Evaluation of Vertebral Function and Long-Term Quality of Life after Percutaneous Minimally Invasive Surgery in Patients with Thoracolumbar Spine Fractures.

OBJECTIVE: To investigate the changes in vertebral function after minimally invasive surgery in patients with thoracolumbar spinal fractures and investigate the impact of percutaneous minimally invasive surgery on patients' quality of life by following up the patients in the long term. METHODS: A retrospective analysis was performed to select 80 patients with thoracolumbar spinal fractures treated in our hospital from April 2013 to October 2018, and the patients were divided into a study group and a control group according to the difference in their choice of procedure. The two groups were compared in terms of perioperative wound pain, serum creatine kinase (CK) activity, and C-reactive protein (CRP) levels, and the two groups were followed up for 2 years to compare the changes in anterior vertebral body height and Cobb's angle during the follow-up period and to compare the differences in quality of life between the two groups. RESULTS: (1) The pain level of patients in the study group was significantly lower than that of the control group at the 1st and 3rd postoperative days (p < 0.05). (2) The CK activity and CPR level of patients in the study group were significantly lower than that of the control group at the 1st and 3rd postoperative days (p < 0.05). (3) Compared with the preoperative period, the height of the anterior border of the vertebral body and the Cobb's angle in both groups showed significant changes at 7 d, 6 months, one year, and two years after surgery (p < 0.05), suggesting that both procedures can significantly restore the height of the injured vertebra and improve the function of the vertebral body. (4) The somatic, physical, and psychological functions of patients in the study group were significantly greater than those in the control group at 6 months postoperatively (p > 0.05). CONCLUSION: Compared to traditional open surgery, minimally invasive percutaneous surgery for thoracolumbar fractures can significantly reduce perioperative pain and improve perioperative stress in patients, while achieving better surgical outcomes and a significantly improved quality of life in patients at long-term follow-up.

Effect of Combined Thoracic Paravertebral Block and General Anesthesia vs General Anesthesia Alone on Postoperative Stress and Pain in Patients Undergoing Laparoscopic Radical Nephrectomy.

BACKGROUND This single-center study compared the effect of combined thoracic paravertebral block (TPVB) and general anesthesia vs general anesthesia alone on postoperative stress and pain in patients undergoing laparoscopic radical nephrectomy. MATERIAL AND METHODS Patients undergoing laparoscopic radical nephrectomy were selected and randomized into a study group given TPVB combined with general anesthesia (n=43) and a reference group (n=43) given general anesthesia. The perioperative clinical indicators, blood pressure, pulse rate, visual analog scale (VAS) score, and adverse reactions were compared. RESULTS Perioperative clinical indicators of the study group (other than operation duration) were superior to those of the reference group (P<0.05). At 90 min in the operation, systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse rate were lower than before anesthesia (t=7.691, 10.017, and 7.728, P<0.05). SBP, DBP, and pulse rate at 90 minutes during operation were significantly lower in the study group than in the reference group (t=7.582, 8.754, and 6.682, P<0.01). The study group had lower VAS scores both during activity and at rest 48 h after the operation than in the reference group (t=5.171 and 6.025, P<0.001). The total incidence of adverse reactions in the study group was lower than in the reference group (χ²=5.018, P=0.024). CONCLUSIONS The findings from this study from a single center showed that TPVB combined with general anesthesia for patients undergoing laparoscopic radical nephrectomy significantly reduced postoperative pain and stress.

"Decreasing Postamputation Pain with the Regenerative Peripheral Nerve Interface (RPNI)".

Over 185,000 limb amputations are performed in the United States annually, many of which are due to the sequelae of peripheral vascular disease. Symptomatic neuromas remain a significant source of postamputation morbidity and contribute to both phantom limb (PLP) and residual limb pain (RLP). While many interventions have been proposed for the treatment of symptomatic neuromas, conventional methods lead to a high incidence of neuroma recurrence. Furthermore, these existing methods do not facilitate an ability to properly interface with myoelectric prosthetic devices. The Regenerative Peripheral Nerve Interface (RPNI) was developed to overcome these limitations. The RPNI consists of an autologous free muscle graft secured around the end of a transected nerve. The muscle graft provides regenerating axons with end organs to reinnervate, thereby preventing neuroma formation. We have shown that this simple, reproducible, and safe surgical technique successfully treats and prevents neuroma formation in major limb amputations. In this paper, we describe RPNI surgery in the setting of major limb amputation and highlight the promising results of RPNIs in our animal and clinical studies.

Short-Term Efficacy and Quality of Life of Gastric Cancer Patients Undergoing Radical Gastrectomy Assisted by External Vision.

OBJECTIVE: To evaluate the clinical effects and survival prognosis of radical gastrectomy assisted by external vision in gastric cancer. METHODS: A total of 60 hospitalized gastric cancer patients from June 2016 to December 2018 were selected and divided into the observation group and control group according to different surgical procedures. The control group was treated with traditional open radical gastrectomy, while the observation group was treated with radical gastrectomy assisted by an external vision microscope. Relevant surgical indicators, visual analogue scale (VAS), postoperative complications, and life quality assessment were analyzed and compared between the two groups. RESULTS: The incision length and intraoperative blood loss in the observation group were smaller than those in the control group, and the difference was statistically significant (P < 0.05); compared with the control group, the observation group had significantly shorter hospital stay, earlier postoperative first exhaust time, and lower gastric fluid volume at the 3rd day after surgery (P < 0.05). The pain scores of the observation group at 1, 4, and 12 weeks after surgery were lower than those of the control group (P < 0.05), and the difference was significant. The quality of life scores at the 1st week and 12th week after surgery showed that the dysphagia symptom scores of the observation group and the control group were significantly reduced but the two groups had significant differences in fatigue, physical function, pain score, postoperative pain, and overall quality of life. The observation group was significantly better than the control group (P < 0.05). Follow-up studies showed no significant difference between mortality and cancer recurrence (P > 0.05); the patients recovered well at postoperation, and the diet of the observation group was better than that of the control group (P < 0.05); gastric reflux and knife pain were less than those of the control group (P < 0.05). CONCLUSION: Radical gastrectomy assisted by external vision for gastric cancer yields clinical benefits for gastric cancer patients, which not only dramatically shortened the length of hospital stay but also effectively ameliorated the quality of life of patients, all indicating that external vision-assisted surgery was significantly better than traditional gastrectomy in improving the postoperative quality of life of gastric cancer patients in the absence of increasing the risk of adverse events.

Postoperative Pain and Age: A Retrospective Cohort Association Study.

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; ß = -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.

A Retrospective Study of the Risk Factors for Postoperative Foot or Ankle Pain in 90 Patients with Varus Osteoarthritis of the Knee who Underwent Total Knee Arthroplasty.

BACKGROUND The reasons for foot and ankle pain following total knee arthroplasty (TKA) for knee varus osteoarthritis are unknown. This retrospective study aimed to investigate the risk factors for postoperative foot and ankle pain in patients with varus osteoarthritis of the knee who underwent TKA. MATERIAL AND METHODS We enrolled 90 patients who underwent TKA for varus knee osteoarthritis. The visual analog scale (VAS) was used to evaluate patients' foot or ankle pain before and after surgery. The correlation between independent variables (eg, age, sex, body mass index [BMI], ankle osteoarthritis, and varus angle) and foot and ankle pain in patients with osteoarthritis of the knee was measured. Moreover, radiological changes were compared between the groups with and without worsened pain. RESULTS No significant difference in VAS was found between patients <60 and ≥60 years of age (P>0.05). Male sex and BMI <30 kg/m² were weakly correlated with preoperative foot or ankle pain. However, patients with varus of ≥6° and preexisting ankle osteoarthritis had a higher incidence of foot or ankle pain before surgery. Moreover, no significant differences in radiological changes were found between the groups with and without worsened foot or ankle pain after surgery (P>0.05). CONCLUSIONS In male patients with osteoarthritis of the knee, a BMI <30 kg/m², varus of <6°, and no preexisting ankle osteoarthritis were protective factors for foot and ankle pain. TKA corrected knee and ankle malalignment. Therefore, postoperative foot and ankle pain was not associated only with TKA surgery.

Postoperative pain after clitoral reconstruction in women with female genital mutilation: An evaluation of practices.

INTRODUCTION: More than 200 million women and girls have undergone genital mutilation. Clitoral reconstruction (CR) can improve the quality of life of some of them, but is accompanied by significant postoperative pain. OBJECTIVE: Assess and describe the management of postoperative pain after CR, and the practices amongst specialists in different countries. METHODS: Between March and June 2020, 32 surgeons in 14 countries (Germany, Austria, Belgium, Burkina Faso, Canada, Ivory Coast, Egypt, Spain, United States of America, France, the Netherlands, Senegal, Switzerland, Sweden) responded to an online questionnaire on care and analgesic protocols for CR surgery. RESULTS: At day 7 post CR, 97% of the surgeons observed pain amongst their patients, which persisted up to 1 month for half of them. 22% of the participants reported feeling powerless in the management of such pain. The analgesic treatments offered are mainly step II and anti-inflammatory drugs (61%). Screening for neuropathic pain is rare (3%), as is the use of pudendal nerve block, used by 8% of the care providers and only for a small percentage of women. CONCLUSION: Pain after CR is frequent, long-lasting, and potentially an obstacle for the women who are willing to undergo clitoral surgery and also their surgeons. Most surgeons from different countries follow analgesic protocols that do not use the full available therapeutic possibilities. Early treatment of neuropathic pain, optimisation of dosing of standard analgesics, addition of opioids, use of acupuncture, and routine intraoperative use of pudendal nerve block might improve the management of pain after CR.

Histone modification of pain-related gene expression in spinal cord neurons under a persistent postsurgical pain-like state by electrocautery.

Chronic postsurgical pain (CPSP) is a serious problem. We developed a mouse model of CPSP induced by electrocautery and examined the mechanism of CPSP. In this mouse model, while both incision and electrocautery each produced acute allodynia, persistent allodynia was only observed after electrocautery. Under these conditions, we found that the mRNA levels of Small proline rich protein 1A (Sprr1a) and Annexin A10 (Anxa10), which are the key modulators of neuropathic pain, in the spinal cord were more potently and persistently increased by electrocautery than by incision. Furthermore, these genes were overexpressed almost exclusively in chronic postsurgical pain-activated neurons. This event was associated with decreased levels of tri-methylated histone H3 at Lys27 and increased levels of acetylated histone H3 at Lys27 at their promoter regions. On the other hand, persistent allodynia and overexpression of Sprr1a and Anxa10 after electrocautery were dramatically suppressed by systemic administration of GSK-J4, which is a selective H3K27 demethylase inhibitor. These results suggest that the effects of electrocautery contribute to CPSP along with synaptic plasticity and epigenetic modification.

Safety evaluation of oliceridine for the management of postoperative moderate-to-severe acute pain.

INTRODUCTION: Opioids for managing postoperative pain are associated with side effects including opioid-induced respiratory depression (OIRD) and gastrointestinal complications. Opioids induce analgesia via G-protein signaling, while adverse effects are mediated by the ß-arrestin pathway. Oliceridine is a biased ligand that preferentially activates G-protein signaling over ß-arrestin, theoretically reducing adverse effects. Oliceridine has been approved by the Food and Drug Administration to treat acute pain severe enough to require intravenous opioid analgesics. AREAS COVERED: Preclinical and clinical trials demonstrate the analgesic efficacy of oliceridine. Available evidence suggests that oliceridine may have a lower risk of OIRD and gastrointestinal complications compared to conventional opioids. EXPERT OPINION: The analgesic efficacy of oliceridine has been evaluated in several clinical trials. However, safety data were obtained from an open-label observational study and studies assessing adverse effects as secondary outcomes, as post-hoc analyses, or from retrospective studies. These may be affected by gaps in detecting adverse events, heterogeneity in the original studies, and the limitations of retrospective studies. Prospective trials examining the safety of oliceridine versus conventional opioids are needed. Studies are also needed to assess the safety and efficacy of oliceridine in obstetric and pediatric populations, and in the context of multimodal analgesia and Enhanced Recovery after Surgery protocols.

G protein-coupled estrogen receptor in the rostral ventromedial medulla contributes to the chronification of postoperative pain.

AIMS: Chronification of postoperative pain is a common clinical phenomenon following surgical operation, and it perplexes a great number of patients. Estrogen and its membrane receptor (G protein-coupled estrogen receptor, GPER) play a crucial role in pain regulation. Here, we explored the role of GPER in the rostral ventromedial medulla (RVM) during chronic postoperative pain and search for the possible mechanism. METHODS AND RESULTS: Postoperative pain was induced in mice or rats via a plantar incision surgery. Behavioral tests were conducted to detect both thermal and mechanical pain, showing a small part (16.2%) of mice developed into pain persisting state with consistent low pain threshold on 14 days after incision surgery compared with the pain recovery mice. Immunofluorescent staining assay revealed that the GPER-positive neurons in the RVM were significantly activated in pain persisting rats. In addition, RT-PCR and immunoblot analyses showed that the levels of GPER and phosphorylated µ-type opioid receptor (p-MOR) in the RVM of pain persisting mice were apparently increased on 14 days after incision surgery. Furthermore, chemogenetic activation of GPER-positive neurons in the RVM of Gper-Cre mice could reverse the pain threshold of pain recovery mice. Conversely, chemogenetic inhibition of GPER-positive neurons in the RVM could prevent mice from being in the pain persistent state. CONCLUSION: Our findings demonstrated that the GPER in the RVM was responsible for the chronification of postoperative pain and the downstream pathway might be involved in MOR phosphorylation.

Anesthesia Method, Tourniquet Use, and Persistent Postsurgical Pain after Total Knee Arthroplasty: A Prespecified Secondary Analysis of a Randomized Trial.

BACKGROUND: Persistent postsurgical pain after total knee arthroplasty is a common problem and a major reason for patient dissatisfaction. This secondary analysis aimed to investigate the effects of anesthesia (spinal vs. general) and tourniquet use on persistent pain after total knee arthroplasty. METHODS: In this secondary analysis of a previously presented parallel, single-center, randomized trial, 404 patients scheduled for total knee arthroplasty were randomized to spinal versus general anesthesia and no-tourniquet versus tourniquet groups. Patients assessed pain using the Brief Pain Inventory-short form preoperatively and 3 and 12 months postoperatively. The prespecified main outcome was the change in "average pain" measured with numerical 0 to 10 rating scale 1 yr postoperatively. The threshold for clinical importance between groups was set to 1.0. RESULTS: The change in average pain scores 1 yr postoperatively did not differ between the spinal and general anesthesia groups (-2.6 [SD 2.5] vs. -2.3 [SD 2.5], respectively; mean difference, -0.4; 95% CI, -0.9 to 0.1; P = 0.150). The no-tourniquet group reported a smaller decrease in the average pain scores than the tourniquet group (-2.1 [SD 2.7] vs. -2.8 [SD 2.3]; mean difference, 0.6; 95% CI, 0.1 to 1.1; P = 0.012). After 1 yr, the scores concerning the mean of four pain severity variables (numerical rating scale) decreased more in the spinal than in the general anesthesia group (-2.3 [SD 2.2] vs. -1.8 [SD 2.1]; mean difference, -0.5; 95% CI, -0.9 to -0.05; P = 0.029) and less in the no-tourniquet than in the tourniquet group (-1.7 [SD 2.3] vs. -2.3 [SD 2.0]; mean difference, 0.6; 95% CI, 0.2 to 1.0; P = 0.005). None of the differences in pain scores reached the threshold for clinical importance. CONCLUSIONS: The type of anesthesia (spinal vs. general) or tourniquet use has no clinically important effect on persistent postsurgical pain after total knee arthroplasty.

Osmotically balanced, large unilamellar liposomes that enable sustained bupivacaine release for prolonged pain relief in in vivo rat models.

To efficiently prolong analgesic effects, we developed osmotically balanced, large unilamellar liposomes (~ 6 µm in diameter) in which highly concentrated bupivacaine (up to 30 mg/mL) was encapsulated, and their sustained bupivacaine release was highly effective in relieving postoperative pain over 24 h in a rat model. Our reverse-phase evaporation method based on non-toxic alcohol, ethanol, enabled simple and cost-effective production of bupivacaine-loaded liposomes, of which osmotic pressure was readily balanced to improve the structural stability of the enlarged unilamellar liposomes along with extension of their shelf life (> a month). The in vitro release profile verified that the release duration of the bupivacaine-loaded liposomes extended up to 6 days. For the in vivo study, male Sprague-Dawley rats were used for the incisional pain model, simulating postoperative pain, and the mechanical withdrawal threshold (MWT) was measured using a von Frey filament. Compared to the control group that received intraplantar administration of normal saline, the group of liposomal bupivacaine showed that the initially increased MWT gradually decreased up to 24 h, and importantly, the analgesic effect of the liposomal bupivacaine was maintained 6 times longer than that of bupivacaine only, proving the potential of effective long-acting anesthetics.

To drain or not to drain: the association between residual intraperitoneal gas and post-laparoscopic shoulder pain for laparoscopic cholecystectomy.

Residual intra-peritoneal gas may be associated with post-laparoscopic shoulder pain (PLSP), which is a frequently and disturbance compliant after surgery. Herein, we aimed to examine whether expiring residual gas via a surgical drain reduces the frequency and intensity of PLSP in the first day after laparoscopic cholecystectomy. 448 participants were enrolled in this prospective cohort study. The incidence and severity of PLSP after surgery were recorded. Of these, the cumulative incidence of PLSP in the drain group was lower particularly at the 12th postoperative hour (18.3% vs. 27.6%; P = 0.022), 24th postoperative hour (28.8% vs. 38.1%; P = 0.039), and throughout the first postoperative day (P = 0.035). The drain group had less severe PLSP (crude Odds ratio, 0.66; P = .036). After adjustment using inverse probability of treatment weighting, the drain group also had a significant lower PLSP incidence (adjusted hazard ratio = 0.61, P < 0.001), and less severe PLSP (adjusted odds ratio = 0.56, P < 0.001). In conclusion, the maneuver about passive force to expel residual gas, surgical drain use, contributes to reduce the incidence and severity of PLSP, suggesting that to minimize residual gas at the end of surgery is useful to attenuate PLSP.

Predicting factors that determine patients' satisfaction with post-operative pain management following abdominal surgeries at Komfo Anokye Teaching Hospital, Kumasi, Ghana.

INTRODUCTION: Poorly controlled postoperative pain has been known to be characterized by longer post-operative care, longer hospital stays with increased readmission rates, and decreased patient satisfaction. Post-operative pain has been continuously addressed in the past three (3) to four (4) decades and has been shown that 20 to 80% of post-operative patients suffer ineffective pain management. OBJECTIVE: The study was aimed at assessing the factors that may predict the satisfaction of patients with early postoperative pain management following abdominal surgeries at the Komfo Anokye Teaching Hospital, Kumasi. METHODOLOGY: A descriptive cross-sectional study was conducted among patients who had undergone abdominal surgeries between October 2019 and December 2019 at the Komfo Anokye Teaching Hospital. Structured questionnaires based on the IPO-Q were used to obtain responses from the patients. Descriptive and Inferential statistical analysis were employed in analyzing the data obtained from the respondents of the study. RESULTS: 138 patients were involved in this study. The mean age of patients in the study was 45.81 (±16.81) years. A higher percentage, 58.7% of the patients were males. 39.1% had completed their tertiary level of education. The majority (50.7%) of the patients had had persistent pain for more than three (3) months. The satisfaction of the patients with the post-operative pain management received was generally high among a significant majority of the patients. Meanwhile, among the factors that influence the satisfaction of the patients with the post-operative pain management received, type of analgesia and pain relief methods (Pearson Coefficient = 0.523, p-value <0.05), patient's ability to request more pain relief, (Pearson Coefficient = 0.29, p-value <0.05), patient's access to information about their pain treatment options from the Nurses (Pearson coefficient = -0.22, p<0.05), were the only predictors of satisfaction in patients. CONCLUSION: This study found out that patients were generally satisfied with the post-operative pain management offered by their healthcare providers although the degree of satisfaction depended largely on the type of analgesia and pain relief methods, the ability to request for more pain relief, and access to information on pain treatment.

Are Patient Expectations and Illness Perception Associated with Patient-reported Outcomes from Surgical Decompression in de Quervain's Tenosynovitis?

BACKGROUND: Psychological factors such as depression, pain catastrophizing, kinesiophobia, pain anxiety, and more negative illness perceptions are associated with worse pain and function in patients at the start of treatment for de Quervain's tenosynovitis. Longitudinal studies have found symptoms of depression and pain catastrophizing at baseline were associated with worse pain after treatment. It is important to study patients opting for surgery for their condition because patients should choose surgical treatment based on their values rather than misconceptions. Psychological factors associated with worse patient-reported outcomes from surgery for de Quervain's tenosynovitis should be identified and addressed preoperatively so surgeons can correct any misunderstandings about the condition. QUESTION/PURPOSE: What preoperative psychosocial factors (depression, anxiety, pain catastrophizing, illness perception, and patient expectations) are associated with pain and function 3 months after surgical treatment of de Quervain's tenosynovitis after controlling for demographic characteristics? METHODS: This was a prospective cohort study of 164 patients who underwent surgery for de Quervain's tenosynovitis between September 2017 and October 2018 performed by 20 hand surgeons at 18 centers. Our database included 326 patients who underwent surgery for de Quervain's tenosynovitis during the study period. Of these, 62% (201 of 326) completed all baseline questionnaires and 50% (164 of 326) also completed patient-reported outcomes at 3 months postoperatively. We found no difference between those included and those not analyzed in terms of age, sex, duration of symptoms, smoking status, and workload. The mean ± SD age of the patients was 52 ± 14 years, 86% (141 of 164) were women, and the mean duration of symptoms was 13 ± 19 months. Patients completed the Patient-Rated Wrist Evaluation (PRWE), the VAS for pain and function, the Patient Health Questionnaire for symptoms of anxiety and depression, the Pain Catastrophizing Scale, the Credibility/Expectations Questionnaire, and the Brief Illness Perceptions questionnaire at baseline. Patients also completed the PRWE and VAS for pain and function at 3 months postoperatively. We used a hierarchical multivariable linear regression model to investigate the relative contribution of patient demographics and psychosocial factors to the pain and functional outcome at 3 months postoperatively. RESULTS: After adjusting for demographic characteristics, psychosocial factors, and baseline PRWE score, we found that only the patient's expectations of treatment and how long their illness would last were associated with the total PRWE score at 3 months postoperatively. More positive patient expectations of treatment were associated with better patient-reported pain and function at 3 months postoperatively (ß = -2.0; p < 0.01), while more negative patient perceptions of how long their condition would last were associated with worse patient-reported pain and function (timeline ß = 2.7; p < 0.01). The final model accounted for 31% of the variance in the patient-reported outcome at 3 months postoperatively. CONCLUSION: Patient expectations and illness perceptions are associated with patient-reported pain and functional outcomes after surgical decompression for de Quervain's tenosynovitis. Addressing misconceptions about de Quervain's tenosynovitis in terms of the consequences for patients and how long their symptoms will last should allow patients to make informed decisions about the treatment that best matches their values. Prospective studies are needed to investigate whether addressing patient expectations and illness perceptions, with decision aids for example, can improve patient-reported pain and function postoperatively in those patients who still choose surgery for de Quervain's tenosynovitis. LEVEL OF EVIDENCE: Level III, therapeutic study.

Percutaneous Peripheral Nerve Stimulation (Neuromodulation) for Postoperative Pain: A Randomized, Sham-controlled Pilot Study.

BACKGROUND: Percutaneous peripheral nerve stimulation is an analgesic technique involving the percutaneous implantation of a lead followed by the delivery of electric current using an external pulse generator. Percutaneous peripheral nerve stimulation has been used extensively for chronic pain, but only uncontrolled series have been published for acute postoperative pain. The current multicenter study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent clinical trial and (2) estimate the treatment effect of percutaneous peripheral nerve stimulation on postoperative pain and opioid consumption. METHODS: Preoperatively, an electrical lead was percutaneously implanted to target the sciatic nerve for major foot/ankle surgery (e.g., hallux valgus correction), the femoral nerve for anterior cruciate ligament reconstruction, or the brachial plexus for rotator cuff repair, followed by a single injection of long-acting local anesthetic along the same nerve/plexus. Postoperatively, participants were randomized to 14 days of either electrical stimulation (n = 32) or sham stimulation (n = 34) using an external pulse generator in a double-masked fashion. The dual primary treatment effect outcome measures were (1) cumulative opioid consumption (in oral morphine equivalents) and (2) mean values of the "average" daily pain scores measured on the 0 to 10 Numeric Rating Scale within the first 7 postoperative days. RESULTS: During the first 7 postoperative days, opioid consumption in participants given active stimulation was a median (interquartile range) of 5 mg (0 to 30) versus 48 mg (25 to 90) in patients given sham treatment (ratio of geometric means, 0.20 [97.5% CI, 0.07 to 0.57]; P < 0.001). During this same period, the average pain intensity in patients given active stimulation was a mean ± SD of 1.1 ± 1.1 versus 3.1 ± 1.7 in those given sham (difference, -1.8 [97.5% CI, -2.6 to -0.9]; P < 0.001). CONCLUSIONS: Percutaneous peripheral nerve stimulation reduced pain scores and opioid requirements free of systemic side effects during at least the initial week after ambulatory orthopedic surgery.

Effects of Curcumin and Its Different Formulations in Preclinical and Clinical Studies of Peripheral Neuropathic and Postoperative Pain: A Comprehensive Review.

Lesion or disease of the somatosensory system leads to the development of neuropathic pain. Peripheral neuropathic pain encompasses damage or injury of the peripheral nervous system. On the other hand, 10-15% of individuals suffer from acute postoperative pain followed by persistent pain after undergoing surgeries. Antidepressants, anticonvulsants, baclofen, and clonidine are used to treat peripheral neuropathy, whereas opioids are used to treat postoperative pain. The negative effects associated with these drugs emphasize the search for alternative therapeutics with better efficacy and fewer side effects. Curcumin, a polyphenol isolated from the roots of Curcuma longa, possesses antibacterial, antioxidant, and anti-inflammatory properties. Furthermore, the low bioavailability and fast metabolism of curcumin have led to the advent of various curcumin formulations. The present review provides a comprehensive analysis on the effects of curcumin and its formulations in preclinical and clinical studies of neuropathic and postoperative pain. Based on the positive outcomes from both preclinical and clinical studies, curcumin holds the promise of mitigating or preventing neuropathic and postoperative pain conditions. However, more clinical studies with improved curcumin formulations are required to involve its use as adjuvant to neuropathic and postoperative drugs.

Do Relaxation Exercises Decrease Pain After Arthroscopic Rotator Cuff Repair? A Randomized Controlled Trial.

BACKGROUND: Pain after rotator cuff repair is commonly managed with opioid medications; however, these medications are associated with serious adverse effects. Relaxation exercises represent a potential nonpharmacologic method of pain management that can be easily implemented without substantial adverse effects; however, the effects of relaxation exercises have not been studied in a practical, reproducible protocol after arthroscopic rotator cuff repair. QUESTIONS/PURPOSES: (1) Does performing relaxation exercises after arthroscopic rotator cuff repair (ARCR) decrease pain compared with standard pain management medication? (2) Does performing relaxation exercises after ARCR decrease opioid consumption? (3) What proportion of patients who used the relaxation techniques believed they decreased their pain level, and what proportion continued using these techniques at 2 weeks? (4) Does performing relaxation exercises after ARCR affect shoulder function? METHODS: During the study period, 563 patients were eligible for inclusion; however, only 146 were enrolled, randomized, and postoperatively followed (relaxation group: 74, control group: 72); 68% (384 of 563) of patients were not contacted due to patient and research staff availability. Thirty-three patients were unenrolled preoperatively or immediately postoperatively due to change in operative procedure (such as, only debridement) or patient request; no postoperative data were collected from these patients. Follow-up proportions were similar between the relaxation and control groups (relaxation: 80%, control: 81%; p = 0.90). The relaxation group received and reviewed educational materials consisting of a 5-minute video and an educational pamphlet explaining relaxation breathing techniques, while the control group did not receive relaxation education materials. Patients recorded their pain levels and opioid consumption during the 5 days after ARCR. Patients also completed the American Shoulder and Elbow Surgeons shoulder score preoperatively and 2, 6, 13, 18, and 26 weeks postoperatively. Linear mixed models were created to analyze postoperative pain, opioid consumption measured in morphine milligram equivalents (MMEs), and shoulder function outcomes. A per-protocol approach was used to correct for patients who were enrolled but subsequently underwent other procedures. RESULTS: There was no difference in pain scores between the relaxation and control groups during the first 5 days postoperatively. There was no difference in pain scores at 2 weeks postoperatively between the relaxation and control groups (3.3 ± 3 versus 3.5 ± 2, mean difference -0.22 [95% CI -1.06 to 0.62]; p = 0.60). There was no difference in opioid consumption during the first 5 days postoperatively between the relaxation and control groups. The use of relaxation exercises resulted in lower 2-week narcotics consumption in the relaxation group than in the control group (309 ± 241 MMEs versus 442 ± 307 MMEs, mean difference -133 [95% CI -225 to -42]; p < 0.01). Sixty-two percent (41 of 66) of patients in the relaxation group believed the relaxation exercises decreased their pain levels. Fifty-two percent (34 of 66) were still performing the exercises at 2 weeks postoperatively. During the 6-month follow-up period, there was no difference in shoulder function between the relaxation and control groups. CONCLUSION: The preoperative administration of quick, basic relaxation exercises allowed patients to use appreciably lower opioid analgesic doses over the first 2 weeks after ARCR, without any worsening of pain scores. We consider this result promising but preliminary; it is possible that a more intense mindfulness intervention-the one we studied here was disseminated using only a 5-minute video-would deliver reductions in pain and further reductions in opioid usage. LEVEL OF EVIDENCE: Level II, therapeutic study.

Association of serotonin transporter-linked polymorphic region (5-HTTLPR) with heat pain stimulation and postoperative pain in gastric cancer patients.

BACKGROUND: The aim of this study was to assess whether the genotype of the serotonin transporter-linked polymorphic region (5-HTTLPR) in gastric cancer patients is associated with postoperative pain and pain threshold. METHODS: We conducted a prospective cohort study of 251 patients scheduled for gastrectomy from May to September 2019. All patients enrolled in the study were asked to complete the Hospital Anxiety and Depression Scale questionnaire. Heat pain threshold (HPT), cold pain threshold (CPT) and Pressure pain threshold (PPT) were measured for all participants one day prior to surgery. Blood samples were collected for genetic testing. All patients were connected to a patient-controlled intravenous analgesia (PCIA) pump at the end of the surgery. After exclusion of 15 patients, the postoperative conditions of 236 patients were recorded. RESULTS: Distribution of homozygous long (L/L), heterozygous (L/S), and homozygous short (S/S) 5-HTTLPR genotypes among participants were 26 (11.0%), 91 (38.6%), and 119 (50.4%), respectively. Heat pain threshold (P = 0.038) and Numerical rating scale (NRS) in the 1st postoperative 24 h (P = 0.026) were significantly different between long (L/L) and short (S/S) genotype carriers. CONCLUSIONS: In patients with gastric cancer, heat pain stimulation is associated with 5-HTTLPR polymorphism, and postoperative pain may be related to 5-HTTLPR polymorphism.