The aim of this study was to compare the success rate of anaesthesia with 3% prilocaine and felypressin (0.03 IU/mL) in maxillary first and second molar teeth with irreversible pulpitis.The study population was 159 patients  who had maxillary first or second molar teeth with irreversible pulpitis . A buccal infiltration of 3% prilocaine with 0.03 IU/mL felypressin was used as the primary anaesthetic technique. In addition to using a categorised pain score, sound, eye movement and body motion were considered signs of anaesthesia efficacy. The data were analysed with independent t and Chi-square tests. Significance was set at α=0.05.Overall, the success rate was 56.6% in maxillary molars, 53.6% in maxillary first molars, and 60% in maxillary second molars. There was no statistically significant difference between maxillary first and second molars in terms of anaesthesia success rate (P>0.05). The overall success rate of intraligament supplementary injections was 50%, and intrapulpal supplementary injections was 97.91%. No significant difference was found between maxillary first and second molars in terms of the success rate of the supplemental techniques (P>0.05).No significant difference was found between maxillary first and second molars in terms of anaesthesia success rate when 3% prilocaine with 0.03 IU/mL felypressin was used as an anaesthetic solution for the infiltration injection. Effective pain management can be a challenge in endodontic practice . TherefoLidocaine has been the most popular anaesthetic agent employed by dentists around the world . HoweverIt has been generally accepted that mandibular molars are the most difficult teeth to anaesthetise, especially if irreversible pulpitis is present , 8. TherSupplementary injections should be used when a primary anaesthesia technique has not provided adequate anaesthesia . HoweverTherefore, the aim of the present investigation was to compare the efficacy of 3% prilocaine with 0.03 IU/mL felypressin as the anaesthetic agent for maxillary first and second molar teeth. The primary hypothesis of this clinical investigation was that there is no significant difference between anaesthesia success rates for maxillary first and the second molars. The secondary hypothesis was that there is no significant difference between the success rates of supplementary techniques for anaesthetising maxillary first and second molars.•This study compared the success rate of anaesthesia with 3% prilocaine and felypressin (0.03 IU/mL) in maxillary first and second molar teeth with irreversible pulpitis.•A categorised scale based on patients’ need for further anaesthesia was used to evaluate the patients’ pain and anaesthesia success.•Anaesthesia success rate between maxillary first and second molars with irreversible pulpitis was not significantly different following buccal infiltration injections of 3% prilocaine with 0.03 IU/mL felypressin.In a prospective investigation with Ethics Committee reference number IR.KMU.REC.1398.236, the study population were all patients with the following inclusion criteria that attended a private office limited to endodontic treatments from April 2016 to October 2019.Sample size calculations required 70 patients in each group to detect a difference of 20% in the success rate of anaesthesia.The inclusion criteria were males and females with ASA I and II health classification, 18 to 65 years old, maxillary first and second molars with irreversible pulpitis, and no systemic contraindication. Furthermore, they had no history of hypersensitivity to 3% prilocaine with 0.03 IU/mL felypressin, the presence of pulp bleeding after preparing the access cavity, and no history of analgesic consumption during the 12 hours before treatment. Irreversible pulpitis was defined with a history or presence of spontaneous pain and lingering pain to a cold stimulus.The exclusion criteria were lactation or pregnancy, presence of a periapical radiolucency, sensitivity to percussion, chronic consumption of alcohol or any medication that may affect pain perception. Furthermore, unrestorable teeth, teeth with severe periodontal involvement, moderate to severe spontaneous pain, pulp necrosis, and teeth with swellings or sinus tracts were excluded.After applying the inclusion and exclusion criteria, 159 patients  with 84 first and 75 second maxillary molars with irreversible pulpitis were included.Before commencing the treatment, patients were interviewed and graded with a four-category pain scale . One well-experienced practitioner performed all steps of the treatment. All patients received a complete description of the procedure and were asked to raise their hand if they felt any pain or discomfort during access cavity preparation and root canal instrumentation. In addition, during the treatment, the practitioner paid full attention to the patients’ responses, such as any sound, eye movement, or body motion (SEM) .For each patient, 20% benzocaine gel  was used as a topical agent to anaesthetise the buccal mucosa at the injection site. After 1 minute, all patients received 1.8 mL of 3% prilocaine with 0.03 IU/mL felypressin  as the anaesthetic agent by needle penetration . An infiltration injection was used as the primary anaesthetic technique. The place of injection was between the mesiobuccal and the distobuccal roots of the maxillary first or second molars. The injection was slowly administered for over 1 minute. Five minutes after injection of the anaesthetic solution, the tooth was isolated with a dental dam, and the access cavity preparation was commenced. If a patient felt pain and raised their hand or any SEM were noted, the practitioner stopped working and asked the patient about the quality of pain and if they needed another anaesthetic injection for pain relief. The anaesthetic injection was considered a “success” if the patient had no pain or mild pain and no need for supplementary techniques. The injection was considered a “failure” if the patient had moderate to severe pain or asked for a further anaesthetic injection. If a patient’s initial response was “success” but later raised a hand or had a positive SEM response following the treatment without supplementary injection, the anaesthetic injection was categorised as a “failure”, and a supplementary injection was administered. Supplementary injections were palatal, intraligamentary and intrapulpal injections, as required for each case. In the palatal infiltration technique, 0.5 ml of 3% prilocaine anaesthetic solution with felypressin 0.03 IU/mL was injected gently in the middle of the space between the midpalatal raphe and the palatal gingival margin using a 27-G, 25 mm length needle, while the needle tip was toward the bone. The needle penetration depth was based on preoperative periapical radiography. The tooth’s length was estimated using the parallel technique based on the periapical radiograph taken with an XCP . In maxillary first molar, since the malar bone process may prevent determining the needle penetration depth, the needle was penetrated as far as possible.The needle for the maxillary second molar was penetrated based on the estimated working length. In case of anaesthesia failure and need for supplementary injection, the same syringe was used. The intraligamentary technique was performed with a 27-G, 25 mm length needle placed at an angle of 30 degrees to the longitudinal axis of the tooth, entering the mesial gingival sulcus with maximum penetration and 0.2 ml of 3% prilocaine anaesthetic solution with felypressin 0.03 IU/mL was injected with pressure. This was also done on the distal side of the tooth. The distinction between “success” and “failure” of supplementary injections was similar to the main infiltration technique. “Failures” of the main technique received supplementary injections, and “failures” of a supplementary technique received another injection. One week later, all patients were questioned to ask about any side effects from the infiltration and supplementary injections.Continuous and categorical data were analysed with an independent t-test and a Chi-square test, respectively. P<0.05 was considered statistically significant. Statistical analysis was performed using SPSS software version 22 .One hundred fifty-nine patients were eligible to participate in this study. The patients’ characteristics, such as gender and mean age, are summarised in At the beginning of the study, a palatal injection was used as a supplementary technique. However, since one patient felt discomfort following an injection into the soft palate when her maxillary second molar was being treated, supplementary injections were subsequently limited to intraligamentary and intrapulpal injections. Other than that, no side effects were reported by the patients. Overall, 56.6% of the teeth were successfully anaesthetised, with no significant difference between the genders (P>0.05). The results of this study confirmed the primary and secondary hypotheses that there was no significant difference between maxillary first and second molars in terms of anaesthesia success rates following infiltration injections and supplementary injections (P>0.05).Previous studies have reported a range of 30 to 100% success rate for maxillary first molars with irreversible pulpitis by using either 2% lidocaine with different concentrations of adrenaline or 4% articaine with 1:100000 adrenaline when infiltration injections were used as the primary anaesthetic technique -15. In tA few studies have evaluated the anaesthesia success rate for maxillary molars , but no study has compared the anaesthesia success between maxillary first and second molars. Anatomical differences such as cortical plate thickness, root divergence, and the presence of the maxillary sinus between the buccal and palatal roots might have the potential influence on the anaesthesia success rate in maxillary molars. For example, Kang et al.  2015 shoTwo separate investigations reported no significant difference in anaesthesia success rates of maxillary molars following buccal infiltrations compared with buccal and palatal infiltrations , 23. TheThere are several possible side effects when prilocaine is used as an anaesthetic agent. Methemoglobinemia and paresthesia are two important side effects . MoreoveThe intraligamental injection has been the most popular supplementary technique amongst dentists in the USA . The tecThe Heft-Parker visual analogue scale (VAS)  has beenThe intrapulpal injection has been considered as the most successful technique among the various supplementary injections, although the most important drawback of this technique is the significant injection pain which is very important when managing patients with low pain tolerance . HoweverIt has been reported that premedication can influence the success rate of anaesthesia in mandibular posterior teeth . One of The present study’s results showed that maxillary first molars had an anaesthesia success rate of 53.6% and second molars had a 60% anaesthesia success rate. Several investigations have reported an anaesthesia success rate on maxillary molars; however, some did not mention if they included or excluded patients based on their pain severity, i.e., mild, moderate, severe -13. AnotThis study showed no significant difference between maxillary first and second molars with irreversible pulpitis following buccal infiltration injections of 3% prilocaine with 0.03 IU/mL felypressin. In addition, there was no significant difference in anaesthesia success rate between maxillary first and second molars when intraligamentary and intrapulpal injections were also used.Conflict of interest: The authors deny any conflict of interest.Ethics Committee Approval: This study was approved by the ethics committee of the Kerman University of Medical Sciences .Peer-review: Externally peer-reviewed.Financial Disclosure: This study did not receive any financial support.Authorship contributions: Concept – M.P.; Design – M.P.; Supervision – M.P.; Funding - None; Materials - None; Data collection &/or processing – I.S.; Analysis and/or interpretation – N.N.; Literature search – I.S.; Writing – I.S.; Critical Review – P.A.


The association of the severity of clinical symptoms and level of functional performance with the degree of magnetic resonance imaging abnormalities in patients with lateral epicondylitis has not been fully elucidated. This study aimed to investigate the association between the degree of anatomical abnormalities by evaluating three-dimensional magnetic resonance imaging models of the common extensor tendon and clinical parameters in patients with lateral epicondylitis.A total of 61 patients (24 men and 37 women) with lateral epicondylitis were included in this study. 3-Tesla magnetic resonance imaging was performed for all patients, and clinical parameters, including pain visual analog scale score, Quick Disabilities of Arm, Shoulder and Hand questionnaire score, elbow range of motion, and demographic factors, were evaluated. The proportion of lesion volume of common extensor tendon was adopted for three-dimensional model analysis. To determine the factors associated with clinical parameters, univariate, and multivariate linear regression analyses were performed.The proportion of lesion volume of common extensor tendon was not associated with clinical parameters. Gender and muscle edema were independently associated with pain visual analog scale scores. However, demographic factors and magnetic resonance imaging abnormalities were not associated with the Quick Disabilities of Arm, Shoulder, and Hand questionnaire score or elbow range of motion.The three-dimensional volumetric lesion size of common extensor tendon was not associated with clinical symptoms and functional performance in patients with lateral epicondylitis. The clinical parameters of lateral epicondylitis may be influenced by several factors. Lateral epicondylitis, commonly referred to as tennis elbow, is one of the most common disease that causes pain in the lateral side of the elbow and upper extremity functional limitation . The incIn the early stage of lateral epicondylitis, conservative treatments such as stretching exercise and counterforce brace application can be performed. If clinical symptoms do not improve or even worsen after sufficient conservative treatment, surgery can be considered. Generally, compared with the patients who receive only conservative treatment, those who undergo surgical treatment might suffer from a greater degree of pain, a lesser degree of elbow range of motion (ROM), and more severe common extensor tendon degeneration . PreviouRecently, with the development of three-dimensional (3D) graphic processing technology, programs to reconstruct 2D image data into 3D models have been widely used in routine clinical practice . Not onlTherefore, this study aimed to investigate the relationships between the degree of anatomical abnormalities of common extensor tendon using 3D reconstructed MR images, and severity of clinical symptoms and level of functional performances in patients with lateral epicondylitis.A total of 61 patients (24 men and 37 women) with lateral epicondylitis from April 2014 to March 2020 were included in this retrospective study. MR imaging data, plain radiographic series, and clinical records of the patients were assessed. The inclusion criteria were as follows: (1) patients who were clinically diagnosed with unilateral lateral epicondylitis with contralateral normal elbow joint, (2) patients who underwent 3-Tesla MR imaging, and (3) patients who suffered from related clinical symptoms more than 3 months before undergoing MR imaging. The exclusion criteria were as follows: (1) patients with a history of corticosteroid injection within 3 months of undergoing MR imaging, (2) patients with a history of trauma to the elbow joint, (3) patients who were diagnosed with degenerative arthritis or inflammatory arthritis in the affected side of the elbow, and (4) patients associated with worker’s compensation such as private or public insurance. The following demographic and clinical data were compiled using an electronic medical record system: age at the time of undergoing MR imaging, affected side, gender, body mass index (BMI), self-assessment pain visual analog scale (VAS) score, Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) questionnaire score, and elbow ROM.A 3-Tesla unit  with a dedicated elbow coil was used to perform all MR imaging. Imaging was performed while the patients were in a supine position with the arm attached to the side of the body, in full extension of the elbow, and in full supination of the wrist. The MR imaging protocols were as follows: 1) axial fat-suppressed T2-weighted fast spin-echo (FSE), (2) axial T1-weighted FSE, (3) coronal T2-weighted FSE, (4) coronal fat-suppressed T2-weighted FSE, (5) coronal T1-weighted FSE, and (6) sagittal T2-weighted FSE , who were blinded to the demographic and clinical information of the patients. Joint pathology (cartilage injury and joint effusion), collateral ligament injury , and muscle edema were assessed in MR images of 2D image data. The presence of each abnormality was examined using all MR imaging protocols. The MR images of each patient were evaluated a total of two times by four specialists. If all eight assessments matched, the results of the assessment were adopted. Otherwise, the presence of each abnormality was decided upon agreement by the four specialists. The inter-observer reliabilities of the assessments were evaluated by the intra-class correlation coefficient (ICC) using 2-way random effects and absolute agreement with the mean of multiple measurements model , and the intra-observer reliabilities were evaluated by ICC using 2-way random effects and absolute agreement with the single measurement model . ForThe digitized MR imaging data in the Digital Imaging and Communications in Medicine (DICOM) format files were imported into 3D reconstruction modeling software  Fig. . Fat-sup7 QuickDASH is a representative patient-reported outcome measurement to evaluate the extent of subjective discomfort and functional performance of the upper limb [Because pain is accounted for the majority symptom of lateral epicondylitis, the pain VAS score can be regarded as an indicator of clinical status in patients with lateral epicondylitis.per limb , and ROMAll clinical parameters were evaluated two weeks before MR imaging was performed. The patients were asked to assess lateral epicondylitis-related pain using a VAS ranging from 0 to 10, with higher scores representing more severe pain. QuickDASH is one of the most widely used self-reporting questionnaires for upper extremity functional performance, and its validity and reliability were verified in various upper extremity diseases . Eleven f2 = 0.25). Univariate linear regression analyses were used to evaluate the relationship between each clinical outcome  and each independent variable . Each variable with a significant outcome in the univariate linear regression analysis (P < 0.10) was integrated into the multivariate linear regression to determine associated factors of clinical outcomes. In the multivariate linear regression analysis, forward stepwise variable selection was used, and the marginal significance levels for the entry and removal were established at 0.05 and 0.1, respectively. Statistical significance was set at P < 0.05. SPSS software  was used to perform all statistical analyses.A Shapiro-Wilk normality test revealed that the data from the present study were normally distributed. Therefore, parametric tests were performed. A power analysis indicated that a sample of 61 participants for a multiple linear regression with three main predictors would provide 90% statistical power and 0.05 significance level with a medium to large effect size , and the mean BMI was 24.6 ± 2.7 (range: 19.6–29.3) (Table P = 0.028), muscle edema (P = 0.045), and pLCET (P = 0.092) were significantly associated with pain VAS score. However, no independent variable was associated with QuickDASH score and elbow ROM (Table P = 0.025) and a higher degree of muscle edema (P = 0.040). However, pLCET was not associated with pain severity (Table Univariate analyses showed that sex ( P = 0.04, and pLCty Table .Table 5The novel finding of the present study was lack of association between 3D reconstructed pLCET and clinical parameters. The aforementioned results showed that female gender and increased severity of muscle edema were independently associated with pain severity. However, there was no association between pLCET and pain severity. In patients with lateral epicondylitis, the clinical symptoms appeared to be affected by factors other than the volume of common extensor tendon lesion. The pain intensity can be affected by various factors, including the patient’s pain threshold and psychological traits . MoreoveThe results of this study showed that the QuickDASH score and elbow ROM were not associated with demographic factors and MR comparisons. This may imply that functional status of the upper extremity might not be affected by anatomic abnormalities or demographic factors in patients with lateral epicondylitis. ROM limitation of the elbow typically occurs in the late stage of lateral epicondylitis and may not be detectable in MR imaging , 19. In Lateral epicondylitis is one of the most prevalent disease, causing lateral elbow pain, and it is difficult to control the symptoms due to the complex elbow structures and diverse pathophysiology . GeneralWith the recent advancement of 3D graphic processing technology, soft tissue images obtained using conventional MR imaging can be easily reconstructed to 3D models . The volThis study had several limitations. First, because the mean thickness of common extensor tendon is approximately 4–5 mm , the comThe aforementioned results showed that 3D reconstructed pLCET was not significantly associated with clinical parameters, and several factors might influence the degree of pain and function of the elbow. These factors, including the patient’s pain susceptibility and gender should be considered for the management of patients with lateral epicondylitis. In addition, this 3D reconstruction method might be useful for 3D MR imaging analysis.


Background: We hypothesize that the addition of local infiltration analgesia (LIA) to a multimodal pain protocol will reduce the total amount of opioids consumed for acute pain control post total knee arthrolplasty (TKA).Methods: This study was a retrospective, matched pair study including patients who had primary TKA. All patients included in the analysis had preoperative oral celecoxib and acetaminophen, had single-dose spinal anesthetic with intrathecal morphine, and had intravenous patient-controlled analgesia with an opioid agent in addition to gabapentin and celecoxib in the first 48 h. Patients whose charts were excluded from the study had revision TKA, received opioid therapy prior to the surgery, were classified as American Society of Anesthesiology (ASA) IV, and had general anesthesia. Fifty patients who underwent TKA and had LIA were matched for age, body mass index (BMI), and gender with patients who did not receive LIA. The primary outcome measures were total doses of opioids consumed post TKA.Results: Patients receiving LIA consumed on average significantly less intravenous (IV) morphine equivalents than patients not receiving LIA, with a mean difference (±SD) of 88.9 ± 15.6 mg IV morphine equivalents. Furthermore, pain control was better in the LIA group. The incidences of nausea and vomiting, pruritis, and excessive sedation were higher in the non-LIA group compared to the LIA group. There was no difference in the hospital length of stay between both groups.Conclusions: The addition of LIA to our multimodal pain protocol for TKA was associated with a reduction in total opioid consumption. However, the best protocol to control in hospital pain post TKA has not been standardized and its features are continuously changing.4 For example, epidural analgesia and single-dose or continuous femoral nerve blockade usage have been steadily declining because of the increased incidence of motor weakness and consequently deferred rehabilitation. Additionally, intravenous patient-controlled analgesia (PCA) is frequently replaced with oral PCA to decrease the incidence of opioid complications, particularly respiratory depression and arrest. Furthermore, the concept of a multimodal protocol including multiple measures for pain control has become more popular to provide better effectiveness and decrease side effects of individual components.5 These components currently include intrathecal opioid, oral PCA with opioids, and nerve blockade, particularly adductor canal block, which does not cause quadriceps motor weakness.6Total knee arthroplasty (TKA) is associated with significant immediate postoperative pain in the majority of patients. Nearly half of patients undergoing TKA experience extreme acute pain.7 Despite the positive experience with LIA, it is still being evaluated for its clinical utility. Therefore, the objective of this retrospective study is to elucidate the role and value of adding LIA to post TKA pain control protocol. We hypothesize that the addition of LIA to a multimodal pain protocol including intrathecal preservative-free morphine and intravenous opioid PCA reduces the total amount of opioids consumed for immediate pain management post TKA. Total opioid consumption in morphine equivalents has been considered a surrogate end point representing the efficacy of LIA for pain control; that is, the less morphine equivalents consumed the more efficacious the addition of LIA.In recent years, there has been an increasing interest in adding local infiltration analgesia (LIA) of the knee as a major component of multimodal acute pain relief protocol.This study was a retrospective, single-center, multisurgeon, matched-pair study including patients who had primary TKA in the period including 2015 and 2016. The study was conducted at a tertiary health care facility after appropriate research ethics board approval.The charts of 270 patients who had primary TKA were reviewed retrospectively. Charts were reviewed in sequence from the beginning of 2015 to the end of 2016. There was no specific temporal sequence for LIA and non-LIA patients because knee replacements were done by all surgeons simultaneously. Patients whose charts were included in the retrospective study had primary TKA, were ≥21 years of age at time of surgery, were classified as ASA I to III, and received or did not receive LIA. In addition, all patients included in the study received spinal anesthesia with hyperbaric bupivacaine 0.75% (1.5–2 ml) with intrathecal morphine (150 μg) as well as the other components of a standardized multimodal pain protocol, including preoperative oral celecoxib and acetaminophen, intravenous PCA with an opioid agent (hydromorphone), and oral gabapentin and celecoxib in the first 48 h. Patients whose charts were excluded from the study had revision TKA, received opioid therapy in any form prior to the surgery, were classified as ASA IV, had general anesthesia, or did not receive the multimodal pain protocol mentioned above.2 (±2.5 kg/m2) intervals respectively. Age, BMI, and gender were chosen for matching because they were shown to affect the prescription of opioids after surgery.8The charts of eligible patients were reviewed in detail. Data were extracted from electronic medical records of the Trillium Health Partners information system and a database kept in the orthopedic department. The chart review was performed by a single person who was not involved in the analysis of the results. The investigator analyzing the results was blinded to the groups. Additionally, all surgeons who performed the knee replacements were not involved in the data collection or the statistical analysis of the results. Patients ≥21 years of age who underwent primary TKA and had LIA (LIA group) were matched for age, body mass index (BMI), and gender with patients who underwent primary TKA who did not receive LIA (non-LIA group). The matching ratio was 1:1 for LIA; that is, the total sample size was 100 patients. Age and BMI were matched based on 5-year (±2.5 years) and 5-kg/mPatients in this cohort had similar surgical interventions. The thigh tourniquet inflation pressure was twice the patients’ preoperative systolic blood pressure and the duration of the tourniquet did not exceed 110 min. They had a medial parapatellar incision without any drains inserted. Tranexamic acid 20 mg/kg was administered intravenously after tourniquet deflation. Wound closure for all cases was performed with absorbable and nonabsorbable sutures at the level of the arthrotomy and absorbable sutures in the subcutaneous layer. The skin was re-approximated with either staples in most patients (about 90% in both groups) or a running subcuticular absorbable suture with steristrips. The dressing of the wound consisted of an inner layer of soft padding surrounded by a layer of short stretch compressive bandage applied firmly from the mid-calf to mid-thigh. All postoperative interventions undertaken were standard of care for our facility and were identical for each patient, including wound dressings and their removal, deep vein thrombosis prophylaxis, and postoperative rehabilitation. Postoperative pain assessed in this study was performed by two registered nurses who were trained to be members of the acute pain service in our institution. They used a standard preprinted 10-cm vertical visual analog scale (VAS) for all patients. Pain was measured at rest with knee in the neutral position and during passive knee flexion to 90°.The primary outcome measures were total opioid consumption including opioids consumed from the intravenous PCA pump and after discontinuation of the PCA pump. All opioids consumed were converted into intravenous (IV) morphine equivalents . The secThe injection mixture was the same for all patients included in this study. The injection mixture consisted of bupivacaine 0.25% (40 ml), preservative-free morphine 5 mg (10 ml), ketorolac tromethamine 30 mg (1 ml), and epinephrine 0.3 mg (0.33 ml). The mixture was made up to 60 ml with normal saline. Strict sterility precautions were implemented. Local infiltration analgesia was achieved by periarticular infiltration of the knee joint. First, before the surgical incision, one third of the mixture was injected along the anticipated skin incision, proximal to the knee joint, to block the intermediate and medial cutaneous nerves of the thigh and in areas of fat deep to the fascia. Second, following bone resection and prior to cementing the prosthesis, the posterior aspect of the joint was exposed and two thirds of the mixture was injected into the posterior capsule on each side .10.1080/t-test. Gender ratio, ASA classification, Zimmerman versus Johnson & Johnson prosthesis, incidence of pre-emptive analgesia, incidence of postoperative complications, and VAS scores were compared using Wilcoxon matched pairs signed rank test.Statistical analysis included the comparison between the non-LIA and LIA groups. Age, BMI, surgical duration, tourniquet time, length of hospital stay, and opioids consumed were compared using paired two-tailed Student’s 10 Based on this information, the required sample size of the study was estimated to be 47 pairs of patient . The sample size was increased by about 10%, resulting in 50 pairs; that is, a total of 100 patients. These 100 patients were chosen from the 270 patients based on the inclusion and exclusion criteria for the study.The sample size estimate for the patient charts to be reviewed was based on the difference in the primary outcome  among patients who had LIA and those who did not have LIA. Reviewing the available data and our clinical experience showed that LIA may produce a savings of up to 25% of the postoperative mean opioid consumption.All of the primary TKAs were performed by four orthopedic surgeons. One surgeon was responsible for administering LIA to the LIA group. The other three surgeons were involved in performing the TKA in the non-LIA group. Each of the four surgeons had at least 15 years experiences as a senior consultant. Both groups had similar demographics indicating adequate matching . All stuDaily opioid consumption through the PCA pump and non-PCA pump was higher in the non-LIA group compared to the LIA group . Total osr). This indicates that the lack of matching of cases and controls for the date of procedure has no effect on the outcomes of the study. The sr for the correlation between total opioid consumption and the surgical date for the non-LIA and LIA groups was 0.09  and −0.05 , respectively. Additionally, there was no statistical difference in total opioid consumption between patients of the three surgeons who did not perform LIA.There was no relationship between total opioid consumption and the date of surgery for patients in both groups as depicted by Spearman’s rank order correlation coefficient  of 88.9 ± 15.6 mg IV morphine equivalents. Furthermore, pain control as measured by VAS was better in the LIA group. The resting and dynamic knee bending 90° VAS scores were consistently higher on the day of surgery and the first postoperative day in the non-LIA group.10 More recently, LIA was found to provide more efficacious pain relief compared to placebo.7 In addition, LIA compared to standard analgesia, including femoral and sciatic nerve blocks, resulted in greater pain relief and improvement in range of motion.11 Despite the above trend of positive results suggesting the superiority of the LIA technique, other previous reports concluded that blocking multiple nerves was preferable or at least comparable to LIA, particularly adductor canal block.15 Our study supports the evidence that LIA added to a multimodal pain protocol without peripheral nerve blocks .17The LIA mixture used in our study consisted of a combination of bupivacaine (100 mg), preservative-free morphine (5 mg), ketorolac tromethamine (30 mg), and epinephrine (0.3 mg),sr correlation coefficient between total opioid consumption and date of procedure in both groups. Second, the LIA group was limited to one surgeon, whereas three surgeons performed TKA in the non-LIA group. This may have led to sampling bias pertaining to the surgical technique and consequently the extent of postoperative pain. Nonetheless, all surgeons who performed the surgical procedures were senior consultants with more than 15 years of experience and used standardized techniques as well as the same type of knee prothesis. Third, there may have been possible variations in individual patient’s perioperative care, thus creating unavoidable sampling bias. However, all intraoperative and postoperative interventions followed standard protocols for our institution and were performed by a single team; that is, there was no specific team for each surgeon. This will largely decrease the variations in the individual patient’s perioperative care and consequently possible sampling bias. In keeping with this concept, the duration of surgery in the LIA group was about 15% shorter than that in the non-LIA group. Such a difference, though statistically significant, is of no clinical significance and the difference did not impact or interfere with patient care. Fourth, possible sampling bias was kept to a minimum pertaining to patient selection for the study because patient selection was based on inclusion and exclusion criteria as well as precise matching. Taken together, sampling bias in the present study is minimal because patient selection and matching followed clear criteria, surgical techniques and type of prostheses used were similar in both groups, all perioperative interventions for all patients included in the study followed institutional defined protocols, and patients were cared for by single team. It is unlikely that significant sampling bias could have had major effects on the results of this study.Our study has a few limitations. First, the cases and controls were not matched for the date of procedure. However, there was no relationship between the extent of the primary outcomes of the study and the date of surgery in the whole cohort as depicted by the insignificant In conclusion, LIA is a promising technique for reducing in hospital acute pain following TKA. The LIA technique has a minor impact on the workflow and on the operating room budget while providing significant benefit to patients. It decreases total opioid consumption and consequently their side effects, namely, nausea and vomiting, sedation, ileus, and urinary retention. Thus, patients will start rehabilitation quicker and will be discharged sooner. Future studies should aim to provide objective information pertaining to the optimal combination of the LIA mixture as well as its value when added to different multimodal acute pain management protocols.


To analyze the follow-up results of patients suffering from symptomatic early-stage endometriosis after a consistent laparoscopic peritoneal stripping of the altered peritoneum  was performed. This type of endometriosis is resistant to medical therapy and/or impairs fertility.Using our prospectively maintained database, we were able to identify all symptomatic women with the suspicion of only peritoneal endometriosis who underwent laparoscopy at our endometriosis center over a period of 5 years. All procedures were carried out in a standardized fashion by one single surgeon, who is highly experienced in minimal invasive surgery, and included a suspended hormonal pretreatment for 2 months. Postoperative outcomes including complications, fertility and recurrence rates were analysed.Laparoscopic peritonectomy was performed on 94 women. Follow-up data were available in 87% of these cases. At the time of surgery, almost all patients tested showed signs of stage I or II endometriosis . More than three-quarters of the women reported pain relief, inter alia, due to the post-surgical hormonal therapy. About one-third of the patients wanted to have children after the procedure. 62% of them became pregnant and the majority did so without the need for assisted reproductive therapy. In seven women a re-operation was performed.According to our data, a consistent excision of altered peritoneum followed by adjuvant hormonal therapy and multimodal concepts results in better outcomes for the patient, particularly in regards to pregnancy and recurrence rates. Endometriosis is a benign chronic inflammatory disease affecting millions of women worldwide during their reproductive years , 2. The Pain is the main symptom of endometriosis patients with a very heterogenous variation of several symptoms including dysmenorrhoea, cyclical and acyclical pelvic pain, dysuria, dyschezia, dyspareunia etc. . These sThe first step in the treatment of patients with suspected endometriosis symptoms should be hormonal treatment. If this fails then surgery should be indicated as the next treatment option –28. The In a randomized, placebo-controlled trial by Abbott et al. comparing immediate excision with delayed surgery on 39 women, of whom about 50% had rAFS stage I and II, surgery was associated with a 30% placebo response rate, not dependent on the severity of the disease. Approximately 20% of women did not report an improvement after surgery for endometriosis . In anotAs a consequence, early stage surgical intervention in endometriosis should be limited to patients with painful symptoms and contraindications or ones who show a poor response to medical therapies or in cases of subfertility . Hormona. According to a review the 2 years recurrence rate is estimated to be 21.5% [Aside from invasiveness, morbidity and complication risks, the recurrence of symptoms or lesions after surgery is highly concerning –40. Accobe 21.5% . The assbe 21.5% –45.2-laser are the most common techniques in laparoscopic surgery for endometriosis. The question of which techniques should be preferred to manage superficial peritoneal disease has not yet been answered [Sharp excision, bipolar diathermy and ablation by COanswered  .We analysed our prospectively maintained database to identify all women who underwent laparoscopy at our endometriosis center from January 2014 to June 2019. Women with a sonographic exclusion of complex endometriosis manifestation and symptomatic endometriosis and/or impaired fertility older than 18 years were included. Indication for surgery was only given for typical symptoms of endometriosis after the failure of sufficient hormonal treatment (amenorrhoea > 6 months) with ongoing acyclical pelvic pain. The estimated endometriotic lesions were peritoneal lesions (with or without adenomyosis). Patients were not excluded if they had already been diagnosed with endometriosis. An initial survey of the pelvis was performed, and any patient found to have ovarian cysts or endometriomas, retrospectively, or any signs for deep infiltrating endometriosis, was excluded. Exclusion criteria included further intraoperative bilateral salpingo-oophorectomy and hysterectomy for adenomyosis. The goal was to concentrate on women with only peritoneal endometriosis.The database contained all information about demographic and clinical characteristics, medical examination, imaging and surgical therapy. The preoperative pelvic pain severity was assessed by a 10-point visual analog scale (VAS) that was routinely performed at preoperative visits and covered different types of pain: dysmenorrhea, cyclic pain, complex chronic pain, dyspareunia, dysuria and dyschezia. VAS scores were a validated way to measure pain and used to measure overall pelvic pain as well as the different types of visceral pain . We statAll procedures were carried out in a standardized fashion by one single surgeon, who is highly experienced in minimal invasive surgery for endometriosis. A suspended hormonal pretreatment for 2 months followed the surgery . In all The primary outcome was the confirmation of diagnosis, a change in pain symptoms, quality of life assessment and pregnancy in cases of patients who wanted children at the follow-up visit. A therapeutic response defined a > 50% reduction in symptoms. Patients who did not visit our outpatient clinic were contacted by telephone at least three times.p < 0.05 was considered statistically significant.Statistical analysis was performed using IBM SPSS Statistics software, version 26 . If data are missing, the total number of cases with available information is referred to. Categorical variables are reported as frequencies and percentages. Continuous variables are reported as the mean and standard deviation. Spearman’s correlation coefficient was used to compare non-normally distributed variables. A within-group comparison was undertaken with the Wilcoxon rank-sum test for nonparametric data. We performed a stepwise backward logistic regression to assess potential clinical characteristics independently associated with pain scores. A value of A total of 94 patients, who showed symptoms resistant to medical treatment and had received peritonectomy within a time period of 5 years at our endometriosis center, were included in this study. The follow-up data of 82 patients (87.23%) were available.The average age of the patients was 29.40 years (± 6.751) at the time of surgery, 84.9% of women were nulliparous, 15.1% were uni- or multiparous. 42.6% completed a preoperative questionnaire, while the other patients were questioned in detail during a personal interview.The vast majority 91.2%) of women had taken pain medication  before surgery without sufficient pain relief, and 68.1% women had taken at least one form of hormonal treatment  (Table % of womeThe majority of women had vegetative symptoms (59.4%), such as nausea, vomiting, headache, migraine, diarrhea and obstipation. About one-third 34.2%) indicated nicotine abuse while nearly one-fifth (17%) suffered from depression  as classified by the rASRM score. 6.4% indicated stage III, in 17% of patients, in addition to pelvic peritoneal lesions, extragenital endometrial lesions were found outside of the pelvis, mainly on the diaphragm .Postoperative data showed a remarkable improvement in the quality of life of the majority of patients. More than three-quarters of women reported pain relief Fig. . Of thesDespite our insistent recommendation only 29.87% (23/77) of patients took postoperative hormonal treatment (HT), 11 women rejected the hormonal therapy, seven women did not tolerate therapy, in one patient the gynecologist refused to prescribe HT. In six women multimodal pain therapy was proposed. Twenty-nine patients wanted to get pregnant and consequently opted against HT Table .Table 5FZ − 4.330, p < 0.000). In comparison to the group of women without HT post surgically, there was a significant decrease of pain in the HT-group  . InteresThe pelvic peritoneum appears to play a key role in the development and maintenance of endometriosis. The attempt of hormonal therapy before surgery helps to identify patients with exclusively acyclic pain resistant to hormonal treatment as an indication for the occurrence of peritoneal lesions with neurogenic inflammation. Such patients might have a benefit from the excision of these lesions. Accordingly, it was shown that the removal of peritoneal lesions remarkably decreased not only the pain level, but the low pain threshold went back to the normal level of healthy controls –57. AnotThe patients’ hormonal therapy had been stopped before surgery (minimum 2 months prior to surgery) due to the chance of failure. So, the altered peritoneum was more visible and glassy lesions and inflammation could be removed. Interestingly not only the endometriotic lesions could be confirmed, but also the presence of inflammation in nearly 75% of cases. This extended inflammatory reaction might be underestimated as an essential part of pain generation. However, certain patients suffered from persistent pelvic pain after the excision of endometriosis. This might also be associated with adenomyosis, a main cause of dysmenorrhea. During sonography examinations, it was discovered that three-quarters of women in our cohort had adenomyosis. It is well known that in up to 90% of the cases, endometriosis and adenomyosis appear at the same time .In more than 20–25% of patients, pain still remains a part of their daily life despite the well processed surgical or hormonal treatment . SimilarOur renewed surgery rate is low (8.54%) compared to the probability of a further surgical procedure of about 15–20% according to literature and this may be attributed to the correct suspicion of peritoneal endometriosis and the adequate excision of all areas of abnormal peritoneum  with a sufficient safety margin in all cases –63. An eIn patients who received further surgery after extensive peritonectomy, all but two had no evidence of endometriosis, neither macroscopically nor histologically at the time of re-operation. This does not signify that endometriosis has not been the cause of pelvic pain but proves the concept of chronic long-term pain which may be a consequence of the up-regulation of pain sensitization and not recurrent disease. Such pain may not go away even after hormonal and/or surgical therapy . These cBased on two older contradictory studies and a Cochrane review comparing laparoscopic surgical treatment with diagnostic laparoscopy only in minimal and mild endometriosis, the laparoscopic surgery had better results for pregnancy after 20 weeks, regardless of the surgical method –31. The One methodological strength of this study is the standardized documentation of clinical data and pain history on a dedicated questionnaire in the majority of cases. Surgery was done with the expectation of peritoneal endometriotic lesions and good and uniform preparation of the patients. All interventions were done by a single high-volume minimally invasive gynecologic surgeon with a focus on endometriosis. Consistent techniques were performed throughout the duration of the study. All patients had to discontinue their choice of standard medical suppression treatment for endometriosis at least 2 months before surgery. All women were evaluated and treated by physicians with long-standing and extensive expertise in the management of endometriosis. This is indirectly confirmed by the observation that endometriosis was confirmed in all cases. In addition, the follow-up interviews were performed mainly face-to-face, reducing the risk of recall bias. Our follow-up rate was high compared to other studies .Regarding the limitations of this study, many women (43.6%) had previously been operated on due to symptoms of endometriosis, prior to having surgical excision. It is possible that this may bias the outcome, with women being preselected because they had had a previously failed therapy. This highlights two points: the first is that the perfect treatment has yet to be found. All current available treatments have a significant “failure rate” as noted by the recurrence of pain and the desire for further treatment. The second is that endometriosis is a very individual chronic disease requiring different treatments depending on the patient’s particular phase of life. Interestingly our surgeries on women, who had been operated previously, were as successful as first time interventions. One possible explanation could be that the first operations had been performed under hormonal therapy Fig. .Fig. 7StThe design was one cohort and the time of follow-up was inconsistent. With the given sample size of the study, it cannot be excluded that some of the observed effects could be clouded by subsequent medical or surgical treatment not reported by patients or recorded in our medical files.We do not have the post-surgical VAS scores of symptoms. An important change for the patient may be one that represents a meaningful reduction in symptoms or improvement in HRQoL from her point of view. Vincent et al. suggest that the definition of a responder in endometriosis corresponds to a > 30 or > 50% reduction in symptoms . We clasIt is possible that the results of this study may be affected by the 12.77% of women who were not reached for follow-up, since subjects lost to follow-up notoriously have a worse prognosis . We compWe understand endometriosis as a complex and multifactorial disease. Patients with endometriosis need individual management of the disease regarding the personal situation (symptoms and family planning). Early and recurrent surgeries for diagnosis only without any therapeutical concept have to be avoided , 51. Lon


Does a psychosocial aftercare program (PAC) after in-hospital intensive interdisciplinary pain treatment (IIPT) for pediatric patients with chronic pain improve functional outcomes?In this randomized clinical trial including 419 patients aged 8 to 17 years randomized and 222 patients analyzed at 6 months, PAC significantly improved all pain-related as well as emotional outcome parameters compared with treatment as usual.These findings suggest PAC should be considered in IIPT for pediatric chronic pain and its effectiveness tested in other pediatric psychosomatic conditions. This randomized clinical trial evaluates the effectiveness of a psychosocial aftercare program for pediatric patients with severe chronic pain vs usual care after discharge from intensive interdisciplinary pain treatment. Severe chronic pediatric pain causes individual suffering and significantly affects social functioning and psychological well-being. For children with high pain severity, intensive interdisciplinary pain treatment (IIPT) is a well-established treatment. However, across specialized centers, it is not sufficient for all patients.To evaluate the effectiveness of a psychosocial aftercare (PAC) program for pediatric patients with severe chronic pain followed up for 6 months after discharge from IIPT.This multicenter randomized clinical trial with 4 assessment points  was conducted at 3 pediatric specialized tertiary care pain centers in Germany between September 11, 2018, and March 31, 2020. Included patients were aged 8 to 17 with a severe chronic pain condition who had been admitted for IIPT. Data were analyzed from June 8 to September 4, 2020.Patients and their families were randomly assigned to 1 of 2 study groups at inpatient IIPT admission. Both groups received standardized 3- to 4-week IIPT. After IIPT discharge, the intervention group received PAC and the control group received usual care. PAC involved ongoing contact with a social worker for as long as the family requested the support, up to a maximum of 6 months.The primary outcome measure was pain at 6 months, measured using the Chronic Pain Grading (CPG), an instrument based on an algorithm indicating severity of the chronic pain disorder. Secondary outcomes included other pain-related and emotional parameters.r = 0.30; 95% CI, 0.17-0.41). Additionally, PAC significantly improved emotional parameters .A total of 419 patients were randomized , with 218 assigned to usual care and 201 assigned to PAC. At baseline in both groups, the median (IQR) CPG was 3 (2-4). Superiority of PAC compared with usual care was demonstrated at 6 months (median [IQR] CPG: usual care, 2 [2-3]; PAC, 1 [1-2]; This randomized clinical trial found that PAC improved pain-related and emotional parameters during the intervention 6 months after discharge from IIPT. Future research is needed to investigate the intervention’s long-term effects.DRKS00015230German Clinical Trials Register ID:  For example, patients with psychological comorbidities often do not engage with a psychotherapist after IIPT, despite this being recommended.4 The transtheoretical model5 highlights that changing maladaptive health behaviors can be challenging. Consolidating and generalizing the active behavior learnt during treatment requires a substantial change in coping efforts. Interventions supporting transition from clinician-led treatment to self-determined use of learned strategies have been assessed in other chronic health conditions. Meta-analyses provide evidence that clinician-led multicomponent interventions  can empower pediatric patients with chronic health conditions, such as asthma or diabetes, to self-reliantly follow their treatment plan, leading to improvements in disease management and disease severity.6 In light of this evidence, an adjunctive family-centered treatment module for severe chronic pain was developed: personalized psychosocial aftercare (PAC), which aims to provide support for pediatric patients and their families in adherence to discharge recommendations and facilitate maintenance of IIPT treatment outcomes.Intensive interdisciplinary pain treatment (IIPT) is a well-established treatment for severe pediatric chronic pain.To test the effectiveness of PAC as an adjunctive IIPT treatment module, we conducted a multicenter randomized clinical trial comparing treatment effectiveness in patients receiving PAC compared with patients receiving usual aftercare. A real-world study design was chosen to compare these aftercare strategies in a typical clinical setting. We expected that PAC would lead to greater improvements in pain severity  and other pain-related and psychological outcomes compared with usual care 3 and 6 months after discharge. Moreover, we expected that at both time points, patients who received PAC would show greater overall therapy satisfaction and greater adherence to therapy recommendations than patients who received usual care.CONSORT) reporting guideline.This randomized clinical trial was approved by the ethics committees of Witten/Herdecke University, Baden-Wuerttemberg State Chamber for Medicine, and the Faculty of Medicine at Ludwig Maximilian University Munich. Written informed consent was obtained from all participants’ parents, and all participants provided written informed assent. This study is reported following the Consolidated Standards of Reporting Trials  intervention frequency and intensity, and a primary outcome measure consisting of aggregated patient-reported symptoms of high importance to patients.For randomization, one of us (G.H.) created computer-generated randomization lists. Patients were randomly assigned to 1 of 2 study groups: PAC or usual care. Blinding was not feasible. Furthermore, the study design embodied typical characteristics of real-world trials,8 Most of these patients are diagnosed with either International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, German Modification (ICD-10-GM) code F45.40 or F45.41. The only exclusion criterion was withdrawal of study participation. The sample size was determined a priori based on anticipated between-group differences of the primary outcome of pain severity. Assuming an effect size of d = 0.5, an α level of 5%, and a power of 95%, we calculated that 92 patients per group were needed to detect an advantage of PAC using a 1-sided Mann-Whitney test. Based on attrition rates of approximately 50% reported by prior studies with comparable follow-ups, 419 patients were recruited to achieve the desired sample size at follow-up. Inclusion criteria were pediatric patients aged 8 to 17 years admitted to IIPT from September 2018 to October 2019, patient’s and at least 1 parent’s sufficient German language skills to complete questionnaires and engage in the treatment (determined by clinician or nurse judgment), and patient’s and parent’s agreement to study participation. In Germany, children with chronic pain are eligible for IIPT if they fulfil at least 3 of the following criteria: reduced quality of life owing to pain, unsuccessful unimodal pain treatment, medication misuse, presence of psychological comorbidity, and presence of somatic comorbidity.9 . The second set was completed on discharge day (post-IIPT). For the following assessments, survey links were sent via email. All participants received manualized IIPTPatients in the control group received the standard aftercare after IIPT. This involved the option of a 1- to 1.5-hour refresher session with the treating pediatrician and psychotherapist 3 and 6 months after discharge at the pain center . This intervention was based on a standardized manual and guided by the concept of case-management. A detailed description of PAC is provided in eAppendix 2, eTable 1, and the eFigure in 10 This semi-structured instrument assesses multiple aspects of the child's pain experience.Patient and pain characteristics  were assessed by the German Pain Questionnaire for Children and Adolescents.7 an instrument to classify chronic pain patients into different severity grades .11 Chronic pain severity is calculated based on an algorithm including the patient’s rating of pain intensity , days absent from school, and pain-related disability in everyday life11 (eAppendix 3 in 12 Patients reported the number of days they had missed school owing to pain within the past 4 weeks (maximum: 20 days). Pain-related disability was measured using the validated Paediatric Pain Disability Inventory (PPDI),14 which consists of 12 self-report items assessing pain-related disability in daily activities, eg, reading or sports, on a Likert scale . The assessment of missed school days and pain-related disability was not assessable at post-IIPT; thus, CPG was not calculable at that point.The primary outcome, pain severity, was derived using the Chronic Pain Grading (CPG),Secondary outcomes included pain-related characteristics, psychological measures, and treatment-related measures. Pain intensity, pain-related school absence and pain-related disability were included as pain-related characteristics.15 was measured with the validated Scale for Pain Self-Efficacy. This tool consists of 11 items , with responses reported on a Likert scale . This scale has good internal consistency (in this sample: Cronbach α = .86).Pain self-efficacy, a measure of one’s confidence in successfully dealing with pain by implementing pain coping strategies,17 a 47-item self-reported measure with a depression and an anxiety subscale . The items are reported on a Likert scale .Depression and anxiety symptoms were assessed using the validated Revised Child Anxiety and Depression Scale,18 This measure consists of 5 dimensions  summing up in a total score. Items are rated on Likert scales . This tool was not used at post-IIPT.Health-related quality of life was measured using the validated Kidscreen-27 (in this sample: Cronbach α = .91).During PAC treatment, therapy adherence was reported at 3 and 6 months by patients on an NRS  using the items “I was able to implement the recommendations from IIPT” and “It was easy to implement the recommendations from IIPT.” Additionally, PAC intensity  and PAC frequency (defined as the number of treatment contacts) were documented by social workers for the whole duration of intervention.At post-IIPT and during PAC-treatment, overall treatment satisfaction was reported by patients on an NRS using the item “I am satisfied with my overall pain treatment.”t tests and Welch tests; categorical variables: χ2 tests). Second, changes in the primary outcome  from pre-IIPT to 3 and 6 months were calculated with the Wilcoxon test. Pain outcomes at 3 and 6 months were compared with pre-IIPT scores because disability scores were not calculable at post-IIPT. We then used the Mann-Whitney U test to compare the distribution of the primary outcome (CPG) between groups at 3 and 6 months. Additionally, in the PAC group alone, Spearman correlations between CPG improvement and PAC intensity and PAC frequency were assessed. Third, the secondary outcomes (continuous data) were analyzed using mixed-model analyses  according to the approach defined in the statistical analysis plan . First, P values were 1-sided for our primary outcome and 2-sided for all secondary outcomes. Statistical significance was set at P = .05. Data were analyzed from June 8 to September 4, 2020.We used R statistical software version 4.0.3  for our analyses. A total of 419 pediatric patients with chronic pain  were randomized, with 218 patients assigned to usual care and 201 assigned to PAC. r = 0.36; 95% CI, 0.17-0.41; P < .001; 6 months, r = 0.42; 95% CI, 0.26-0.57; P < .001; PAC: 3 months, r = 0.65; 95% CI, 0.53-0.74; P < .001; 6 months, r = 0.75; 95% CI, 0.65-0.80; P < .001). The CPG differences between usual care and PAC groups showed a moderate effect at 6 months . Specifically, 25 patients (23.3%) in the usual care group had reached a CPG 0 or 1, compared with 58 patients (50.4%) in the PAC group. Both groups had a comparable percentage of patients in CPG 2 . The usual care group had a higher proportion of participants with CPG 3 or 4 (39 patients [36.4%]) than the PAC-group (16 patients [13.0%]). A detailed description of CPG distribution is provided in eTable 3 in r = 0.17; 95% CI, 0.06-0.28; P = .008). No significant correlations were identified between CPG improvement at 6 months and PAC intensity  or PAC frequency , indicating these measures were not linearly associated with CPG improvement. The CPG distribution for all available data can be found in eTable 4 in In both treatment groups at 3 months, as well as at 6 months, the primary outcome CPG (pain severity) showed significant improvements compared with pre-IIPT  compared with the usual care group. At 6 months, the overall level of reported adherence did not significantly differ, but patients in the PAC group reported that it was easier for them to adhere to the treatment recommendations . Details on these parameters are presented in eTable 5 in Overall treatment satisfaction was high at post-IIPT, with groups not significantly differing regarding this measure. However, patients in the PAC group reported a higher satisfaction at 6 months . However, the reduction was significantly greater when IIPT was followed by PAC, with 86% of these patients reaching CPG 2 or lower 6 months after discharge. The core component of the pain severity measure we used was level of functioning, of which improvement is a central goal of IIPT and of high clinical relevance.1 Against the background of the transtheoretical model5 patients receiving PAC were regularly encouraged by their social worker to continue engaging with and adapting their new strategies into everyday life. When difficulties were experienced, the social worker was available to support the patient and the family.This multicenter randomized clinical trial demonstrated the additive impact of PAC on regular IIPT. PAC led to a lower pain severity and emotional impairment 3 and 6 months after discharge from IIPT compared with usual care. In line with prior studies,19 that has found only small long-term benefits associated with IIPT in anxiety and depression. Moreover, a study by Moessner et al20 that evaluated the effectiveness of an aftercare program for adult patients with lower back pain also reported a reversion in posttreatment trajectories for anxiety and depression in the absence of an aftercare program.PAC also had a beneficial impact on emotional functioning. At 3 and 6 months after IIPT, the PAC group showed a continued reduction in anxiety and depressive symptoms. In contrast, the usual care group did not experience this improvement and instead reverted to levels of psychological symptoms experienced pre-IIPT. This corresponds with previous research21 there are 4 sources of efficacy: mastery experiences, vicarious experiences, verbal persuasion, and emotional state. Most of these are likely to have been addressed by PAC. For example, the social workers may have facilitated more mastery experiences by motivating patients to continue with their normal daily activities despite pain. An increase in self-efficacy beliefs likely contributed to the improvement in functioning and emotional well-being observed in the PAC group, as supported by previous work.15Results of this randomized clinical trial illustrate that the patients’ pain self-efficacy was improved by PAC. In contrast, pain self-efficacy in usual care patients decreased again after discharge, although it remained higher than pre-IIPT levels. According to the theory of self-efficacy by Bandura,22 This design component allowed PAC to respond to the individual needs of patients.Interestingly, no significant correlation was found between frequency or intensity of PAC and its effectiveness. During PAC, patients determined the frequency of contact with the social worker, which aligns with the “What you need is what you get” design advised for patient-controlled analgesia studies.This study has some limitations. As an inherent drawback of real-world trials, no detailed insight into the treatment’s possible modes of action can be drawn. Thus, mechanisms underlying the positive effects of PAC remain unclear. Furthermore, the high dropout rate might have resulted in a selection bias. Moreover, this study lacks a follow-up assessment after the completion of PAC. Therefore, it remains unclear whether and how long the positive effects of PAC can be maintained. Additionally, the findings may not be generalizable to other countries.This randomized clinical trial is the first study, to our knowledge, to investigate and find robust support for the effectiveness of a PAC program for pediatric patients receiving IIPT. Future research should investigate the modes of action and the long-term effects of the program.


Introduction: Spinal stenosis is a chronic, debilitating condition that is expected to affect an increasing number of people as the population ages. Symptomatic spinal stenosis, like other spine pathologies, including disc herniation and degenerative disc disease, traditionally required an open decompressive surgical approach if more conservative approaches failed. An emerging alternative has been developed to address the needs of this population of patients in the form of endoscopic spine surgery (ESS). Advantages of ESS include minimal tissue trauma, decreased risk of damage to the neurovascular structures, minimal epidural fibrosis/scarring, reduced hospital stay, early functional recovery, and improved cosmetic outcomes. The purpose of this study was to review the outcomes of patients undergoing transforaminal endoscopic spinal decompression at an academic pain program.Methods: We conducted a retrospective review of electronic medical records with approval from the University of Florida Institutional Review Board (IRB #202001529). Twenty patients underwent successful transforaminal endoscopic lumbar spinal decompression surgery at UF Health Pain Medicine from July 1, 2019, to June 1, 2020. The majority of cases were performed at L4-5 (n = 14), followed by an equal number (n = 3) of cases at L3-4 and L5-S1. Preoperative and postoperative visual analog scale (VAS) pain scores from patients' pain clinic appointments were obtained from the electronic health records system to assess the intervention as a pain relief strategy.Results: Patients had an average pain reduction of 82% (SD = 31%), resulting in an average postoperative pain score of 1.8 (SD = 2.8) on a 10-point VAS.Conclusion: This study highlights the benefits of endoscopic spine surgery for patients, including pain reduction and reduced scarring. Spinal stenosis is a chronic, debilitating condition that affects up to 9.3% of people, most commonly in the sixth or seventh decade of life . The numPotential complications of this procedure include surgical site infection, epidural abscess, epidural hematoma, posterior dural tear, ventral dural tear, and nerve root injury. Ventral dural tears are particularly feared because they are very difficult to repair, and larger tears can lead to herniation of the nerve root(s) through the tear with potential strangulation of the nerve root, leading to catastrophic consequences. These complications are avoided by maintaining an adequate view of target structures throughout and use of safe landmarks . TraininThe evidence supporting ESS as an alternative to more invasive surgical options is steadily growing. However, there is a dearth of literature reviewing the outcomes of interventional pain physicians using ESS. The purpose of this study was to review the outcomes of patients undergoing endoscopic spinal decompression from an academic pain program.Study designAfter the University of Florida Institutional Review Board approval (IRB#202001529), we performed a retrospective electronic medical record review of 22 patients undergoing transforaminal endoscopic spine decompression between July 1, 2019, and June 1, 2020, by UF Health Pain Medicine physicians. Data were extracted from electronic medical records from the Epic electronic health record by three members of the study staff who underwent training to standardize data collection methods. Two patients were excluded because their procedures were aborted intraoperatively, one for inability to dock the working channel into or around the neuroforamen without compressing the exiting nerve and the other for superficial bleeding. Preoperative and postoperative visual analog scale (VAS) pain scores from the patients’ preoperative and postoperative pain clinic appointments were obtained from the electronic health records system to assess the intervention as a pain relief strategy. Statistical analysis was performed on Microsoft Excel for calculations of mean and standard deviations.Surgical techniqueDuring an ESS, the neural structures are accessed either via the neuroforamen or via an interlaminar approach. The neuroforamen is formed anteriorly by the vertebral body and intervertebral disc, posteriorly by the superior articulating process and inferior articulating process, and superiorly and inferiorly by the pedicles. This foramen is the site where the nerve root exits the spinal canal. Common pathologies leading to stenosis in the foramen and the lateral recess zone include facet hypertrophy, disc bulge/herniation, ligamentum flavum hypertrophy, facet cyst, epidural fibrosis/scarring after previous spine surgery, and degenerative changes of age. Each of these pathologies can be targeted and resected by ESS. Transforaminal endoscopy via Kambin’s triangle is the simpler approach to the neural structures of the spinal canal. Kambin’s triangle is bordered anteriorly by the exiting nerve root, inferiorly by the endplate of the proximal vertebral body, medially by the traversing nerve root and dural sac, and posteriorly by the proximal articular process . Kambin’Transforaminal ESS can be performed under local anesthesia with mild intravenous sedation, which allows the patient to communicate discomfort, as well as follow commands, thereby improving the safety profile of the procedure and guiding the end point of surgery. Alternatively, the procedure can be performed under general anesthesia with neuromonitoring using sensory evoked potentials and/or motor evoked potentials. The procedure can be performed as "inside out" or "outside in" depending on entry to the intervertebral disc, as the starting point in the "inside out" approach. Our preferred approach is "outside in": first, a needle is introduced to target the inferior pedicle under fluoroscopic guidance Figure . This taHere, patients were placed on the fluoroscopic operating table in the prone position. Following “time out,” placement of monitors, surgical preparation, and draping was completed. All cases were performed under local anesthesia with intravenous sedation. The skin entry point was identified, and after injecting skin locally, a 16-gauge needle was driven targeting the inferior pedicle. A guidewire was placed through the needle and the needle was removed. Serially larger dilators and trephines for foraminotomy were inserted over the guidewire under fluoroscopic guidance. Finally, a 7.2-mm beveled working tube was placed, through which a 6.3-mm spinal endoscope was inserted. While maintaining continuous cold saline irrigation, endoscopic instruments were used to dissect/debulk the pertinent structures and complete the decompression. An anatomical image as seen through the endoscope is presented in Figure Outcome data from the 20 cases were collected Table . The majPreoperatively, patients reported an average (mean) typical pain score of 7.2 (SD = 1.4) and an average (mean) maximum pain score of 8.7 (SD = 1.2) on a 10-point VAS scale (Table One example highlights the extent of herniated disc resection, evident in changes in imaging. Preoperative magnetic resonance imaging revealed a prominent right-sided disc herniation at L4-5 Figure , which wFirst surfacing in the late 1980s, the full endoscopic decompression technique for lumbar pathology as a minimally invasive option has evolved into a standard of care at some institutions because of its demonstrated efficacy and safety . Over thFull endoscopic decompression can provide reduced tissue trauma, preserved stability, reduced rehabilitation time, and minimal scarring while maintaining equal efficacy as more established procedures such as direct and microscopic decompression . ESS canFurther advantages for the surgery include continuous, direct illumination and visualization of the target anatomy. Additionally, the operator is able to achieve hemostasis and minimal tissue disruption under continuous irrigation and drainage . Beyond The statistical significance of our case series of 20 patients is that it reinforces the benefits of transforaminal endoscopic decompression in reducing pain and opioid consumption in the immediate postoperative period, for appropriately selected lumbar spine pathology. There are some limitations in our retrospective study: transforaminal endoscopy represents a relatively small sample size of our endoscopic spine surgery patients since the majority of them undergo an interlaminar endoscopic approach. This case series also did not include a randomized design and had a limited follow-up window. We are in the process of conducting a much larger prospective study on all our endoscopic spine surgery patients, which will likely validate the finding of our small retrospective case series.This case series demonstrates that ESS can benefit patients by improving their pain and that it decreases analgesic requirements at postoperative day number three. Future studies can be aimed at including all our endoscopic surgery patients and can include long-term follow-up and outcome tracking, including any symptom recurrence in patients receiving the full endoscopic technique. In conclusion, endoscopic spine decompression has proved to be a beneficial technique for the patient and an advanced skill set for the operator when performed by properly trained pain management physicians.