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Introduction: In the early postoperative period after total knee arthroplasty (TKA), joint range of motion (ROM) limitation and increased stiffness due to pain are commonly observed. Previous studies have reported that a single bout of foam rolling (FR) can acutely increase ROM and pain threshold on the contralateral (non-intervention) side in healthy participants. In this study, we aimed to expand this knowledge for TKA rehabilitation and investigated the acute effects of FR intervention on the non-operative side on ROM, stiffness, and pain of the operative side in postoperative patients within the first week after TKA. Materials and methods: The study employed a randomized crossover design: 20 patients (mean age 75.0 ± 7.8 years) in the first postoperative week after TKA were divided alternately into Roll_Break and Break_Roll groups in the order of prescription. In the Roll_Break group, after the initial evaluation, a 180-s (60-s × three sets) FR intervention using a roller massager by a physiotherapist for the knee extensors was performed on the contralateral side (non-operative side), followed by the measurement. Afterwards, after 180-s of supine at rest, the measurement was performed again (i.e., control phase). In the Break_Roll group, after the initial evaluation, each patient was placed in a seated resting position for 180-s, and then another measurement was performed (i.e., control phase). After this, the FR intervention was performed for 180-s, and then the measurement was performed again. The intensity of the FR intervention was set to the maximum intensity that did not cause pain. We measured pain using the visual analogue scale at rest and during the knee joint ROM measurements, knee joint active movement ROM, knee joint passive ROM, and stiffness during the knee joint active movement. Results: All outcome variables showed significant improvements after the FR intervention (intervention phase) when compared pre- to post-intervention, and significantly favourable effects were found compared to the control condition. Conclusion: The results showed significant improvements in ROM, pain, and stiffness of the operative side after the FR intervention on the non-operative side. For future therapy approaches for TKA patients, FR treatment of the non-operative side should be employed in the first weeks after surgery. [ABSTRACT FROM AUTHOR]

Background: Patients with primary Bone Sarcoma and Giant Cell Tumors in the lower extremities often require major surgery involving tumor prostheses. The postoperative course for this patient group can be complex and influenced by various factors and challenges that demand careful nursing care. This study aims to identify challenges related to the nursing care of individuals with primary bone tumors following surgery for tumor prostheses in the lower extremities. Methods: A retrospective cohort study of 15 patients treated at Rigshospitalet, Copenhagen, Denmark, between November 5. 2016, and April 1. 2020 was conducted by medical record review, focusing on challenges related to postoperative nursing care. All patients with the surgery code "Bone Excision" were identified within the surgery booking system and screened for eligibility. Results: Patients experienced postoperative challenges such as severe pain, prolonged time to mobilization (mean: 4 days), and defecation (mean: 5 days). The mean length of stay at the Rigshospitalet was 13 days. Furthermore, eleven patients (73%) reported disrupted sleep and nausea. Conclusion: Patients undergoing tumor prosthesis surgery in the lower extremities face considerable postoperative challenges that contribute to a prolonged hospital stay. These challenges, including severe pain, delayed mobilization, and gastrointestinal issues, significantly impact recovery. The findings highlight the urgent need for targeted nursing interventions to address these issues effectively. Enhanced pain management protocols, early mobilization strategies, and comprehensive postoperative care plans are essential to improve patient outcomes and reduce the length of hospital stays. Addressing these challenges through dedicated nursing care is crucial for optimizing the recovery process for patients receiving lower extremity tumor prostheses. [ABSTRACT FROM AUTHOR]

Copyright of Douleur et Analgésie is the property of John Libbey Eurotext Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Mobilisation difficulties, due to muscle weakness, and urinary retention are common reasons for prolonged admission following hip and knee arthroplasty procedures. Whether spinal anaesthesia is detrimental to early mobilisation is controversial. Previous studies have reported differences in post‐operative recovery between spinal anaesthesia and general anaesthesia; however, up‐to‐date comparisons in fast‐track setups are needed. Our randomized, single‐blinded, multi‐centre, clinical trials aim to compare the post‐operative recovery after total hip (THA), total knee (TKA), and unicompartmental knee arthroplasties (UKA) respectively when using either spinal anaesthesia (SA) or general anaesthesia (GA) in a fast‐track setup. Included patients (74 THA, 74 TKA, and 74 UKA patients) are randomized (1:1) to receive either SA (2 mL 0.5% Bupivacaine) or GA (Induction: Propofol 1.0–2.0 mg/kg iv with Remifentanil 3–5 mcg/kg iv. Infusion: Propofol 3–5 mg/kg/h and Remifentanil 0.5 mcg/kg/min iv). Patients undergo standard primary unilateral hip and knee arthroplasty procedures in an optimized fast‐track setup with intraoperative local infiltrative analgesia in TKA and UKA, post‐operative multimodal opioid sparing analgesia, immediate mobilisation with full weightbearing, no drains and in‐hospital only thromboprophylaxis. Data will be collected on the day of surgery and until patients are discharged. The primary outcome is the ability to be safely mobilised during a 5‐m walking test within 6 h of surgery. Secondary outcomes include fulfilment of discharge criteria, post‐operative pain, dizziness, and nausea as well as patient reported recovery and opioid related side effects. Data will also be gathered on all hospital contacts within 30‐days of surgery. This study will offer insights into advantages and disadvantages of anaesthetic methods used in fast‐track arthroplasty surgery. [ABSTRACT FROM AUTHOR]

Background: Various medications such as opioids and non-steroidal anti-inflammatory drugs (NSAIDs) are used to alleviate discomfort following caesarean surgery. Particular attention has been paid to NSAIDs due to complications of opioids, and doctors use these medications as useful analgesics to manage various forms of pain. This research was conducted to evaluate the effect of either diclofenac suppository, intravenous acetaminophen or their combination on reduction of the severity of postoperative pain in patients undergoing caesarean section spinal analgesia. Methods: This was comparative prospective interventional clinical study in Zagazig University Maternity Hospital during the period from August 2017 to December 2017. Includes 48 patients undergoing caesarean section. Patients were randomly divided (by alternation) into three groups of 16 patients, group A: 100 mg diclofenac suppository, group B: 1000 mg acetaminophen by intravenous infusion injection in 200 ml of 0.9 percent saline, group C: 100 mg diclofenac suppository and 500 mg intravenous acetaminophen. All patients underwent full clinical assessment and 24-hour pain follow-up. At the end of the surgery, pain severity was measured on a VAS scale at various intervals. Results: The lowest mean pain severity was found in the combination group during the study and the highest was observed in the diclofenac group. There was significant difference of times of additional doses of analgesia which high in group diclofenac then group acetaminophen and the least times detected at combination group. Conclusion: The combination of acetaminophen and diclofenac has stronger and longer analgesic effects than the single use of each drug. [ABSTRACT FROM AUTHOR]

Purpose: The objective of this study was to determine if intra-operatively measured joint gaps are associated with 2-year pain outcomes in total knee arthroplasty (TKA) and whether balance and laxity windows could be defined throughout flexion to optimize 2-year pain outcomes. Our hypothesis is that intra-operative joint gaps are associated with 2 year post-operative pain outcome. Methods: A prospective study investigating 310 robotically assisted TKAs was performed. Final intra-operative joint gap data were recorded using a digital tensioner and component alignment data were recorded by the robotics system. Patient demographics and Knee Injury and Osteoarthritis Outcome Score (KOOS) were recorded pre-operatively and KOOS and Hospital for Special Surgery (HSS) satisfaction were recorded at 2 years post-op. A random search Simulated Annealing (SANN) optimisation algorithm was used to determine global optimum laxity and balance windows at different flexion angles which maximized the 2-year KOOS pain scores. The windows were combined to determine the impact of achieving optimal laxity and balance throughout flexion. To improve clinical utility, boundaries identified by the SANN algorithm were rounded to the nearest 0.5 mm before statistical analysis. Results: Laxity and balance windows were defined in extension (Med lax: -2.0 to 2.5 mm, Lat lax: -0.5 to 2.5 mm, Balance: -3.0 to 0.0 mm), mid-flexion (Med lax: -1.0 to 2.5 mm, Lat lax: -0.5 to 3.0 mm, Balance: -2.0 to 2.0 mm), and flexion (Med lax: -2.0 to 3.5 mm, Lat lax: -2.0 to 1.5 mm, Balance: -3.0 to 3.0 mm). When all windows were satisfied, the greatest difference in KOOS pain score was observed (100.0 vs 94.4, p < 0.0001). The highest percentage of knees satisfying the Patient Acceptable Symptom State (PASS) for KOOS pain was also observed in knees which satisfied all windows compared to knees which did not (93% vs 71%, p = 0.0009). The proportion of knees which satisfy the PASS threshold decreased in knees which only satisfied 1–3 (29%) or 4–6 (69%) windows (p ≤ 0.0018). No optimal windows were found between component alignment and KOOS pain outcome (p ≥ 0.1180). High satisfaction was found across all groups (≥ 95%). Conclusion: Intra-operatively measured joint gaps are associated with all KOOS sub-score outcomes at 2 years after TKA. Optimal windows for a clinically relevant improvement in post-operative KOOS pain were defined for laxity and balance but not for alignment indicating balance may have a greater impact on outcome than alignment. Level of evidence: II. [ABSTRACT FROM AUTHOR]

Background: Patients undergoing corneal abrasion as part of Descemet membrane endothelial keratoplasty (DMEK) under general anesthesia suffer from early burning pain postoperatively. This pain appears to be poorly treatable with systemic analgesics. This study aims to evaluate postoperative pain management using topical lidocaine gel after DMEK with iatrogenic corneal abrasion. Methods: Retrospective analysis of 28 consecutive patients undergoing DMEK with corneal abrasion from October 19, 2021, to November 12, 2021, at a German university hospital. Patients during week 1 and 2 received peri-operative standard pain treatment (cohort S) and additional local lidocaine gel during week 3 and 4 immediately postoperatively (cohort L). Results: 13 patients were included in cohort S and 15 patients in cohort L. At awakening all patients (100%) in cohort S reported burning pain, and six of 15 patients (40%) in cohort L reported burning pain. Burning pain scores were significantly lower in cohort L (p < 0.001 at awakening, p < 0.001 at 10 min, p < 0.001 at 20 min, p < 0.001 at 30 min, p = 0.007 at 40 min after awakening, and p < 0.001 at leaving recovery room). No significant differences between cohort S and cohort L were detected concerning surgical outcome during 1-month-follow-up (p = 0.901 for best corrected visual acuity). Conclusion: Patients undergoing DMEK with corneal abrasion suffer significant pain in the recovery room. A single dose of topic lidocaine gel reduces the early postoperative burning pain sufficiently and does not affect the surgical outcome. Key messages: What is already known on this topic: Descemet membrane endothelial keratoplasty (DMEK) normally causes low levels of pain. What this study adds: When corneal abrasion is required during DMEK surgery under general anesthesia, patients experience pain sensations that can severely affect their well-being. An immediate postoperative single dose of topical lidocaine gel applied by the surgeon reduces the early burning pain sufficiently and does not affect the surgical outcome. To reduce postoperative pain levels and to improve the postoperative well-being of patients, all patients undergoing DMEK with corneal abrasion should receive topical lidocaine gel at least once. However, this simple intervention should still be investigated in prospective studies. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the effectiveness of dynamic intermittent compression cryotherapy (DICC) (CryoNov®) with an intravenous nefopam-based pain management protocol (DCIVNPP) in reducing post-operative pain following anterior cruciate ligament reconstruction (ACLR) compared to static compression cryotherapy (SCC) (Igloo®) and oral Nefopam. Methods: This was a retrospective analysis of prospectively collected data including 676 patients who underwent primary ACLR in 2022. Patients were either in the DCIVNPP group or in the SCC (control group), and were matched for age, sex, and Lysholm and Tegner scores (338 per arm). The primary outcome was pain on the visual analogue scale (VAS), analyzed in relation to the minimal clinically important difference (MCID) and the Patient Acceptable Symptom State (PASS) thresholds for VAS. The secondary outcome was side effects. Results: Postoperative pain in the DCIVNPP group was less severe on the VAS than in the control group (p < 0.05). The maximum difference in the VAS between groups was 0.57, which is less than the MCID threshold for VAS. The DCIVNPP group crossed the PASS threshold for VAS on Day 3, sooner than the control group. The side effect profiles were similar in both groups except for higher rates of dizziness and malaise in the DCIVNPP group, and higher rates of abdominal pain in the control group. Most of the side effects decreased over time in both groups, with no significant side effects after Day 3. Conclusion: DCIVNPP effectively allows for faster pain recovery than in the control group. The difference in side effects between the protocols may be due to mode of administration of nefopam. Level of evidence: III. [ABSTRACT FROM AUTHOR]

aima Ferrante,1,2 Barbara K Keller,1 Julian S Flury,1 Michael A Harnik,3 Martin grosse Holtforth,2,4 Maria M Wertli1,51Department of General Internal Medicine, University Hospital of Bern, Inselspital, University of Bern, Bern, 3010, Switzerland; 2Department of Psychology, University of Bern, Bern, 3012, Switzerland; 3Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; 4Psychosomatic Competence Center, University Hospital of Bern, Inselspital, University of Bern, Bern, 3010, Switzerland; 5Department of Internal Medicine, Kantonsspital Baden, Baden, 5404, SwitzerlandCorrespondence: Asha-Naima Ferrante, Department of General Internal Medicine, University Hospital, Inselspital, Freiburgstrasse 18, Bern, 3010, Switzerland, Email [email protected] Purpose: To describe the details of a systematic review to assess the current evidence about the efficacy of communication strategies on the prevention of chronic postsurgical pain (CPSP). Methods: The protocol for this systematic review was based on the Cochrane Handbook methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) recommendations. A systematic search of the literature on electronic databases Medline, Embase, Cochrane Library, CINAHL, PsycINFO, and Web of Science (from the inception to 19 June 2022) was carried out using predefined search terms to identify relevant studies. This review will include randomized clinical trials or observational studies. The search strategy consisted of keywords and index terms related to "clinician", "communication" or "post-surgical pain". Inclusion criteria are as follows: randomized clinical trials or observational studies using a parallel group design that assess the efficacy of communication interventions in patients undergoing surgery and that assess pain and pain-related disability. We considered interventions that included any type of written, verbal, and non-verbal communication in combination with other interventions or without. Control groups may include no communication intervention or another intervention distinctly different. We excluded studies with follow-up duration of less than 3 months, patients aged < 18 years, and studies for which no reviewer had language proficiency (eg, Chinese, Korean). Descriptive statistics will be used to summarize quantitative findings. Meta-analysis will only be considered if at least three studies used the same outcome with comparable interventions, as we expect a wide heterogeneity of study population and settings. Conclusion: This systematic review and meta-analysis will be an important source for clinicians and researchers to understand the influence of communication to prevent CPSP. Study Registration: This protocol is registered with the International Prospective Register of Systematic Reviews (PROSPERO). Registration number: CRD42021241596. [ABSTRACT FROM AUTHOR]

Objective: Despite various pain management methods, chronic pain is still a challenging issue after thoracotomy. This retrospective study was designed to determine the possible factors affecting the development of chronic pain following open thoracotomy. Methods: The study included patients who underwent elective open thoracotomy at Ankara University İbni Sina Hospital, between 01.01.2016 and 31.12.2020. The medical files and electronic records of the patients were scanned from the system. Patient history, analgesic methods, and surgical details were recorded. The need for and usage analgesic drugs after the surgery were also recorded. Results: A total of 229 patients who underwent thoracotomy were included in the study, and 83 (36.2%) patients had chronic pain. Duration of surgery, doses of remifentanil, fentanyl or NSAI drugs, duration or number of chest tubes (more than 4 days, or more than 2 tubes), diabetes, or PCEA usage were found as variables affecting pain. Logistic Regression, Multilayer Perceptron, Naive Bayes, AdaBoost, and Random Forest methods were used to evaluate the prediction performances. According to the model created with logistic regression, the rate of the correct classification was 90.8%. The duration of surgery, remifentanil administration, chest tube for more than 4 days, and diabetes were found to be risk factors for developing chronic pain. Fentanyl bolus, PCEA-bupivacaine, and NSAID bolus were determined as preventive factors. Conclusion: A careful analysis of risk factors should be performed for each patient to prevent chronic pain after thoracotomy, and preemptive effective analgesia methods should be performed. [ABSTRACT FROM AUTHOR]

Background: Despite the increasing use of patient-reported outcome measures (PROMs), the methodology used to evaluate clinically significant postoperative outcomes after total knee arthroplasty (TKA) is variable. The review aimed to survey studies with identified PROM-based metrics of clinical efficacy and the assessment procedures after TKA. Methods: The MEDLINE database was queried from 2008–2020. Inclusion criteria were: full texts, English language, primary TKA with minimum one-year follow-up, use of metrics for assessing clinical outcomes with PROMs, and primary derivations of metrics. The following PROM-based metrics were identified: minimal clinically important difference (MCID), minimum detectable change (MDC), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB). Study design, PROM value data, and methods of derivation for metrics were recorded. Results: We identified 18 studies (including 46,173 patients) that met the inclusion criteria. Across these studies, 10 different PROMs were employed, and MCID was derived in 15 studies (83%). The MCID was calculated using anchor-based techniques in nine studies (50%) and distribution techniques in eight studies (44%). PASS values were presented in two studies (11%) and SCB in one study (6%) using an anchor-based method; MDC was derived in four studies (22%) using the distribution method. Conclusion: There is variability in the TKA literature with respect to the definition and derivation of measurements of clinically significant outcomes. Standardization of these values may have implications for optimal case selection and PROM-based quality measurement, ultimately improving patient satisfaction and outcomes. [ABSTRACT FROM AUTHOR]

Background: Due to the continued growth of surgical procedures in older adults and the significant impact of chronic postsurgical pain (CPSP), it is crucial to improve our understanding of the occurrence of CPSP as well as the appropriate prevention and treatment. We therefore conducted this study to determine the incidence, characteristics and risk factors of CPSP in elderly patients at both 3 and 6 months after surgery. Methods: Elderly patients (aged ≥ 60 years) undergoing elective surgery in our institution between April 2018 and March 2020 were prospectively enrolled in this study. Data on demographics, preoperative psychological well-being, intraoperative surgical and anesthesia management, and acute postoperative pain intensity were collected. At 3 and 6 months after surgery, patients received telephone interview and completed the questionnaires regarding chronic pain characteristics, analgesic consumption, and interference of the pain with activities of daily living (ADL). Results: A total of 1065 elderly patients were followed up for 6 postoperative months and included in final analysis. At 3 and 6 months after operation, the incidence of CPSP was 35.6% [95% confidence interval (95% CI) 32.7 − 38.8%] and 21.5% (95% CI 19.0% − 23.9%), respectively. CPSP cause negative impacts on patient's ADL and most particularly on mood. Neuropathic features were found in 45.1% of the patients with CPSP at 3 months. At 6 months, 31.0% of those with CPSP reported that the pain had neuropathic features. Preoperative anxiety [3 months: Odds ratio (OR) 2.244, 95% CI 1.693 to 2.973; 6 months: OR 2.397, 95% CI 1.745 to 3.294], preoperative depression (3 months: OR 1.709, 95% CI 1.292 to 2.261; 6 months: OR 1.565, 95% CI 1.136–2.156), orthopedic surgery (3 months: OR 1.927, 95% CI 1.112 to 3.341; 6 months: OR 2.484, 95% CI 1.220 to 5.061), higher pain severity on movement within postoperative 24 h (3 months: OR 1.317, 95% CI 1.191 to 1.457; 6 months: OR 1.317, 95% CI 1.177 to 1.475) were associated with a higher risk for CPSP independently at both 3 and 6 months after surgery. Conclusions: CPSP is a common postoperative complication in elderly surgical patients. Preoperative anxiety and depression, orthopedic surgery, and greater intensity of acute postoperative pain on movement are associated with an increased risk for CPSP. It should be kept in mind that developing psychological interventions to reduce anxiety and depression and optimizing the management of acute postoperative pain will be effective in reducing the development of CPSP in this population. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Pain is an unpleasant sensory and emotional experience and is considered the fifth vital sign. Opioid-free anesthesia (OFA) is a technique where no intraoperative systemic, neuraxial, or intracavitary opioids are administered during the anesthesia. The prescription misuse/ overuse has generated an opioid crisis which has led to the need for OFA. In this study, we will investigate the 24-h postsurgical analgesia and analgesic consumption with the use of OFA versus opioid anesthesia (tramadol) in patients undergoing abdominal surgery under general anesthesia. METHODOLOGY: Sixty patients of the American Society of Anesthesiologists Grade I-II scheduled for various abdominal surgeries were randomly assigned into two groups, with 30 patients in each group. Group A (opioid-free group): received IV lignocaine (2 mg/kg), IV magnesium sulfate (20 mg/kg), and V paracetamol (15 mg/kg) in 100 ml NS. Group B (opioid group): received IV tramadol (2 mg/kg) in 100 ml NS. Hemodynamic parameters, postoperative analgesic consumption, duration of analgesia, and any adverse effects were recorded. RESULTS: A very significant difference was observed between the study groups for mean values of mean arterial pressure at the last stages of surgery, with hemodynamics more stable in the opioid-free group (P < 0.01). In terms of mean values of minimum alveolar concentration throughout the surgery, the opioid group showed more anesthetic-sparing effect (P < 0.05). In terms of postoperative pain scores between the groups, the opioid-free group experienced less pain (P < 0.01). There was no difference between the groups in postoperative analgesic consumption and duration of analgesia. More side effects were noted in the opioid group. CONCLUSION: This study concludes that avoiding opioid use by preemptive administration of intravenous paracetamol, lignocaine, and magnesium sulfate provides safe, effective, and satisfactory analgesia in patients undergoing various abdominal surgeries under general anesthesia. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Prolapse is a common condition seen in women and its therapeutical management consists first and foremost of surgery. Postoperative pain is one of the most common side effects seen after surgery. The objective of this study was to identify risk factors for postoperative pain after cystocele repair with mesh. Methods: This is a secondary analysis of the multicenter randomized trial PROSPERE, which compared cystocele repair with mesh according to the vaginal or laparoscopic approach. The presence of postoperative pain was assessed by a pain-specific self-reported questionnaire (Questionnaire de Baudelocque). The statistical analysis is based on the Wilcoxon, Chi-squared, and Fisher's tests. Results: The prevalence of postoperative pain (pain persisting more than 6 months) was 39% (80 out of 205, 95% CI 32.4–46.1), with 6.3% (13 out of 205) of chronic pain reports. Preoperative pain was the only statistically significant risk factor OR = 2.32 (p = 0,007; 95% CI 1.24–4.36). Conclusions: Surgeons must be careful with preoperative painful prolapse and should inform their patient of the risk of developing postoperative chronic pain. [ABSTRACT FROM AUTHOR]

Opioid-induced hyperalgesia, a paradoxical increase in pain sensitivity associated with ongoing opioid use, may worsen the postoperative pain experience. This pilot study examined the effect of chronic opioid use on pain responses in patients undergoing a standardized dental surgery. Experimental and subjective pain responses were compared prior to and immediately following planned multiple tooth extractions between patients with chronic pain on opioid therapy (≥30 mg morphine equivalents/d) and opioid-naïve patients without chronic pain matched on sex, race, age, and degree of surgical trauma. Preoperatively, chronic opioid users rated experimental pain as more severe and appreciated less central modulation of that pain than did opioid-naïve participants. Postoperatively, chronic opioid-using patients rated their pain as more severe during the first 48 hours and used almost twice as many postoperative analgesic doses during the first 72 hours as the opioid-naïve controls. These data suggest that patients with chronic pain taking opioids approach surgical interventions with heightened pain sensitivity and have a more severe postoperative pain experience, providing evidence that their complaints of postoperative pain should be taken seriously and managed appropriately. [ABSTRACT FROM AUTHOR]

Objective: To determine whether multivariate pattern regression analysis based on gray matter (GM) images constrained to the sensorimotor network could accurately predict trigeminal heat pain sensitivity in healthy individuals. Background: Prediction of individual pain sensitivity is of clinical relevance as high pain sensitivity is associated with increased risks of postoperative pain, pain chronification, and a poor treatment response. However, as pain is a subjective experience accurate identification of such individuals can be difficult. GM structure of sensorimotor regions have been shown to vary with pain sensitivity. It is unclear whether GM structure within these regions can be used to predict pain sensitivity. Methods: In this cross‐sectional study, structural magnetic resonance images and pain thresholds in response to contact heat stimulation of the left supraorbital area were obtained from 79 healthy participants. Voxel‐based morphometry was used to extract segmented and normalized GM images. These were then constrained to a mask encompassing the functionally defined resting‐state sensorimotor network. The masked images and pain thresholds entered a multivariate relevance vector regression analysis for quantitative prediction of the individual pain thresholds. The correspondence between predicted and actual pain thresholds was indexed by the Pearson correlation coefficient (r) and the mean squared error (MSE). The generalizability of the model was assessed by 10‐fold and 5‐fold cross‐validation. Non‐parametric permutation tests were used to estimate significance levels. Results: Trigeminal heat pain sensitivity could be predicted from GM structure within the sensorimotor network with significant accuracy (10‐fold: r = 0.53, p < 0.001, MSE = 10.32, p = 0.001; 5‐fold: r = 0.46, p = 0.001, MSE = 10.54, p < 0.001). The resulting multivariate weight maps revealed that accurate prediction relied on multiple widespread regions within the sensorimotor network. Conclusion: A multivariate pattern of GM structure within the sensorimotor network could be used to make accurate predictions about trigeminal heat pain sensitivity at the individual level in healthy participants. Widespread regions within the sensorimotor network contributed to the predictive model. [ABSTRACT FROM AUTHOR]

Copyright of Douleur et Analgésie is the property of John Libbey Eurotext Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Patient-Reported Outcomes Measurement Information System (PROMIS) domains for sleep disturbance, anxiety, and dyspnea have been under-reported for total joint arthroplasty (TJA). The aims of this study were to report postoperative differences for these domains based on TJA location and chronic pain state. We also investigated whether these domains were associated with physical function and pain interference outcomes. Methods: This was a retrospective, observational study of patients who underwent hip, knee, or shoulder TJA (primary and revision surgeries) at a single academic tertiary referral center. A subset of these patients completed an email-based survey for chronic pain grade (Chronic Pain Grade Scale-Revised) and sleep disturbance, anxiety, dyspnea, physical function, and pain interference (PROMIS short forms). Pre-operative and operative data were extracted from the electronic health record. Data analysis investigated PROMIS domains for differences in TJA location and chronic pain grade. Hierarchical linear regression determined associations of these domains with physical function and pain interference. Results: A total of 2638 individuals provided informed consent and completed the email survey. In the ANOVA models for sleep disturbance, anxiety, and dyspnea, there was no location by chronic pain grade interaction (p > 0.05) and no difference based on TJA location (p > 0.05). There were differences for chronic pain grade (p < 0.01). The poorest postoperative outcome score for each domain was associated with high impact chronic pain. Furthermore, sleep disturbance and dyspnea had the strongest associations with physical function and pain interference (p < 0.01). Conclusions: Sleep disturbance, anxiety, and dyspnea did not vary based on TJA location, but were associated with postoperative chronic pain grade. Sleep disturbance and dyspnea were strongly associated with commonly reported outcomes of physical function and pain interference. These findings provide guidance for those interested in expanding TJA outcome assessment to include sleep disturbance, anxiety, and/or dyspnea. [ABSTRACT FROM AUTHOR]

Background: Perioperative pain after total knee arthroplasty (TKA) may seriously affect the rapid recovery of patients. The purpose of this study was to assess whether the combined use of adductor canal block (ACB) and local infiltration anesthesia (LIA) can further reduce postoperative pain and improve early functional recovery. Materials and methods: PubMed, Web of Science, EMBASE, and Cochrane Central Register of Controlled Trials were systematically searched for randomized controlled trials (RCTs) comparing ACB + LIA and LIA alone in primary TKA. The primary outcomes were visual analog scale (VAS) scores at rest and walking, morphine consumption, range of motion (ROM) at 24 and 48 h postoperatively and distance walked. The secondary outcomes were the length of stay, the incidence of nausea and vomiting, and the total complications. Subgroup analyses were performed on the VAS at rest and walking, morphine consumption, and distance walked at 24, 48, and 72 h postoperatively. Results: A total of 10 RCTs involving 797 patients were enrolled in this meta-analysis. The results demonstrated that the combined application of ACB + LIA had a lower resting VAS at 24 h postoperatively (p = 0.02) and the walking score at 24 (p = 0.0002) and 48 h (p = 0.02) postoperatively compared with LIA alone. Similarly, the combined ACB + LIA group also had less morphine consumption at 48 h postoperatively (p = 0.0005) and had a higher ROM score at 24 h (p = 0.01) postoperatively compared to the LIA group. There were no statistical differences in length of stay, distance walked, and incidence of nausea and vomiting. Conclusion: The current meta-analysis showed that ACB + LIA significantly reduced postoperative walking pain and morphine consumption and promoted rapid recovery in the early postoperative period. There is no statistical difference in the length of stay and ROM after 72 h in the two groups. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive adrenalectomy is the standard of care for small adrenal tumours. Both the transperitoneal lateral approach and posterior retroperitoneal approach are widely used and have been proven to be safe and effective. However, the prevalence of chronic postsurgical pain has not been specifically investigated in previous studies. The primary goal of this study was to identify the prevalence of chronic postsurgical pain after minimally invasive adrenalectomy. Methods: A cross-sectional study was performed among all consecutive patients who had undergone minimally invasive adrenalectomy in a single university medical centre. The primary outcome was the prevalence of chronic postsurgical pain. Secondary outcomes were the prevalence of localized hypoesthesia, risk factors for the development of chronic postsurgical pain, and the Health-Related Quality of Life. Three questionnaires were used to measure the prevalence and severity of chronic postsurgical pain, hypoesthesia, and Health-Related Quality of Life. Logistic regression analysis was performed to determine risk factors for development of chronic postsurgical pain. Results: Six hundred two patients underwent minimally invasive adrenalectomy between January 2007 and September 2019, of whom 328 signed informed consent. The prevalence of chronic postsurgical pain was 14.9%. In the group of patients with chronic postsurgical pain, 33% reported hypoesthesia as well. Young age was a significant predictor for developing chronic postsurgical pain. The prevalence of localized hypoesthesia was 15.2%. In patients with chronic postsurgical pain, Health-Related Quality of Life was significantly lower, compared to patients without pain. Conclusions: The prevalence of chronic postsurgical pain following minimally invasive adrenalectomy is considerable. Furthermore, the presence of chronic postsurgical pain was correlated with a significant and clinically relevant lower Health-Related Quality of Life. These findings should be included in the preoperative counselling of the patient. In the absence of evidence for effective treatment in established chronic pain, prevention should be the key strategy and topic of future research. [ABSTRACT FROM AUTHOR]

While children with cerebral palsy (CP) may undergo 8‐22 orthopedic surgeries in their lifetime, little is known about the associated pain. We aimed to assess the pain presence before and one year after lower extremity orthopedic surgery, predictors of pain presence at follow‐up, and the association between pain and orthopedic outcomes related to surgery. This retrospective study included 86 children with CP (M age = 10.0 years, SD = 3.2; range = 4.1‐17.3 years, Gross Motor Functional Classification System (GMFCS) level I‐III) who underwent orthopedic surgery and had completed questionnaires at gait analyses before (M = 2.7 months; range = 0.0‐5.7) and after surgery (M = 11.8 months; range = 9.0‐14.9). Pain presence, location, and Pediatric Outcomes Data Collection Instrument (PODCI) scores were documented before and after surgery at gait analyses. Pain prevalence was 60% at baseline and 56% at follow‐up. Significant predictors of pain presence at follow‐up included (1) pain presence at baseline (range of odds ratios [OR] across any/all locations = 3.22 to 15.54), (2) older age (range of OR for any pain, back, knee, and foot pain = 1.24‐1.26), (3) female sex (decreased OR for males for ankle pain = 0.12), (4) having hip surgery (decreased OR for foot pain = 0.20), and (5) lower GMFCS level (OR for foot pain = 0.41). Changes in PODCI Sports and Physical Function scores were associated with changes in hip and knee pain (P <.03); PODCI scores worsened for patients who had pain at both time points and improved for patients who had pain at baseline but not follow‐up. Pain was present for over half of the participants before and after orthopedic surgery. Pain presence at follow‐up was predicted by pain presence at baseline. Pain and functional outcomes were correlated at follow‐up. Prospective studies examining perioperative pain experience and factors predicting pain outcomes are warranted. [ABSTRACT FROM AUTHOR]

Summary: Widespread adoption of intrathecal morphine into clinical practice is hampered by concerns about its potential side‐effects. We undertook a systematic review, meta‐analysis and trial sequential analysis with the primary objective of determining the efficacy and safety of intrathecal morphine. Our secondary objective was to determine the dose associated with greatest efficacy and safety. We also assessed the impact of intrathecal morphine on respiratory depression. We systematically searched the literature for trials comparing intrathecal morphine with a control group in patients undergoing hip or knee arthroplasty under spinal anaesthesia. Our primary efficacy outcome was rest pain score (0–10) at 8–12 hours; our primary safety outcome was the rate of postoperative nausea and vomiting within 24 hours. Twenty‐nine trials including 1814 patients were identified. Rest pain score at 8–12 hours was significantly reduced in the intrathecal morphine group, with a mean difference (95%CI) of −1.7 (−2.0 to −1.3), p < 0.0001 (19 trials; 1420 patients; high‐quality evidence), without sub‐group differences between doses (p = 0.35). Intrathecal morphine increased postoperative nausea and vomiting, with a risk ratio (95%CI) of 1.4 (1.3–1.6), p < 0.0001 (24 trials; 1603 patients; high‐quality evidence). However, a sub‐group analysis by dose revealed that rates of postoperative nausea and vomiting within 24 hours were similar between groups at a dose of 100 µg, while the risk significantly increased with larger doses (p value for sub‐group difference = 0.02). Patients receiving intrathecal morphine were no more likely to have respiratory depression, the risk ratio (95%CI) being 0.9 (0.5–1.7), p = 0.78 (16 trials; 1173 patients; high‐quality evidence). In conclusion, there is good evidence that intrathecal morphine provides effective analgesia after lower limb arthroplasty, without an increased risk of respiratory depression, but at the expense of an increased rate of postoperative nausea and vomiting. A dose of 100 µg is a 'ceiling' dose for analgesia and a threshold dose for increased rate of postoperative nausea and vomiting. [ABSTRACT FROM AUTHOR]

Purpose: To determine the characteristics of the acute pain after laparoscopic-assisted vaginal hysterectomy (LAVH), laparoscopic myomectomy (LM), and laparoscopic adnexectomy (LA) and compare them with each other. Patients and Methods: Patients undergoing LAVH, LM, and LA under general anaesthesia at the First Affiliated Hospital of Wenzhou Medical University between December 2017 and December 2019 were selected. Their data were collected before, during, and after the surgery. We evaluated the degrees of pain in each group of patients and compared them. Results: There were differences in the baseline characteristics of the patients in the LAVH, LM, and LA groups. The severity and incidence of postoperative pain were higher in the LAVH group than in the LM and LA groups, followed by the LM and LA groups. Compared with the LA group, the postoperative pain in the LAVH and LM groups was more complicated. The LA group had the lowest incidence of two or more types of moderate to severe pain. The LAVH and LM groups mainly had visceral pain and low back pain, and the LA group mainly had incisional pain. Shoulder pain had the lowest incidence in the three groups. Conclusion: There were different postoperative pain characteristics after the LAVH, LM, and LA, and we should clinically adjust analgesia programs for different gynaecological laparoscopic surgeries. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the effect of single nucleotide polymorphisms in the COMT, OPRM1, 5HT1A, 5HT2A and 5HTR3B genes on the intensity of postoperative pain following root canal treatment. Methodology: Ninety‐five patients with mandibular and maxillary molar teeth diagnosed with symptomatic apical periodontitis and a level of preoperative pain greater than 50 on a 100 mm visual analogue scale (VAS) were included. Salivary DNA was collected from the participants and stored in Eppendorf tubes at −80 °C. Preoperative percussion pain values were recorded before the root canal treatment procedures. After completion of root canal treatment, the participants were given instructions to record their postoperative pain intensity levels at 24, 48 and 72 h, 5 days and 1 week after treatment, using the VAS. A second visit for the patients after seven days was planned to record their intensity levels of percussion pain on VAS. The percussion test was performed by tapping on the occlusal surface of the tooth with a blunt instrument. A QIAamp DNA Mini Kit was used to isolate DNA from saliva, and SNP Genotyping Analysis software version 1 was used to analyse the genotypes by calculating FAM and HEX signals. The Kruskal–Wallis and Mann–Whitney U‐tests were used to evaluate pain intensity values amongst the genotypes, alleles, haplotypes and allele combinations. Nominal data (gender, intake and tooth number) were analysed using a Chi‐square test. Bonferroni correction was performed. Thus, the significance level was set at 1.6% (P = 0.016), 2.5% (P = 0.025) and 1.25% (P = 0.0125) for genotype, allele and haplotype comparisons, respectively. Results: There was no significant difference amongst the genotypes and alleles in terms of pre‐ and postoperative pain intensity. There was no significant difference amongst the haplotypes formed for the COMT gene in terms of pain intensity. Additionally, there was no significant association between the allelic combination formed for 5HT1A + 5HT2A genes and the intensity of postoperative pain. Conclusion: The findings indicate that none of the evaluated SNPs for COMT, OPRM1, 5HT1A, 5HT2A and 5HTR3B genes were associated with the intensity of postoperative pain. [ABSTRACT FROM AUTHOR]

Background: Nerve identification is recommended in inguinal hernia repair to reduce or avoid postoperative pain. The aim of this prospective observational study was to identify nerve prevalence and find a correlation between neuroanatomy and chronic neuropathic postoperative inguinal pain (CPIP) after 6 months.Material: A total of 115 patients, who underwent inguinal hernia mesh repair (Lichtenstein tension-free mesh repair) between July 2018 and January 2019, were included in this prospective observational study. The mean age and BMI respectively resulted 64 years and 25.8 with minimal inverse distribution of BMI with respect to age. Most of the hernias were direct (59.1%) and of medium dimension (47.8%). Furthermore, these patients were undergoing Dermatome Mapping Test in preoperatively and postoperatively 6 months evaluation.Results: Identification rates of the iliohypogastric (IH), ilioinguinal (II) and genitofemoral (GF) nerves were 72.2%, 82.6% and 48.7% respectively. In the analysis of nerve prevalence according to BMI, the IH was statistically significant higher in patients with BMI < 25 than BMI ≥ 25 P (< 0.05). After inguinal hernia mesh repair, 8 patients (6.9%) had chronic postoperative neuropathic inguinal pain after 6 months. The CPIP prevailed at II/GF dermatome. The relation between the identification/neurectomy of the II nerve and chronic postoperative inguinal pain after 6 months was not significant (P = 0.542).Conclusion: The anatomy of inguinal nerve is very heterogeneous and for this reason an accurate knowledge of these variations is needed during the open mesh repair of inguinal hernias. The new results of our analysis is the statistically significant higher IH nerve prevalence in patients with BMI < 25; probably the identification of inguinal nerve is more complex in obese patients. In the chronic postoperative inguinal pain, the II nerve may have a predominant role in determining postoperative long-term symptoms. Dermatome Mapping Test in an easy and safe method for preoperative and postoperative 6 months evaluation of groin pain. The most important evidence of our analysis is that the prevalence of chronic pain is higher when the nerves were not identified. [ABSTRACT FROM AUTHOR]

Introduction: Tibial component design and positioning contribute more to patient satisfaction than previously realized. A surgeon needs to decide on the size and rotation, bearing in mind that coverage should be as high as possible, whilst malrotation and overhang should be avoided. No study investigates the impact of each of these components on clinical outcomes in a single cohort. Materials and methods: This is a retrospective analysis of 1-year postoperative outcomes measured with the Knee Injury and Osteoarthritis Outcome (KOOS) Score, as well as a previously validated rotational CT protocol. Coverage, rotation from Insall's axis, and overhang of an asymmetric tibial baseplate were measured, and positive and negative correlations to clinical outcomes were calculated. Results: A total of 499 knees were analyzed. Patient average age was 68.4 years. Rotation within 7° internal and 5° external from Insall's axis was a "safe zone". Mean coverage was 76%. A total of 429 knees (94%) had a coverage of at least 70% and 102 knees (22%) greater than 80%. Overhang was detected in 23% of the cohort. Increased coverage was correlated to increased KOOS score and overhang correlated with a decreased KOOS score (p = 0.008). Conclusions: This study demonstrates the individual role of three aspects of tibial component implantation properties in postoperative pain and short-term functional outcomes. Upsizing to the point of overhang with rotational tolerance of 7° internal and 3° external to Insall's axis demonstrates best patient reported outcomes. Overhang decreases the clinical outcome by the same margin as loss of 16% of coverage. [ABSTRACT FROM AUTHOR]

Background: A method for modeling the acute pain trajectory using the simple linear fit of an individual's pain intensity scores after surgery was developed and affords more precise measurement than conventional pain assessment. However, the method has the disadvantage of using only the slope without considering the intercept. The purpose of this study was to verify our modification of the pain trajectory model including slope and intercept and to identify clusters. Methods: The pain intensity was measured in 60 patients after surgery, and we calculated their pain trajectories. The pain trajectory normally resolves in intensity over a period of days, and the linear fit of an individual patient's pain intensity score defines the trajectory. In this simple linear model (x axis, days; y axis, pain intensity), each patient's trajectory has the slope and the intercept. A multiple regression analysis model known as structural equation modeling was used to predict postoperative pain at 30 days after surgery. Finally, we performed hierarchical cluster analysis using the pain trajectory. Results: The slope and intercept model was the best fit among the models. Based on cluster analysis results, we created 4 pain trajectory groups (slope and intercept). Conclusion: Our results suggest that the pain trajectory using the slope and intercept is quite useful for predicting postoperative pain at 30 days after surgery. Additionally, patients were classified into 4 groups using the slope and intercept. By considering both the slope and intercept, clinicians may be able to detect the risk for prolonged pain earlier than other methods. [ABSTRACT FROM AUTHOR]

Background: Chronic musculoskeletal pain (MSP) affects more than 40% of adults aged 50 years and older and is the leading cause of disability in the USA. Older adults with chronic MSP are at risk for analgesic-related side effects, long-term opioid use, and functional decline. Recognizing the burden of chronic MSP, reducing the transition from acute to chronic pain is a public health priority. In this paper, we report the protocol for the Brief EducaTional Tool to Enhance Recovery (BETTER) trial. This trial compares two versions of an intervention to usual care for preventing the transition from acute to chronic MSP among older adults in the emergency department (ED).Methods: Three hundred sixty patients from the ED will be randomized to one of three arms: full intervention (an interactive educational video about pain medications and recovery-promoting behaviors, a telecare phone call from a nurse 48 to 72 h after discharge from the ED, and an electronic communication containing clinical information to the patient's primary care provider); video-only intervention (the interactive educational video but no telecare or primary care provider communication); or usual care. Data collection will occur at baseline and at 1 week and 1, 3, 6, and 12 months after study enrollment. The primary outcome is a composite measure of pain severity and interference. Secondary outcomes include physical function, overall health, opioid use, healthcare utilization, and an assessment of the economic value of the intervention.Discussion: This trial is the first patient-facing ED-based intervention aimed at helping older adults to better manage their MSP and reduce their risk of developing chronic pain. If effective, future studies will examine the effectiveness of implementation strategies.Trial Registration: ClinicalTrials.gov NCT04118595 . Registered on 8 October 2019. [ABSTRACT FROM AUTHOR]

Postoperative pain remains poorly managed for many patients. Effective pain management begins with accurate pain assessment, with patient self-reporting considered the most accurate measure of pain. This literature review aimed to identify how congruent nurses' assessments of pain were with patients' self-reporting. A search identified six observational studies and one quasi-experimental study that met the inclusion criteria. The findings from these studies were summarised under two themes: nurses' underestimation of patients' pain and nurses' knowledge and understanding of pain assessment. Some nurses' pain management knowledge was deemed inadequate, with evidence of negative attitudes towards managing pain in certain groups of patients. Educational interventions have so far had limited impact on correcting the ethical and professional problem of inadequate pain relief in many patients postoperatively. Randomised controlled trials are required to identify effective education interventions that can contribute to ending this avoidable suffering. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate postoperative pain following Descemet membrane endothelial keratoplasty (DMEK). Methods: Seventy-one patients completed perioperatively (day before surgery, day of surgery, 1st, 2nd, and 3rd day after surgery) four different questionnaires (a hospital internal protocol, QUIPS, PainDETECT®, and SF36) regarding their pain and other clinical parameters such as constipation, tiredness, vertigo, sleep disorders, concentration disorders, nausea, and emesis. All standardised questionnaires were evaluated to quantify average pain intensity as well as maximum pain intensity (NRS, 0 [no pain] to 10 [maximal pain], respectively). Analgesic treatment and intraocular pressure (IOP) during the perioperative stay were documented. Results: Mean average pain intensity was 0.70 ± 1.64 before surgery, 1.97 ± 2.05 on the day of surgery, 1.39 ± 1.68 on day 1, 0.87 ± 1.36 on day 2, and 0.81 ± 1.24 on day 3 after surgery. Maximum pain intensity was 0.65 ± 1.81 before surgery, 3.35 ± 2.98 on the day of surgery, 2.68 ± 2.99 on day 1, 1.49 ± 2.15 on day 2, and 1.26 ± 2.02 on day 3 after surgery. During the first three postoperative days, over 90% of the patients stated no or well tolerable pain. Eighty-three percent had postoperatively no need for analgesics at all. On the first two postoperative days, maximum IOP correlated significantly with reported increased maximum pain intensity (p = 0.043 and p = 0.029, respectively). All patients had very little problems with constipation, tiredness, vertigo, sleep disorder, concentration disorders, nausea, and emesis. Conclusions: DMEK is associated with low postoperative pain intensity. Strong pain increase may indicate IOP elevation and should be further investigated and treated. Clinical trial registration: German Clinical Trial Register (DRKS00013995) [ABSTRACT FROM AUTHOR]

Purpose: Most of the genetic variants that are reported to be associated with common pain phenotypes and analgesic use are common polymorphisms. The objective of our study was to identify new variants and investigate less common genetic variants that are usually not included in either small single-gene studies or high-throughput genotyping arrays. Patients and methods: From a cohort of 1075 patients who underwent a scheduled total abdominal hysterectomy, 92 who had higher self-rated pain scores and used more morphine were selected for the re-sequencing of 105 genes. Results: We identified over 2400 variants in 104 genes. Most were intronic with frequencies >5%. There were 181 novel variants, of which 30 were located in exons: 17 nonsynonymous, 10 synonymous, 2 non-coding RNA, and 1 stop-gain. For known variants that are rare (population frequency <1%), the frequencies of 54 exonic variants and eight intronic variants for the sequenced samples were higher than the weighted frequencies in the Genome Aggregation Database for East and South Asians (P-values ranging from 0.000 to 0.046). Overall, patients who had novel and/or rare variants used more morphine than those who only had common variants. Conclusion: Our study uncovered novel variants in patients who reported higher pain and used more morphine. Compared with the general population, rare variants were more common in this group. [ABSTRACT FROM AUTHOR]

Background and aims: The relative contribution of patient-related factors and intraoperative nerve damage for the development of chronic pain after surgery is unclear. This study aimed to examine chronic pain after bilateral thoracotomy. We hypothesized, that individual patient-related risk factors would be important resulting in an intraindividual uniformity of pain and hyperphenomena between the two sides of the thorax. Methods: Twenty patients who had undergone lung transplantation via bilateral thoracotomy 6–12 months previously were included from the Danish Lung Transplant program, Rigshospitalet, Denmark, from October 2016 to August 2017. All patients answered questionnaires about pain in and around the scar, completed the Neuropathic Pain Symptom Inventory, and underwent bedside examination for hyperphenomena (brush- and cold-evoked allodynia, pinprick hyperalgesia) and pinprick hypoalgesia. Results: Nine patients reported spontaneous pain bilaterally, five patients had pain on one side only, and six patients had no pain. Hyperphenomena were present on both sides of the thorax in 13 patients, on one side in four patients, and three patients had no hyperphenomena. The intraindividual uniformity of pain (p=0.029) and hyperphenomena (p=0.011) between the two sides of the thorax suggests that patient-related factors play an important role in the development of chronic pain. Conclusions: The results of the present study provide support for the hypothesis of an individual predisposition for the development of chronic pain after thoracotomy. Implications: Patient-related risk factors contribute to the development of chronic pain after thoracotomy. This result most likely can be transferred to chronic pain after other surgical procedures and therefore help us understand risk factors for chronic pain after surgery. [ABSTRACT FROM AUTHOR]

In line with other major surgeries including breast cancer surgery (BCS), recent studies suggest a striking rate of chronic postsurgical pain (CPSP) following breast reconstruction. This commentary will critically examine evidence for the degree to which the prevalence of CPSP following breast reconstruction is directly attributable to reconstructive surgery. The discussion will trace similarities and distinctions between breast reconstruction and BCS in considering the risk for CPSP, and describe recent advances in the definition of CPSP, highlighting methodological limitations in the general investigation of CPSP, which also characterize the study of CPSP more specifically for breast reconstruction outcome. A convenience sample of relevant studies examining CPSP following breast reconstruction reveals inadequate evidence to support a serious concern for reconstruction-induced CPSP and further that these studies fail to adhere to recommended methodological standards to effectively isolate surgery as the etiology of persistent pain reported by women following reconstructive surgery. Suggestions for future exploration of problematic chronic pain after breast reconstruction are considered. [ABSTRACT FROM AUTHOR]

Abstract: Background: Inadequately treated postoperative pain can lead to longer healing processes, longer hospital stays, and the development of chronic pain. In a 900‐bed university hospital in Switzerland, pain scores were assessed systematically. The study's primary aim was to define whether the routine pain assessment on the ward is accurate and reproducible. Subsequently the obtained data were used for a benchmark analysis to determine the hospital's performance in pain assessment quality compared with similar centers. Methods: During a 3‐month period, PAIN OUT questionnaires were used for patients’ interviews. Patients were included randomly according to the daily surgical schedule. Pain scores were assessed routinely by nursing staff on the wards and compared to PAIN OUT data. The ascertained data were analyzed by descriptive statistics as well as the Wilcoxon test for nonparametric values using IBM SPSS. Results: 658 patients were included in the study. Comparing routine pain measurements with PAIN OUT results revealed that within the first 24 hours on the ward, pain scores were significantly lower than measured with PAIN OUT questionnaires. This difference increased with increasing pain scores. The quality of pain management of the hospital in which this study was performed ranged around the 50th percentile when compared to similar centers. Conclusion: The cross‐sectional data comparison of pain assessment by the ward staff and by interviews with the PAIN OUT questionnaire showed a large gap of underrated pain. The benchmark analysis with the method of PAIN OUT suggests a decent pain management among reference groups. [ABSTRACT FROM AUTHOR]

Purpose: The development of emergence agitation (EA) is associated with several factors including age, preoperative anxiety, postoperative pain, anesthesia method, and surgery type. No studies have investigated whether the withdrawal reaction following rocuronium injection can predict the occurrence of EA. Therefore, we investigated this relationship in preschool-aged children undergoing inguinal herniorrhaphy, and which grade of withdrawal reaction is appropriate for identifying patients at risk of experiencing EA.Methods: A total of 40 patients were enrolled in this study. During anesthesia induction, the withdrawal reaction after loss of consciousness following rocuronium injection was assessed using a 4-point scale. After surgery, EA was assessed using the Watcha scale.Results: There was a correlation between withdrawal reaction and EA on admission to the postanesthesia care unit (PACU). Patients with a severe withdrawal reaction (grade 3) showed a significantly higher incidence of severe EA requiring medication on admission to the PACU.Conclusion: The findings of this preliminary exploratory observational study suggest that it is possible for withdrawal movement following rocuronium injection during anesthesia induction to reflect pain sensitivity of pediatric patients, which in turn may be useful in identifying those at risk of severe EA on admission to the PACU among preschool children undergoing inguinal herniorrhaphy. Further studies with a larger sample size are required to validate these findings. The exact correlation between pain reaction following rocuronium injection and postoperative pain or pain-related phenomenon should be elucidated. [ABSTRACT FROM AUTHOR]

This review provides an overview of the clinical issue of poorly controlled postoperative pain and therapeutic approaches that may help to address this common unresolved health-care challenge. Postoperative pain is not adequately managed in greater than 80% of patients in the US, although rates vary depending on such factors as type of surgery performed, analgesic/anesthetic intervention used, and time elapsed after surgery. Poorly controlled acute postoperative pain is associated with increased morbidity, functional and quality-of-life impairment, delayed recovery time, prolonged duration of opioid use, and higher health-care costs. In addition, the presence and intensity of acute pain during or after surgery is predictive of the development of chronic pain. More effective analgesic/anesthetic measures in the perioperative period are needed to prevent the progression to persistent pain. Although clinical findings are inconsistent, some studies of local anesthetics and nonopioid analgesics have suggested potential benefits as preventive interventions. Conventional opioids remain the standard of care for the management of acute postoperative pain; however, the risk of opioid-related adverse events can limit optimal dosing for analgesia, leading to poorly controlled acute postoperative pain. Several new opioids have been developed that modulate μ-receptor activity by selectively engaging intracellular pathways associated with analgesia and not those associated with adverse events, creating a wider therapeutic window than unselective conventional opioids. In clinical studies, oliceridine (TRV130), a novel μ-receptor G-protein pathway-selective modulator, produced rapid postoperative analgesia with reduced prevalence of adverse events versus morphine. [ABSTRACT FROM AUTHOR]

Chronic postsurgical pain (CPSP) is a common and debilitating complication of major surgery. We undertook a pilot study at three hospitals to assess the feasibility of a proposed large multicentre placebo-controlled randomised trial of intravenous perioperative ketamine to reduce the incidence of CPSP. Ketamine, 0.5 mg/kg pre-incision, 0.25 mg/kg/hour intraoperatively and 0.1 mg/kg/hour for 24 hours, or placebo, was administered to 80 patients, recruited over a 15-month period, undergoing abdominal or thoracic surgery under general anaesthesia. The primary endpoint was CPSP in the area of the surgery reported at six-month telephone follow-up using a structured questionnaire. Fourteen patients (17.5%) reported CPSP (relative risk [95% confidence interval] if received ketamine 1.18 [0.70 to 1.98], P=0.56). Four patients in the treatment group and three in the control group reported ongoing analgesic use to treat CPSP and two patients in each group reported their worst pain in the previous 24 hours at ≥3/10 at six months. There were no significant differences in adverse event rates, quality of recovery scores, or cumulative morphine equivalents consumption in the first 72 hours. Numeric Rating Scale pain scores (median [interquartile range, IQR]) for average pain in the previous 24 hours among those patients reporting CPSP were 17.5 [0 to 40] /100 with no difference between treatment groups. A large (n=4,000 to 5,000) adequately powered multicentre trial is feasible using this population and methodology. [ABSTRACT FROM AUTHOR]

Background: Pre-operative identification of high-pain responders for acute pain after total knee arthroplasty (TKA) could lead to targeted analgesic trials and individualized analgesic strategies to improve recovery and potentially reduce the risk of persistent post-surgical pain. The aim of this study was to use simple clinical tests and questionnaires to identify predictive nociceptive and psychological factors for acute post-TKA pain.Methods: Sixty consecutive TKA patients were included in a prospective descriptive study of pain during a 5-m walk-test 24 h post-operatively as the primary outcome. Predictive variables collected prior to surgery included demographics, nociceptive testing (pressure pain threshold (PPT), cold pressor tolerance, electrical pain threshold and tolerance) and psychological profile (pain catastrophizing scale (PCS) and hospital anxiety and depression scale). The prediction of acute post-TKA pain was assessed by univariate analysis, logistic regressions and ROC curves.Results: Reduced PPT on the arm and increased PCS were predictive variables for moderate/severe post-TKA pain 24 h after surgery (P = 0.007 and P = 0.026, respectively, R-squared 0.21) in the logistic regression model. Odds ratios were 0.67 for a 50 kPa increased PPT and 1.36 for a 5 point increase in PCS. A predictive model with cut-off values of PPT ≤ 245 kPa and PCS≥ 8 point had a sensitivity of 71.4 and a specificity of 62.5.Conclusion: Pre-operative widespread pressure pain hypersensitivity and pain catastrophizing are predictive of moderate severe post-TKA pain. If validated in a larger population, the clinically applicable tests should be considered in future interventions aiming to minimize post-operative pain in high-risk patients. [ABSTRACT FROM AUTHOR]

Chronic post-surgical pain (CPSP) is currently an inevitable surgical complication. Despite the advances in surgical techniques and the development of new modalities for pain management, CPSP can affect 15-60% of all surgical patients. The development of chronic pain represents a burden to both the patient and to the community. In order to have a meaningful impact on this debilitating condition it is essential to identify those at risk. Early identification of patients at risk will help to reduce the percentage of patients who go on to develop CPSP. Unfortunately, evidence about any effective actions to reduce this condition is limited. This review will focus on providing context to the challenging problem of CPSP. The possible role of both the surgeon and anesthesiologist in reducing the incidence of this problem will be explored. [ABSTRACT FROM AUTHOR]

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Background: Pain after surgery is a major issue for patient discomfort and often associated with delayed recovery. The aim of the present study was to evaluate the prevalence of pain and requirement for analgesics up to 6 months after elective surgery, independent if new pain symptoms occurred after surgery or if preoperative pain persisted in the postoperative period. Methods: A prospective observational single center cohort study was conducted between January 2012 and August 2013. Eligible patients were scheduled to undergo elective surgical interventions including joint (hip, knee arthroplasty), back (nucleotomy, spondylodesis), or urological surgery (cystectomy, prostatectomy, nephrectomy). Pain was assessed on an 11-point numerical rating scale (NRS) before, on postoperative day 2 and 6 months after surgery. Clinical information was collected with structured questionnaires and by telephone interview. Results: Six hundred and forty-four patients gave informed consent, including 54.4 % men (mean age 62.2, SD 14.3). Higher preoperative pain scores were found in patients undergoing joint (mean 7.6; 95 % confidence interval [CI]: 7.2-8.0) and back surgery (mean 7.1, CI: 6.8-7.5) than in patients prior to urological surgery (mean 2.3; CI: 1.8-2.8). After 6 months, about 50 % of patients after joint or back surgery indicated pain levels ≥3/10, compared to 15. 9 % of patients after urological surgery (p < .001). 35.3 % of the patients after joint surgery and 41.3 % after back surgery still use pain medication 6 months postoperatively, in contrast to 7.3 % of patients after urological surgery. 13.6 % of patients who underwent back surgery indicated the regular intake of opioids. Conclusions: Our results reveal that a significant percentage of patients undergoing procedures in joint or back surgery still need pain medication up to 6 months postoperatively due to ongoing pain symptoms. Improved monitoring of pain management is warranted, especially after discharge from hospital, to improve long-term results. Trial registration: Clinicaltrials.gov (Identifier: NCT01488617); date of registration December 6th 2011. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses reports within the issue including the continued use of patients of opioid after their operative intervention, link of pre-operative opioid use with post-operative pain, and growth of opioid consumption in Denmark.

Background: The contribution of nerve lesions and neuropathic pain to persistent post-surgical pain (PPSP) is poorly established. The aim of this study was to assess the association between PPSP and symptoms and signs of possible nerve injury in an unselected surgical sample.Methods: Eighty-one individuals with and without persistent pain after surgical procedures, were recruited from a cross-sectional study. Follow-up examination with questionnaires and quantitative sensory testing was performed 15-32 months later (21-64 months after surgery).Results: The median rating of maximum pain intensity among individuals with PPSP decreased from numerical rating scale 4/10 at baseline to 2/10 at follow-up, but considerable changes occurred in both directions. Individuals with PPSP at follow-up were significantly more likely to self-report sensory abnormalities than those without PPSP; however, results from sensory testing did not differ significantly between the groups. Self-report of sensory disturbances at the site of surgery was associated with increased warm detection thresholds and tactile pain thresholds. Among individuals with PPSP, 61% had positive findings on sensory testing, suggesting probable neuropathic pain.Conclusion: In this study, associations between self-reported symptoms and PPSP were stronger than associations between self-reported symptoms and results of psychophysical tests. Fluctuations in pain intensity together with wide ranges for normal variability in sensory functions, hampers detection of significant group differences. Methodological aspects of quantitative sensory testing applied in a mixed clinical sample are discussed. [ABSTRACT FROM AUTHOR]

Background: Risk factors associated with postoperative pain intensity and duration, as well as consumption of analgesics after ophthalmic surgery are poorly understood.Methods: A prospective study was conducted among adults (N=226) who underwent eye surgery at the University Hospital Split, Croatia. A day before the surgery, the patients filled out questionnaires assessing personality, anxiety, pain catastrophizing, sociodemographics and were given details about the procedure, anesthesia, and analgesia for each postoperative day. All scales were previously used for the Croatian population. The intensity of pain was measured using a numerical rating scale from 0 to 10, where 0 was no pain and 10 was the worst imaginable pain. The intensity of pain was measured before the surgery and then 1 hour, 3 hours, 6 hours, and 24 hours after surgery, and then once a day until discharge from the hospital. Univariate and multivariate analyses were performed.Results: A multivariate analysis indicated that independent predictors of average pain intensity after the surgery were: absence of premedication before surgery, surgery in general anesthesia, higher pain intensity before surgery and pain catastrophizing level. Independent predictors of postoperative pain duration were intensity of pain before surgery, type of anesthesia, and self-assessment of health. Independent predictors of pain intensity ≥5 during the first 6 hours after the procedure were the type of procedure, self-assessment of health, premedication, and the level of pain catastrophizing.Conclusion: Awareness about independent predictors associated with average postoperative pain intensity, postoperative pain duration, and occurrence of intensive pain after surgery may help health workers to improve postoperative pain management in ophthalmic surgery. [ABSTRACT FROM AUTHOR]

Purpose: This manuscript proposes pharmacological strategies that might decrease persistent postsurgical pain (PPSP). These recommendations are based on a review of current publications available in the literature.Principal Findings: Persistent postsurgical pain has been defined by the International Association for the Study of Pain as clinical discomfort that lasts more than two months after surgery. Recent reviews reported that 10-50% of patients develop chronic pain after surgery, 2-10% with disabling chronic pain at six months. Preventive interventions should target all types of surgery, but specific attention should be placed on surgical insults that carry a high risk of pain chronicization. Regional anesthesia (RA) should be used whenever feasible, and a continuous perineural/epidural local anesthetic infusion is preferred over a single-shot technique. The RA should be initiated prior to the surgical incision and then continued for at least 24-72 hr after the surgery. Perioperative opioids should be used for nociceptive stimuli not managed by the RA. An intravenous infusion of ketamine, an N-methyl-D-aspartate receptor (NMDA) antagonist, might be added for a further decrease in neuronal sensitization, especially when the procedure is extensive or when RA is not feasible or contraindicated. A multimodal approach is always suggested. The literature still does not strongly support the use of gabapentinoids for PPSP prevention; however, they might be maintained in patients who use them preoperatively.Conclusions: A winning strategy to reduce the incidence of PPSP may well involve performing minimally invasive surgery, providing adequate perioperative analgesia based on RA, and using a multimodal approach with NMDA antagonists. [ABSTRACT FROM AUTHOR]

Many studies still indicate insufficient pain management after surgery, e.g., in patients after small- or medium-size operations. Yet it is still uncertain if postoperative pain based on patient-related outcomes can be improved by implementing guideline-related programmes in a multicentre approach. Adult patients in six hospitals in one German city were included in this prospective study. Data collection took place twice in each hospital, once before and once after implementation of concepts and in-house training. Pain and pain-related aspects were assessed one day after surgery and compared between the pre- and post-test group including subgroup analysis of certain surgical procedures by using Student’s t-tests, Mann-Whitney U tests and chi-square tests (alphatwo-tailed = 0.05). Overall, pain at rest and during movement was slightly lower after the intervention. Significant changes were observed after thoracic surgery, small joint surgery and other minor surgical procedures. The rather moderate decrease in pain likely relates to a reasonable pre-existing pain management and to detached improvements in certain patient subgroups. Interestingly, specific analyses revealed significantly lower post-test pain as compared to pre-test pain only in patients without pre-existing chronic pain. Side effects related to pain medication were significantly lower after intervention. Our data show, for the first time, benefits of a perioperative teaching programme in a multicentre approach. Pain ratings improved mainly in specific subgroups of patients, e.g., small surgical procedures and patients without preoperative pain. Thus, general improvement is possible but special attention should be paid to the group of patients with preoperative pain. [ABSTRACT FROM AUTHOR]

Objectives The aim of this trial was to determine risk factors for chronic saphenous neuralgia ( SN) following harvesting of the great saphenous vein ( GSV) for coronary artery bypass graft ( CABG) surgery. Methods In a prospective observational trial, 526 patients with no history of chronic painful disorders or surgery in the lower limbs were followed up for 13 weeks after undergoing CABG surgery in which GSV grafts were used. The primary outcome measure was persistence of clinically significant pain of neuropathic type in the territory supplied by the saphenous nerve beyond 12 weeks after surgery. Results Eighty-one (15.4%) patients consistently had probable neuropathic pain of clinically significant severity throughout the follow-up period and were labeled as suffering from chronic SN. Multivariable binary logistic regression analysis showed that younger age ( OR, 0.92; 95% CI, 0.88-0.95; P-value, < 0.0001), female gender ( OR, 2.28; 95% CI, 1.21-4.29; P-value, 0.011), higher body mass index ( OR, 1.25; 95% CI, 1.17-1.35; P-value, < 0.0001), diabetes mellitus ( OR, 2.13; 95% CI, 1.13-4.01; P-value, 0.020), distal-to-proximal dissection of the GSV ( OR, 7.28; 95% CI, 3.62-14.66; P-value, < 0.0001), and closure of the leg wound in two layers ( OR, 3.28; 95% CI, 1.81-5.95; P-value, 0.0001) were independent risk factors for chronic SN. Conclusions Chronic SN after CABG surgery utilizing GSV grafts is not uncommon. Risk factors identified in this trial are younger age, female gender, higher body mass index, diabetes mellitus, distal-to-proximal dissection of the GSV, and closure of the leg wound in two layers. [ABSTRACT FROM AUTHOR]

On an individual level, there is a difference in the analgesic response to a given opioid. Various factors such as gender, age, and genetic variation can affect the analgesic response. The genetic variation can influence pharmacokinetics (eg drug transporters and drug-metabolizing enzymes) and/or pharmacodynamics (eg opioid receptor and catechol-O-methyltransferase enzymes). We present recent experimentally induced pain, postoperative pain, and cancer pain and chronic non-malignant pain conditions studies in humans, focusing on the association between genetic variation and analgesic response assessed as opioid consumption or changes in pain scores. Studies have shown promising results regarding pharmacogenetics as a diagnostic tool for predicting the individual response to a given opioid in the experimental settings; however, in the clinic, it is a more complicated task to accomplish. [ABSTRACT FROM AUTHOR]

Background Persistent post-surgical pain is recognised as a major problem. Prevalence after different surgical procedures has been reported to range from 5% up to 85%. Limb amputation and thoracotomy have the highest reported prevalence. Prediction of persistent post-surgical pain has over the last decade caught attention. Several factors have been investigated, but in-depth knowledge is still scarce. The purpose of this study was to investigate the prevalence of persistent post-surgical pain, and predictive factors for persistent post-surgical pain 12 months after thoracotomy. Methods A prospective longitudinal study was conducted. One-hundred and seventy patients were recruited before scheduled thoracotomy, and asked to answer a questionnaire. One-hundred and six patients completed the same questionnaire at 12-month follow-up. Regression analysis was performed to explore variables assumed predictive of persistent post-surgical pain. Results One-hundred and six patients (62%) filled out the questionnaire at both time points. Preoperative, 34% reported muscle-skeletal related chronic pain. At 12-month follow-up, 50% of the patients reported persistent post-surgical pain. Of the variables explored in the logistic regression model, only preoperative pain ( P < 0.001) and dispositional optimism ( P = 0.04) were statistically significant. In this study, preoperative pain was a predominant predictor for persistent postoperative pain ( OR 6.97, CI 2.40-20.21), while dispositional optimism ( OR 0.36, CI 0.14-0.96) seem to have protective properties. Conclusion Our results show that preoperative pain is a predominant predictor of future pain. This implies that patients presenting with a chronic pain condition prior to surgery should be assessed thoroughly preoperatively and have an individually tailored analgesic regimen. [ABSTRACT FROM AUTHOR]

Objectives To investigate the overall incidence and risk factors for persistent pain and its interference with daily life after cesarean section. Design Prospective long-term follow-up study. Setting Karolinska University Hospital, Stockholm, Sweden. Population 260 healthy women who underwent elective cesarean section. Methods Information on demographics, medical history, postoperative pain and analgesic requirements was collected. A questionnaire consisting of the Brief Pain Inventory was posted at 3, 6 and 12 months after surgery. Women rated pain intensity as well as interference with factors related to general function and quality of life. Main outcome measures The overall incidence and risk factors for persistent postoperative pain at three time points. Persistent pain was considered a secondary outcome. Results At 3, 6 and 12 months respectively 40, 27 and 22% of patients reported pain in one or more locations, in the surgical site as well as in other areas. A psychological indication, as well as a first cesarean section, increased the risk for pain at 3 months. Severe postoperative pain in the immediate postoperative period or undergoing a first cesarean section were significant independent risk factors for the development of persistent pain up to 6 months after cesarean section. Parameters related to quality of life were significantly impaired in women with persistent pain. Conclusion Several factors, including severe postoperative pain, were shown to influence the risk for persistent pain after cesarean section. Long-term pain markedly affected women's wellbeing. [ABSTRACT FROM AUTHOR]