Radiofrequency Ablation for Chronic Lumbar Zygapophyseal Joint Pain Using a V-Shaped Active Tip Needle: An Observational Retrospective Study.

Background: Lumbar zygapophyseal joint dysfunction represents one of the major sources of chronic low back pain. Radiofrequency ablation (RFA) using a V-shaped active tip needle may offer a larger lesion of the medial branch nerves, improving clinical outcome. The aim of our study is to evaluate the efficacy and the feasibility of RFA using V-shaped active tip needles. Methods: This is a single-center observational retrospective study. Clinical records were screened and analyzed if they met the following inclusion criteria: adult patients (>18 years), diagnosis of chronic lumbar zygapophyseal joint pain, failure of conservative treatments, ability to provide informed consent for data analysis and publication. Exclusion criteria: lumbar pain not related to zygapophyseal joints, previous spinal/lumbar surgery, incomplete data, absence or withdrawal of informed consent. The primary outcome of the study was a change in pain intensity at follow-up. The secondary outcomes were the evaluation of quality-of-life improvement, the occurrence of adverse events and the impact on post-procedural analgesic consumption. For these purposes, pre- and post-treatment numeric rating scale (NRS), neuropathic pain 4 questions (DN4), EuroQoL - EQ-5D-3L, EQ-VAS, EQ-index and North American Spine Society (NASS) index were retrieved and analysed. Results: Sixty-four patients were included. 7.8% of patients at 1-month (CI95% 0.026, 0.173), 37.5% at 3-month (CI95% 0.257, 0.505), 40.6% at 6-month (CI95% 0.285, 0.536) and 35.9% at 9-month (CI95% 0.243, 0.489) follow-up reported a reduction of more than 80% in NRS Statistical analysis indicated a significant change in NRS, DN4, EQ-index and EQ-5D-VAS (p-value <0.001) at the different time-points. Conclusion: RFA using a V-shaped active tip needle might be a feasible and effective treatment for chronic lumbar zygapophyseal joint pain.

A Multimodal Clinical Approach for the Treatment of Bone Metastases in Solid Tumors.

Context: Bone metastasis (BM) is a frequent complication of cancer, representing the third most common site of secondary spread in solid cancers behind the lung and liver. Bone metastasis is found in up to 90% of prostate and breast cancer patients. They can cause significant complications, such as pathological fractures and paralysis of the spine, which decrease daily functioning and quality of life (QoL) and worsen prognosis. The growing life expectancy of cancer patients due to improvements in systemic therapies may further increase BM's eventuality and clinical burden in cancer patients. Evidence Acquisition: Four physicians from five different specialties were interviewed and resumed the most relevant literature of the last 20 years focusing on pain treatment in BM patients. Results: Treatment for BM ideally involves various types of specialists and assessments. The disease status and patient background should be considered, requiring holistic care and expertise from various medical specialties. Conclusions: Interventional, nuclear medicine, radiotherapy, and mini-invasive techniques can be safe and effective for relieving pain and modifying health-related QoL in BM patients.

Dorsal Root Ganglion Stimulation for Chronic Postoperative Pain Following Thoracic Surgery: A Pilot Study.

OBJECTIVES: Post-thoracotomy pain syndrome (PTPS) is defined as persistent pain following a thoracotomy and has an incidence of 21-61%. Dorsal root ganglion stimulation (DRG-S) is a form of neuromodulation that modulates pain signal transmission to the spinal cord. The aims of this study were to investigate the efficacy of DRG-S for the management of PTPS and to assess the role of thoracic paravertebral blocks (t-PVB) as a tool for prediction of success of DRG-S. MATERIALS AND METHODS: In this prospective study, we included all patients undergoing thoracic surgery, with PTPS not responding to pharmacotherapy and treated with DRG-S from September 2018 to February 2019. t-PVB followed by a percutaneous DRG-S trial was performed on all patients. Pain intensity was assessed through a numeric rating scale (NRS) and Douleur Neuropathique en 4 Questions (DN4) at baseline, post-trial, at 14 days, 90 days, and at one year after DRG-S implantation. Data summarized as continuous variables were expressed as means and standard deviations (SDs), and categorical variables were expressed as raw numbers and percentages. RESULTS: Four patients out of 51 who underwent thoracic surgery at our institution surveyed were included (mean age ± SD, 56 ± 16 years old). Mean NRS and DN4 were, respectively, 7.2 ± 0.96 SD and 8.2 ± 0.5 SD at baseline, 2.5 ± 0.6 SD and 3.2 ± 0.5 SD after t-PVB, 2.2 ± 0.5 SD and 2.2 ± 0.5 SD at 14 days, 90 days, and at one year after DRG-S implantation. No complications or side effects were reported. CONCLUSIONS: Our preliminary results show that DRG-S is an effective therapy for PTPS after thoracic surgery. In addition, thoracic paravertebral blocks performed prior to DRG-S correlated with a positive outcome with treatment.

Day-surgery stapled prolassectomy: a "ten minutes job".

INTRODUCTION: Accordingly with the new physiopathologic insights of the 70s and 80s, hemorrhoidal disease appears to originate not much from venous hyperplasia but rather from a progressive deterioration of connective and support tissues with subsequent venous and mucosal prolapse. In the late 90s a new surgical technique for a more physiological treatment of hemorrhoids was introduced: stapled prolassectomy. MATERIALS AND METHODS: Between October 2017 and June 2018 we performed 50 hemorrhoidal stapled prolassectomies under local-regional anesthesia. All patients were classified as ASA I and were aged between 18 and 65 years. Patients were administered Atropine 1 mg and Flunitrazepam 0,7 mg orally 30 minutes prior to the intervention. A topical anesthetic preparation of Lidocaine and Procaine was also applied. A local anesthesia of the anal and perineal region was performed by the surgeon in the presence of an anesthesiologist. RESULTS: Intraoperative pain control was found to be complete and optimal for the majority of patients (92%). Six of the patients (8%) reported mild pain during the stapling phase but did not require further intervention. A conversion to general anesthesia was never required. Forty-four of the patients (88%) were discharged on the same day of the operation. In four cases (9%) discharge was postponed and patients were kept overnight because of early postoperative complications. DISCUSSION AND CONCLUSION: Over 20 years after its introduction, stapled prolassectomy has become the allows to gold standard for treating hemorrhoids. This procedure allows for an effective and appropriate treatment of the condition. It preserve the physiology of the anal channel and to reconstruct the correct topographic relationship between anal derma, anal-rectal mucosa, hemorrhoidal plexus and sphincter apparatus . The absence of surgical wounds in the perineal region allows for a reduced stimulation of pain receptors, leading to a less painful post-operatory course and to a reduced risk of long term complications such as stenotizing scarring and soiling .The use of a mechanic stapler leads to higher costs, but they are in part balanced by the possibility of a faster recovery of patients and of an earlier resumption of work activities. The possibility to perform the operation in day surgery may allow for a global reduction health care expenses leaving more resources available for more complex cases. KEY WORDS: Hemorrhoids, Recto-Anal prolapse, Posterior perineal block.