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ObjectiveTo conduct a systematic literature review of dorsal root ganglion (DRG) stimulation for pain.DesignGrade the evidence for DRG stimulation.MethodsAn international, interdisciplinary work group conducted a literature search for DRG stimulation. Abstracts were reviewed to select studies for grading. General inclusion criteria were prospective trials (randomized controlled trials and observational studies) that were not part of a larger or previously reported group. Excluded studies were retrospective, too small, or existed only as abstracts. Studies were graded using the modified Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the US Preventative Services Task Force level-of-evidence criteria.ResultsDRG stimulation has Level II evidence (moderate) based upon one high-quality pivotal randomized controlled trial and two lower-quality studies.ConclusionsModerate-level evidence supports DRG stimulation for treating chronic focal neuropathic pain and complex regional pain syndrome.

Failed back surgery syndrome (FBSS) is a stigmatizing and misleading term, and in many cases surgery is not relevant to the development, persistence, worsening or recurrence of the symptoms. An international panel recently proposed the notion of Persistent spinal pain syndrome (PSPS) as the preferred option to replace FBSS. The new label avoids ambiguity and inappropriately-implied causation. PSPS type 1 applies when there was no spinal surgery; type 2 applies when surgery had occurred. PSPS is therefore broader than FBSS but more accurate.

ObjectiveFor many medical professionals dealing with patients with persistent pain following spine surgery, the term Failed back surgery syndrome (FBSS) as a diagnostic label is inadequate, misleading, and potentially troublesome. It misrepresents causation. Alternative terms have been suggested, but none has replaced FBSS. The International Association for the Study of Pain (IASP) published a revised classification of chronic pain, as part of the new International Classification of Diseases (ICD-11), which has been accepted by the World Health Organization (WHO). This includes the term Chronic pain after spinal surgery (CPSS), which is suggested as a replacement for FBSS.MethodsThis article provides arguments and rationale for a replacement definition. In order to propose a broadly applicable yet more precise and clinically informative term, an international group of experts was established.Results14 candidate replacement terms were considered and ranked. The application of agreed criteria reduced this to a shortlist of four. A preferred option—Persistent spinal pain syndrome—was selected by a structured workshop and Delphi process. We provide rationale for using Persistent spinal pain syndrome and a schema for its incorporation into ICD-11. We propose the adoption of this term would strengthen the new ICD-11 classification.ConclusionsThis project is important to those in the fields of pain management, spine surgery, and neuromodulation, as well as patients labeled with FBSS. Through a shift in perspective, it could facilitate the application of the new ICD-11 classification and allow clearer discussion among medical professionals, industry, funding organizations, academia, and the legal profession.

Objective: Many patients are discharged from hospital after surgery with excessive doses of opioid, and prescription opioid addiction has become a serious public health problem. Inpatient opioid de-escalation performed by clinical pharmacists may assist in reducing opioids before discharge. We aimed to evaluate whether clinical pharmacist-led opioid de-escalation for inpatients after orthopedic surgery led to significant reductions in opioid use at discharge, without resulting in greater pain intensity and side effects. Design: This retrospective pre-/post-intervention study evaluated patients before and after implementation of a pharmacist-led opioid de-escalation service. Setting: A major tertiary institution. Participants: Ninety eight participants underwent de-escalation, and 98 controls received standard care following orthopedic surgery. Intervention: Pharmacist-led opioid de-escalation was initiated after discharge from the institution's Acute Pain Service. Main outcome measure: Primary outcome was total morphine oral equivalence (MOE) required in the 24-hours before discharge between the two groups. Secondary outcomes included pain intensity scores and opioid-related side effects. Results: The post-intervention group used significantly less opioids in the 24 hours preceding discharge compared with the precohort (total MOE 30 vs 45 mg; p = 0.025).There were no differences in pain intensity at rest (p = 0.19) or with movement (p = 0.19). Cases experienced significantly less constipation (29 vs 49 percent; p = 0.004); no differences were observed for other side effects. Discussion: We observed statistically similar pain intensity ratings, in the setting of significantly lowered opioid doses among the post-intervention group prior to discharge. Conclusion: Pharmacist-led inpatient opioid de-escalation is effective, does not increase pain intensity, and reduces constipation. Hospitals should explore the viability of extending pharmacist-led opioid de-escalation to other surgical patients and following hospital discharge, aiming for opioid cessation.

ObjectiveTo conduct a systematic literature review of spinal cord stimulation (SCS) for pain.DesignGrade the evidence for SCS.MethodsAn international, interdisciplinary work group conducted literature searches, reviewed abstracts, and selected studies for grading. Inclusion/exclusion criteria included randomized controlled trials (RCTs) of patients with intractable pain of greater than one year’s duration. Full studies were graded by two independent reviewers. Excluded studies were retrospective, had small numbers of subjects, or existed only as abstracts. Studies were graded using the modified Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the US Preventative Services Task Force level-of-evidence criteria.ResultsSCS has Level 1 evidence (strong) for axial back/lumbar radiculopathy or neuralgia (five high-quality RCTs) and complex regional pain syndrome (one high-quality RCT).ConclusionsHigh-level evidence supports SCS for treating chronic pain and complex regional pain syndrome. For patients with failed back surgery syndrome, SCS was more effective than reoperation or medical management. New stimulation waveforms and frequencies may provide a greater likelihood of pain relief compared with conventional SCS for patients with axial back pain, with or without radicular pain.

Sir,Flawed nomenclature and classification inevitably hamper diagnosis, clinical communication and research, and may impede access to appropriate treatment. This is clearly illustrated by the term ...

Introduction Current treatments for pain have limited benefits and worrying side effects. Some studies suggest that pain is reduced when clinicians deliver positive messages. However, the effects of positive messages are heterogeneous and have not been subject to meta-analysis. We aimed to estimate the efficacy of positive messages for pain reduction. Methods We included randomized trials of the effects of positive messages in a subset of the studies included in a recent systematic review of context factors for treating pain. Several electronic databases were searched. Reference lists of relevant studies were also searched. Two authors independently undertook study selection, data extraction, risk of bias assessment, and analyses. Our primary outcome measures were differences in patient- or observer-reported pain between groups who were given positive messages and those who were not. Results Of the 16 randomized trials (1703 patients) that met the inclusion criteria, 12 trials had sufficient data for meta-analysis. The pooled standardized effect size was −0.31 (95% confidence interval [CI] −0.61 to −0.01, p = 0.04, I2 = 82%). The effect size remained positive but not statistically significant after we excluded studies considered to have a high risk of bias (standard effect size −0.17, 95% CI −0.54 to 0.19, P = 0.36, I2 = 84%). Conclusion Care of patients with chronic or acute pain may be enhanced when clinicians deliver positive messages about possible clinical outcomes. However, we have identified several limitations of the present study that suggest caution when interpreting the results. We recommend further high-quality studies to confirm (or falsify) our result.

A growing body of evidence suggests that positive framing–inducing positive expectations about the outcome of treatments can reduce pain symptoms. However there is no pooled estimate of the effect size of positive framing for treating pain. Such an estimate is useful to understand the extent to which positive expectations can enhance usual care.

Postoperative surgical patients are at risk of developing multiple types of hospital-acquired infections. These include surgical site infections which are relatively common (incidence 5–20%), can prolong hospital stay, cause morbidity, increase the cost of health care, and even lead to mortality. Other hospital-acquired infections affecting surgical patients include respiratory and urinary tract infections, methicillin-resistant Staphylococcus aureus bacteraemias, antibiotic-related Clostridium difficile enteritis, and intravascular cannulaerelated infections. All surgical wounds are likely to become contaminated, usually by resident bacterial flora from skin or viscera. This may not be of clinical significance and contaminated wounds may go unnoticed. However, progression from wound contamination to clinical infection is largely determined by the adequacy of host defence, the most important immune mechanism of which is neutrophil phagocytosis which occurs during a crucial few hours intraoperatively and after operation. When a neutrophil ingests bacteria (or any foreign debris), it undergoes a ‘respiratory burst’, temporarily increasing its oxygen consumption which results in the production of anti-microbial oxygen free radicals. Oxygen free radicals such as superoxide ions and hydrogen peroxide are produced by the enzymes superoxide dismutase and myeloperoxidase. Variables that affect tissue oxygen delivery or enzyme function can impair the production of oxygen free radicals and allow bacteria to survive and infection to become established. Well-known variables that influence surgical site infection include surgical factors (e.g. haematoma, anastomotic leak, poor surgical technique, choice of antiseptic, prolonged or technically difficult procedure) and patient factors (immunosuppression, age, ASA status, comorbidities, colonization by S. aureus) (Table 1). However, there are now a number of emerging factors that can also affect the incidence of bacterial infections of the surgical site. Some of these other variables are pre-existing or unmodifiable, whereas several can be altered by the anaesthetist. These modifiable factors will be the focus of this discussion. Factors that can be optimized in the perioperative period can be divided into

The word ‘bariatric’ is derived from the Greek words baros meaning ‘weight’ and iatrics meaning ‘medical treatment’. Obesity is one of the greatest health challenges facing Western countries. Obesity is defined as a body mass index (BMI) .30 kg m, whereas those with a BMI .35 and .55 kg m are considered ‘morbidly’ obese and ‘super morbidly’ obese, respectively. Recent figures suggest that up to 23% of men and 25% of women in the UK are obese. Associated obesity-related medical conditions include hypertension, coronary artery disease, sudden (cardiac) death, restrictive lung disease, obstructive sleep apnoea (OSA), diabetes mellitus, gallstones, a range of cancers (breast, gynaecological, and gastrointestinal), degenerative joint disease, and socioeconomic and psychosocial impairment. Quality of life and life expectancy are reduced. Obesity also leads to an increased demand for health-care services. Studies have shown that weight loss of 5– 10% of initial body weight can improve glucose intolerance, type II diabetes mellitus, hypertension, and hyperlipidaemias. Treatment for overweight patients should encompass a multidisciplinary team offering a complete weight loss programme, which includes diet and lifestyle modification alongside increased physical activity. Approved drug therapy may also have a role in weight loss. Unfortunately, weight loss obtained by these non-invasive measures is rarely sustained, which has led to bariatric surgery increasingly being offered as a solution. Bariatric surgery has been recommended by the National Institute of Clinical Excellence as a treatment for obesity. Bariatric procedures may achieve weight loss of more than 50% of excess weight. Bariatric surgery is relatively safe, has low morbidity and mortality, and can provide longterm sustained weight loss with significant improvement of co-morbidity and quality of life in the morbidly obese patient. It is one of the fastest growing areas of surgery in terms of patient numbers treated. This reflects both the ability of bariatric surgical procedures to provide a solution to an otherwise insoluble problem and the evolution of safer, less invasive surgical methods. This article will focus on anaesthesia and how it relates directly to the speciality of bariatric surgery. For a more detailed and generalized review of obesity and how it relates to anaesthesia, the reader is directed to alternative text for further reading.

OBJECTIVE To institute and evaluate the benefits of an enhanced recovery after surgery (ERAS) program across three hospitals in Victoria. DESIGN, SETTING AND PARTICIPANTS We used a before-and-after quality improvement study design consisting of three phases: pre-ERAS program data collection from March to September 2012; ERAS training and implementation during September 2012; and change performance measurement following ERAS implementation from October 2012 to May 2013. MAIN OUTCOME MEASURES The primary end point was duration of hospital stay after knee or hip arthroplasty. Secondary end points were adherence to the ERAS bundle, and process and patient recovery characteristics. RESULTS We enrolled 412 patients to the pre-ERAS (existing-practice) phase and compared them with 297 patients in the ERAS phase. For ERAS patients, compared with existing-practice patients, hospital stay was reduced (geometric mean, 5.3 [SD, 1.6] v 4.9 [SD, 1.6] days; P

Since being reported in 2008, high volume local infiltration analgesia (HVLIA) has rapidly gained popularity for patients undergoing hip and knee replacement. We undertook this review to investigate whether there was evidence for equivalence of HVLIA compared to peripheral nerve block techniques with respect to early postoperative analgesia and functional recovery, or for other outcomes such as cost and process efficiency, persistent postsurgical pain and arthroplasty revision rate. We found that despite the popularity of HVLIA, supporting evidence for its use is currently limited. HVLIA certainly provides postoperative analgesia, but it is not clear whether it is equivalent to contemporary peripheral nerve block techniques in terms of either analgesia or early or later functional outcome in the context of a modern, comprehensive enhanced recovery program. Nor is it possible to state whether HVLIA provides benefits in terms of persistent postsurgical pain or cost and process efficiency. Well designed trials directly comparing peripheral nerve block with a standardised HVLIA technique are urgently required.

Chronic pain and major depression commonly occur together. Major depression in patients with chronic pain is associated with decreased function, poorer treatment response and increased health care costs. The experience and expression of chronic pain vary between individuals, reflecting complex and changing interactions between physical, psychological and social processes. The diagnosis of major depression in patients with chronic pain requires differentiation between the symptoms of pain and symptoms of physical illness. Antidepressants and psychological therapies can be effective and should be delivered as part of a coordinated, cohesive, multidisciplinary pain management plan.

Introduction Pain continues to be an ongoing issue of concern in adult burn patients. Inadequate pain assessment hinders meaningful research, and prevents the optimal management of burn pain. The objective of this study was to examine the content of existing research in burn pain with the frequency and context of pain assessment tool use in randomized clinical trials in order to further inform their use for future researchers and clinicians. Methods Electronic searches of MEDLINE, CINAHL, EMBASE and The Cochrane Library databases from 1966 onwards were used to identify English articles related to clinical trials utilising pain assessment in adult burns patients. Results The systematic literature search identified 25 randomized clinical trials utilising pain assessment tools. Unidimensional pain assessment tools were most frequently used pain assessment tools, with multidimensional tools used less often, despite the multifaceted and complex nature of burn pain. Conclusion The review highlights the lack of consistency of pain assessment tool use in randomized clinical trials with respect to managing burn pain. We recommend a broader but consistent use of multidimensional pain assessment tools for researchers undertaking clinical trials in this field. The review supports the need for an international expert consensus to identify the necessary critical outcomes and domains for clinicians and researchers undertaking further research into burn pain.

Background Early studies suggested that ropivacaine had clinical advantages over bupivacaine with respect to cardiotoxicity and motor block, and that it was suitable for epidural caesarean section. This study was set up to compare epidural 0.75% ropivacaine with a popular bupivacaine/fentanyl mixture for elective caesarean section. Methods Eighty women having elective caesarean section under epidural anaesthesia were randomly allocated to receive 20mL of either 0.75% ropivacaine or 0.5% bupivacaine plus fentanyl 100μg. Supplementation with 2% plain lidocaine was used where necessary. Times were recorded for onset of sensory block, density and duration of motor block, and the need for supplementation. Results There was no difference between the groups in the time (mean [SD]) to achieve sensory blockade to cold to T4 (ropivacaine 15.8 [5.6]min, bupivacaine/fentanyl 18.7 [9.1]min, P =0.13) or to S1 (ropivacaine 18.3 [4.6]min, bupivacaine/fentanyl 17.4 [7.6]min, P =0.59), or in the need for supplementation. However, ropivacaine produced a motor block that was denser (median Bromage score ropivacaine 3, bupivacaine/fentanyl 1.5, P =0.0041), and of longer duration (ropivacaine 237 [84]min, bupivacaine/fentanyl 144 [76] min, P Conclusions This study suggests that epidural 0.75% ropivacaine without opioid may be used as an alternative to bupivacaine 0.5% with fentanyl for elective caesarean section, but it does not induce anaesthesia any faster and may result in a denser, more prolonged, motor block.

Pain is a complex phenomenon, defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. This definition is widely accepted and has led to many advances in pain medicine, but it has shortcomings and has been challenged. The definition of pain underlies the complexity of its measurement. Pain is individual and subjective, modulated by physiological, psychological and environmental factors such as previous events, culture, prognosis, coping strategies, fear and anxiety. Multiple attempts to quantify and analyse the pain experience have been published, with most based on self-reporting. Self-report measures have weaknesses and may be influenced by mood, sleep disturbance and medication. Attempting to ‘objectify the subjective’ can be hazardous because of response biases, situational influences and the context in which pain is reported.