Full endoscopic versus open discectomy for sciatica: randomised controlled non-inferiority trial.

OBJECTIVE: To assess whether percutaneous transforaminal endoscopic discectomy (PTED) is non-inferior to conventional open microdiscectomy in reduction of leg pain caused by lumbar disc herniation. DESIGN: Multicentre randomised controlled trial with non-inferiority design. SETTING: Four hospitals in the Netherlands. PARTICIPANTS: 613 patients aged 18-70 years with at least six weeks of radiating leg pain caused by lumbar disc herniation. The trial included a predetermined set of 125 patients receiving PTED who were the learning curve cases performed by surgeons who did not do PTED before the trial. INTERVENTIONS: PTED (n=179) compared with open microdiscectomy (n=309). MAIN OUTCOME MEASURES: The primary outcome was self-reported leg pain measured by a 0-100 visual analogue scale at 12 months, assuming a non-inferiority margin of 5.0. Secondary outcomes included complications, reoperations, self-reported functional status as measured with the Oswestry Disability Index, visual analogue scale for back pain, health related quality of life, and self-perceived recovery. Outcomes were measured until one year after surgery and were longitudinally analysed according to the intention-to-treat principle. Patients belonging to the PTED learning curve were omitted from the primary analyses. RESULTS: At 12 months, patients who were randomised to PTED had a statistically significantly lower visual analogue scale score for leg pain (median 7.0, interquartile range 1.0-30.0) compared with patients randomised to open microdiscectomy (16.0, 2.0-53.5) (between group difference of 7.1, 95% confidence interval 2.8 to 11.3). Blood loss was less, length of hospital admission was shorter, and timing of postoperative mobilisation was earlier in the PTED group than in the open microdiscectomy group. Secondary patient reported outcomes such as the Oswestry Disability Index, visual analogue scale for back pain, health related quality of life, and self-perceived recovery, were similarly in favour of PTED. Within one year, nine (5%) in the PTED group compared with 14 (6%) in the open microdiscectomy group had repeated surgery. Per protocol analysis and sensitivity analyses including the patients of the learning curve resulted in similar outcomes to the primary analysis. CONCLUSIONS: PTED was non-inferior to open microdiscectomy in reduction of leg pain. PTED resulted in more favourable results for self-reported leg pain, back pain, functional status, quality of life, and recovery. These differences, however, were small and may not reach clinical relevance. PTED can be considered as an effective alternative to open microdiscectomy in treating sciatica. TRIAL REGISTRATION: NCT02602093ClinicalTrials.gov NCT02602093.

Effects of rTMS and tDCS on neuropathic pain after brachial plexus injury: a randomized placebo-controlled pilot study.

Neuropathic pain after brachial plexus injury (NPBPI) is a highly disabling clinical condition and is increasingly prevalent due to increased motorcycle accidents. Currently, no randomized controlled trials have evaluated the effectiveness of non-invasive brain stimulation techniques such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct-current stimulation (tDCS) in patients suffering from NPBPI. In this study, we directly compare the efficacy of 10-Hz rTMS and anodal 2 mA tDCS techniques applied over the motor cortex (5 daily consecutive sessions) in 20 patients with NPBPI, allocated into 2 parallel groups (active or sham). The order of the sessions was randomised for each of these treatment groups according to a crossover design and separated by a 30-day interval. Scores for "continuous" and "paroxysmal" pain (primary outcome) were tabulated after the last stimulation day and 30 days after. Secondary outcomes included the improvement in multidimensional aspects of pain, anxiety state and quality of life from a qualitative and quantitative approach. Active rTMS and tDCS were both superior to sham in reducing continuous (p < 0.001) and paroxysmal (p = 0.002; p = 0.02) pain as well as in multidimensional aspects of pain (p = 0.001; p = 0.002) and anxiety state (p = < 0.001; p = 0.005). Our results suggest rTMS and tDCS are able to treat NPBPI with little distinction in pain and anxiety state, which may promote the use of tDCS in brachial plexus injury pain management, as it constitutes an easier and more available technique.Clinical Trial Registration: http://www.ensaiosclinicos.gov.br/, RBR-5xnjbc - Sep 3, 2018.

Subgrouping of Peripheral Neuropathic Pain Patients According to Sensory Symptom Profile Using the Korean Version of the PainDETECT Questionnaire.

BACKGROUND: A culturally validated Korean version of the PainDETECT Questionnaire (PD-Q) was used to identify neuropathic pain components (NeP) in patients suffering from chronic pain. The purpose of this study was to determine if the Korean PD-Q can be used to subgroup patients with peripheral NeP according to sensory symptom profiles. METHODS: This study included 400 Korean patients with peripheral neuropathic pain diagnosed as probable or definite NeP. The total scores and subscores for each item in PD-Q were transformed into a Z-score for standardization. Hierarchical cluster analysis was performed to identify clusters of subjects by PD-Q scores. RESULTS: The mean total PD-Q score of the study participants was 14.57 ± 6.46. A hierarchical cluster analysis identified 5 clusters with distinct pain characteristic profiles. Cluster 1 had relatively severe burning and tingling sensations. The mean total PD-Q score for cluster 2 was the lowest of the 5 clusters. Cluster 3 tended to be vulnerable to pain in response to cold/heat stimulation. Cluster 4 showed relatively severe pain induced by physical stimuli, such as light touch or slight pressure. Cluster 5 had high scores for all NeP symptoms. CONCLUSION: This study demonstrates the ability of patients to cluster by symptoms using the Korean PD-Q. Subgrouping of peripheral neuropathic pain by sensory symptom profile may be useful in making effective drug treatment decisions.

ABCDEF Bundle Practices for Critically Ill Children: An International Survey of 161 PICUs in 18 Countries.

OBJECTIVES: To evaluate current international practice in PICUs regarding components of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Sedation, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Engagement/Empowerment" (ABCDEF) bundle. DESIGN: Online surveys conducted between 2017 and 2019. SETTING: One-hundred sixty-one PICUs across the United States (n = 82), Canada (n = 14), Brazil (n = 27), and Europe (n = 38) participating in the Prevalence of Acute Rehabilitation for Kids in the PICU study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 161 participating PICUs, 83% were in academic teaching hospitals and 42% were in free-standing children's hospitals. Median size was 16 beds (interquartile range, 10-24 beds). Only 15 PICUs (9%) had incorporated all six ABCDEF bundle components into routine practice. Standardized pain assessment (A) was the most common (91%), followed by family engagement (F, 88%) and routine sedation assessment (C) with validated scales (84%). Protocols for testing extubation readiness or conducting spontaneous breathing trials (B) were reported in 57%, with 34% reporting a ventilator weaning protocol. Routine delirium monitoring with a validated screening tool (D) was reported by 44% of PICUs, and 26% had a guideline, protocol, or policy for early exercise/mobility (E). Practices for spontaneous breathing trials were variable in 29% of Canadian PICUs versus greater than 50% in the other regions. Delirium monitoring was lowest in Brazilian PICUs (18%) versus greater than 40% in other regions, and family engagement was reported in 55% of European PICUs versus greater than 90% in other regions. CONCLUSIONS: ABCDEF bundle components have been adopted with substantial variability across regions. Additional research must rigorously evaluate the efficacy of specific elements with a focus on B, D, E, and full ABCDEF bundle implementation. Implementation science is needed to facilitate an understanding of the barriers to ABCDEF implementation and sustainability with a focus on specific cultural and regional differences.

Dor crônica, ansiedade e sintomas depressivos em estudantes de Enfermagem em tempos de pandemia / Chronic pain, anxiety, and depressive symptoms in nursing students in pandemic times / Dolor crónico, ansiedad y síntomas depresivos en estudiantes de Enfermería en tiempos de pandemia

Objetivos: Identificar as manifestações de dor crônica (DC), ansiedade e sintomas depressivos em estudantes de Enfermagem de uma universidade pública federal em tempos de pandemia, analisando a associação entre essas variáveis, e descrever as características sociodemográficas e de hábitos de vida na população estudada. Método: Estudo quantitativo, transversal, observacional e analítico, realizado de julho a novembro de 2020, com amostra de 119 estudantes de Enfermagem matriculados no segundo semestre de 2020. Foram utilizados questionários para caracterização sociodemográfica e de hábitos de vida, o mapa corporal da Escala Multidimensional de Avaliação de Dor, o Inventário de Ansiedade Traço-Estado e o Patient Health Questionnaire-9. Resultados: A maioria dos estudantes de Enfermagem da amostra é do sexo feminino, com idade média de 23,4 anos, e 37,8% convivem com DC. Os estudantes com DC apresentaram maiores níveis de ansiedade e mais sintomas depressivos. Verificou-se associação entre DC, ansiedade e sintomas depressivos nessa amostra. Conclusão: Durante o período pandêmico investigado, foi encontrada associação entre DC, ansiedade e sintomas depressivos na população de estudantes de Enfermagem da universidade investigada, indicando que os acadêmicos com DC experimentam maiores níveis de ansiedade e mais sintomas depressivos do que aqueles sem DC

Objectives: To identify the manifestations of chronic pain (CP), anxiety, and depressive symptoms in nursing students at a federal public university in pandemic times, analyzing the association between these variables and to describe population characteristics. Method: This was a quantitative, cross-sectional, observational, and analytical study carried out from July to November 2020 with a sample of 119 nursing students enrolled in the second half of 2020. Questionnaires were used to characterize sociodemographic and lifestyle habits, the body map of the Multidimensional Pain Evaluation Scale, the State-Trait Anxiety Inventory, and the Patient Health Questionnaire-9. Results: Nursing students in the studied sample are mostly female, with a mean age of 23.4 years, and 37.8% live with CP. Students with CP had higher anxiety levels and more depressive symptoms. There was an association between PC, anxiety, and depressive symptoms in this sample. Conclusion: During the pandemic period investigated, an association was found between PC, anxiety, and depressive symptoms in the population of nursing students at the studied university, indicating that those who live with PC experience higher anxiety levels and more depressive symptoms than students without PC

Objetivos: Identificar las manifestaciones de dolor crónico (DC), ansiedad y síntomas depresivos en estudiantes de enfermería de una universidad pública federal en tiempos de pandemia, analizando la asociación entre estas variables; y describir las características de la población. Método: Estudio cuantitativo, transversal, observacional y analítico, realizado de julio a noviembre de 2020, con una muestra de 119 estudiantes de enfermería matriculados en el segundo semestre de 2020. Se utilizaron cuestionarios para caracterizar hábitos sociodemográficos y de estilo de vida: el mapa corporal de la Escala Multidimensional de Evaluación del Dolor, el Inventario de Ansiedad Rasgo-Estado y el Patient Health Questionnaire-9. Resultados: La mayoría de los estudiantes de enfermería de la muestra estudiada son mujeres, con una edad media de 23,4 años, y el 37,8% vive con DC. Los estudiantes con DC tenían niveles más altos de ansiedad y más síntomas depresivos. Hubo una asociación entre DC, ansiedad y síntomas depresivos en esta muestra. Conclusión: Durante el período pandémico investigado, se encontró asociación entre DC, ansiedad y síntomas depresivos en la población de estudiantes de Enfermería de la universidad estudiada, señalando que quienes viven con DC experimentan mayores niveles de ansiedad y más síntomas depresivos que los estudiantes sin DC

Single-center outcomes of image-guided radiotherapy in the management of vertebral hemangioma with daily kilovoltage cone-beam computerized tomography.

BACKGROUND: Vertebral hemangiomas are defined as benign proliferation of blood vessels. Vertebral hemangiomas are generally found incidentally by computerized tomography or magnetic resonance imaging; however, they may also cause pain and quality-of-life impairment in some circumstances with reference to their location and association with the spinal cord. In this study, we assessed the utility of image-guided radiation therapy (IGRT) in the management of patients with painful vertebral hemangioma. MATERIALS AND METHODS: Patients receiving IGRT for the management of painful vertebral hemangioma were evaluated. The total dose was 24 Gy delivered in 12 daily fractions. The verbal numeric scale (VNS) was used for the assessment of pain relief. The median follow-up duration was 13 months (range: 6-24 months). RESULTS: Median preradiotherapy VNS score was 8 (range: 6-10) and median postradiotherapy VNS score was 1 (range: 0-2) for the total 135 patients treated with IGRT at our department for painful vertebral hemangioma. Reduction in VNS scores after IGRT was statistically significant (P < 0.05). CONCLUSION: Our single-center study revealed that IGRT resulted in substantial relief of pain from vertebral hemangioma. Randomized prospective multicenter trials are needed to shed light on the optimal management of patients suffering from pain due to vertebral hemangioma.

Complexity Assessment of Chronic Pain in Elderly Knee Osteoarthritis Based on Neuroimaging Recognition Techniques.

The chronic pain of knee osteoarthritis in the elderly is investigated in detail in this paper, as well as the complexity of chronic pain utilising neuroimaging recognition techniques. Chronic pain in knee osteoarthritis (KOA) has a major effect on patients' quality of life and functional activities; therefore, understanding the causes of KOA pain and the analgesic advantages of different therapies is important. In recent years, neuroimaging techniques have become increasingly important in basic and clinical pain research. Thanks to the application and development of neuroimaging techniques in the study of chronic pain in KOA, researchers have found that chronic pain in KOA contains both injury-receptive and neuropathic pain components. The neuropathic pain mechanism that causes KOA pain is complicated, and it may be produced by peripheral or central sensitization, but it has not gotten enough attention in clinical practice, and there is no agreement on how to treat combination neuropathic pain KOA. As a result, using neuroimaging techniques such as magnetic resonance imaging (MRI), electroencephalography (EEG), magnetoencephalography (MEG), and near-infrared spectroscopy (NIRS), this review examines the changes in brain pathophysiology-related regions caused by KOA pain, compares the latest results in pain assessment and prediction, and clarifies the central brain analgesic mechanistic. The capsule network model is introduced in this paper from the perspective of deep learning network structure to construct an information-complete and reversible image low-level feature bridge using isotropic representation, predict the corresponding capsule features from MRI voxel responses, and then, complete the accurate reconstruction of simple images using inverse transformation. The proposed model improves the structural similarity index by about 10%, improves the reconstruction performance of low-level feature content in simple images by about 10%, and achieves feature interpretation and analysis of low-level visual cortical fMRI voxels by visualising capsule features, according to the experimental results.

Defining Enhanced Recovery Pathway with or without Liposomal Bupivacaine in DIEP Flap Breast Reconstruction.

BACKGROUND: Enhanced recovery after surgery (ERAS) includes multiple interventions that have yielded positive outcomes in a number of surgical fields. The authors evaluated whether an ERAS protocol and the subsequent addition of liposomal bupivacaine affect patient outcomes specifically in deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS: All patients treated with DIEP flaps from January of 2016 to December of 2019 were reviewed retrospectively. The ERAS protocol was implemented midway through 2017; halfway through 2018, intraoperative transversus abdominis plane blocks with liposomal bupivacaine were added to the protocol. Such interventions allowed for comparison of three patient groups: before ERAS, during ERAS, and after ERAS plus liposomal bupivacaine. Primary outcomes observed were postoperative opioid consumption and length of stay. The p values were obtained using the Wilcoxon test for pairwise comparisons. RESULTS: After adjusting for ERAS group compliance, 216 patients were analyzed. The pre-ERAS group was composed of 67 patients, the ERAS group was composed of 69 patients, and the ERAS plus liposomal bupivacaine group was composed of 80 patients. Postoperative opioid consumption was reduced when comparing the pre-ERAS and ERAS groups (from 275.7 oral morphine equivalents to 146.7 oral morphine equivalents; p < 0.0001), and also reduced with the addition of liposomal bupivacaine (115.3 oral morphine equivalents; p = 0.016). Furthermore, hospital length of stay was decreased from 3.6 days in the pre-ERAS group to 3.2 days (p = 0.0029) in the ERAS group, and to 2.6 days (p < 0.0001) in the ERAS group plus liposomal bupivacaine groups. CONCLUSIONS: Enhanced recovery after surgery protocols decrease postoperative opioid consumption and hospital length of stay in DIEP flap breast reconstruction. The addition of liposomal bupivacaine further strengthens the impact of the protocol. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Computed Tomography-Guided Radiofrequency Ablation of the Cervical Dorsal Root Ganglia in 27 Patients with Cervical and Occipital Postherpetic Neuralgia.

BACKGROUND Postherpetic neuralgia (PHN) is a common complication of herpes zoster virus infection that is associated with intense pain. The present study aimed to investigate the use of computed tomography (CT)-guided radiofrequency ablation (RFA) of the cervical dorsal root ganglia (DRG) for treatment of cervical and occipital PHN in 27 patients at a single center. MATERIAL AND METHODS Twenty-seven patients with PHN in the cervical and/or occipital region were enrolled. After imaging the area of PHN in the patients, axial scanning was performed on the upper cervical segment in the spinal scanning mode. The puncture path was defined and then RFA therapy (90°C for 180 s) was performed by targeting the corresponding intervertebral foramen. Patients were followed 2 days later and at 1, 3, 6, and 12 months after surgery. Observation at each follow-up visit included rating of pain on a visual analog scale (VAS) and assessment of complications and adverse events. RESULTS VAS scores significantly decreased in patients with PHN after RFA compared with their scores before RFA (P<0.05). Skin sensation decreased in the area that was originally painful and allodynia significantly diminished. CONCLUSIONS The findings from this small study from a single center showed that CT-guided percutaneous RFA of cervical DRG safely and effectively reduced cervical and occipital PHN in the short term.

Cutoff criteria for the placebo response: a cluster and machine learning analysis of placebo analgesia.

Computations of placebo effects are essential in randomized controlled trials (RCTs) for separating the specific effects of treatments from unspecific effects associated with the therapeutic intervention. Thus, the identification of placebo responders is important for testing the efficacy of treatments and drugs. The present study uses data from an experimental study on placebo analgesia to suggest a statistical procedure to separate placebo responders from nonresponders and suggests cutoff values for when responses to placebo treatment are large enough to be separated from reported symptom changes in a no-treatment condition. Unsupervised cluster analysis was used to classify responders and nonresponders, and logistic regression implemented in machine learning was used to obtain cutoff values for placebo analgesic responses. The results showed that placebo responders can be statistically separated from nonresponders by cluster analysis and machine learning classification, and this procedure is potentially useful in other fields for the identification of responders to a treatment.

[Antalgic effects of socio-aesthetics in cancer patients]. / Effets antalgiques de la socio-esthétique chez les patients atteints de cancer.

INTRODUCTION: Socio-aesthetics is the delivery appropriate beauty care in a population weakened by a physical, psychological and/or social attack. It has found its place in indications in both medical (especially in oncology) and social settings. It offers many types of treatments including facials, foot beauty, make-up, wig tips, body massage, product advice, cosmetic manicure, varnishing… The main purpose of this study was to evaluate pain reduction as a result of socio-aesthetics. METHODS: One hundred and eighty patients were offered a socio-aesthetic session between 12/01/2018 and 11/30/2019. One hundred and fifty-seven (87,2%) accepted the care (56.7% of women/43.3% of men, regardless of the type of cancer) and all agreed to complete a questionnaire on the type of treatment received, the benefits felt and a Likert pain assessment scale before and after the treatment. RESULTS: No patient experienced an increase in pain after the socio-aesthetic care. In the general population, the mean pain evaluation was rated at 1.31/10 and 0.78/10 before and after the session respectively, p<10-5. By selecting patients experiencing pain before treatment (40 patients, 28.0% of the total population), the mean pain evaluation was 4.27/10 and 2.52/10 before and after the treatment respectively, p<10-5. Pain was significantly reduced by massage. No patient found the socio-aesthetic treatment unnecessary. CONCLUSION: Socio-aesthetics is definitely a supportive care in oncology as it is significantly analgesic. It is easily accepted by men and regardless of the type of cancer. Researchers should conduct more studies on its impact on the quality of life.

Treosulfan-induced myalgia in pediatric hematopoietic stem cell transplantation identified by an electronic health record text mining tool.

Treosulfan is increasingly used as myeloablative agent in conditioning regimen prior to allogeneic hematopoietic stem cell transplantation (HSCT). In our pediatric HSCT program, myalgia was regularly observed after treosulfan-based conditioning, which is a relatively unknown side effect. Using a natural language processing and text-mining tool (CDC), we investigated whether treosulfan compared with busulfan was associated with an increased risk of myalgia. Furthermore, among treosulfan users, we studied the characteristics of given treatment of myalgia, and studied prognostic factors for developing myalgia during treosulfan use. Electronic Health Records (EHRs) until 28 days after HSCT were screened using the CDC for myalgia and 22 synonyms. Time to myalgia, location of pain, duration, severity and drug treatment were collected. Pain severity was classified according to the WHO pain relief ladder. Logistic regression was performed to assess prognostic factors. 114 patients received treosulfan and 92 busulfan. Myalgia was reported in 37 patients; 34 patients in the treosulfan group and 3 patients in the busulfan group (p = 0.01). In the treosulfan group, median time to myalgia was 7 days (0-12) and median duration of pain was 19 days (4-73). 44% of patients needed strong acting opiates and adjuvant medicines (e.g. ketamine). Hemoglobinopathy was a significant risk factor, as compared to other underlying diseases (OR 7.16 95% CI 2.09-30.03, p = 0.003). Myalgia appears to be a common adverse effect of treosulfan in pediatric HSCT, especially in hemoglobinopathy. Using the CDC, EHRs were easily screened to detect this previously unknown side effect, proving the effectiveness of the tool. Recognition of treosulfan-induced myalgia is important for adequate pain management strategies and thereby for improving the quality of hospital stay.

Does Implant Selection Affect Patient-Reported Outcome Measures After Primary Total Hip Arthroplasty?

BACKGROUND: Total hip arthroplasty (THA) is a reliable operation, but it is critical that orthopaedic surgeons characterize which surgical factors influence patient-reported outcomes. The purpose of this study was to determine whether implant selection at the time of THA affects the odds of having (1) inadequate improvement according to patient-reported pain, function, and activity; (2) failure to achieve a substantial clinical benefit (SCB) with respect to pain; or (3) failure to achieve a patient-acceptable symptomatic state (PASS) according to pain and function. METHODS: Prospective data were collected from 4,716 patients who underwent primary THA (from July 2015 to August 2018) in a single health-care system with standardized care pathways. Patients were categorized according to the type of femoral and acetabular components and bearing surface used. Outcomes included 1-year postoperative patient-reported outcome measures (PROMs) and improvement in the Hip disability and Osteoarthritis Outcome Score (HOOS) and the University of California at Los Angeles (UCLA) activity score. Inadequate improvement was defined as PROMs that changed by less than the minimal clinically important difference (MCID) for the HOOS pain and physical function short form (PS) and as failure to improve beyond a mostly homebound activity status for the UCLA activity score (a score of ≤3). The MCID and SCB thresholds were set at values reported in the literature. RESULTS: One-year PROM data were available for 3,519 patients (74.6%). There were no differences in the proportion of patients who attained the MCID in terms of HOOS pain, HOOS PS, or UCLA activity scores at 1 year for all analyzed implant parameters. Multivariate regression demonstrated that implant selection was not a significant driver of inadequate improvement, according to HOOS pain and HOOS PS (p > 0.05). Larger (36-mm) femoral heads demonstrated lower odds of inadequate improvement versus 28-mm femoral heads according to UCLA activity scores (odds ratio [OR]: 0.64; 95% confidence interval, 0.47 to 0.86; p = 0.003). Implant-related criteria were not significant drivers of attaining a PASS or achieving an SCB with respect to HOOS pain. CONCLUSIONS: For the most part, THA implant characteristics are not drivers of inadequate improvement with respect to pain and function. Surgeons should utilize implants with an acceptable track record that allow stable fixation and restoration of hip biomechanics. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Targeted Muscle Reinnervation Improves Pain and Ambulation Outcomes in Highly Comorbid Amputees.

BACKGROUND: Approximately 200,000 people undergo a lower extremity amputation each year. Following amputation, patients suffer from chronic pain, inability to ambulate, and high mortality rates. Targeted muscle reinnervation is a nerve transfer procedure that redirects transected sensory and mixed nerves into motor nerves to treat neuroma and phantom limb pain. This study evaluates outcomes with prophylactic targeted muscle reinnervation at the time of below-knee amputation. METHODS: This is a cohort study comparing 100 patients undergoing below-knee amputation with primary targeted muscle reinnervation and 100 patients undergoing below-knee amputation with standard traction neurectomy and muscle implantation. Outcome metrics included the presence of residual and phantom limb pain, pain severity, opioid use, ambulation ability, and mortality rates. RESULTS: The targeted muscle reinnervation group was on average 60 years old with a body mass index of 29 kg/m2. Eighty-four percent had diabetes, 55 percent had peripheral vascular disease, and 43 percent had end-stage renal disease. Average follow-up was 9.6 months for the targeted muscle reinnervation group and 18.5 months for the nontargeted muscle reinnervation group. Seventy-one percent of targeted muscle reinnervation patients were pain free, compared with 36 percent (p < 0.01). Fourteen percent of targeted muscle reinnervation patients had residual limb pain, compared with 57 percent (p < 0.01). Nineteen percent of targeted muscle reinnervation patients had phantom limb pain, compared with 47 percent (p < 0.01). Six percent of targeted muscle reinnervation patients were on opioids, compared with 26 percent (p < 0.01); and 90.9 percent of targeted muscle reinnervation patients were ambulatory, compared with 70.5 percent (p < 0.01). CONCLUSION: Targeted muscle reinnervation reduces pain and improves ambulation in patients undergoing below-knee amputation, which may be critical in improving morbidity and mortality rates in this comorbid patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Randomized Controlled Trial of Virtual Reality in Awake Minor Pediatric Plastic Surgery Procedures.

BACKGROUND: Virtual reality has been used to alleviate pain and anxiety in a variety of medical procedures. The authors sought to explore the effects of virtual reality in common awake minor plastic surgery procedures where children may experience discomfort. METHODS: A randomized controlled trial compared virtual reality to standard-of-care distraction among children aged 6 to 16 years undergoing awake minor plastic surgery procedures at a quaternary children's hospital. Primary outcome was change in Faces Pain Scale-Revised pain score, and secondary outcomes included change in Venham Situational Anxiety Scale score, procedure duration, administration of local anesthetic, and pain/anxiety management satisfaction. RESULTS: Mean pain and anxiety scores were similar in both groups (p = 0.60 and p = 0.18, respectively), and procedure duration was shorter with virtual reality (22 minutes versus 29 minutes; p = 0.002). Duration remained shorter in a linear regression model accounting for procedure type (p = 0.01). Similar proportions of children received additional local anesthetic after the initial dose (virtual reality, n = 6; standard of care, n = 9; p = 0.19) and median pain management satisfaction was similar (virtual reality, 9 of 10; standard of care, 9 of 10; p = 0.41). Median anxiety management satisfaction was similar (virtual reality, 9 of 10; standard of care, 9 of 10; p = 0.05). Younger children reported more "fun" than older children with virtual reality (p = 0.02). Surgeons reported interest "using virtual reality again" in 83 percent of cases. CONCLUSIONS: The use of virtual reality for awake pediatric plastic surgery reduced procedure time but not pain or anxiety compared to standard of care in children aged 6 to 16 years. Virtual reality was safe and well-liked and should be considered as an additional tool. Increased efficiency may allow more cases to be performed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Mental-Health Phenotypes and Patient-Reported Outcomes in Upper-Extremity Illness.

BACKGROUND: Prior studies have suggested that misconceptions (i.e., unhelpful thoughts or cognitive errors resulting from cognitive bias) and distress (symptoms of anxiety or depression) are key factors associated with variation in health, as quantified with use of patient-reported outcome measures. The primary purpose of the present study was to identify mental-health phenotypes (i.e., combinations of various types of misconceptions and distress) that might help direct care and to test for differences in magnitude of activity tolerance, pain intensity, and self-efficacy in response to pain between phenotypes. We also studied demographic factors and diagnostic categories associated with mental-health phenotypes. METHODS: In a cross-sectional study, 137 patients seeking upper-extremity musculoskeletal specialty care completed a survey including demographics, mental-health questionnaires, and measures of upper-extremity-specific activity tolerance, pain intensity, and pain self-efficacy. We used cluster analysis to identify groups of patients with similar phenotypes. We used analysis of variance testing to assess differences in activity tolerance, pain intensity, and pain self-efficacy among phenotypes. RESULTS: The cluster analysis yielded 4 unique mental-health phenotypes, which fit the theoretical conceptualizations of "low misconception and low distress," "notable misconception," "notable depression and notable misconception," and "notable anxiety, depression, and misconception." Patients with low bias and low distress had significantly greater activity tolerance and greater pain self-efficacy than the other phenotypes, as well as a significantly lower pain intensity than phenotypes with notable distress. CONCLUSIONS: Cluster analysis of mental-health questionnaire data can identify mental-health phenotypes that are associated with greater activity tolerance and pain intensity. This approach might help clinicians to strategize and prioritize approaches that correct unhelpful thoughts and ameliorate symptoms of distress among patients seeking musculoskeletal specialty care. Such strategies have the potential to achieve more comprehensive, whole-person care, more selective operative treatment, and improved outcomes. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Thumb Carpometacarpal Arthritis Surgery: The Patient Experience.

BACKGROUND: Patients with symptomatic recalcitrant thumb carpometacarpal arthritis often undergo surgery. Although most surgical patients do well, the authors anticipated that a substantial portion of their thumb carpometacarpal surgery patients would have unsatisfactory experiences and express unmet expectations, dissatisfaction, and regret, regardless of surgical procedure performed. The authors hypothesized those experiences would correlate with patient-reported outcomes scores. METHODS: The authors identified patients who had undergone trapeziectomy alone or with ligament reconstruction 1 to 4 years previously for primary thumb carpometacarpal arthritis. One hundred twelve patients completed Quick Disabilities of the Arm, Shoulder and Hand and visual analogue scale pain, expectations, satisfaction, and regret questionnaires. RESULTS: More than 40 percent of patients expected to "return to normal" after surgery for pain, strength, and/or function. Including all patients, 7, 19, and 11 percent had unmet expectations for improvement in pain, strength, and function, respectively. Twelve percent expressed dissatisfaction with their outcome. Although just 4 percent regretted undergoing surgery, 13 percent would likely not recommend the procedure to someone they care about. There were no statistically significant differences for any patient-reported outcomes between trapeziectomy-alone (n = 20) and trapeziectomy with ligament reconstruction (n = 92). Visual analogue scale and Quick Disabilities of the Arm, Shoulder and Hand questionnaire scores were both moderately correlated with expectations being met for pain, strength, and function and for satisfaction with surgical outcome. CONCLUSIONS: Patients' thumb carpometacarpal surgical experiences vary considerably. Many express dissatisfaction or a lack of expectations met with the two most common procedures. A thorough understanding and review of expectations preoperatively may be uniquely pertinent for these patients. Further research should determine predictors and potentially modifiable factors for unsatisfactory outcomes.

Long-term pulmonary function, thoracic pain, and quality of life in patients with one or more rib fractures.

BACKGROUND: Long-term outcomes after rib fractures and the effect of treatment modality or chest wall injury severity on these outcomes remains uncertain. This retrospective cohort study evaluated the long-term pulmonary function, thoracic pain, and quality of life in patients admitted with rib fractures. METHODS: Patients admitted with rib fractures between January 1, 2012, and December 1, 2019, were included. Data on long-term outcomes were collected during one follow-up visit. Patients were stratified by chest wall injury severity (one or two rib fractures, ≥3 rib fractures, or a flail chest) and treatment modality (surgical stabilization of rib fractures [SSRF] or nonoperative management). Multivariable analysis was performed to compare outcomes after SSRF with nonoperative treatment in patients with three or more rib fractures. RESULTS: In total, 300 patients were included. The median follow-up was 39 months (P25-P75, 18-65 months). At follow-up, the corrected forced vital capacity returned to 84.7% (P25-P75, 74.3-93.7) and the forced expiratory volume in 1 second to 86.3% (P25-P75, 75.3-97.0) of the predicted reference values. Quality of life was determined using the Short Form-12 version 2 and EuroQoL-5D-5L. The Short Form-12 version 2 physical and mental component summary were 45 (P25-P75, 38-54) and 53 (P25-P75, 43-60), respectively. The EuroQoL-5D-5L utility score was 0.82 (P25-P75 0.66-0.92) and visual analog scale score 75 (P25-P75 70-85). This indicated a quality of life within normal population ranges. Moderate to severe thoracic pain was reported by 64 (21.3%) patients. Long-term outcomes returned to values within population ranges and were similar across chest wall injury severity and for patients treated with SSRF or nonoperatively. CONCLUSION: While long-term pulmonary function and quality of life recover to values considered normal, subjective thoracic complaints, such as pain and dyspnea, remain frequently present following rib fractures. No effect of chest wall injury severity or treatment modality on long-term outcomes was demonstrated. LEVEL OF EVIDENCE: Therapeutic, level III.