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Background: Complex regional pain syndrome (CRPS) can profoundly affect many aspects of everyday life. Spinal cord stimulation (SCS) is a potential therapeutic option. This retrospective, single-site evaluation explored health-related quality of life (HRQoL) in individuals with CRPS treated with SCS in our Pain Service., Materials and Methods: All patients aged ≥18 years with fully implanted SCS for CRPS between June 2013 and January 2023 were identified from hospital records. The following data were collected: sex, age, chronic pain diagnosis, CRPS type (I or II), location of CRPS (upper or lower limb), years of CRPS before first SCS implant, SCS system, preimplant and follow-up scores for HRQoL (euroqol 5 dimensions 3 levels [EQ-5D-3L] index score), average pain, worst pain and the influence of pain on aspects of everyday life (all numerical rating scale [NRS]), patient and clinician global impression of change at follow-up, and the occurrence and reasons for revisions and explants. An intention-to-treat approach was used and data statistically analyzed., Results: The final cohort comprised 83 patients (46 women), with a median (minimum, maximum) follow-up duration of 29 months (seven, 72). There were statistically and clinically significant improvements in HRQoL, despite relatively low pain response rates. The pain response rate was 34% (reduction of ≥30% in average pain NRS); the pain remission rate was 13% (average pain score ≤3 NRS), and all patients had preimplant EQ-5D-3L index values below the population norm of 0.82. However, 60% of patients reported EQ-5D-3L index scores greater than the published minimally important difference of 0.074, and scores were better at follow-up than at preimplant (p < 0.001); 44% of patients and 41% of clinicians reported improved symptoms at the most recent follow-up. Explants occurred in eight of 83 patients (10%)., Conclusions: Patients had meaningful improvements in HRQoL, which is a key outcome in ascertaining the overall outcome of SCS in CRPS. Randomized controlled clinical trials should build on the findings to improve understanding of the benefits and risks of treating CRPS with SCS., Competing Interests: Conflict of Interest Beatrice Bretherton has provided consultancy to Abbott and Platform 14. Ganesan Baranidharan has a consulting agreement with Saluda, Nevro Corp, Abbott, Medtronic, Boston Scientific, Stryker, and Mainstay Medical. Ganesan Baranidharan had educational and research grants from Nevro Corp, Abbott, and Boston Scientific. Ganesan Baranidharan is on the advisory board for Abbott and Nalu Medical. The remaining authors reported no conflict of interest., (Copyright © 2024. Published by Elsevier Inc.)

Background: Pain trajectories have been described in numerous surgical settings where preoperative characteristics have been used to predict trajectory membership. Suboptimal pain intensity trajectories have been linked to poor longitudinal outcomes. However, numerous biopsychosocial modulators of postoperative pain may also have distinct longitudinal trajectories that may inform additional targets to improve postoperative recovery., Methods: Patients undergoing total joint arthroplasty, thoracic surgery, spine surgery, major abdominal surgery, or mastectomy completed Patient Reported Outcome Measurement Information System (PROMIS) measures and additional scales preoperatively and at 1 week, 2 weeks, 1 month, 3 months, and 6 months postoperatively. A k-means clustering for longitudinal data was utilized to explore and describe distinct pain impact (PROMIS Pain Interference and Physical Function) trajectories and associated changes in additional biopsychosocial measures. Follow-up analyses examined participant demographics and clinical characteristics associated with trajectory memberships., Results: Three postoperative biopsychosocial symptom clusters were identified across all patients (n = 402): low (35%), average (47%), and high (18%) performance cluster trajectories. Participants undergoing total knee arthroplasty (TKA), spinal surgery, reporting presurgical opioid use, and higher pain catastrophizing scale scores were found to be associated with the low performance trajectory. Patients within the low performance trajectory, while demonstrating small improvements by 6 months, remained mild to moderately impaired in both pain impact and physical health outcomes. Alternatively, participants in the average performance trajectory demonstrated improvement in pain impact to population norms compared to baseline and demonstrated continued improvement across physical and psychological outcomes. Patients within the high performance cluster started within population norms across all measures at baseline and returned to baseline or exceeded baseline values by 6 months postoperatively. Self-reported opioid utilization was significantly higher in the low performance cluster across all time points. While a larger proportion of average performance patients reported opioid utilization during the first postoperative month compared to the high performance cluster, no differences were detected at 6 months postoperatively between these 2 clusters., Conclusions: These pain impact trajectories build upon previous unidimensional pain intensity trajectories and suggest that additional distinct biopsychosocial measures may have unique trajectories related to cluster assignment. Additionally, these findings highlight the importance of continued pain impact surveillance through the perioperative recovery period to detect patients at risk of experiencing a poor trajectory and subsequently poor longitudinal health outcomes., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2021 International Anesthesia Research Society.)

Best practices in preclinical algesiometry (pain behaviour testing) have shifted over the past decade as a result of technological advancements, the continued dearth of translational progress and the emphasis that funding institutions and journals have placed on rigour and reproducibility. Here we describe the changing trends in research methods by analysing the methods reported in preclinical pain publications from the past 40 years, with a focus on the last 5 years. We also discuss how the status quo may be hampering translational success. This discussion is centred on four fundamental decisions that apply to every pain behaviour experiment: choice of subject (model organism), choice of assay (pain-inducing injury), laboratory environment and choice of outcome measures. Finally, we discuss how human tissues, which are increasingly accessible, can be used to validate the translatability of targets and mechanisms identified in animal pain models., (© 2021. Springer Nature Limited.)

Background: Microvascular decompression (MVD) is an effective treatment for trigeminal neuralgia, but pain recurs in a substantial minority of patients. Two recently published scoring systems by Hardaway et al. and Panczykowski et al. use simple preoperative clinical and imaging features to predict durable pain relief following MVD, but their predictive performance has not been independently validated. This study aimed to compare predictive performance of the Hardaway et al. score (HS) and Panczykowski et al. score (PS) for 1-year, 3-year, and long-term pain-free outcomes after MVD for trigeminal neuralgia., Methods: HS and PS were computed for a retrospective, single-institution cohort of 68 patients with trigeminal neuralgia who underwent MVD. Primary outcome was pain recurrence after MVD. Predictive performance of HSs and PSs was evaluated with area under the curve sensitivity analysis and regression models for survival analyses at 1 year, 3 years, and last follow-up., Results: Area under the curve for predicting pain-free outcome was higher for PS versus HS at 1 year (0.873 vs. 0.775) and 3 years (0.793 vs. 0.704). Cox proportional hazard models showed that PS better predicted long-term pain-free outcomes compared with HS (P < 0.05). One-year pain-free outcome was best predicted by pain type; longer-term outcomes were better predicted by presence and degree of neurovascular compression on preoperative imaging., Conclusions: PS is superior to HS in predicting pain-free outcomes after MVD, which may aid in patient selection and counseling. Overall, more significant neurovascular compression of the trigeminal nerve root, and to a lesser extent classical paroxysmal pain, are good predictors of durable pain relief after MVD., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: As the population ages, the number of elderly people undergoing surgery increases. Literature on the incidence and intensity of postoperative pain in the elderly is conflicting. This study examines associations between age and pain-related patient reported outcomes and perioperative pain management in a dataset of surgical patients undergoing four common surgeries: spinal surgery, hip or knee replacement, or laparoscopic cholecystectomy. Based on the authors' clinical experience, they hypothesize that pain scores are lower in older patients., Methods: In this retrospective cohort, study data were collected between 2010 and 2018 as part of the international PAIN OUT program. Patients filled out the International Pain Outcomes Questionnaire on postoperative day 1., Results: A total of 11,510 patients from 26 countries, 59% female, with a mean age of 62 yr, underwent one of the aforementioned types of surgery. Large variation was detected within each age group for worst pain, yet for each surgical procedure, mean scores decreased significantly with age (mean Numeric Rating Scale range, 6.3 to 7.3; β = -0.2 per decade; P ≤ 0.001), representing a decrease of 1.3 Numeric Rating Scale points across a lifespan. The interference of pain with activities in bed, sleep, breathing deeply or coughing, nausea, drowsiness, anxiety, helplessness, opioid administration on the ward, and wish for more pain treatment also decreases with age for two or more of the procedures. Across the procedures, patients reported being in severe pain on postoperative day one 26 to 38% of the time, and pain interfered moderately to severely with movement., Conclusions: The authors' findings indicate that postoperative pain decreases with increasing age. The change is, however, small and of questionable clinical significance. Additionally, there are still too many patients, at any age, undergoing common surgeries who suffer from moderate to severe pain, which interferes with function, supporting the need for tailoring care to the individual patient., (Copyright © 2021, the American Society of Anesthesiologists. All Rights Reserved.)

Background: Patient satisfaction has become an important variable in assessing outcomes after spine surgery. Although minimally invasive surgery (MIS) techniques have become popular owing to reduced perioperative complications compared with open deformity surgery, whether patient-reported postoperative satisfaction differ between the 2 surgical approaches is unclear. The aim of this study was to characterize postoperative patient-reported outcomes (PRO) in patients who underwent open surgery or MIS for adult spinal deformity (ASD)., Methods: PRO scores were prospectively collected for patients undergoing deformity correction surgery between 2016 and 2018. Inclusion criteria were age >18 years, ASD, and completed PRO surveys. Patient demographic, clinical, and radiographic data and PRO survey responses were analyzed. A post hoc analysis comparing patients who were satisfied with their outcome and those who were unsatisfied was performed., Results: Forty patients who underwent operative management of ASD (19 in the open surgery group and 21 in the MIS group) met the criteria for inclusion in this study. Patients in the MIS group reported higher mental health and self-image scores at 6 months; however, at the 12-month follow-up, both the open surgery and MIS groups reported minimal clinically important differences in back pain, leg pain, and functional status. Patient satisfaction scores did not differ based on surgical approach or intraoperative complications., Conclusions: PRO after open surgery and after MIS for ASD reflected successful outcomes with significant improvements in PRO survey scores but with subtle differences in the postoperative recovery process. The MIS group reported faster recovery with earlier improvement in self-image and mental health scores, which may stem from correction of smaller deformities. At the 12-month follow-up, postoperative satisfaction was high for the majority of patients in both groups., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Pain is common in children with cerebral palsy. The purpose of this systematic review was to evaluate the evidence regarding assessments and interventions for chronic pain in children aged ≤2 years with or at high risk for cerebral palsy., Methods: A comprehensive literature search was performed. Included articles were screened using PRISMA guidelines and quality of evidence was reviewed using best-evidence tools by independent reviewers. Using social media channels, an online survey was conducted to elicit parent preferences., Results: Six articles met criteria. Parent perception was an assessment option. Three pharmacologic interventions (gabapentin, medical cannabis, botulinum toxin type A) and 1 nonpharmacologic intervention were identified. Parent survey report parent-comfort and other nonpharmacologic interventions ranked as most preferable., Conclusion: A conditional GRADE recommendation was in favor of parent report for pain assessment. Clinical trials are sorely needed because of the lack of evidence for safety and efficacy of pharmacologic interventions.

Background: Thoracic epidural analgesia (TEA) has been suggested to improve survival after curative surgery for colorectal cancer compared with systemic opioid analgesia. The evidence, exclusively based on retrospective studies, is contradictory., Methods: In this prospective, multicentre study, patients scheduled for elective colorectal cancer surgery between June 2011 and May 2017 were randomised to TEA or patient-controlled i.v. analgesia (PCA) with morphine. The primary endpoint was disease-free survival at 5 yr after surgery. Secondary outcomes were postoperative pain, complications, length of stay (LOS) at the hospital, and first return to intended oncologic therapy (RIOT)., Results: We enrolled 221 (110 TEA and 111 PCA) patients in the study, and 180 (89 TEA and 91 PCA) were included in the primary outcome. Disease-free survival at 5 yr was 76% in the TEA group and 69% in the PCA group; unadjusted hazard ratio (HR): 1.31 (95% confidence interval [CI]: 0.74-2.32), P=0.35; adjusted HR: 1.19 (95% CI: 0.61-2.31), P=0.61. Patients in the TEA group had significantly better pain relief during the first 24 h, but not thereafter, in open and minimally invasive procedures. There were no differences in postoperative complications, LOS, or RIOT between the groups., Conclusions: There was no significant difference between the TEA and PCA groups in disease-free survival at 5 yr in patients undergoing surgery for colorectal cancer. Other than a reduction in postoperative pain during the first 24 h after surgery, no other differences were found between TEA compared with i.v. PCA with morphine., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: For most procedures, there is insufficient evidence to guide clinicians in the optimal timing of advanced analgesic methods, which should be based on the expected time course of acute postoperative pain severity and aimed at time points where basic analgesia has proven insufficient., Methods: We conducted a systematic search of the literature of analgesic trials for total hip arthroplasty (THA), extracting and pooling pain scores across studies, weighted for study size. Patients were grouped according to basic anaesthetic method used (general, spinal), and adjuvant analgesic interventions such as nerve blocks, local infiltration analgesia, and multimodal analgesia. Special consideration was given to high-risk populations such as chronic pain or opioid-dependent patients., Results: We identified and analysed 71 trials with 5973 patients and constructed pain trajectories from the available pain scores. In most patients undergoing THA under general anaesthesia on a basic analgesic regimen, postoperative acute pain recedes to a mild level (<4/10) by 4 h after surgery. We note substantial variability in pain intensity even in patients subjected to similar analgesic regimens. Chronic pain or opioid-dependent patients were most often actively excluded from studies, and never analysed separately., Conclusions: We have demonstrated that it is feasible to construct procedure-specific pain curves to guide clinicians on the timing of advanced analgesic measures. Acute intense postoperative pain after THA should have resolved by 4-6 h after surgery in most patients. However, there is a substantial gap in knowledge on the management of patients with chronic pain and opioid-dependent patients., Competing Interests: Declarations of interest GJ has received honoraria from Baxter Pharmaceutical and Pacira Pharmaceutical. The other authors have declared no conflict of interest., (Copyright © 2021. Published by Elsevier Ltd.)

Both posterior decompression and fusion (PDF) and laminoplasty (LAMP) have been used to treat cervical myelopathy due to multilevel ossification of posterior longitudinal ligament (OPLL). However, considerable controversy exists over the choice of the two surgical strategies. Thus, the aim of this study is to compare clinical outcomes of PDF and LAMP for treatment of cervical myelopathy due to multilevel OPLL. We searched PubMed, EMBASE and Cochrane Central Register of Controlled Trials database to identify relevant clinical studies compared with clinical outcomes of PDF and LAMP for cervical OPLL. The primary outcomes including Japanese Orthopaedic Association (JOA) score and recovery rate of JOA were evaluated, and the secondary outcomes involving visual analogue scale (VAS), cervical curvature, OPLL progression rate, complication rate, reoperation rate and surgical trauma were also evaluated using Stata software. A total of nine studies were included in the current study, involving 324 patients. The current study suggests that compared with LAMP, PDF achieves a lower OPLL progression rate, better postoperative cervical curvature and similar neurological improvement in the treatment of multilevel cervical OPLL. However, PDF has a higher complication rate, more surgical trauma and higher postoperative VAS than LAMP.

Study Design: Retrospective review of prospectively-collected registry data., Objectives: The aim of this study was to determine how different combinations of preoperative neck pain (NP) and arm pain (AP) influence functional outcomes, patient satisfaction, and return-to-work in patients undergoing anterior cervical discectomy and fusion (ACDF) for degenerative cervical radiculopathy (DCR)., Summary of Background Data: Surgeons often base decisions on the traditional belief that the predominance of radicular upper extremity symptoms is a stronger indication for cervical spine surgery than axial pain. However, there is a paucity of literature supporting this notion., Methods: A prospectively maintained registry was reviewed for all patients who underwent primary ACDF for DCR. Patients were categorized into three groups depending on predominant pain location: AP predominant ([APP]; AP > NP), NP predominant ([NPP]; NP > AP), and equal pain predominance ([EPP]; NP = AP). Patients were prospectively followed for at least 2 years., Results: In total, 303 patients were included: 27.4% APP, 38.9% NPP, and 33.7% EPP cases. The APP group was significantly older (P = 0.030), although there were no other preoperative differences among the three groups. After adjusting for baseline differences, the SF-36 Physical Component Summary was significantly better in the APP group at 6 months (P = 0.048) and 2 years (P = 0.039). In addition, they showed a trend towards better 6-month Neck Disability Index (P = 0.077) and 2-year SF-36 Mental Component Summary (P = 0.059). However, an equal proportion of patients in each group achieved the Minimal Clinically Important Difference for each outcome, were satisfied, and returned to work 2 years after surgery., Conclusion: Although patients with NPP had slightly poorer function and quality of life, all patients experienced a clinically meaningful improvement in patient-reported outcomes, regardless of the predominant pain location. High rates of satisfaction and return-to-work were also achieved. In the context of proper indications, these findings suggest that ACDF can be equally effective for DCR patients with varying combinations of NP or AP.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Current evidence shows that the benefits of epidural analgesia (EA) are not as impressive as believed in the past, while the risks of adverse effects and serious complications are greater than previously estimated. There are many reasons for the decreasing role of epidural technique in clinical practice (table). Indeed, EA can cause harm and hinder early mobilization in enhanced recovery after surgery (ERAS) programmes. Some ERAS interventions are complex, confusing, sometimes contradictory and apparently unimplementable. In spite of much hype and after almost 25 years, the originator of the concept has described the current status of ERAS as 'far from good'. Outpatient surgery setup has been a remarkable success for many major surgical procedures, and it predates ERAS and appears to be a simpler and better model for reducing postoperative morbidity and hospitalization times. Systematic reviews of comparative studies have shown that less invasive and safer but equally effective alternatives to EA are available for almost all major surgical procedures. These include: paravertebral block, peripheral nerve blocks, catheter wound infusion, periarticular local infiltration analgesia, preperitoneal catheters and transversus abdominis plane block. Increasingly, these non-EA methods are being used as surgeon-delivered regional analgesia (RA) techniques. This encouraging trend of active surgeon participation, with anaesthesiologist collaboration, will undoubtedly improve the decades-old twin problems of underused RA techniques and undertreated postoperative pain. The continued use of EA at any institution can only be justified by results from its own audits; however, regrettably only very few institutions perform such regular audits., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Rebound pain is a common, yet under-recognised acute increase in pain severity after a peripheral nerve block (PNB) has receded, typically manifesting within 24 h after the block was performed. This retrospective cohort study investigated the incidence and factors associated with rebound pain in patients who received a PNB for ambulatory surgery., Methods: Ambulatory surgery patients who received a preoperative PNB between March 2017 and February 2019 were included. Rebound pain was defined as the transition from well-controlled pain (numerical rating scale [NRS] ≤3) while the block is working to severe pain (NRS ≥7) within 24 h of block performance. Patient, surgical, and anaesthetic factors were analysed for association with rebound pain by univariate, multivariable, and machine learning methods., Results: Four hundred and eighty-two (49.6%) of 972 included patients experienced rebound pain as per the definition. Multivariable analysis showed that the factors independently associated with rebound pain were younger age (odds ratio [OR] 0.98; 95% confidence interval [CI] 0.97-0.99), female gender (OR 1.52 [1.15-2.02]), surgery involving bone (OR 1.82 [1.38-2.40]), and absence of perioperative i.v. dexamethasone (OR 1.78 [1.12-2.83]). Despite a high incidence of rebound pain, there were high rates of patient satisfaction (83.2%) and return to daily activities (96.5%)., Conclusions: Rebound pain occurred in half of the patients and showed independent associations with age, female gender, bone surgery, and absence of intraoperative use of i.v. dexamethasone. Until further research is available, clinicians should continue to use preventative strategies, especially for patients at higher risk of experiencing rebound pain., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Discectomy is sometimes associated with recurrence of disc herniation and pain after surgery. The evidence to use an interspinous dynamic stabilization system or instrumented fusion in association with disc excision to prevent pain and re-operation remains controversial. In this study, we analyzed if adding interspinous spacer or fusion, offers advantages in relation to microdiscetomy alone., Methods: Patients with lumbar disc herniation were divided in 3 groups; microdiscectomy alone (MD), microdiscectomy plus interspinous spacer (IS) and open discectomy plus posterior lumbar interbody fusion (PLIF). The clinical efficacy was measured using the Owestry Disability Index (ODI). Other outcome parameters including visual analogue scale for pain (VAS) back and legs, length of stay, direct in-hospital cost, 90-day complication rate, and 1-year re-operation rate were also evaluated., Results: A total of 103 patients whose mean age was 39.1 (±8.5) years were included. A significant improvement of the ODI and VAS back and legs pain baseline score was detected in the 3 groups. After 1 year, no significant differences in ODI, VAS back and legs pain were found between the 3 groups. There was an increase of 169% of the total direct in- hospital cost in IS group and 287% in PLIF group, in relation to MD (p < 0.001). Length of stay was 86% higher in the IS group and 384% longer in the PLIF group compared to MD (p < 0.001). The 1 year re-operation rates were 5.6%, 10% and 16.2% (p = 0.33). Discectomy seems to be the main responsible for the clinical improvement, without the interspinous spacer or fusion adding any benefit. The addition of interspinous spacer or fusion increased direct in-hospital cost, length of stay, and did not protect against re-operation., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests. The authors declare that they have no financial or personal relationship with any institution or manufactures of spinal implants related to the content of this publication that could cause a conflict of interest., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Minimal clinically important difference (MCID) is determined when a patient or physician defines the minimal change that outweighs the costs and untoward effects of a treatment. These measurements are "anchored" to validated quality-of-life instruments or physician-rated, disease-activity indices. To capture the subjective clinical experience in a measurable way, there is an increasing use of MCID., Objective: To review the overall concept, method of calculation, strengths, and weaknesses of MCID and its application in the neurosurgical literature., Methods: Recent articles were reviewed based on PubMed query. To illustrate the strengths and limitations of MCID, studies regarding the measurement of pain are emphasized and their impact on subsequent publications queried., Results: MCID varies by population baseline characteristics and calculation method. In the context of pain, MCID varied based on the quality of pain, chronicity, and treatment options., Conclusion: MCID evaluates outcomes relative to whether they provide a meaningful change to patients, incorporating the risks and benefits of a treatment. Using MCID in the process of evaluating outcomes helps to avoid the error of interpreting a small but statistically significant outcome difference as being clinically important., (© Congress of Neurological Surgeons 2020.)

Study Design: Retrospective review of a multi-institutional data registry., Objective: The authors sought to determine the association between age and complications & patient-reported outcomes (PRO) in patients undergoing multilevel transforaminal interbody lumbar fusion (MTLIF)., Summary of Background Data: Elderly patients undergoing MTLIF are considered high risk. However, data on complications and PRO are lacking. Additionally, safety of multilevel lumbar fusion in the elderly remains uncertain., Methods: Patients ≥50-year-old who underwent MTLIF for degenerative lumbar spine conditions were analyzed. Ninety-day complications and PROs (baseline, 90-d, 1-y, 2-y) were queried using the MSSIC database. PROs were measured by back & leg visual analog scale (VAS), Patient-reported Outcomes Measurement Information System (PROMIS), EuroQol-5D (EQ-5D), and North American Spine Society (NASS) Patient Satisfaction Index. Univariate analyses were used to compare among elderly and complication cohorts. Generalized estimating equation (GEE) was used to identify predictors of complications and PROs., Results: A total of 3120 patients analyzed with 961 (31%) ≥ 70-y-o and 2159 (69%) between 50-69. A higher proportion of elderly experienced postoperative complications (P = .003) including urinary retention (P = <.001) and urinary tract infection (P = .002). Multivariate analysis demonstrated that age was not independently associated with complications. Number of operative levels was associated with any (P = .001) and minor (P = .002) complication. Incurring a complication was independently associated with worse leg VAS and PROMIS scores (P = <.001). Preoperative independent ambulation was independently associated with improved PROMIS, and EQ5D (P = <.001). Within the elderly, preoperative independent ambulation and lower BMI were associated with improved PROMIS (P = <.001). Complications had no significant effect on PROs in the elderly., Conclusions: Age was not associated with complications nor predictive of functional outcomes in patients who underwent MTLIF. Age alone, therefore, may not be an appropriate surrogate for risk. Furthermore, baseline preoperative independent ambulation was associated with better clinical outcomes and should be considered during preoperative surgical counseling.Level of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Backgrounds: The main objective of this study was to compare the pain control efficacy of local administration of Lidocaine with or without the nonsteroidal anti-inflammatory drug, Ketorolac, and local conventional Lidocaine injection in core needle biopsy of the musculoskeletal tumor., Methods: The current study was a randomized, double-blind controlled clinical trial that included 128 patients with suspected musculoskeletal tumors. Patients were randomly assigned to either the Ketorolac plus Lidocaine (n = 64) or Lidocaine group (n = 64). The Ketorolac - Lidocaine combination syringe contained 30 mg Ketorolac and 2% Lidocaine - adrenaline dosage, and the Lidocaine syringe contained 2% Lidocaine - adrenaline dosage. The level of pain after core needle biopsy was evaluated for each patient at 1, 6, 12, 24, 48, and >48 hours by a Visual Analog Scale (VAS). The mean VAS changes over time were compared between the Ketorolac plus Lidocaine and Lidocaine groups using a linear mixed model., Results: baseline information including mean age of patients in Lidocaine group (51.5 ± 19.4 years) and in Lidocaine - Ketorolac combination group (50.1 ± 18 years), diagnosis (malignant, benign, metastatic, infection), tumor location (upper and lower extremities, back), VAS score 1-hour post-operation (mild and moderate pain) were noted. The VAS score ratings were significantly lower in Lidocaine - Ketorolac combination group when compared to the Lidocaine group during the 1 to 24 hours post-operation time period., Conclusion: Patients receiving Lidocaine - Ketorolac combination dosage had significantly lower VAS scores, and these results confirm that local injection of Lidocaine - Ketorolac combination had a superior pain-controlling effect during the first 24 hours after the biopsy procedure in comparison to Lidocaine injection alone, as measured by VAS score scale., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Postsurgical patients usually have difficulty in answering the self-report pain scales due to the residual effects of anesthetic or sedative agents in the post-anesthesia care unit (PACU). A comparative analysis of pain assessment tools used in the PACU is lacking.In this prospective observational study, we compared the intensity of pain using the 11-point numeric rating scale (NRS) and the 4-category verbal rating scale (VRS) thrice, 5 minutes after PACU admission, 20 minutes after the first assessment, and just before discharge from the PACU in 200 patients undergone surgery. Spearman rank correlation analysis was used to investigate the correlation between 2 scales, and the weighted kappa (κ) coefficient was performed to evaluate inter-scale reliability. Response rates of the 2 scales were also compared.VRS and NRS were highly correlated during all 3 comparisons (r = 0.767, 0.714, and 0.653, respectively; P < .0001). Each category of VRS showed a statistically significant difference in pain intensity measured by NRS during all 3 assessments. Inter-scale reliability had a fair strength of agreement for all 3 measurements (weighted κ = 0.519, 95% CI: 0.421-0.618; weighted κ = 0.511, 95% C.I: 0.409-0.613; weighted κ = 0.452, 95% C.I: 0.352-0.551, respectively). VRS showed a higher response rate for PACU patients compared to NRS in all 3 measurements (96% vs 77.5%, 99% vs 81.5%, and 96.5% vs 86.5%, respectively; P < .0001).In the PACU, VRS is a reasonable and practical pain intensity measurement tool for postsurgical patients, considering the high correlation between VRS and NRS, and a higher response rate., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Study Design: Observational multicenter study., Objective: The aim of this study was to evaluate changes in pain during sexual activity after surgery for lumbar disc herniation (LDH)., Summary of Background Data: There are limited data available on sexual function in patients undergoing surgery for LDH., Methods: Data were retrieved from the Norwegian Registry for Spine Surgery. The primary outcome was change in pain during sexual activity at one year, assessed by item number eight of the Oswestry disability index (ODI) questionnaire. Secondary outcome measures included ODI, EuroQol-5D (EQ-5D), and numeric rating scale (NRS) scores for back and leg pain., Results: Among the 18,529 patients included, 12,103 (64.8%) completed 1-year follow-up. At baseline, 16,729 patients (90.3%) provided information about pain during sexual activity, whereas 11,130 (92.0%) among those with complete follow-up completed this item. Preoperatively 2586 of 16,729 patients (15.5%) reported that pain did not affect sexual activity and at 1 year, 7251 of 11,130 patients (65.1%) reported a normal sex-life without pain. Preoperatively, 2483 (14.8%) patients reported that pain prevented any sex-life, compared to 190 patients (1.7%) at 1 year. At baseline, 14,143 of 16,729 patients (84.5%) reported that sexual activity caused pain, and among these 7232 of 10,509 responders (68.8%) reported an improvement at 1 year. A multivariable regression analysis showed that having a life partner, college education, working until time of surgery, undergoing emergency surgery, and increasing ODI score were predictors of improvement in pain during sexual activity. Increasing age, tobacco smoking, increasing body mass index, comorbidity, back pain >12 months, previous spine surgery, surgery in two or more lumbar levels, and complications occurring within 3 months were negative predictors., Conclusion: This study clearly demonstrates that a large proportion of patients undergoing surgery for LDH experienced an improvement in pain during sexual activity at 1 year., Level of Evidence: 2.

Study Design: Prospective cohort study., Objective: The aim of this study was to identify treatment response trajectories in patients with low back pain (LBP) during and after multidisciplinary care in a tertiary spine center, and to examine baseline patient characteristics that can distinguish trajectories., Summary of Background Data: Treatment response is often heterogeneous between patients with LBP. Knowledge on key characteristics that are associated with courses of disability could identify patients at risk for less favorable outcome. This knowledge will help improve shared decision-making., Methods: Adult patients with LBP completed questionnaires on disability (Pain Disability Index) and LBP impact (Impact Stratification of the National Institutes of Health minimal dataset) at baseline, 6, 12, 18, and 24 months' follow-up. Latent class analyses were applied to identify trajectories of disability and LBP impact. Baseline sociodemographic and clinical patient characteristics were compared between trajectory subgroups., Results: Follow-up was available for 996 patients on disability and 707 patients on LBP impact. Six trajectories were identified for both outcome measures. Three disability trajectories remained stable at distinct levels of severity (68% of patients) and three trajectories showed patterns of recovery (32%). For LBP impact there was one stable trajectory (17%), two slightly improving (59%), two recovering (15%), and one with a pattern of recovery and relapse (15%). Significant differences between trajectories were observed for almost all baseline patient characteristics., Conclusion: On average, patients show moderate improvements in disability and LBP impact 2 years after visiting a multidisciplinary tertiary spine center. However, latent class analyses revealed that most patients belong to subgroups experiencing stable levels of disability and LBP impact. Differences in baseline patient characteristics were mostly associated with baseline levels of functioning, instead of (un)favorable outcome during follow-up., Level of Evidence: 2.

Abnormal muscle stiffness is a potential complication after injury and identifying interventions that modify muscle stiffness may be useful to promote recovery. The purpose of this study was to identify the short-term effects of dry needling (DN) on resting and contracted gastrocnemius muscle stiffness and strength of the triceps surae in individuals with latent myofascial trigger points (MTrPs). In this randomized controlled trial, 52 individuals received two DN treatment sessions to latent MTrPs and 50 individuals received two sham needling sessions. Resting and contracted muscle stiffness were assessed both at the treatment site and a standardized central site in the medial gastrocnemius head immediately post-treatment and one week after the last session. There were significant group by time interactions for resting muscle stiffness at the site of the MTrP (p = .03), but not at the central site (p = .29). Post-needling between group comparison indicated that the DN group had significantly lower resting muscle stiffness at the site of the MTrP than the sham group after adjusting for baseline differences. There were no significant between group differences in contracted muscle stiffness or muscle strength. Identifying strategies that can reduce aberrant muscle stiffness may help to guide management of individuals with neuromuscular pain-related conditions. Level of evidence: Therapy, level 2., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Study Design: This is a retrospective cohort study., Objective: To evaluate the long-term outcomes after surgery for refractory coccygodynia in patients with normal imaging studies compared with patients where imaging shows an anomaly., Summary of Background Data: Patients with coccydynia who do not respond to conservative treatment will often profit from coccygectomy. Most surgeons employ plain radiographs or magnetic resonance imaging (MRI) in their preoperative work-up. These will often show anomalies, but in some cases they do not. We investigated whether these patients do less well than those with abnormal images., Methods: We operated on 184 patients with coccydynia during a 7-year period and 171 (93%) responded to follow-up questionnaires after 37 (range: 12-85) months. Images of 33 patients were normal and 138 showed some coccygeal pathology. Surgery was considered to have been unsuccessful when respondents stated at review that they were somewhat better, unchanged, or worse., Results: There were no clinically or statistically significant differences in outcome between the groups. Surgery was unsuccessful in 24% of patients with normal images and in 32% among those with abnormal images. The median pain scores (0-10) during the week before review were two (interquartile range [IQR]: 0-3) and one (IQR: 1-5) in the two groups respectively. Similar proportions in the two groups stated that they would not have consented to surgery if they had known the outcome in advance., Conclusion: Patients with severe coccydynia who have not responded to conservative treatment should not be denied surgery only because their radiographs or MRI studies look normal., Level of Evidence: 4.

Study Design: A prospective observational study., Objective: This study was done to examine the influence of hand grip strength (HGS) on surgical outcomes of adult spinal deformity (ASD) patients., Summary of Background Data: No study has investigated the relation between hand grip strength and treatment outcome of adult spinal deformity correction surgery., Methods: A total of 78 consecutive patients who underwent adult spinal deformity correction surgery were included in this study. Patients were assigned to either the high HGS (≥ 26 kg for men and ≥ 18 kg for women, n = 26) or the low HGS (< 26 kg for men and < 18 kg for women, n = 52) based on their preoperative measurements. The Oswestry disability index (ODI), EQ-5D, and visual analog scale (VAS) for back pain were assessed preoperatively, and 3 months, 6 months, and 12 months postoperatively. The primary outcome measure was ODI scores 12 months after surgery. The secondary outcome measures included the overall ODI scores, EQ-5D, and VAS for back pain, assessed at each time point during the 12-months follow-up., Results: The ODI score at 12 months after surgery was significantly lower in the high HGS group than the low HGS group (P < 0.001), which was best predicted by a multivariate regression model including age, gender, BMI, HGS, and preoperative ODI scores. The overall ODI score, EQ-5D, and VAS for back pain had better outcomes in the high HGS group across each follow-up assessment (P < 0.001 for all follow-ups), while they improved significantly with time after surgery in both groups., Conclusions: Patients with higher preoperative HGS displayed better surgical outcomes, in terms of disability and health-related quality of life at 12 months after reconstructive spinal surgery for ASD., Level of Evidence: 2.

Study Design: Prospective longitudinal cohort., Objectives: The aim of this study was to determine whether functional treadmill testing (FTT) demonstrates differences between patients treated operatively and nonoperatively for adult symptomatic lumbar scoliosis (ASLS)., Summary of Background Data: ASLS has become increasingly prevalent as the population ages. ASLS can be accompanied by neurogenic claudication, leading to difficulty walking. FTT may provide a functional tool to evaluate patients with ASLS., Methods: One hundred and eighty-seven patients who underwent nonoperative (n = 88) or operative treatment (n = 99) of ASLS with complete baseline and 2-year post-treatment FTTs and concurrent patient-reported outcomes were identified. FTT parameters included maximum speed, time to onset of symptoms, distance ambulated, time ambulated, and Back and Leg pain severity before and after testing., Results: At baseline, patients treated operatively reported worse post-FTT back pain (4.39 vs. 3.45, P = 0.032) than those treated nonoperatively, despite similar ODI, SRS-22 Pain and Activity domain scores. Mean time ambulated (+2.15 vs. -1.20 P = 0.001), pre-FTT back pain (+0.19 vs. -1.60, P < 0.000) and leg pain (+0.25 vs. -0.54, P = 0.024) improved in the operative group but deteriorated in the nonoperative group. On the 2-year follow-up FTT, both groups showed improvement in post-FTT back pain (-0.53 vs. -2.64, P < 0.000) and leg pain (-0.13 vs. -1.54, P = 0.001) severity but the improvement was statistically significantly greater in the operative compared to the nonoperative group., Conclusion: FTT results at baseline were worse in patients treated operatively than those treated non-operatively. FTT may be a useful adjunct to assess treatment outcomes in patients with ASLS and may help surgeons counsel patients regarding expectations 2 years after operative or nonoperative treatment for ASLS. At 2-year follow-up, time ambulated deteriorated in patients treated nonoperatively but improved in patients treated operatively. Although both groups showed improvement in post-FTT Back and Leg pain at 2 years, the improvement was greater in the operative compared to the nonoperative group., Level of Evidence: 2.

Study Design: Retrospective study., Objective: The preoperative parameters for predicting the loss of lordosis after cervical laminoplasty were investigated in the present study., Summary of Background Data: Cervical laminoplasty is an effective surgical method to decompress the cervical spinal cord. Maintaining cervical lordosis after laminoplasty is an important factor to ensure the successful surgical treatment. To know the preoperative parameters for predicting loss of lordosis after cervical laminoplasty is important for better outcome after laminoplasty., Methods: In this retrospective study, 106 patients who underwent cervical laminoplasty from 2011 to 2015 were reviewed. The preoperative parameters; T1 slope (TS), Cobb lordotic angle (CLA) and sagittal vertical axis (SVA) at C2-C7, relative cross-sectional area (RCSA), and fatty degeneration of deep extensor muscles (DEMs) were measured. Visual analogue scale (VAS) and modified Japanese Orthopedic Association (mJOA) scores were used for clinical assessment. Correlation analysis was performed between the postoperative CLA change and preoperative parameters. The patients were divided into the decreased- or maintained-lordosis groups based on the difference between postoperative and preoperative CLA. All preoperative parameters were compared between groups., Results: Based on correlation analysis, preoperative TS (P = 0.001), TS-CLA (P = 0.046), RCSA at C7-T1 (P < 0.001), and fatty degeneration of DEMs (P < 0.001) were correlated with loss of lordosis. Among the 106 patients, 68 showed decreased-lordosis and 38 maintained-lordosis. Preoperative TS (P = 0.003), SVA (P = 0.014), TS-CLA (P = 0.015), and RCSA at C7-T1 (P = 0.005) were significantly different between groups. In both correlation and comparative analyses, higher TS and TS-CLA and less RCSA at C7-T1 were associated with loss of lordosis. Neck pain VAS (P < 0.001) and mJOA scores (P < 0.001) were significantly improved in the maintained-lordosis group., Conclusion: Maintaining cervical lordosis is important for clinical outcomes after laminoplasty. Preoperative higher TS, TS-CLA, and less RCSA at C7-T1 were considered as predictors for loss of lordosis. These characteristics should be considered when choosing the surgical method to help maintain cervical lordosis., Level of Evidence: 3.

Study Design: A registry-based comparative cohort study with 2-year follow-up., Objective: To assess whether Modic changes (MCs) are associated with health-related quality of life, long-term physical disability, back- or leg pain after discectomy., Summary of Background Data: Previous studies have failed to show a clinically significant association between MCs and patient-reported outcomes (PROs) after discectomy., Methods: Data from the Danish National Spine Registry on patients undergoing first-time lumbar discectomy at a single institution from 2014 to 2017 with an accessible preoperative lumbar magnetic resonance imaging, complete preoperative, and 2-year follow-up questionnaires were obtained. PROs including Oswestry disability index (ODI), European Quality of Life-Five Dimensions (EQ-5D), visual analogue scale (VAS) back and leg pain, and patient satisfaction were collected. Patients were stratified based on the presence (+MC) or absence (-MC) of MCs on the preoperative MRI., Results: Of 620 patients included, MCs were present in 290 patients (47%). Of these, MC type 1 (MC-1) was present in 73 (25%) and MC type 2 (MC-2) in 217 (75%) patients. Preoperative data for ODI, EQ-5D, VAS-BP, and VAS-LP were comparable for the +MC and -MC groups. Both groups had a statistically significant improvement in PROs from baseline compared with 2-year follow-up (P < 0.001). At 2-year follow-up, both groups had improved with no significant difference between them in regards to ODI (15.5 vs. 17.2, P = 0.208); EQ-5D (0.75 vs. 0.72, P = 0.167); VAS-BP (27.1 vs. 28.3, P = 0.617); VAS-LP (26.8 vs. 25.0, P = 0.446); and patient satisfaction (74% vs. 76%, P = 0.878)., Conclusion: MCs were not found to be associated with health-related quality of life, disability, back- or leg pain, or patient satisfaction 2 years after discectomy., Level of Evidence: 2.

Study Design: Retrospective cohort study., Objective: The goal of the present study was to determine whether neck pain responds differently to anterior cervical discectomy and fusion (ACDF) between patients with cervical radiculopathy and/or cervical myelopathy., Summary of Background Data: Many patients who undergo ACDF because of radiculopathy/myelopathy also complain of neck pain. However, no studies have compared the response of significant neck pain to ACDF., Methods: Patients undergoing one to three-level primary ACDF for radiculopathy and/or myelopathy with significant (Visual Analogue Scale [VAS] ≥ 3) neck pain and a minimum of 1-year follow-up were included. Based on preoperative symptoms patients were split into groups for analysis: radiculopathy (R group), myelopathy (M group), or both (MR group). Groups were compared for differences in Health Related Quality of Life outcomes: Physical Component Score-12, Mental Component Score (MCS)-12, Neck Disability Index, VAS neck, and VAS arm pain., Results: Two hundred thirty-five patients met inclusion criteria. There were 117 patients in the R group, 53 in the M group, and 65 in the MR group. Preoperative VAS neck pain was found to be significantly higher in the R group versus M group (6.5 vs. 5.5; P = 0.046). Postoperatively, all cohorts experienced significant (P < 0.001) reduction in VAS neck pain, (ΔVAS neck; R group: -2.9, M: -2.5, MR: -2.5) with no significant differences between groups. However, myelopathic patients showed greater improvement in absolute MCS-12 scores (P = 0.011), RR (P = 0.006), and % minimum clinically important difference (P = 0.013) when compared with radiculopathy patients. This greater improvement remained following regression analysis (P = 0.025)., Conclusion: Patients with substantial preoperative neck pain experienced significant reduction in their neck pain, disability, and physical function following ACDF, whether treated for radiculopathy or myelopathy. However, in this study, only myelopathy patients had significant improvements in their mental function as represented by MCS improvements., Level of Evidence: 3.

Study Design: Longitudinal analysis of prospectively collected data., Objective: Investigate potential predictors of poor outcome following surgery for degenerative lumbar spinal stenosis (LSS)., Summary of Background Data: LSS is the most common reason for an older person to undergo spinal surgery, yet little information is available to inform patient selection., Methods: We recruited LSS surgical candidates from 13 orthopedic and neurological surgery centers. Potential outcome predictors included demographic, health, clinical, and surgery-related variables. Outcome measures were leg and back numeric pain rating scales and Oswestry disability index scores obtained before surgery and after 3, 12, and 24 postoperative months. We classified surgical outcomes based on trajectories of leg pain and a composite measure of overall outcome (leg pain, back pain, and disability)., Results: Data from 529 patients (mean [SD] age = 66.5 [9.1] yrs; 46% female) were included. In total, 36.1% and 27.6% of patients were classified as experiencing a poor leg pain outcome and overall outcome, respectively. For both outcomes, patients receiving compensation or with depression/depression risk were more likely, and patients participating in regular exercise were less likely to have poor outcomes. Lower health-related quality of life, previous spine surgery, and preoperative anticonvulsant medication use were associated with poor leg pain outcome. Patients with ASA scores more than two, greater preoperative disability, and longer pain duration or surgical waits were more likely to have a poor overall outcome. Patients who received preoperative chiropractic or physiotherapy treatment were less likely to report a poor overall outcome. Multivariable models demonstrated poor-to acceptable (leg pain) and excellent (overall outcome) discrimination., Conclusion: Approximately one in three patients with LSS experience a poor clinical outcome consistent with surgical non-response. Demographic, health, and clinical factors were more predictive of clinical outcome than surgery-related factors. These predictors may assist surgeons with patient selection and inform shared decision-making for patients with symptomatic LSS., Level of Evidence: 2.

Background: Regional nerve blocks are an integral part of multimodal analgesia and should be chosen based on their efficacy, convenience, and minimal side effects. Here, we compare the use of pectoral (PEC II) and serratus-intercostal fascial plane (SIFP) blocks in breast carcinoma cases undergoing modified radical mastectomy (MRM) in terms of the postoperative analgesic efficacy and shoulder mobility., Methods: The primary outcome of this prospective controlled study was to compare the postoperative static and dynamic pain scores, and the secondary outcome was to assess the shoulder pain, range of shoulder joint motion, and hemodynamic parameters. Sixty patients were randomly allocated to three groups and given general anesthesia. All patients received paracetamol, diclofenac, and rescue doses of tramadol based on the Institute's Acute Pain Service (APS) policy. No block was performed in group C (control), whereas groups P and S received PEC II and SIFP blocks, respectively, before surgical incision., Results: The groups were comparable in terms of age, weight, height, and body mass index distribution (P > 0.05). Dynamic pain relief was significantly better 12 and 24 h postoperatively in groups P (P = 0.034 and P = 0.04, respectively) and S (P = 0.01 and P = 0.02, respectively) compared to group C. Shoulder pain relief and shoulder mobility were better in group S, while the hemodynamic parameters were more stable in group P., Conclusions: Both SIFP and PEC blocks have comparable dynamic and static pain relief with better shoulder pain scores in patients receiving SIFP.

Rebound pain after regional anesthesia can be defined as transient acute postoperative pain that ensues following resolution of sensory blockade, and is clinically significant, either with regard to the intensity of pain or the impact on psychological well-being, quality of recovery, and activities of daily living. Current evidence suggests that it represents an unmasking of the expected nociceptive response in the absence of adequate systemic analgesia, rather than an exaggerated hyperalgesic phenomenon induced by local anesthetic neural blockade. In the majority of patients, it does not appear to significantly impact cumulative postoperative opioid consumption, quality of recovery, or patient satisfaction, and is not associated with longer-term sequelae such as persistent post-surgical pain. Nevertheless, it must be considered whenever regional anesthesia is incorporated into perioperative management. Strategies to mitigate the impact of rebound pain include routine prescribing of a systemic multimodal analgesic regimen, as well as patient education on appropriate expectations regarding block offset and expected surgical pain, and timely initiation of analgesic medication. Prolonging the duration of action of regional anesthesia with continuous catheter techniques or local anesthetic adjuncts may also help alleviate rebound pain, although further research is required to confirm this.

Objective: Minimally invasive anterior lumbar interbody fusion surgery (MIS ALIF) is a technique that restores disc height and lumbar lordosis through a smaller exposure and less soft-tissue trauma compared to open approaches. The mini-open and laparoscopic assistance techniques are two main forms of MIS ALIF. The authors conducted a systematic review that sought to critically summarize the literature on back pain following MIS ALIF., Methods: In March 2020, the authors searched the PubMed, Web of Science, and Cochrane Library databases for studies describing back pain visual analog scale (VAS) outcomes after MIS ALIF. The following exclusion criteria were applied to studies evaluated in full text: 1) the study included fewer than 20 patients, 2) the mean follow-up duration was shorter than 12 months, 3) the study did not report back pain VAS score as an outcome measure, and 4) MIS ALIF was not studied specifically. The methodology for the included studies were evaluated for potential biases and assigned a level of evidence., Results: There were a total of 552 patients included from 13 studies. The most common biases were selection and interviewer bias. The majority of studies were retrospective. The mean sample size was 42.3 patients. The mean follow-up duration was approximately 41.8 months. The mean postoperative VAS reduction was 5.1 points. The mean VAS reduction for standalone grafts was 5.9 points, and 5.0 points for those augmented with posterior fixation. The most common complications included bladder or urinary dysfunction, infection, and hardware-related complications., Conclusions: This was a systematic review of back pain outcomes following MIS ALIF. Back pain VAS score was reduced postoperatively across all studies. The complication rates were low overall. MIS ALIF is safe and effective at reducing back pain in appropriate patient populations.

Objective: Pain management in the emergency department (ED) is a key issue that must be regularly evaluated. Practice evaluation gold standard remains patient file analysis, but is highly time consuming. The aim of this study is to evaluate the interest of a defined daily dose (DDD) based analysis in the evaluation of pain management in the ED., Methods: A local indicator was elaborated based on the DDD concept: the defined dose per admission (DDA). Unlike the DDD that corresponds to a standardised total dose administered over a day, the DDA represents the average total dose administrated to a patient throughout the stay in the ED. A DDA was assigned to every analgesic, from step 1 to step 3. Oral and injectable forms were studied, but transdermal forms were not considered. DDA values were assimilated to the existing DDDs when these were officially established by the WHO. When values were not defined by the WHO, mean values observed in local practice were selected. Annual numbers of patients admitted to the ED and quantities of each analgesic supplied by the pharmacy ward were annually extracted from respective data files. Paediatric patients being treated at a specific separate ED, only adults were considered throughout the study. Raw quantities of analgesics used each year were converted to their equivalent amounts in DDA, and then expressed in numbers of DDA per 100 admissions (DDA/100A). This indicator allowed us to describe relative evolutions of analgesics prescriptions from 2006 to 2017., Results: Analgesic overall use rose from 18.4 to 30.2 DDA/100A between 2006 and 2017, representing a prescription increase of 64%. Throughout the study, step 1 analgesics rose from 10.8 to 19.3 DDA/100A (+79%), step 3 from 1.8 to 5.4 (+200%) and step 2 remained stable around 5.6 DDA/100A. The integration of orodispersible paracetamol tablets in 2013 allowed us to halve the consumption of injectable paracetamol in the long term and had no effect on classic paracetamol oral forms such as tablets or capsules. Tramadol increased from 41% to 78% among step 2 analgesics after the withdrawal of dextropropoxyphene in 2011. Codeine use shows a steady decline from 1.9 DDA/100A in 2011 to 0.72 in 2017., Discussion/conclusion: The DDA concept appears to be an effective tool for assessing long-term analgesic-use trends at hospital EDs. This tool can also mitigate one major bias at EDs, that is the lack of traceability of analgesic administration in emergency contexts. This tool could be adjusted by integrating the average length of stay in the ED., Competing Interests: Competing interests: None declared., (© European Association of Hospital Pharmacists 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Pain is a pervasive problem that affects nearly half of the U.S. Veterans deployed in support of the Global War on Terror (Post-9/11 Veterans) and over half of the Post-9/11 Veterans with diagnosed traumatic brain injury (TBI). The goal of the current study was to identify pain phenotypes based on distinct longitudinal patterns of pain scores in light of pain treatment among Post-9/11 Veterans over 5 years of care using latent growth mixture analysis stratified by TBI status. Five pain phenotypes emerged: 1) simple low impact stable pain, 2) complex low impact stable pain, 3) complex low impact worsening pain, 4) complex moderate impact worsening pain, and 5) complex high impact stable pain. Baseline pain scores and slopes were significantly higher in Veterans with mild TBI for some phenotypes. The mild TBI cohort was younger, had more men, more whites, less blacks, less education, more unmarried, more Marines and Army, more active duty in comparison to the no TBI cohort. Distinct trajectories in pain treatment were apparent among the pain intensity subgroups. PERSPECTIVE: The complexity of pain in patients with mTBI is categorically different than those with no TBI. Pain in patients with mTBI is heterogeneous with distinct phenotypes which may explain poor outcomes in this group. Identification of the individual differences may have a significant impact on the success of interventions., (Copyright © 2020. Published by Elsevier Inc.)

Study Design: A multicenter retrospective case series., Objective: The purpose of this study was to compare the clinical outcomes of a surgical treatment for adult spinal deformity (ASD) in the United States (US) with those in Japan (JP) in a matched cohort., Summary of Background Data: Surgical outcomes of thoracic-lumbar-sacral (TLS) spinal fusions in adult spinal deformity ASD patients who live in Asian countries are poorly understood., Methods: A total of 300 surgically treated ASDs of age more than 50 years with the lowest instrumented vertebra at the pelvis and a minimum follow-up of 2 years (2y) were consecutively included. Patients were propensity-score matched for age, sex, levels fused, and 2y postop sagittal spinal alignment. Demographic, surgical, and radiographic parameters were compared between the US and JP groups., Results: A total of 186 patients were matched by propensity score and were almost identical within these parameters: age (US vs. JP: 66 ± 8 vs. 65 ± 7 yr), sex (females: 90% vs. 89%), levels fused (10 ± 3 vs. 10 ± 2), 2y C7 sagittal vertical axis (C7SVA) (5 ± 5 vs. 5 ± 4 cm), 2y Pelvic incidence minus lumbar lordosis (9 ± 15° vs. 9 ± 15°), and 2y pelvic tilt (PT) (25 ± 10° vs. 24 ± 10°). Oswestry Disability Index (ODI) scores and Scoliosis Research Society patient questionnaire ((SRS-22) function and pain scores were similar at 2y between the US and JP groups (ODI: 27 ± 19% vs. 28 ± 14%, P = 0.72; SRS-22 function: 3.6 ± 0.9 vs. 3.6 ± 0.7, P = 0.54; SRS-22 pain: 3.6 ± 1.0 vs. 3.8 ± 0.8, P = 0.11). However, significantly lower satisfaction was observed in JP than in the US (SRS-22 satisfaction: 4.3 ± 0.9 vs. 4.0 ± 0.8, P < 0.01)., Conclusion: Surgical treatment for ASD was similarly effective in patients in the US and in JP. However, satisfaction scores were lower in JP compared with the US. Differences in lifestyle and cultural expectations may impact patient satisfaction following ASD surgery., Level of Evidence: 3.

Objective: To explore 1) whether the degree of facet joint distraction during single-segment anterior cervical discectomy and fusion for cervical spondylotic radiculopathy affects functional outcome and 2) whether the degree of facet joint distraction is related to cervical sagittal parameters., Methods: This study retrospectively analyzed data from 72 patients with single-segment cervical spondylotic radiculopathy from January 2013 to December 2018. Lateral cervical radiographs were performed preoperatively and 12 months postoperatively. Disc height, interfacet distance, and segmental angle were measured from the lateral cervical radiographs to evaluate facet joint distraction, and cervical sagittal parameters were measured. The outcome measures included visual analog scale (VAS) and Neck Disability Index scores., Results: Sixty-eight patients were included. ΔInterfacet distance was statistically significant in relation to ΔVAS score (P < 0.01). In a receiver operating characteristic curve analysis, less than the mean ΔVAS score for all patients was set as a positive result, and the critical value of Δinterfacet distance was 0.7 mm (P = 0.024, area under the curve = 0.659, sensitivity = 46.8%, specificity = 78.8%). According to the critical value determined by the receiver operating characteristic curve, all patients were divided into the appropriate distraction group or the excessive distraction group. There was a significant difference in VAS scores between the 2 groups (P < 0.05)., Conclusions: After undergoing single-segment ACDF for the treatment of cervical spondylotic radiculopathy, patients with an interfacet distance of 0.7 mm or more had worse VAS pain scores. However, this was not related to the improvement in postoperative Neck Disability Index scores; changes in the interfacet distance were not associated with changes in the cervical sagittal parameters., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Acute pain services (APS) have developed over the past 35 years. Originally implemented solely to care for patients with regional catheters or patient-controlled analgesia after surgery, APS have become providers of care throughout the perioperative period, with some institutions even taking the additional step toward providing outpatient services for patients with acute pain. Models vary considerably in terms of tasks and responsibilities, staffing, education, protocols, quality, and financing. Many challenges face today's APS, including the increasing number of patients with preexisting chronic pain, intake of analgesics and opioids before surgery, substance-dependent patients needing special care, shorter hospital stays, early discharge of patients in need of further analgesic treatment, prevention and treatment of chronic postsurgical pain, minimization of adverse events, and side effects of treatment. However, many APS lack a clear-cut definition of their structures, tasks, and quality. Development of APS in the future will require us to face urgent questions, such as, "What are meaningful outcome variables?" and, "How do we define high quality?" It is obvious that focusing exclusively on pain scores does not reflect the complexity of pain and recovery. A broader approach is needed-a common concept of surgical and anesthesiological services within a hospital (eg, procedure-specific patient pathways as indicated by the programs "enhanced recovery after surgery" or the "perioperative surgical home"), with patient-reported outcome measures as one central quality criterion. Pain-related functional impairment, treatment-induced side effects, speed of mobilization, as well as return to normal function and everyday activities are key.

Depression and anxiety co-occur with chronic pain, and all three are thought to be caused by dysregulation of shared brain systems related to emotional processing associated with body sensations. Understanding the connection between emotional states, pain, and bodily sensations may help understand chronic pain conditions. We developed a mobile platform for measuring pain, emotions, and associated bodily feelings in chronic pain patients in their daily life conditions. Sixty-five chronic back pain patients reported the intensity of their pain, 11 emotional states, and the corresponding body locations. These variables were used to predict pain 2 weeks later. Applying machine learning, we developed two predictive models of future pain, emphasizing interpretability. One model excluded pain-related features as predictors of future pain, and the other included pain-related predictors. The best predictors of future pain were interactive effects of (a) body maps of fatigue with negative affect and (b) positive affect with past pain. Our findings emphasize the contribution of emotions, especially emotional experience felt in the body, to understanding chronic pain above and beyond the mere tracking of pain levels. The results may contribute to the generation of a novel artificial intelligence framework to help in the development of better diagnostic and therapeutic approaches to chronic pain.

Opioid-related death and overdose have now reached epidemic proportions. In response to this public health crisis, the National Institutes of Health (NIH) launched the Helping to End Addiction Long-term Initiative SM , or NIH HEAL Initiative SM , an aggressive, trans-agency effort to speed scientific solutions to stem the national opioid public health crisis. Herein, we describe two NIH HEAL Initiative programs to accelerate development of non-opioid, non-addictive pain treatments: The Preclinical Screening Platform for Pain (PSPP) and Early Phase Pain Investigation Clinical Network (EPPIC-Net). These resources are provided at no cost to investigators, whether in academia or industry and whether within the USA or internationally. Both programs consider small molecules, biologics, devices, and natural products for acute and chronic pain, including repurposed and combination drugs. Importantly, confidentiality and intellectual property are protected. The PSPP provides a rigorous platform to identify and profile non-opioid, non-addictive therapeutics for pain. Accepted assets are evaluated in in vitro functional assays to rule out opioid receptor activity and to assess abuse liability. In vivo pharmacokinetic studies measure plasma and brain exposure to guide the dose range and pretreatment times for the side effect profile, efficacy, and abuse liability. Studies are conducted in accordance with published rigor criteria. EPPIC-Net provides academic and industry investigators with expert infrastructure for phase II testing of pain therapeutics across populations and the lifespan. For assets accepted after a rigorous, objective scientific review process, EPPIC-Net provides clinical trial design, management, implementation, and analysis.

Background: The efficacy and safety of buprenorphine transdermal patch (BTP) has been well established in chronic pain, but data regarding acute postoperative pain relief is still very limited. Therefore, we design a prospective, randomized, controlled study to evaluate the effectiveness and safety of the BTP for postoperative analgesia in total hip arthroplasty., Methods: This study is designed as a single-center, prospective, double-blind, randomized controlled trial. Group A receives a 10 mg patch of buprenorphine at the conclusion of surgery which is continued for 14 days. Group B receives a conventional analgesic regimen, that is, IV paracetamol 1 mg every 8 hours alternating with parenteral tramadol 50 mg every 8 hours for the first 2 postoperative days followed by oral administration of the same drug still the end of 2 weeks. A total of 160 patients are needed with an allowance for 10% drop-out. The primary outcome of this noninferiority study is opioid consumption within the first 24 hours following surgery. The secondary outcomes included numerical rating scale scores at rest, postoperative complications, length of hospital stay, and patient satisfaction., Results: This trial is expected to be the largest randomized trial assessing the efficacy of BTP after primary total hip arthroplasty and powered to detect a potential difference in the primary outcome., Trial Registration Number: This study protocol was registered in Research Registry (researchregistry5524).

Objectives: Psychological pain increases the risk of suicidal ideas and acts, and represents a potential therapeutic target. However, the mechanisms of mental pain remain unclear. Here, we assessed the peripheral transcriptomic and central neural correlates of mental pain during a depressive episode., Methods: 172 adult un-medicated depressed patients were recruited. Leucocytes were extracted for RNA quantification at baseline (T0) and after 8 weeks (T8) of an antidepressant treatment. Ninety-nine genes of the cortisol, immune, opioid, serotonergic, and kynurenine systems were a priori selected, and 41 were sufficiently expressed to be analyzed. At both T0 and T8, mean level of mental pain over the last 15 days was measured with a visual analog scale. A subset of 38 patients was additionally scanned with Magnetic Resonance Imaging at T0. Resting-state sequences of 4 networks (default-mode, basal ganglia, central executive, salience) were examined., Results: Mean psychological pain scores significantly decreased between T0 and T8. At conservative p-corrected levels, T0 mental pain was significantly correlated with 11 brain clusters encompassing the prefrontal, parietal, and temporal cortices, the striatum, and the cerebellum. There was no direct association between peripheral gene expression and mean mental pain at any time points or in terms of temporal changes. However, expressions of 5HTR2B at p-corrected levels, and 5HTR3A, TPH1, and OPRL1 were correlated with the activity of several identified brain clusters at T0. Finally, while suicidal ideas and mental pain were correlated, the neural and molecular correlates of suicidal ideas were not the same., Conclusion: Our study suggests that the serotonergic and nociceptin systems are associated with the activity of a cortico-subcortical brain network underlying the perception of mental pain during depression. Mental pain may be a necessary but insufficient condition for the emergence of suicidal ideation during depression., Competing Interests: Declaration of Competing Interest All authors have no conflict of interest to report., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: When students with intellectual disability (ID) experience pain, the pain may limit the extent to which they may engage in school activities. Although school nurses are primarily responsible for addressing students' pain, there are many barriers to identifying pain in students with ID., Aims: The purpose of the present study was to describe pain assessment practices of school nurses for students with and without ID., Design: A retrospective review was conducted of 4,660 school health office visit records for elementary school students presenting to the health office with headache, stomachache, or sore throat., Methods: Data were extracted and transcribed to a matrix. Data extracted included school grade, referral source, visit month, gender, cognitive ability, chief concern, pain assessment, external contact, and disposition. Descriptive statistics were calculated., Results: School nurses spent more time on average addressing pain in neurotypical students than in students with ID. Neurotypical students more often presented with a teacher and were dismissed from school, but parents and guardians were contacted less often for these students, when compared to students with ID. Quantified pain ratings were documented for 1% of visits., Conclusions: Because pain intensity ratings were rarely documented, the utility of such ratings in the school setting may be low. Alternatively, obtaining pain intensity ratings from younger children may be challenging without the use of appropriate tools. Nurses, teachers, and other staff providing education and care to students with ID may require pain training. Implementation of tools that elicit student pain information from parents/guardians in the school setting could decrease point-of-care contact during the school day and proactively provide information on unique child pain behaviors., (Copyright © 2019 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

Study Design: A prospective observational 10-year follow-up study., Objective: This study aimed to examine preoperative predictors for better surgical outcomes in patients with lumbar spinal stenosis (LSS) 10 years after surgery., Summary of Background Data: LSS is a leading cause of low back surgery in patients older than 65 years. Limited data are available for predictors of long-term surgical outcomes in patients with LSS., Methods: At the baseline, 102 patients with LSS underwent decompressive surgery, and 72 of the original study sample participated in a 10-year follow-up study. Study patients filled out a questionnaire preoperatively, and follow-up data were collected at 3 months, 6 months, 1 year, 2 years, 5 years, and 10 years postoperatively. Surgical outcomes were evaluated in terms of disability with the Oswestry Disability Index (ODI) and pain with the visual analog scale (VAS). Predictors in the models were nonsmoking status, absence of previous lumbar surgery, self-rated health, regular use of painkillers for symptom alleviation, and BMI. Statistical analyses included longitudinal associations, subgroup analyses, and cross-sectional analyses., Results: Using multivariate analysis, statistically significant predictors for lower ODI and VAS scores at 10 years were nonsmoking status, absence of previous lumbar surgery, better self-rated health, and regular use of painkillers for <12 months. Patients who smoked preoperatively or had previous lumbar surgery experienced more pain and disability at the 10-year follow-up., Conclusion: These study results can enhance informed decision-making processes for patients considering surgical treatment for LSS by showing preoperative predictors for surgical outcomes up to 10 years after surgery. Smokers and patients with previous lumbar surgery showed a decline in surgical benefits after 5 years., Level of Evidence: 3.

Concerning the diagnosis and therapy of pain syndromes, standardized descriptions similar to those used in the examination of psychopathological findings via the system produced by the AMDP ("Arbeitsgemeinschaft für Methodik und Dokumentation in der Psychiatrie", i. e., the working group establishing standardized methodology and documentation within psychiatry) are still lacking. Therefore, the authors of this article have founded a working group to establish standardized methodology and documentation for symptoms and signs associated with pain, although not at a diagnosis-specific level, in order to promote standardization in the documentation of pain and rating of the symptoms associated with a given set of medical results. This article presents a system for documenting the symptoms and signs associated with pain globally and independently of the diagnosis (Structured Pain Assessment System) with nomenclature that is inspired by the AMDP system. The objective of this working group is to develop documentation for a uniform multidimensional pain assessment (with defined terminology) that serves as a comparable and unified standard in the field.

Background: To evaluate the effectiveness of a self-made modular elastic compression device for patients with a fracture of the tibia and fibula., Methods: Fifty-nine healthy adult patients with a unilateral fracture of the tibia and fibula were randomly divided into an experimental group and a control group. The experimental group was given the self-made combined elastic compression device for the compression treatment of the affected limbs after the operation. The main endpoints included the convenience, safety, and effectiveness of the self-made modular elastic compression device for patients with a fracture of the tibia and fibula., Results: There were 29 cases in the experimental group and 30 cases in the control group. There were no significant differences between the two groups in the general data: age, gender, fracture site, and cause of injury. The preoperative swelling elimination time was 3.3 ± 1.2 days, and the postoperative swelling elimination time was 3.1 ± 1.4 days in the experimental group; the preoperative swelling elimination time was 6.3 ± 1.2 days, and the postoperative swelling elimination time was 7.3 ± 1.2 days in the control group. The preoperative and postoperative swelling degree in the experimental group was shorter than those in the control group. The difference in the postoperative detumescence time between the experimental group (3.1 ± 1.4 days) and the control group (7.3 ± 1.2 days) was significant, and the total hospital stay was 8.1 ± 1.5 days in the experimental group and 13 ± 2.5 days in the control group with a statistical significance of P < 0.05. The change of discharge hemoglobin volume (11.2 ± 6.5 g/L) of the experimental group was lower than that of the control group (3.5 ± 1.2 days), the total drainage volume was 260 ± 50 ml, and the change of admission and discharge hemoglobin volume was 30.3 ± 10.4 g/L. Specifically, although the difference in the average hospital stay between the two groups was statistically significant, the difference was only 1 day, and the clinical difference was not significant. However, in the change of the cumulative drainage volume and hemoglobin volume, the experimental group that was given compression therapy was significantly lower than the control group with a statistical significance (P < 0.05). The pressure injury (4 cases) in the experimental group was significantly lower than that in the control group (8 cases) (P < 0.05)., Conclusion: A modular combined elastic compression device in patients with a tibial and fibular fracture can significantly accelerate a patient's rehabilitation, shorten the hospital stay, reduce blood loss, relieve the patient's pain, and relieve the patient's social-economic burden during recovery.

Background: Currently available procedures for the treatment of minimally displaced acetabular fractures include conservative treatment and minimally invasive percutaneous screw fixation. Screw fixation of acetabular fractures allows patients' early full-weight bearing due to improved biomechanic stability. Can the range of motion, pain and mobility and quality of life in patients with acetabular fractures be improved by minimally invasive screw fixation, compared to conservative treatment in the long term?, Methods: Patients treated for a minimally displaced acetabular fracture, either conservatively or by closed reduction percutaneous screw fixation, in the period from 2001 to 2013 were included in this retrospective study. Minimal displacement was considered to be less than 5 mm. As well as the collection and analysis of baseline data, Harris Hip Score, Merle d'Aubigné score and Short Form 12 (SF-12) questionnaire data were recorded in the context of a clinical study. To better account for confounding factors, patients of each group were matched. The matched-pair criteria included age, BMI, Letournel fracture classification and the presence of associated injuries., Results: Twenty-five patients from each group were matched. On the Harris Hip Score, conservatively treated patients obtained 96 points (52-100, SD 17) vs. 89 points (45-100, SD 17, p = 0.624). On the Merle d'Aubigné score, conservatively treated patients obtained 17 points (10-18, SD 2) vs. 17 points (11-18, SD 2, p = 0.342). Patients with acetabular fractures treated by minimally invasive screw fixation did not result in improved quality of life, measured by SF-12 questionnaire, compared to conservatively treated patients (PCS 47, SD 9 vs. 44, SD 10; p = 0.294 and MCS 51, SD 7 vs. 53, SD 7; p = 0.795)., Conclusions: The clinical results of the two groups revealed no statistically significant differences. From the data, it cannot be deduced that minimally invasive surgical therapy is superior to conservative treatment of minimally displaced acetabular fractures. Prospective randomised studies are recommended to allow reliable evaluation of both treatment options., Trial Registration: Retrospectively registered.

Study Design: A cross-sectional study., Objective: The aim of this study is to describe the profile of patients with acute low back pain (LBP) who sought emergency departments (EDs) in Brazilian public hospitals. We also described the profile of these patients according to the STarT Back Screening Tool (SBST)., Summary of Background Data: LBP is the most common musculoskeletal condition worldwide and is one of the main complaints in EDs. There is a lack of evidence describing the profile of these patients from low- to middle-income countries., Methods: This is a cross-sectional study involving patients with a new episode of nonspecific acute LBP that was conducted between August 2014 and August 2016. Variables related to clinical, psychological, sociodemographic and work status characteristics were investigated through structured, in-person oral questionnaire., Results: A total of 600 patients were included in the study. The majority of the patients were women (58%), with a median of eight points on pain intensity (measured on an 11-point scale) and 17 points on disability (measured on a 24-item questionnaire). With regards to the SBST evaluation, 295 (49.2%) patients were classified as being at high risk of developing an unfavorable prognosis with a median pain intensity of nine points on pain intensity, 20 points on disability, and seven points on depression (measured on an 11-point scale). Despite this, the majority of the patients (74%) continued working normally without interference from LBP., Conclusion: Identifying the profile of patients seeking care in EDs can help to define effective management for LBP in low- and middle-income countries. Patients with nonspecific acute LBP who seek EDs in Brazil present high levels of pain intensity and disability. Most patients were classified as having a high risk of developing an unfavorable prognosis., Level of Evidence: 2.

Background: Heel pain is one of the most common complaints in foot and ankle clinic, and one of the leading causes of heel pain is plantar fasciitis., Methods: A retrospective analysis was carried out in 31 cases (39 feet) of patients with intractable plantar fasciitis. In the enrolled 26 cases, 16 patients (19 feet) received open plantar fascia release, and the other 15 patients (20 feet) received percutaneous radiofrequency ablation. The surgical results were assessed by visual analog scale (VAS) and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AH) before and after surgery in all patients., Results: All 31 patients were followed up successfully, with a mean follow-up time of 58.77 months. There were no differences of patient's demographics and characteristics information between the two groups. The average operative time of the feet in the open plantar fascia release is longer than that in the percutaneous radiofrequency ablation. Furthermore, the percutaneous radiofrequency ablation group had a shorter recovery time to normal activity than the open plantar fascia release group. There were no differences of postoperative VAS scores and the AOFAS-AH scores between the two groups. All patients reported satisfaction after either operation., Conclusion: The symptoms of pain and limb function were significantly improved in patients both of the partial plantar fascia release treated group and the percutaneous radiofrequency ablation treated group. The two types of surgical procedures shared the same long-term curative effects. However, percutaneous radiofrequency ablation was a better technique from the point of shorter operative time and postoperative recovery time., Trial Registration: Retrospectively registered.

Study Design: Pilot randomized controlled trial., Objective: To examine the acceptability and preliminary safety and outcome effects of an early self-directed home exercise program (HEP) performed within the first 6 weeks after anterior cervical discectomy and fusion (ACDF)., Summary of Background Data: Little is known regarding optimal postoperative management after ACDF., Methods: Thirty patients (mean ± standard deviation, age = 50.6 ± 11.0 years, 16 women) undergoing ACDF were randomized to receive an early HEP (n = 15) or usual care (n = 15). The early HEP was a 6-week self-directed program with weekly supportive telephone calls to reduce pain and improve activity. Treatment acceptability was assessed after the intervention period (6 weeks after surgery). Safety (adverse events, radiographic fusion, revision surgery) was determined at routine postoperative visits. Disability (Neck Disability Index), pain intensity (Numeric Rating Scale for neck and arm pain), physical and mental health (SF-12), and opioid use were assessed preoperatively, and at 6 weeks and 6 and 12 months after surgery by an evaluator blinded to group assignment., Results: Participants reported high levels of acceptability and no serious adverse events with the early HEP. No difference in fusion rate was observed between groups (P > 0.05) and no participants underwent revision surgery. The early self-directed HEP group reported lower 6-week neck pain than the usual care group (F = 3.3, P = 0.04, r = 0.3, mean difference = -1.7 [-3.4; -0.05]) and lower proportion of individuals (13% vs. 47%) using opioids at 12 months (P = 0.05). No other between-group outcome differences were observed (P > 0.05)., Conclusion: An early self-directed HEP program was acceptable to patients and has the potential to be safely administered to patients immediately after ACDF. Benefits were noted for short-term neck pain and long-term opioid utilization. However, larger trials are needed to confirm safety with standardized and long-term radiograph assessment and treatment efficacy., Level of Evidence: 2.

Objective: Full-endoscopic lumbar discectomy (FELD) is a minimally invasive surgical option for recurrent lumbar disc herniation (LDH). Nonetheless, patients' clinical outcomes may be poorer after surgery for recurrent LDH than for primary LDH. Therefore, we compared patients' longitudinal clinical outcomes after FELD for recurrent LDH or primary LDH., Methods: The medical records of patients who underwent FELD for primary LDH (group A) or recurrent LDH (group B) were retrospectively reviewed. The inclusion criteria were: 1) single-level LDH or recurrent LDH at L4-5 or L5-S1, 2) age ≤60 years, 3) previous open discectomy (group B), and 4) ≥6 months of follow-up. In total, 244 patients (group A, 211; group B, 33) were included. Clinical outcomes (Oswestry Disability Index [ODI]; visual analogue pain score for the back and leg [VAS-B] and [VAS-L]) over 24 months of follow-up were compared between groups with a linear mixed-effects model., Results: All clinical outcomes significantly improved from pre-operation to 3 months postoperatively (p < 0.01), and the improvement was maintained for 24 months postoperatively in both groups. The clinical outcomes of groups A and B were not significantly different during 24 months follow-up (ODI, p = 0.94; VAS-B, p = 0.11; and VAS-L, p = 0.48). The reoperation rate was 3.3% in group A and 3.0% in group B, but the overall complication rate was higher in group B (9.8%) than in group A (6.6%)., Conclusion: The longitudinal clinical outcomes after FELD for recurrent LDH may not be poor as feared. However, the higher complication rate in patients undergoing FELD for recurrent LDH should be noted., Competing Interests: Declaration of Competing Interest A grant from the Korea Health Technology R&D Project supported this work through the Korea Health Industry Development Institute (KHIDI) funded by the Ministry of Health & Welfare, Republic of Korea (HC15C1320). Grant No. 0320160210 (2016-1062) from the Seoul National University Hospital supported this study. This research was partially supported by Korean Spinal Neurosurgery Society. The first author (CHK) is a consultant of RIWOspine GmbH. The other authors declare that they have no conflicts of interest concerning the materials/methods used in this study or the findings described in this paper. The institutional review board at the Seoul National University Hospital approved this study (H-1611-015-803)., (Copyright © 2019 Elsevier Ltd. All rights reserved.)