Electroacupuncture as a complement to usual care for patients with non-acute low back pain after back surgery: a pilot randomised controlled trial.

OBJECTIVES: The aim of this pilot study was to estimate the sample size for a large pragmatic study of the comparative effectiveness of electroacupuncture (EA) for low back pain (LBP) after back surgery. DESIGN: A randomised, active-controlled, assessor-blinded trial. PARTICIPANTS: Patients with recurrent or persistent LBP, defined as a Visual Analogue Scale (VAS) score of ≥50 mm, with or without leg pain after back surgery. INTERVENTIONS: Patients were randomised to an EA plus usual care (UC) group or to a UC alone group at a 1:1 ratio. Patients assigned to each group received UC, including drug therapy, physical therapy and back pain education, twice a week for 4 weeks; those assigned to the EA plus UC group additionally received EA. OUTCOME MEASURES: The primary outcome was severity of LBP as measured by VAS. Secondary outcomes included back pain-related disability, assessed using the Oswestry Disability Index (ODI) and quality of life, assessed using the EuroQol Five Dimensions (EQ-5D) questionnaire. Statistical analysis was performed using paired and independent t-tests. A p value of <0.05 was considered statistically significant. RESULTS: Thirty-nine patients were allocated to receive EA plus UC (n=18) or UC alone (n=21). There was no statistically significant difference in VAS or EQ-5D scores between the two groups, but there was a significant decrease in ODI scores (p=0.0081). Using G*Power, it was calculated that 40 participants per group would be needed for a future trial according to VAS scores. Considering for a 25% dropout rate, 108 participants (54 per group) would be needed. CONCLUSIONS: A future trial addressing the risk of bias and including the estimated sample size would allow for better clinical assessment of the benefits of EA plus UC in treatment of patients with non-acute pain after back surgery. TRIAL REGISTRATION NUMBER: NCT01966250; Results.

Novel method of minimally invasive removal of large lipoma after laser lipolysis with 980 nm diode laser.

Lipomas are the most common benign tumor of the soft tissue, often presenting as soft, mobile subcutaneous masses. These lesions are often removed for cosmetic reasons, although they may be removed secondary to considerable discomfort or paresthesias. The large majority of lipomas appear as small, solitary lesions that are best removed by surgical excision. However, surgical removal of large (>10 cm) or multiple lesions may result in significant scarring. Tumescent local anesthesia and liposuction of larger lesions has been successful in a number of cases although this technique can be hindered by overly fibrous lesions. Laser lipolysis, performed alone or before liposuction, can further facilitate removal of these lesions. This technique is a minimally invasive and effective method of lipoma removal, resulting in an excellent cosmetic outcome. This report describes step-by-step removal of a large lipoma located on the back, as well as a review of currently employed techniques for minimally invasive treatment of lipomas.

Neuro-reflexotherapy for the management of myofascial temporomandibular joint pain: a double-blind, placebo-controlled, randomized clinical trial.

PURPOSE: To assess the efficacy of neuro-reflexotherapy intervention (NRT) for treating temporomandibular joint dysfunction attributed to myofascial pain. Neuro-reflexotherapy intervention consists of the temporary implantation of epidermal devices in trigger points in the back and ear. It has shown efficacy, effectiveness, and cost-effectiveness in treating subacute and chronic common back pain. No study, however, has explored its efficacy in treating myofascial temporomandibular joint pain (MF/TMJP). PATIENTS AND METHODS: This was a randomized, double-blind, placebo-controlled trial. Patients with MF/TMJP for more than 3 months in spite of conservative treatment, and with no evidence of major structural damage in the joint, were recruited at the Maxillofacial Department of the Hospital Clínico Universitario, a teaching hospital in Madrid, Spain. Patients were randomly assigned to an intervention group and to a control group. Patients in the treated group underwent 2 NRTs, immediately after baseline assessment and 45 days later. Sham interventions in the control group consisted of placement of the same number of epidermal devices within a 5-cm radius of the target zones. In both groups, conservative treatment during follow-up was allowed and recorded. Patients underwent clinical evaluations on 4 occasions: 5 minutes before intervention, 5 minutes after intervention, and 45 and 90 days later. The preintervention assessment was performed by the physician at the hospital service who included the patient in the study. The 3 follow-up assessments were performed independently by 1 of 2 physicians who had no connection with the research team, and who were blinded to patients' assignments. The primary outcome variable was level of pain severity during jaw movements at the last assessment (90 days), and the key comparison of interest was change in pain over time (pain levels at baseline and at 90 days). Level of pain was measured using a visual analog scale (VAS). RESULTS: Fifty-one patients with MF/TMJP were recruited into the study. Random assignment allocated 27 patients to the intervention group, and 24 to the control group. Differences in pain severity in favor of the intervention group appeared immediately after the intervention, persisted for 45 days, and increased after the second intervention. Differences at last follow-up were highly clinically and statistically significant (4 to 5 points on the VAS, P = .000), allowing for patients in the intervention group to cease drug treatment (P = .005). There were no differences in the evolution of crepitus or clicking in the joint. There were no clinically relevant side effects associated with the intervention. CONCLUSIONS: For patients in whom conservative treatment has failed, NRT improves the chronic pain associated with MF/TMJP syndrome.

Functional magnetic resonance imaging of cerebral activation during spinal cord stimulation in failed back surgery syndrome patients.

Spinal cord stimulation (SCS) consisting of electrical stimulation of the dorsal spinal cord using epidural electrodes has been shown to relieve chronic neuropathic pain. To analyze the cerebral activation patterns related to SCS, and to evaluate the effects of SCS on the processing of acute experimental pain, we performed functional magnetic resonance imaging (fMRI) on eight patients suffering from failed back surgery syndrome who were also being treated with SCS for severe pain in their legs and lower back. Three types of stimulation were used, each lasting 36s: (i) SCS, (ii) heat pain (HP) applied to the leg affected by neuropathic pain, and (iii) simultaneous HP and SCS. During SCS, we found increased activation of the medial primary sensorimotor cortex somatotopically corresponding to the foot and/or perineal region, contralateral posterior insula, and the ipsilateral secondary somatosensory cortex (S2). Decreased activation was seen in the bilateral primary motor cortices and the ipsilateral primary somatosensory cortex corresponding to the shoulder, elbow and hand. Compared to separately presented HP and SCS, simultaneous HP and SCS showed statistically significant activation of the bilateral inferior temporal cortex and the ipsilateral cerebellar cortex. The activation of the primary motor cortex, insula and S2 during SCS may directly interfere with the processing of neuropathic pain. When SCS is associated with heat pain, the paralimbic association cortex and cerebellum show activation exceeding the sum of activations resulting from separate SCS and heat pain stimulation. The explanation of this could possibly rest with the continuous comparisons of simultaneous pain and somatosensory sensations occurring in a single dermatome.

Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomised controlled trial in patients with failed back surgery syndrome.

Patients with neuropathic pain secondary to failed back surgery syndrome (FBSS) typically experience persistent pain, disability, and reduced quality of life. We hypothesised that spinal cord stimulation (SCS) is an effective therapy in addition to conventional medical management (CMM) in this patient population. We randomised 100 FBSS patients with predominant leg pain of neuropathic radicular origin to receive spinal cord stimulation plus conventional medical management (SCS group) or conventional medical management alone (CMM group) for at least 6 months. The primary outcome was the proportion of patients achieving 50% or more pain relief in the legs. Secondary outcomes were improvement in back and leg pain, health-related quality of life, functional capacity, use of pain medication and non-drug pain treatment, level of patient satisfaction, and incidence of complications and adverse effects. Crossover after the 6-months visit was permitted, and all patients were followed up to 1 year. In the intention-to-treat analysis at 6 months, 24 SCS patients (48%) and 4 CMM patients (9%) (p<0.001) achieved the primary outcome. Compared with the CMM group, the SCS group experienced improved leg and back pain relief, quality of life, and functional capacity, as well as greater treatment satisfaction (p

Island vertical trapezius myocutaneous flap procedure under the tumescent technique.

We describe the application of local anesthesia with intravenous sedation for covering a large defect of the upper back with the use of the island vertical trapezius myocutaneous flap to an 85-year-old male. According to the anesthesiologist, the patient was graded as ASA IV. A 200-ml solution which consisted of 0.75 mg xylocaine, 2 mg adrenaline (1/2,000,000) and 10 mmol/l sodium bicarbonate in a physiologic saline solution was used. The total operating time was about 90 min. During the first postoperative 24 h, the flap pedicle was checked every hour by Doppler. The postoperative course of the patient was uneventful. We believe that in selected cases, when microsurgery is not indicated due to the general medical condition of the patient, the combination of the tumescent technique with sedation and the vertical trapezius myocutaneous flap can be considered a reliable and low-risk procedure.

"Three-dimensional tumescent liposculpture" of the abdomen, waist, and flanks.

Treating the entire area as a cosmetic unit is the best approach to tumescent liposculpture of the abdomen, waist, and flanks. This "Three-Dimensional Tumescent Liposculpture" procedure is performed under tumescent local anesthesia with optional intraoperative external ultrasound. Areas treated are the abdomen, waist, flanks, and infrascapular fat pad if indicated. Postoperatively, patients show a flatter abdomen, a smaller and better-defined waist (the "Cook waist"), reduction of unsightly bulges, and a smoother, better proportioned and more attractive overall contour. Patient recovery is rapid with minimal complications.

Contouring the female buttocks. Liposculpting the buttocks.

Body sculpting has progressed during the past decade to a point where cosmetic units may be sculpted to improve contours which blend imperceptibly and appropriately with adjacent cosmetic units. The buttocks is ideally suited for sophisticated contouring as its frame is determined by the hips, thighs, and lower back and its proportions are balanced by the anterior projection of the breasts. In addition, ethnic differences in the shape and proportions of the buttocks create a variety of aesthetically pleasing variations in size and shape. The article attempts to elucidate these considerations combined with a logical surgical approach to achieve pleasing results in body sculpting.

Spinal cord stimulation for treatment of failed back surgery syndrome--two case reports.

Severe, persistent back pain following back surgery is often referred to as Failed Back Surgery Syndrome (FBSS). Conservative measures such as physiotherapy, back strengthening exercises, transcutaneous electrical nerve stimulation and epidural steroids may be inadequate to alleviate pain. Spinal Cord Stimulators were implanted into two patients suffering from FBSS. Both patients responded successfully to spinal cord stimulation with reduction of pain and disability.

Radiofrequency lumbar sympatholysis. The evolution of a technique for managing sympathetically maintained pain.

BACKGROUND AND OBJECTIVES: To develop lumbar radiofrequency sympatholysis for the relief of pain in patients with neuropathic pain who had previously responded to sympathectomy or sympathetic blocks. METHODS: The technique described by Sluijter was modified to attempt to obtain long lasting pain relief in each patient. No one technique was universally applicable. The variations in technique are illustrated by the case reports. The basic technique that evolved is as follows: a 20-gauge 15-cm insulated needle with a 5-mm active tip was inserted in the direction of an x-ray beam (C arm). The initial target was slightly cephalad to the middle of the L3 vertebra. Contrast medium was injected to confirm the location of the needle. The temperature of the tip of the needle was controlled at 80 degrees C for 90 seconds. RESULTS: Thirty-eight procedures were performed on 20 patients. Reproduction of the pain for which the sympatholysis was undertaken, induced dysesthesia, spread of dye, rapidity of temperature rise in the legs, and increase in pulse volume of the toes were useful guides to proper placement of the needle. Five patients continue to be pain free 5 months to 3 years after the last radiofrequency sympatholysis. Fifteen had temporary relief or no relief at all. The procedure was temporarily complicated by an excessively hot, swollen foot, and postsympathectomy neuralgia in a few cases. CONCLUSIONS: A single technique of radiofrequency sympatholysis does not appear to be applicable to all patients with reflex sympathetic dystrophy or sympathetically maintained pain. Despite early successful sympathetic block with radiofrequency, as confirmed by a warm foot, long lasting pain relief was difficult to obtain. The author concludes that individualized patient management is necessary when considering radiofrequency sympatholysis in the treatment of patients with sympathetically maintained pain.

Pain relief after low back surgery: the efficacy of transcutaneous electrical nerve stimulation.

Transcutaneous electrical nerve stimulation (TENS) was used for the relief of post-operative pain following low back surgery in a consecutive series of over 157 patients. A comparative study of the use of post-operative narcotic analgesics by 52 of these patients (26 in each of two groups) was made to determine the effectiveness of TENS in relieving post-operative pain. Fifty per cent of the sample used analgesics only; 50% used TENS in addition to analgesics. The data collected included its frequency of post-operative analygesic use, a rank order of analgesic potency, and a post-operative "pain score" derived from the combination of analgesic potency and frequency of use. Data analysis revealed significant differences between the groups in the use of analgesics. TENS decreased the need for narcotics in the relief of post-operative pain following low back surgery, although it is not a replacement for post-operative medication.