an image-guided core-needle breast biopsy. Using multiple questionnaires, there was a demonstrated reduction in anxiety, fatigue, and pain when compared to the standard care control . Wren etAromatherapyAromatherapy is the use of essential oils that come from seeds, stems, leaves, needles, petals, flowers, rinds and fruits, woods and resins, roots and rhizomes, and grasses for medical purposes . Four paThree papers explored the effect of lavender aromatherapy. Kim et al. investigated the addition of lavender to post-operative oxygen therapy. There was no difference in narcotic requirements or objective pain scores between control and intervention; however, patients in the lavender group reported a higher satisfaction rate with pain control than control patients . Franco Overall, while there were no adverse effects of aromatherapy documented, the evidence supporting the benefits of aromatherapy was mixed in the studies analyzed.Guided Imagery, Hypnosis, and MeditationGuided imagery is a relaxation technique, also known as visualization, that involves creating specific conscious experiences, such as imagining oneself on a beach, without the use of external stimuli . When fuKwekkeboom et al. tested the efficacy of guided imagery in reducing post-operative pain in women with breast and gynecologic cancers. Participants who underwent breast surgery completed guided imagery tasks and returned pain diaries 48 hours after discharge. Though this study reported a high percentage of patients opting to implement nonpharmacological pain management strategies, pain-related intensity and distress remained similar among patients who used analgesics alone and those who used an analgesic in combination with a nonpharmacologic intervention, such as guided imagery, re-positioning, heat, music, or meditation .Three papers examined the impact of meditation as an intervention, one in patients undergoing autologous tissue reconstruction and two in patients undergoing breast biopsies. Using various scales, both Soo et al. and Wren et al. found that guided meditation reduced pain and anxiety about both breast surgery and the potential cancer diagnosis. Additionally, Wren et al. demonstrated a significant improvement in self-compassion and heart rate over time compared to the control group. The papers differed in that Soo et al. saw a significant reduction in fatigue scores following biopsy, while Wren et al. demonstrated no difference in fatigue compared to controls .Dion et al. analyzed patients who underwent autologous tissue reconstruction and were treated with either massage or massage in combination with mediation. There was no difference in stress, anxiety, relaxation, insomnia, alertness, fatigue, tension, pain, mood, and energy between the two cohorts .In two studies comparing hypnosis to a control group, both demonstrated significant psychological benefits. Schnur et al. investigated the effects of presurgical hypnosis on psychological stress in patients undergoing excisional breast biopsy. Prior to surgery, the hypnosis group had significantly improved relaxation and anxiety and decreased emotional upset and depression compared to the control group .Montgomery et al. investigated the effects of adding a 15-minute hypnotic session prior to a breast-related surgical intervention. Patients receiving required less propofol and lidocaine during the intervention and had decreased post-operative pain, discomfort, fatigue, and nausea .Overall, in terms of pain management, patients who took analgesics experienced similar outcomes to those using guided imagery in combination with analgesics. However, hypnosis and meditation both independently demonstrated significant pain reduction and psychological benefits for patients.Yoga TherapyYoga is a practice that combines a sequence of postures with purposeful breathing and heightened self-awareness in order to achieve a state of relaxation and increased awareness of the mind, body, and spirit . In receSudarshan et al. investigated the effects of 12 one-hour weekly Hatha yoga sessions on anxiety, depression, range of motion, and flexibility following breast surgery. The study showed that the Hatha yoga intervention significantly improved flexibility during right and left shoulder abduction, as well as range of motion during left shoulder flexion following breast surgery-related procedure .Electro-Puncture and AcupunctureAcupuncture is a form of traditional Chinese medicine that involves the stimulation of predefined acupoints on the body in order to stimulate the central nervous system. In the most commonly used form of acupuncture, needles are inserted into the acupoints and subsequently manually manipulated by lifting or twisting the needle. Electroacupuncture is a more recently established technique involving the insertion of two needles within acupoint sites. The two needles serve as electrodes to pass an electric current. One of the major benefits of electroacupuncture is the ability to objectively and quantifiably measure the intensity of the electrical stimulation, which is not possible with the traditional form of acupuncture .Bosco et al. investigated the efficacy of combined electroacupuncture and homeopathic medicine (Arnica montana and Apis mellifica) in place of opioid use in two breast surgery candidates who could not tolerate the standard medications due to liver disease. This combination provided sufficient pain relief, maintained liver function, reduced time spent in the post-surgical recovery area, and total time spent in the hospital .Dilaveri et al. demonstrated that acupuncture in combination with massage resulted in decreased levels of anxiety, relaxation, nausea, fatigue, pain, and mood following breast reconstructive surgery compared to baseline. Although the benefits of this intervention were similar to the benefits of massage-only intervention in regards to fatigue, anxiety, relaxation, nausea, pain, and mood scores, the massage plus acupuncture intervention increased stress levels compared to massage alone .Overall, acupuncture and electro-puncture were able to improve post-surgery outcomes and demonstrated to be helpful alternatives or adjuncts to standard treatment options.All articles incorporated into this review are summarized in Table DiscussionERAS protocols focus on reducing post-operative pain and improving the patient’s overall experience. In addition to the standard care addressed in ERAS protocols, a multitude of low-risk adjunctive options exist for increasing patient satisfaction, with the potential for creating superior outcomes. The alternative practices discussed in this review outline such benefits. However, patients are often unaware that complementary measures such as these exist and most physicians do not receive education regarding implementation of these therapies in the clinical setting. Complementary therapies can be tailed to the needs and interests of patients. For instance, patients with an interest in music may benefit more from music therapy compared with patients who lack this interest. Thus, physician and patient education are critical to ensure that patients have the empowering experience of choosing the adjunctive therapies that best fits their needs.Alternative therapies can play a role in optimizing the surgical experience for patients undergoing breast procedures, but the intervention should be tailored to each patient. If a patient has the autonomy to select which interventions they choose to utilize based on their lifestyle and personal preferences, adherence may be improved. Most interventions are fairly easy to implement and do not add a lengthy teaching component to patient-provider encounters. Additionally, many can be self-administered and/or taught through self-help books, video recordings, and classes. Once introduced in the hospital setting, many interventions can be continued at home with little or no cost to the patient. Furthermore, alternative therapies are extremely low-risk and can be utilized in patients with contraindications to standard medications or those wishing to minimize their medication exposure.The studies reviewed should be considered in light of limitations. One limitation in several of the papers was the small sample size which could affect the power of the studies. Further studies with a larger sample size are needed to further strengthen the established relationship between alternative therapies and the reduction of post-operative complications. An additional limitation inherent to alternative therapy interventions is lack of concealment or blinding. Given the impossibility of blinding individuals to interventions including massage, meditation, hypnosis, music, myofascial release, aromatherapy, guided imagery, and electro-puncture, patients are aware of the interventions they are receiving. This can lead to a placebo bias that may sway is review . StudiesAlternative medicine can fill a major gap in surgical recovery in the pre-, peri-, or post-surgical periods. Given the well-established psychosocial component of the pain experience, alternative medicine can play a role in reducing the perception of pain, as well as ameliorating the anxiety, depression, stress, and fatigue endured throughout the surgical experience. This review demonstrates the benefit of sole alternative medical interventions, as well as the potential synergistic benefits of combination therapies. Although most surgeons may not be aware of the efficacy, affordability, availability, and feasibility of these alternative therapies, these interventions could greatly benefit the patient experience. These numerous potential positive benefits of the discussed alternative therapies demonstrate a need for increased awareness and implementation of these approaches for both surgeons and patients to empower patients and improve the surgical experience.