Measuring acute postoperative pain using the visual analog scale: the minimal clinically important difference and patient acceptable symptom state

The acute effects of neuromuscular electrical stimulation on coagulation and cardiovascular factors

Neuromuscular electrical stimulation (NMES) can potentially be used to prevent venous thromboembolism; however, its impact on coagulation-related factors remains poorly understood. We aimed to investigate the acute effects on coagulation- and cardiovascular factors immediately after a 2-h NMES session. Levels of overall hemostatic potential (OHP), fibrinogen, factor VIII, and Olink proteomic cardiovascular factors were assessed before and after the NMES session in 36 healthy participants (20 males and 16 females) with a mean age of 31.9 yr. NMES was administered using integrated textile electrodes in pants (NMES pants). Mean intensities during the quadriceps, hamstrings, and gluteus muscle stimulation were 16.5, 20.5, and 25.4 mA, respectively, corresponding to submaximal intensity levels with acceptable discomfort (just below 4 on the visual analogue scale [VAS], 0-10). The NMES session resulted in a significant increase in mean (SD) OHP [94.4 (28.3) to 103 (31.0)], and overall coagulation potential [292 (50.4) to 307(49.8)], and a decrease in overall fibrinolytic potential [68.2 (5.46) to 67.1 (5.20)]. These changes were highly correlated with the increase in fibrinogen (all R > 0.7, P ≤ 0.001), but not with the increase in factor VIII. In addition, 18 of 92 cardiovascular proteins, specifically those involved in regulating inflammation and extracellular matrix remodeling, were influenced by NMES; however, low correlations were found between the changes in these proteins and OHP analyses. In conclusion, the NMES session resulted in a slight increase in the coagulative state, mirroring that seen after a bout of regular exercise. The changes observed in cardiovascular factors, which are mostly not directly related to coagulation, suggest that NMES may subsequently modulate inflammatory responses, warranting further investigation.NEW & NOTEWORTHY The immediate response to a 2-h neuromuscular electrical stimulation (NMES) session, delivered at an acceptable level of discomfort using NMES-pants, marginally increases the coagulative state, similar to what is observed after regular physical exercise. This change is not expected to significantly increase the risk of blood clotting, as all factors remain within the normal reference range. Interestingly, NMES simultaneously appears to affect proteins that regulate the transition of inflammation into an anti-inflammatory response.

Effectiveness of paravertebral block in patients with herpes zoster according to the contrast spreading pattern: a retrospective cohort study

Objectives

This study aims to evaluate the treatment response to thoracic paravertebral block (PVB) in thoracic herpes zoster (HZ) pain based on the contrast spreading pattern.

Methods

Patients with HZ pain who underwent thoracic PVB under fluoroscopy were retrospectively analyzed. A comparative analysis of the treatment response was conducted between patients with epidural spread (ES group) and those without epidural spread (NES group) at the first visit after PVB. The treatment response was determined by setting the minimum clinically important difference (MCID) as a reduction of more than 1 point on the pain numerical rating scale (NRS). In addition, the treatment responses were compared according to prevertebral spread, intercostal spread, and segmented medial spread (base, foraminal, and subarticular-central spread). The NRS score was assessed at baseline and 3 days, 2 weeks, 1 and month after PVB. Generalized estimating equation (GEE) analysis was performed to identify the factors associated with the treatment response over time.

Results

In total, 48 patients were enrolled (ES, n = 21; NES, n = 27). The ES group had a higher proportion of patients with the treatment response than the NES group (p = 0.025). However, there was no significant difference in the treatment response according to prevertebral, intercostal, and segmented medial spread. In both groups, the mean NRS scores significantly decreased over time. Comparisons between groups at each time point were not significantly different. The GEE analysis showed that the duration after rash onset was the only significantly related factor in treatment response.

Conclusions

Patients with HZ pain who had epidural spread in PVB showed a better treatment response than those who did not at the first post-PVB assessment. Other spreading patterns did not have a significant effect on the treatment response. NRS decreased over time with no differences between groups. Only the duration after rash onset affected the longitudinal treatment response. Additional research is required to verify the efficacy of epidural spread in PVB.

Skin cooling reduces pain associated with peripheral nerve block to the face

PURPOSE

Peripheral nerve blocks are frequently used to treat chronic pain, but nerve block in itself may cause pain. Cooling the skin may inhibit pain associated with needle puncture to a venous, artery to the muscles, but it is not known if skin cooling inhibits pain associated with peripheral nerve block for chronic pain.

METHODS

As a randomized crossover design, we studied 14 patients (after obtaining approval from the research ethics committee and written informed consent) in whom a supraorbital, infraorbital or jaw nerve block was indicated, to compare the degree of pain (assessed using the Numerical Rating Scale) during needle puncture and during injection of a local anesthetic (2 ml of 0.2% ropivacaine), with and without cooling of the skin (to 20 °C).

RESULTS

Pain was significantly less with skin cooling than without, during needle puncture (P = 0.002; 95%CI for median difference: 3-3), and during injection of a local anesthetic (P = 0.0036: 95%CI for median difference: 2-2). Injection of a local anesthetic was significantly more painful than needle puncture, both with skin cooling (P = 0.0039) and without skin cooling (P = 0.015). There was no significant difference in the effect of skin cooling in reducing pain between needle puncture and injection of a local anesthetic (P = 0.48).

CONCLUSION

In patients receiving peripheral nerve blocks to the face, cooling of the puncture site of the skin may effectively inhibit pain during needle puncture and during injection of a local anesthetic. Clinical trial registration jRCT1031230725.

Correlation between dexmedetomidine and postoperative sleep quality in older patients undergoing intestinal surgery

OBJECTIVE

This study examined the correlation between dexmedetomidine and postoperative sleep quality in older patients following intestinal surgery.

METHODS

A total of 112 older patients were randomly assigned to receive either saline (Group A) or dexmedetomidine (Group B). Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI) before surgery and on postoperative days 1, 3, 7 and 30. Urinary melatonin and cortisol levels were measured, and pain intensity was assessed using the Visual Analogue Scale (VAS) at various time points. Logistic regression analysis identified factors influencing postoperative sleep quality.

RESULTS

Both groups showed increased PSQI scores postoperatively, with Group A scoring higher than Group B. Group B exhibited a significantly lower incidence of sleep disorders on Days 1 and 3. Urinary melatonin levels decreased in both groups, with Group A showing lower levels, while cortisol concentrations increased, particularly in Group A. Higher VAS scores were also noted in Group A. Patients not receiving dexmedetomidine had a greater prevalence of sleep disorders. Logistic regression revealed dexmedetomidine dosage, gender and VAS scores at 24 h as significant factors affecting sleep quality.

CONCLUSIONS

Dexmedetomidine enhances postoperative sleep quality in older patients undergoing intestinal surgery by reducing cortisol levels, increasing melatonin production and effectively alleviating pain, thereby supporting better recovery outcomes.

Outcomes of Cooled Radiofrequency Ablation of Lumbar Nerves as Treatment for Chronic Low Back Pain

INTRODUCTION

Worldwide, 23% of adults suffer from chronic lower back pain, which is defined as pain persisting for more than 3-6 months [Merskey in Can J Psychiatry 34:329-336, 1989]. The lifetime prevalence of back pain is as high as 84% in adults [Casiano VE, Sarwan G, Dydyk AM, et al. Back Pain. [Updated 2023 Dec 11]. In: Stat Pearls [Internet]. Treasure Island (FL): Stat Pearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538173/ ]. Conservative treatment options for chronic low back pain include as needed or scheduled analgesics, physical therapy, anticonvulsants, exercise, weight loss, muscle relaxants, and much more. With chronic pain that is refractory to the aforementioned treatments, more invasive procedures may be indicated. Cooled radiofrequency ablation (CRFA), a minimally invasive therapy, utilizes internally cooled radiofrequency probes to deliver targeted thermal energy that causes neurolysis, disrupting the transmission of pain stimuli along nociceptive pathways, thus resulting in pain relief [Walker in J Spinal Disord 13:205-217, 2000 June]. This study investigates whether patients receiving CRFA for relief of chronic low back pain caused by lumbar facet arthropathy experience a reduction in pain scores, the length of this reduction in pain scores, and the magnitude of this reduction in pain.

METHODS

This study was a retrospective analysis of data extracted from UW-Health Electronic Medical Health records (EMR), encompassing lumbar CRFA procedures performed from 2015 through April of 2024. Patient data was obtained, including diagnosis, preoperative pain score, postoperative pain score, duration of relief, patient age, sex, and BMI. A two-tailed paired t test was used to statistically analyze the preoperative and postoperative pain scores, in which a p value ≤ 0.05 was considered significant.

RESULTS

A total of 1450 lumbar CRFA procedures were reviewed, and 206 were excluded due to absent pre- or post-op pain scores. An additional eight procedures were excluded due to weekly lidocaine infusions in between their procedure and reporting of their post-op score. 1026 CRFA patients were included in the analysis, comprising 584 females and 442 males with an average age of 59.81 ± 13.40 and a BMI of 31.67 ± 7.13. The average pre-procedure visual analog scale (VAS) pain score was 6.44 (6.44 ± 1.67, n = 1236), and the average post-procedure VAS pain score was 3.21 (3.21 ± 2.45, n = 1236) this achieved statistical significance (p < 0.0001). Improvement of pain symptoms was reported in 85.92% (n = 1062), 14.08% (n = 174) reported complete pain remission, 7.61% (n = 94) reported no change, and 6.47% (n = 80) reported worsening symptoms. For effective procedures (those with any amount of pain relief, n = 1062) with an available postoperative pain score, the mean percentage improvement was 60.56 ± 27.21%. The average duration of improvement was 267.43 ± 393.18 days.

CONCLUSIONS

This study supports the potential efficacy of CRFA as a minimally invasive treatment for chronic back pain secondary to lumbar facet arthropathy refractory to conventional treatment measures, demonstrating significant relief for a substantial length of time. Due to chronic pain's detrimental effect on one's quality of life, finding effective treatment options is essential, especially for those refractory to conventional treatments.

Comparison of Posterior Quadratus Lumborum Block vs Surgical Wound Infiltration in Patients Undergoing Bariatric Sleeve Gastrectomy Surgery

BACKGROUND

We are studying whether the performance of the posterior quadratus lumborum block (pQLB) will decrease postoperative opioid consumption in patients undergoing laparoscopic sleeve gastrectomy (LSG) compared with surgical wound infiltration with local anesthetic.

METHODS

This is a single-center, prospective, randomized pilot study. Forty ASA 3 patients with severe obesity undergoing LSG were randomized to receive either the pQLB or surgical wound infiltration of local anesthetics. Major endpoints included postoperative analgesic medications in the pQLB group versus the surgical wound infiltration group, visual analog pain scores (VAS 0-10), postoperative time to first opioid, and incidence of nausea and vomiting.

RESULTS

Opioid consumption in morphine equivalents on postoperative days 1 (p = 0.86) and 2 (p = 0.57) was not significantly different between the two groups. However, patients in the pQLB group had significantly lower VAS pain scores on postoperative day 1 (p = 0.003) and postoperative day 2 (p = 0.04) than those who received surgical wound infiltration.

CONCLUSIONS

This prospective, randomized pilot study shows that the performance of pQLB did not reduce postoperative opioid consumption in patients undergoing LSG. However, patients who received the pQLB had significantly lower postoperative VAS pain scores. Therefore, the performance of pQLB is both feasible and may provide analgesic benefits in patients undergoing LSG.

The effect of topical TRanexamic Acid versus placebo on acute postoperative pain following Distal Radius fracture fixation: protocol for a randomised controlled trial at a quaternary care hand surgery centre - The TRADR study

INTRODUCTION

Postoperative pain management is a major concern for patients undergoing distal radius open reduction internal fixation (ORIF). Inadequate pain control negatively impacts patient's satisfaction and may increase opioid use. Topical tranexamic acid (TXA) has been demonstrated as an effective intervention that reduced acute postoperative pain in total knee arthroplasty. There is no study evaluating the effects of TXA on acute postoperative pain for distal radius ORIF. This study aims to evaluate the effect of topical TXA administration during isolated distal radius ORIF on early postoperative pain.

METHODS AND ANALYSIS

The effect of topical TRanexamic Acid versus placebo on acute postoperative pain following Distal Radius fracture fixation (TRADR) study is a randomised controlled double-blinded trial that will enrol 90 patients, 18 years of age or older, undergoing volar open reduction internal fixation. Patients will be randomly assigned to topical TXA versus topical saline (placebo) in a 1:1 ratio. The surgeon at the time of surgical closure after standard distal radius fixation will apply either 1 g of topical TXA (100 mg/mL; treatment group) or 10 mL of saline (control group) to the wound and let it sit for 5 min. Surgeons, patients, and outcome assessors will be blinded to the treatment group. The primary outcome is acute postsurgical pain as measured by the visual analogue scale (VAS). Pain outcomes will be between postoperative days 0 to 7, and at 2 and 6 weeks postsurgery. The secondary outcomes include opioid usage, unscheduled emergency visits, wrist swelling and adverse events.

ETHICS AND DISSEMINATION

This study was approved by the University Health Network Research Ethics Board (REB 23-5708). The results of this trial will be disseminated through peer-reviewed journals and presented at related conferences. The principal investigator will communicate the results with patients who have indicated an interest in knowing the results.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov NCT06384456, April 26, 2024; Pre-enrolment.

PROTOCOL VERSION

Version 2.0: August 26, 2024.

Comparison Between Erector Spinae Plane Block at T9 Level and Transversus Abdominis Plane Block for Postoperative Analgesia and Recovery in Patients with Obesity Undergoing Laparoscopic Sleeve Gastrectomy: A Randomized Controlled Trial

INTRODUCTION

Effective postoperative analgesia is essential for recovery after bariatric surgery. This study examines whether T9 erector spinae plane (ESP) block provides better analgesia and recovery than subcostal transversus abdominis plane (TAP) block in patients with obesity undergoing laparoscopic sleeve gastrectomy (LSG).

METHODS

Patients undergoing LSG were randomized to receive either ESP or TAP blocks. The primary outcome was pain intensity measured by the Numeric Rating Scale (NRS). Secondary outcomes included sensory blockade levels, opioid consumption (morphine equivalents), need for rescue analgesia, and recovery milestones.

RESULTS

Among 168 patients, median age was 29.0 years (ESP) vs 31.0 years (TAP) (p = 0.135), with most being female (67.9% ESP, 65.5% TAP) (p = 0.743). Median BMI was 36.7 kg/m2 (ESP) vs 37.1 kg/m2 (TAP) (p = 0.819). Patients receiving ESP blocks consistently reported lower NRS scores postoperatively (p = 0.002 and p < 0.001). Sensory blockade in the ESP group was more consistent (84.5% at T6-T12), whereas the TAP group exhibited greater variability (p < 0.001). Opioid consumption within 48 h was lower in the ESP group (median reduction of 8 mg) (p < 0.001). Moreover, ESP group patients needed less rescue analgesia (p = 0.001) and demonstrated faster functional recovery (p < 0.001).

CONCLUSIONS

For patients with obesity undergoing LSG, ultrasound-guided ESP block at T9 enhances postoperative analgesia and accelerates recovery compared to subcostal TAP block. While the difference in NRS scores was modest, ESP's ability to reduce opioid use and promote faster recovery highlights its clinical advantage.

Efficacy and safety of intravenous administration of dexamethasone on post-cesarean delivery pain: a systematic review and meta-analysis of current literature

BACKGROUND

Surgical tissue trauma induced by cesarean delivery serves as a pivotal stimulus for initiating the activation of nociceptors, leading to severe postoperative pain. Dexamethasone seems to mitigate pain-elicited inflammatory response and potentially serve as an analgesic adjunct in the post-cesarean period. This systematic review and meta-analysis aimed to assess the administration of intravenous dexamethasone for post-cesarean pain management.

METHODS

An electronic database search involving PubMed, Scopus, CENTRAL, and the Public Library of Science was conducted to identify all randomized controlled trials (RCTs) pertinent to the analgesic efficacy of intravenous dexamethasone compared with placebo for cesarean delivery. The risk of bias and certainty of evidence in eligible trials were assessed using the ROB2 tool and the GRADE approach, respectively.

RESULTS

Seventeen RCTs were included in the qualitative analysis, and 15 in the quantitative analysis. Intravenous dexamethasone was associated with prolonged time to first request for rescue analgesia (mean difference [MD] 3.33 hours, 95% CI 1.67 to 4.99; I2 = 92.7%), lower opioid analgesic consumption (MD, -3.23 mg; 95% CI, -4.04 to -2.41; I2 = 67.5%) within 24 hours and improved pain scores up to 24 hours postoperatively compared with placebo, however prediction intervals failed to confirm these favorable effects. The risk of postoperative nausea and vomiting was reduced with intravenous dexamethasone, but not that of pruritus.

CONCLUSIONS

Intravenous perioperative dexamethasone seems to be a promising adjunct to established analgesic modalities in cesarean delivery, with prolonged time to first request for rescue analgesia, reduced analgesic consumption, and reduced pain scores at rest up to 24 hours postoperatively. However, the substantial heterogeneity and low certainty of available evidence preclude any definite conclusions from being drawn.

Intraperitoneal local anesthetics for postoperative pain management following intra-abdominal surgery: a systematic review and meta-analysis

IMPORTANCE

Although intraperitoneal local anesthetics are commonly used following intra-abdominal surgical procedures, the level of evidence supporting their use for postoperative pain management remains uncertain.

OBJECTIVE

To evaluate the effect of intraperitoneal local anesthetics on postoperative pain following intra-abdominal surgery.

DATA SOURCES

Medline (PubMed), Embase (Embase.com), CENTRAL, Web of science and ClinicalTrials.gov databases were searched from their inception to July 15th, 2022.

TRIAL SELECTION

Randomized controlled trials comparing IPLA to placebo, usual care or other analgesic regimens among patients of any age undergoing any type of surgery.

DATA EXTRACTION AND SYNTHESIS

Trial selection, data extraction, risk of bias assessment and the certainty of evidence were conducted in duplicate independently. Meta-analyses were performed using random effect models.

MAIN OUTCOMES AND MEASURES

The co-primary outcomes were abdominal pain intensity at 6, 12, 24, 48, and 72 h after surgery. Secondary outcomes included postoperative nausea and vomiting, opioid use, recovery of gastrointestinal transit, length of hospital stay, postoperative chronic pain, persistent postoperative opioid use, quality of recovery and adverse events.

RESULTS

A total of 150 trials (n = 11,821 participants were included in our systematic review (97% of trials among adults). Intraperitoneal local anesthetics reduced postoperative pain intensity at 6 h (-0.86 point [95%CI -1.02 to -0.70]), 12 h (-0.74 point [95%CI -0.93 to -0.55]), 24 h (-0.65 point [95%CI -0.82 to -0.48]), and 48 h (-0.51 point [95%CI -0.70 to -0.31]), but not at 72 h (-0.38 point [95%CI -1.04 to 0.27]), with very low to low certainty of evidence. Modelled risk difference for achieving the clinically important effect and subgroup analyses among participants with moderate or high pain showed potential clinically significant effect from IPLA. Opioid use at 24 h (-10.4 mg of oral morphine equivalent [95% CI -13.1 to -7.6]), postoperative nausea and vomiting (RR 0.79 [95% CI -0.71 to 0.88]), and time to gastrointestinal transit recovery (-3.80 h [95% CI -7.54 to -0.07]) were also reduced. We found no association for other outcomes.

CONCLUSION AND RELEVANCE

Intraperitoneal local anesthetics may be associated with a small analgesic effect following intra-abdominal surgery. Considering the low to very low level of evidence supporting these findings, along with the limited data on adverse effects and long-term outcomes, their adoption as a standard of care intervention cannot be recommended at this stage.

REGISTRATION NUMBER

CRD42018115062.

Minimum clinically important differences in acute pain: a patient-level re-analysis of randomized controlled analgesic trials submitted to the US Food and Drug Administration

ABSTRACT

The lack of established minimum clinically important differences in acute pain has made it challenging to interpret efficacy in analgesic trials. We performed a patient-level re-analysis of double-blind, placebo-controlled trials submitted to the US Food and Drug Administration to estimate minimum clinically important differences in acute postoperative pain. Trials were categorized by acute surgical pain model: dental extraction, bunionectomy, orthopedic surgery, and soft tissue surgery. Pain intensity was assessed using the 0 to 10 numeric rating scale (NRS) or 0 to 100 visual analog scale, with visual analog scale scores converted to NRS for analysis. To avoid misclassification from arbitrary thresholds on global impression of change or pain relief scales, meaningful pain relief was determined using the double-stopwatch technique, where patients actively indicated the times they experienced perceptible and meaningful relief. Across 29 trials, 9047 patients with moderate-to-severe baseline pain were included. Patients with severe baseline pain (NRS ≥7) reported meaningful relief at a higher absolute NRS and required larger absolute reductions in pain intensity than those with moderate baseline pain (NRS 4-<7). However, the percent reduction in pain at meaningful relief remained stable across baseline pain levels, suggesting patients assess meaningful relief in relative rather than absolute terms. No appreciable differences in the changes in pain at meaningful relief were observed by age, sex, drug, or route of administration. Receiver operating characteristic curve analysis identified a 50% reduction in pain intensity as a consistent and clinically meaningful threshold across surgical pain models, supporting its use as a standardized patient-centric metric for evaluating analgesic efficacy.

Dosage of epidural morphine analgesia after lower abdominal cancer surgery: a randomized clinical trial among the older adults

BACKGROUND

Epidural morphine is considered one of the most potent drugs used for postoperative analgesia; however, its side effects are dose-related and exaggerated in elderly people. In this study, we aimed to determine which of three doses within that range (1.5 mg, 3 mg, or 4.5 mg) can provide adequate pain relief.

METHODS

A total of 102 patients were assessed for allocation into one of four groups to receive either placebo (group Morphine 0, N = 22), 1.5 mg of epidural morphine (Morphine 1.5, N = 22), 3 mg of epidural morphine (Morphine 3, N = 22), or 4.5 mg of epidural morphine (Morphine 4.5, N = 22) before skin incision, 24 h after surgery and 48 h after surgery. Cumulative intravenous IV-PCA morphine consumption, VAS pain scores, modified Ramsay Sedation Scores, nausea, vomiting, and pruritus were evaluated.

RESULTS

The VAS pain scores at activity of patients who received epidural morphine at doses of 3 mg and 4.5 mg were significantly lower than the placebo and 1.5 mg groups, VAS Score at 72 h was (2 ± 0.8) and (1.7 ± 1) vs (4.3 ± 1.1) and (4 ± 1) respectively, p value = 0.000. The mean total IV-PCA morphine consumption (mg) was significantly higher in patients who received received epidural 0.9% sodium chloride alone compared to 1.5 mg, 3 mg and 4.5 mg epidural morphine groups (38.1 ± 4.8 mg vs 27.2 ± 5.6 mg, 9.2 ± 3.5 mg, and 6.3 ± 3.3 mg respectively), p value = 0.000). However, the difference between the 3 mg and the 4.5 mg groups was not statistically significant in both of VAS scores and IV-PCA morphine consumption (P value > 0.05 for 3 mg vs. 4.5 mg). Patients who received 4.5 mg of epidural morphine experienced a significant increase in the level of sedation, measured by the Ramsay sedation scale, in comparison with 1.5 mg, 3 mg and placebo epidural morphine groups in the first 24 h, the Scale for this group was (2.5 ± 0.5) vs (2.1 ± 0.2, 2.1 ± 0.2, and 2.2 ± 0.5 respectively); p value = 0.000. No relationship between postoperative nausea and the dosage of epidural morphine was found.

CONCLUSION

Epidural morphine 3 mg as a bolus every 24 h with add on IV patient control analgesia (PCA) morphine, set to deliver 1.5 mg boluses on demand without background infusion with a lockout period of 45 min, could achieve effective and adequate analgesia lasting up to 72 h postoperatively without increasing in the level of sedation or other side effects in older adults after a lower abdominal cancer surgery.

Pericapsular nerve group (PENG) block: what have we learned in the last 5 years?

This educational article discusses the current understanding of the pericaspular nerve group block (PENG) of the hip regarding its mechanism of action and spread patterns, as well as plausible explanations for postblock quadriceps weakness. Finally, we will discuss the recent evidence of PENG block as an analgesic block in hip fractures and in different hip surgeries.

Efficacy of transversus abdominis plane block for gastric surgery: a meta-analysis

BACKGROUND

Multimodal analgesia is an important component of Enhanced Recovery After Surgery (ERAS). Transversus abdominis plane (TAP) block helps achieve this pain management in various types of surgeries. To evaluate the efficacy of TAP block versus non-TAP approaches for postoperative pain management and recovery after gastric surgery.

METHODS

A systematic literature search across four databases (Cochrane, Embase, Web of Science, PubMed) until February 2024 identified relevant randomized controlled trials (RCTs) evaluating TAP block in gastric surgery. Two independent reviewers screened studies, extracted data, and assessed analyses.

PRIMARY OUTCOME

postoperative pain scores.

SECONDARY OUTCOMES

postoperative opioid consumption, hospital stay, time to ambulation, and time to flatus.

RESULTS

Twelve RCTs involving 841 participants were included. Compared to non-TAP, the TAP group demonstrated significantly lower visual analog scale (VAS) pain scores at 1, 3, 6, 12, 24, and 48 h postoperatively (WMD range: -0.62 to -0.97). Time to first ambulation (SMD - 0.46; 95% CI: -0.92, 0.00) and first flatus (WMD - 5.17; 95% CI: -8.58, -1.77) were shorter in the TAP group. Postoperative opioid consumption was reduced with TAP (WMD - 1.89; 95% CI: -2.41, -1.37), with no difference in hospital stay between groups.

CONCLUSION

TAP block effectively relieves pain after gastric surgery, decreases postoperative morphine requirements, and modestly shortens bed rest duration while promoting intestinal function recovery. However, it does not significantly affect the overall hospital length of stay.

Outcomes of dual-mobility trapeziometacarpal arthroplasties: a systematic review

This systematic review reports the clinical, patient-reported, radiographic outcomes, complications and survivorship of dual-mobility trapeziometacarpal (TMC) joint arthroplasties including the MAÏA®, Moovis® and Touch® prostheses. Thirteen studies were included and outcomes reported for 1421 such arthroplasties. Overall, improvements in strength, range of motion, pain, function and satisfaction were demonstrated with a complication incidence of 13%. The risk of dislocation was 0.6%. The follow-up period was not long enough to draw conclusions about the long-term survival of the implants. Also, due to the low quality of the evidence, it was not possible to conclude that dual-mobility TMC arthroplasty was superior to trapeziectomy. This review highlights the need for Level I evidence with adequate long-term follow-up for TMC joint arthroplasty.

Deep brain stimulation and motor cortex stimulation for central post-stroke pain: a systematic review and meta-analysis

INTRODUCTION

Deep brain stimulation (DBS) and motor cortex stimulation (MCS) are invasive interventions in order to treat various neuropathic pain syndromes such as central post-stroke pain (CPSP). While each treatment has varying degree of success, comparative analysis has not yet been performed, and the success rates of these techniques using validated, objective pain scores have not been synthesized.

METHODS

A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. Three databases were searched, and articles published from January 2000 to October 2024 were included (last search date October 25, 2024). Meta-Analysis was performed using random effects models. We evaluated the performance of DBS or MCS by assessing studies that reported pain relief using visual analogue scale (VAS) or numerical rating scale (NRS) scores.

RESULTS

Of the 478 articles identified, 32 were included in the analysis (330 patients-139 DBS and 191 MCS). The improvement in mean VAS score for patients that underwent DBS post-surgery was 48.6% compared to a score of 53.1% for patients that had MCS. The pooled number of patients who improved after DBS was 0.62 (95% CI, 0.51-0.71, I2 = 16%). The pooled number of patients who improved after MCS was 0.64 (95% CI, 0.53-0.74, I2 = 40%).

CONCLUSION

The use of neurosurgical interventions such as DBS and MCS are last-resort treatments for CPSP, with limited studies exploring and comparing these two techniques. While our study shows that MCS might be a slightly better treatment option, further research would need to be done to determine the appropriate surgical intervention in the treatment of CPSP.

Combined general and neuraxial anesthesia versus general anesthesia alone for laparoscopic cholecystectomy: a meta-analysis of pain control and hemodynamic stability

Combined general and neuraxial anesthesia (CGNA) is an alternative technique that may enhance intraoperative outcomes and reduce postoperative pain in patients undergoing laparoscopic cholecystectomy. In this meta-analysis, we aimed to compare the perioperative outcomes of CGNA with those of general anesthesia alone. A systematic search of PubMed, Cochrane, Scopus, Web of Science, and gray literature was conducted from inception to July 2024. We evaluated postoperative pain at 2, 4, 6, and 12 h after surgery using the Visual Analogue Scale. Intraoperative outcomes, including systolic, diastolic, and mean arterial pressure, were assessed at the 30-minute mark during surgery. Data analysis was performed using R software. Quality assessment was carried out using Cochrane's risk of bias tools. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework was applied to describe the certainty of our findings. We meta-analyzed nine studies, encompassing a total of 724 patients. The analysis of postoperative pain revealed a significant reduction at 2, 4, 6, and 12 hours in the combined general and neuraxial anesthesia group, with the most pronounced effect occurring within the first four hours. Hemodynamic parameters showed a significant difference only in mean arterial pressure at 30 min during surgery, based on sensitivity analysis and the inclusion of only randomized controlled trials. Other vital signs, as well as the duration of surgery, anesthesia time, and rates of postoperative nausea and vomiting, were comparable between the two groups. A combined general and neuraxial anesthetic approach may improve postoperative pain relief and minimize hemodynamic stress during laparoscopic cholecystectomy and pneumoperitoneum-induced stress.

The analgesic effects of novel fascial plane blocks compared with intrathecal morphine after Caesarean delivery: a systematic review and meta-analysis

BACKGROUND

Intrathecal morphine is the mainstay for post-Caesarean multimodal analgesia but is associated with important side-effects. Novel ultrasound-guided abdominal wall fascial plane blocks are proposed as intrathecal morphine alternatives, but evidence of effectiveness is conflicting. We compared the analgesic effects of fascial plane blocks with those of intrathecal morphine after Caesarean delivery.

METHODS

We sought trials comparing the analgesic effects of intrathecal morphine with quadratus lumborum (QL), transversus abdominus plane (TAP), or erector spinae plane (ESP) blocks after Caesarean delivery. The primary outcome was rest pain intensity at 6 h on a visual analogue scale (VAS) ranging from 0 to 10 cm, with 10 cm indicating severe pain. Secondary outcomes included pain at 12 and 24 h; cumulative 24-h opioid consumption in milligrams of oral morphine; times to first analgesic request, ambulation, and breast feeding in hours; lengths of recovery room and hospital stay in hours; incidence of opioid-related side-effects; and block-related complications.

RESULTS

Eighteen trials (1525 subjects) were included. TAP block was evaluated in 11 studies, QL block in five, and ESP block in two. Intrathecal morphine was superior to TAP block for pain at 6 and 12 h, with mean differences (Hartung-Knapp-Sidik-Jonkman [HKSJ] 95% confidence interval [CI]) of 1.21 cm (0.42-2.00) (P=0.01, I2=80%) and 1.03 cm (0.05-2.01) (P=0.04, I2=86%), respectively. There were no differences in pain at 6 or 12 h between QL or ESP block compared with intrathecal morphine. Both TAP block and QL block reduced the odds of nausea and vomiting by 0.41 (0.21-0.79) (P=0.01) and 0.33 (0.23-0.48) (P=0.002), respectively, compared with intrathecal morphine. There were no differences in other outcomes. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) certainty of evidence was low across these pooled outcomes.

CONCLUSIONS

Quadratus lumborum block, rather than erector spinae or transversus abdominus plane blocks, may be a better intrathecal morphine alternative owing to similar post-Caesarean analgesic effects and reduced opioid-related side-effects.

SYSTEMATIC REVIEW PROTOCOL

CRD42024543371.

Pharmacokinetic Comparability and Safety Between Original and Citrate-Free Mirikizumab Formulations for Subcutaneous Injections: Results from Three Clinical Trials

INTRODUCTION

Mirikizumab, a p19-directed antibody against interleukin-23 (IL-23), is administered by subcutaneous (SC) injection. Injection site pain (ISP) associated with citrate buffers may negatively affect patient adherence to SC-administered treatments. We assessed the bioequivalence and safety of the citrate-free (CF) and original formulations of mirikizumab.

METHODS

The formulations were assessed in three phase 1, two-arm, randomized, single-dose, parallel design studies in healthy participants: study A (NCT04548219), study B (NCT05515601), and study C (NCT05644353). Participants were randomized 1:1 to either formulation, then further randomized to injection site locations of abdomen, arm, or thigh. The relative bioavailability (RBA) study A had a primary objective of assessing the RBA of a single 200 mg dose. Bioequivalence (BE) studies B and C had the primary objective of assessing the BE of a 200 and 300 mg dose, respectively. In all studies, the primary endpoints were Cmax, AUC(0-∞), and AUC(0-tlast). The secondary objective was to assess safety and tolerability by treatment-emergent adverse events and serious adverse events. In study A, ISP was quantified prospectively using the 100-mm validated visual analogue scale (VAS) assessment form.

RESULTS

The primary objective was met in all studies. The RBA study found no significant difference in exposure between the formulations. BE was demonstrated between CF and original mirikizumab in both BE studies, with the 90% confidence intervals of the ratios of geometric least squares means within the pre-specified equivalence limits of 0.80 and 1.25. The frequency of ISP and injection site reactions (ISRs) was lower for CF than original mirikizumab in all studies. Furthermore, a significant difference in mean VAS score was observed in study A.

CONCLUSION

Mirikizumab CF and original formulations were bioequivalent. The CF formulation was associated with less pain and fewer ISRs, with no other notable differences in safety profiles.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT04548219, NCT05515601, NCT05644353.

Hypnosis as a non-pharmacological intervention for invasive medical procedures - A systematic review and meta-analytic update

Hypnosis is recognized as an effective non-pharmacological intervention for managing anxiety, pain, and physiological stress during invasive medical procedures. Despite its growing use, variability in techniques and inconsistent outcome measurements have challenged its clinical standardization. This systematic review and meta-analysis evaluated the effectiveness of hypnosis in reducing anxiety, pain, and physiological stress during invasive procedures, while identifying the most effective techniques as well as assessing analgesic use and safety. A comprehensive literature search was conducted in PubMed, Cochrane Library, and Scopus to identify randomized controlled trials (RCTs) evaluating hypnosis in invasive procedures. Eligible studies were assessed for bias using the Revised Cochrane Risk of Bias Tool. Meta-analyses were performed with a random-effects model, and subgroup analyses were conducted based on hypnosis techniques, patient characteristics, and procedure types. Twenty RCTs with 1250 patients were included. Hypnosis significantly reduced anxiety (SMD = -0.43, 95 % CI: -0.58 to -0.28, p < 0.001) and pain (SMD = -0.35, 95 % CI: -0.50 to -0.20, p < 0.001) compared to standard care. Subgroup analyses indicated that virtual reality-enhanced hypnosis and tailored interventions for high-anxiety procedures were most beneficial. Physiological stress markers, including heart rate and blood pressure, were also reduced, supporting the calming effects of hypnosis. Adverse effects were minimal. Hypnosis is effective and safe for reducing anxiety and pain during invasive medical procedures. Standardized protocols and further research are needed to optimize its clinical use and enhance adoption in routine care.

Preoperative Analgesia in Midurethral Sling: A Cohort Study

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence (SUI) is a common condition among adult women in the USA, with its prevalence expected to rise owing to an aging population. Midurethral sling (MUS) procedures are a well-established surgical treatment for SUI. Enhanced Recovery After Surgery (ERAS) protocols advocate for multimodal pain management strategies, including preoperative analgesia. However, limited data exist on the effectiveness of preoperative pain medications in MUS procedures. This study examines the impact of preoperative analgesia on postoperative pain scores and opioid consumption.

METHODS

A retrospective cohort study analyzed women who underwent MUS placement between 2018 and 2022 within a New England health care system. Patients were stratified by preoperative pain medication use. Primary outcomes included postoperative pain scores and opioid consumption. Secondary outcomes assessed anesthesia type, sling type, and operative time. Multivariable regression analyses adjusted for confounders.

RESULTS

A total of 631 patients met the inclusion criteria, with 400 receiving preoperative pain medications. Patients with preoperative analgesia had significantly lower median postoperative pain scores (p = 0.013) and were more likely to achieve acceptable pain control (p = 0.014). However, adjusted analyses found no significant difference in opioid consumption or pain scores between groups.

CONCLUSION

Preoperative pain medications were associated with improved pain scores in unadjusted analyses but did not demonstrate independent statistical significance after adjusting for confounders. These findings highlight the complexity of pain management in MUS procedures. Further randomized studies are needed to refine ERAS pain strategies in urogynecological surgery.

The Effects of Intraperitoneal Dexmedetomidine in Comparison with Ropivacaine in Postoperative Pain After Laparoscopic Sleeve Gastrectomy: A Double-Blind, Randomized, Placebo-Controlled, Clinical Trial

BACKGROUND

Studies have shown that non-opioid analgesic drugs can reduce the pain of patients after bariatric surgery. Ropivacaine and dexmedetomidine are associated with high efficacy and safety in managing postoperative complications. We evaluated the effectiveness of ropivacaine alone and in combination with dexmedetomidine in improving outcomes after sleeve gastrectomy surgery.

METHODS

This double-blind, randomized clinical trial, included patients undergoing bariatric surgery in 2022 and 2023. The participants were randomly divided into three groups: treated with ropivacaine alone (group A), ropivacaine and dexmedetomidine combination (group B), or normal saline (group C). Pain scores, morphine consumption, and postoperative nausea and vomiting (PONV) were assessed over 24 h.

RESULTS

All groups showed reduced pain, but group B had significantly lower VAS scores than groups A and C at 4-24 h postoperatively, with the highest difference achieved by group B compared to control at 12-h time point (β =  - 2.5, P < 0.001). Morphine use was lowest in group B (4.38 ± 1.24 mg vs. 6.04 ± 2.07 mg in group A and 7.50 ± 2.55 mg in group C; P < 0.001). PONV incidence was also lower in group B (8.3% vs. 29.2% in group A and 50% in group C; P = 0.008).

CONCLUSIONS

The ropivacaine and dexmedetomidine combination therapy was associated with a greater pain relief effect after sleeve gastrectomy, a greater reduction in the need to take opioids, and a lower frequency of PONV compared to the ropivacaine alone or placebo.

Modified transforaminal epidural steroid injection combined with pulsed radiofrequency: an effective treatment measure for lumbar radiculopathy

Background

Lumbar disc herniation (LDH) is a prevalent condition encountered in the clinical diagnosis and management of spinal surgery. Certain people may experience excruciating radicular pain in the lower extremities. If these symptoms are not promptly alleviated, they may progressively deteriorate, ultimately resulting in radiating pain in the lower extremities, advancing neurological impairments, and potential trouble in standing, significantly impairing the patient's quality of life. Consequently, clinicians require an expedited and efficacious approach to address radicular discomfort resulting from lumbar radiculopathy and promptly reinstate the patient's normal functionality.

Objectives

This study seeks to assess the effectiveness of a modified transforaminal epidural steroid injection (TFESI) in conjunction with pulsed radiofrequency (PRF) for treating lumbar radiculopathy using a retrospective analysis.

Methods

Our study examined patients with unilateral lower limb radicular pain persisting for three months or more due to LDH, in whom conservative therapies were ineffective, from January 1, 2023, to October 31, 2023. This trial comprised 106 patients who received modified TFESI alongside PRF. We evaluated clinical efficacy and follow-up at baseline and at 1 week, 1 month, 3 months, 6 months, and 12 months post-surgery primarily using the Visual Analog Scale (VAS), Oswestry disability index (ODI), and modified MacNab score.

Results

Patients who received modified TFESI in conjunction with PRF exhibited substantial enhancements across all three assessment instruments (VAS, ODI, MacNab) when compared to pre-treatment evaluations (p < 0.0001). The alleviation of radicular discomfort was notably enduring, meeting the patients' expectations. At the 12-month follow-up, we noted that patients often achieved substantial pain alleviation within 6 months, and only a minor proportion of patients encountered pain recurrence by the 12th month, with no notable problems detected.

Conclusions

The modified TFESI in conjunction with PRF is a safe, cost-efficient, and successful therapy modality. Our findings indicated that this method can efficiently and swiftly relieve patients' radicular discomfort and produce enduring therapeutic effects.

Lateral closing wedge high tibial osteotomy procedure for the treatment of medial knee osteoarthritis: eleven years mean follow up analysis

PURPOSE

To assess long term survivorship, patient reported (PROMs) and radiological outcomes, and rate of adverse events and hardware removal after lateral closing wedge high tibial osteotomy (CWHTO) for the treatment of medial knee osteoarthritis (OA) and varus malalignment.

METHODS

Retrospective analysis of patients who underwent isolated CWHTO for medial OA in varus knee between 2009 and 2019 at the same institution was performed. Surgical failure was defined as conversion to total knee arthroplasty (TKA) or need for osteotomy revision procedure for varus recurrence, while clinical failure was defined by a Lysholm score under 65 points. Lysholm score, Visual Analogue Scale for pain (VAS), and patients' satisfaction with the treatment were evaluated. Radiographic parameters assessed included OA degree with the Kellgren Lawrence scale (KL), hip-knee-ankle angle (HKA), medial proximal tibial angle (MPTA), lateral distal femoral angle (LDFA), joint line convergence angle (JLCA), and posterior tibial slope (PTS). Adverse events and rate of hardware removal procedures were recorded through follow up visits and clinical records. Survival analysis was conducted through Kaplan-Meier method with surgical and clinical failure as endpoints.

RESULTS

70 knees (mean age at surgery 43.3 years) were included in the survivorship analysis at a mean follow up of 11.6 ± 3.4 years. A failure rate of 12.85% (9/70) was recorded during the follow up period, with a survivorship of 92% and 75% at ten and 15 years of follow up, respectively. Mean Lysholm score and VAS at follow up were above the PASS threshold reported in literature. The 75.7% of patients were satisfied with the treatment. Radiological follow up indicated a residual mechanical varus of 2.1°, a decrease of 0.7° of intra articular deformity (JLCA), no change in PTS nor in KL index. The adverse events rate recorded was 5.7% (4/70). In nine knees (14.7%) among the patients survived from surgical failure a subsequent hardware removal procedure was performed.

CONCLUSION

CWHTO represents a safe procedure, which resulted in high survivorship (92% and 75% at ten and 15 years follow up, respectively), with satisfactory PROMs and radiological outcomes at long term follow up in patients affected by medial OA and varus malalignment.

LEVEL OF EVIDENCE

5, Case Series.

Lived experience perspectives of persons with complex regional pain syndrome: a survey study of the history of their condition, treatments and functional outcomes

Background

Complex Regional Pain Syndrome (CRPS) is a rare, chronic pain disorder that can have a devastating impact. Its cause remains unclear and debate over treatment strategies continues. The aim of the study was to utilise patient-reported outcomes to aid in the further evaluation of treatment options.

Method

An online survey was distributed with ethical approval to members of a CRPS charity. The Checklist for Reporting Results of Internet E-Surveys was implemented. Adults who met the patient-reported aspect of the Budapest Criteria were included (non-validated). Functional scores were reported using the shortened Disabilities of the Arm, Shoulder and Hand outcome measurement tool (QuickDASH) and Lower Extremity Functional Scale (LEFS). Participants completed a pre-injury score, a score related to injury and a score related specifically to CRPS symptoms. Respondents were also asked to rate a number of pharmacological and non-pharmacological treatments for CRPS.

Results

Respondents were mostly female (87%, 447/514) with a mean age of 49 years (SD 13). 69% (354/514) reported trauma as the inciting event. Anxiety (55%, 283/514) was the most commonly reported co-morbidity. Opioids (72%, 258/358) and Physical Therapy/Rehabilitation (63%, 281/444) were reported as the most beneficial (used by >10% of respondents) pharmacological and non-pharmacological therapies respectively. Median CRPS functional scores were significantly worse than scores relating to the injury alone, for both QuickDASH (56 (IQR 36-77) versus 77 (IQR 61-91), p < .001) and LEFS (20 (IQR 8-40) versus 7 (IQR 3-17), p < .001).

Conclusion

We present the first study using validated patient-reported outcome measures of limb-specific function in a solely CRPS population. These data quantify the devastating impact of CRPS and help make its prevention and treatment a priority amongst those who encounter it. The treatment data should inform future research, especially in successful therapies that were less commonly utilised.

Comparing Analgesic Regimen Effectiveness and Safety after Surgery (CARES): protocol for a pragmatic, international multicentre randomised trial

INTRODUCTION

Acute pain is commonly experienced by millions of patients who undergo outpatient surgical procedures. Moreover, an increasing number of procedures are performed on an outpatient basis, requiring greater postoperative planning to ensure effective pain management. Analgesic approaches commonly involve prescription opioids and non-steroidal anti-inflammatory drugs (NSAIDs), but an optimal regimen that balances pain and adverse effects has not been identified. In addition, critical gaps in evidence exist regarding how opioids and NSAIDs compare as analgesic regimens after surgery.

METHODS AND ANALYSIS

The Comparing Analgesic Regimen Effectiveness and Safety after Surgery (CARES) trial is a pragmatic, international, multicentre randomised trial that enrols adults undergoing three elective surgical procedures (laparoscopic cholecystectomy, breast lumpectomy, hernia repair). Participants are randomised to receive discharge analgesic prescriptions that consist of either NSAIDs or low-dose opioids (ie, 10 pills of oxycodone 5 mg or equivalent), with both groups prescribed acetaminophen around-the-clock. The primary effectiveness outcome is patient-reported worst daily pain intensity over the first 7 days after surgery. The primary safety outcome is the occurrence of opioid and/or NSAID side effects over the first 7 days after surgery. Secondary outcomes are assessed by patient report and medical record review at 1 week, 1 month, 3 months and 6 months after surgery and include sleep disturbance, patient perception of improvement/change after treatment, pain interference, anxiety, depression, health-related quality of life, clinically important adverse events, substance use, opioid misuse, chronic pain, healthcare utilisation related to pain and quality of recovery.

ETHICS AND DISSEMINATION

Investigational review boards at the University of Michigan and other sites have approved the CARES trial. The first patient enrolled in CARES in February 2023, with recruitment anticipated through 2026. Dissemination builds on the input of patient partners and other members of an engaged Stakeholder Advisory Board, with activities spanning co-production of summaries to share results with study participants, publications in biomedical journals and lay press, presentations to scientific and community organisations, and other multimedia communication materials.

TRIAL REGISTRATION NUMBER

NCT05722002.

The efficacy of liposomal bupivacaine in parasacral ischial plane block for pain management after total knee arthroplasty: a randomized controlled trial

BACKGROUND

Utilizing liposomal bupivacaine (LB) for postoperative analgesia post-total knee arthroplasty (TKA) is prevalent. However, its effectiveness in pain control, specifically in the parasacral ischial plane block (PIPB) post-TKA, remains unknown.

METHODS

This single-center, double-blinded, randomized controlled trial recruited patients scheduled for unilateral TKA. Forty-five patients were randomly assigned in a 1:1 ratio to receive 133 mg (Group A) or 266 mg (Group B) LB using the block randomization method. The PIPB effectiveness was assessed by evaluating changes in sensory and motor functions. The primary outcome was the cumulative area under the curve (AUC) of the Numerical Rating Scale (NRS) at rest within 72 h postoperatively. All patients were included in the analyses of analgesic efficacy, rehabilitation quality, and adverse events.

RESULTS

Between January 30, 2024, and May 1, 2024, 45 patients were enrolled and randomly assigned to Group A (n = 22) and Group B (n = 23). A significant between-group difference was observed in the NRS-AUC0-72 h at rest postoperatively (132.3 ± 19.7 vs. 97.3 ± 19.1, p = 0.001), but none was observed in NRS-AUC0-72 h during activity (p = 0.642). Kaplan-Meier survival analysis revealed significant between-group differences in the median onset times of sensory [60 vs. 35(min), p < 0.0001] and motor blocks [85 vs. 50(min), p < 0.0001]. The onset time of sensory block was notably shorter than that of motor block in both groups. No significant variance was observed in the median regression time for the sensory block. A significant between-group difference in the rescue analgesic dosage was observed on the first postoperative day [43.1 vs. 27.2(mg), p = 0.009], with no significant differences in the subsequent two days or the total amount. No significant between-group differences were found in adverse events or rehabilitation quality.

CONCLUSION

LB used in the PIPB was effective for analgesia at rest post-TKA, with 266 mg demonstrating superiority. Trial RegistrationThe randomized controlled trial was registered in the Chinese Clinical Trial Registry (https://www.chictr.org.cn/, No: ChiCTR2400079606).

Closed vs open surgical exposure of palatally displaced canines: Patients' perceptions of recovery, operating time, and complications-A 2-center randomized controlled trial

INTRODUCTION

The objective of this trial was to compare, in a 3-week follow-up, patients' perceptions of recovery, surgery time, and complications related to surgical exposure of palatally displaced canines (PDCs) with either the closed or the open techniques.

METHODS

This study was a 2-center, 2-arm parallel randomized clinical trial with a 1:1 allocation ratio. A total of 100 participants with PDC from 2 university clinics, aged <16 years, with unilateral or bilateral PDCs with cusp tip position in sectors II-IV, were randomly allocated to either closed-exposure or open-exposure techniques. Outcomes related to surgery and surgery/dressing removal interventions were analyzed by blinded assessors. Patients' perceptions during both interventions and the week postinterventions were evaluated using take-home questionnaires, which included 3 question types: visual analog scale (VAS) questions about pain/discomfort, binary questions about analgesic intake, and open questions about complications. Surgical duration and professional-reported complications were assessed in patient journals. Mixed models with random intercepts were used to examine the effects of treatment on VAS scores (Gaussian model) and the use of analgesics (logistic model). Linear regression was used to examine the effect of the treatment on the operation. Statistical significance was set at <0.05.

RESULTS

A total of 92 participants were included with no baseline differences between the intervention groups. There were no significant differences in patient perceptions between the centers. The open approach showed higher VAS scores for pain (coefficient, 8.58 [95% confidence interval, 2.29-14.88]; P <0.01) and discomfort (coefficient, 9.15 [95% confidence interval, 2.33-15.98]; P <0.01) from the exposure operation onwards, with nonsignificantly higher scores for patients with bilateral than unilateral PDCs. No pain/discomfort score differences were observed between treatment groups or between patients with bilateral or unilateral PDCs at surgery/dressing removal intervention. There were no differences in analgesic intake after surgery, but there was significantly more consumption after suture/dressing removal with the closed technique. Overall, a shorter duration was observed for the open technique, particularly when no flap surgeries were performed. Few complications were detected and were more common in the open group.

CONCLUSIONS

There was more pain and discomfort in the open group during surgery and the following week; however, no difference was observed during suture/dressing removal or the week after. There was increased analgesic intake in the closed group after suture dressing removal. Open surgical exposure required a shorter time, particularly when no flap surgery was performed. Complications were sparse and more common in the open group.

REGISTRATION

ClinicalTrials.gov (NCT05067712) PROTOCOL: Published before trial commencement.

FUNDING

University of Oslo.

Alkalinised lidocaine as an anaesthetic before onabotulinumtoxinA injections. a randomised trial

OBJECTIVES

To evaluate the effect of intravesical alkalinised lidocaine as an anaesthetic treatment on procedural pain during intradetrusor onabotulinumtoxinA (BTX-A) injections for overactive bladder.

PATIENTS AND METHODS

This single-centre, randomised, double-blind, placebo-controlled two period crossover trial was conducted on women scheduled for BTX-A injections at our outpatient urogynaecology clinic between September 2022 and May 2024. Patients were randomly assigned (1:1) to receive either alkalinised lidocaine or placebo during the first treatment period. Alkalinised lidocaine solution comprised lidocaine hydrochloride (20 mg/mL, 20 mL), sodium hydrogen carbonate (1 mmoL/mL, 10 mL), and sodium chloride (9 g/L, 10 mL). The matching placebo was sodium chloride (9 g/L, 40 mL). The primary outcome measure was procedural pain rated on a 100-mm visual analogue scale (VAS). Secondary outcomes included adverse effects such as post-void residual urine volumes requiring catheterisation, urinary tract infection, haematuria 1 week after treatment, and patient satisfaction measured on a 5-point scale. During the second treatment period, patients received the alternative intervention.

RESULTS

We enrolled 50 patients, of which 41 were eligible for per-protocol analyses. The mean VAS score was significantly lower following intravesical alkalinised lidocaine (mean 21.3 mm, 95% confidence interval [CI] 14.7-27.8 mm) compared to placebo (mean 41.6 mm, 95% CI 35.0-48.1 mm) with a mean difference of -20.3 mm (95% CI -29.2 to -11.5 mm; P < 0.001). Adverse events and patient satisfaction did not significantly differ between the alkalinised lidocaine and placebo treatments (P = 0.825 and P = 0.138, respectively).

CONCLUSIONS

Intravesical instillation of alkalinised lidocaine before BTX-A injections significantly reduced VAS pain scores compared to placebo (ClinicalTrials.gov identifier: NCT05415865).

Interscalene nerve block with plain bupivacaine versus liposomal bupivacaine for arthroscopic rotator cuff repair: A randomized controlled trial

Background

Although single injections with anesthetics are commonly administered given their safety, their short-acting nature limits pain control. Liposomal bupivacaine represents a promising alternative to plain bupivacaine in interscalene nerve blocks. The goal of our study was to determine whether an interscalene block with liposomal bupivacaine provides superior analgesia and reduces opioid requirements compared to plain bupivacaine in patients undergoing arthroscopic rotator cuff repair (ARCR).

Methods and Materials

A single-center, double-blinded, randomized controlled trial of patients undergoing ARCR was performed. Patients received a single-shot interscalene nerve block with plain bupivacaine or liposomal bupivacaine. Visual analog scale pain scores at rest and with activity, as well as morphine milligram equivalents, were recorded in postoperative recovery and on postoperative days 1, 2, 3, and 7. Comparisons between groups were made using descriptive statistics; the significance level was set at P < 0.05.

Results

A total of 41 patients were randomized into the liposomal bupivacaine (n = 18 patients) and plain bupivacaine (n = 23 patients) groups. The differences in visual analog scale and morphine milligram equivalents between the two groups were not significant, with or without movement, on all postoperative days assessed.

Conclusion

There was no difference in the visual analog scale or morphine milligram equivalents after arthroscopic rotator cuff repair with interscalene blocks using liposomal bupivacaine versus plain bupivacaine. Given the increased cost associated with liposomal bupivacaine use and the variation in multimodal pain regimens worldwide, multicenter clinical trials are necessary to examine the clinical benefit and cost-effectiveness of liposomal bupivacaine in patients undergoing rotator cuff repair.

Regional Analgesia in Pediatric Cardiothoracic Surgery: A Bayesian Network Meta-Analysis

Various regional analgesia techniques are used to reduce postoperative pain in pediatric patients undergoing cardiothoracic surgeries. This study aimed to determine the relative efficacy of regional analgesic interventions. PubMed, EMBASE, Web of Science, and Cochrane databases were searched to identify all randomized controlled studies evaluating the effects of regional block after cardiothoracic surgery. The primary endpoint was opioid consumption within 24 hours postoperatively, Pain scores, the time to first rescue analgesic, and the incidence of postoperative nausea and vomiting were also collected. A Bayesian NMA was performed to compare the outcomes of interest. A total of 24 studies involving 1602 patients and 13 regional blocks were included. All techniques reduced opioid consumption within 24 hours postoperatively. The largest decrease was in the thoracic retrolaminar block group, with a WMD of -0.97 (95% CrI -1.1, -0.84) mg/kg morphine equivalent. In terms of pain scores, there was no significant difference between any block and the control at any time point except for the thoracic retrolaminar block group at 0 hours postoperatively. In addition, all regional blocks prolonged the time to first rescue analgesic, which was the longest in the pectoral nerve block group. The incidence of postoperative nausea and vomiting was the lowest in the epidural anesthesia group, followed by the transversus thoracis muscle plane block group. Regional anesthesia revealed significant opioid-sparing effects following pediatric cardiothoracic surgery. However, indirect comparisons are limited because of the heterogeneity of previous studies, and direct comparisons are needed to establish the relative efficacies of different blocks.

The misunderstood P-value: why statistical significance is not enough in clinical practice

P-values have traditionally guided clinical research, but over-reliance on them can lead to misinterpretation and poor decision-making. This article highlights common misconceptions about P-values and suggests incorporating the minimum clinically important difference (MCID) along with other metrics such as effect sizes and Bayesian methods. Evidence-based practice is essential in anaesthesiology, and research findings should be evaluated in the context of patient outcomes to guide clinical decisions.

Piriformis-Sparing vs. Conventional Posterior Approach in Total Hip Arthroplasty: A Retrospective Analysis of the Functional Outcomes

Background and Objectives: The posterior approach in total hip arthroplasty (THA) is widely used among surgeons. This study compares dislocation rates and functional outcomes between patients using a piriformis tendon-sparing posterior approach (PSPA) and those using a conventional posterior approach (CPA). Materials and Methods: 350 patients who underwent THA between 2016 and 2020 were retrospectively reviewed, with 163 patients receiving a PSPA and 187 receiving a CPA. Dislocation complication and the functional outcomes including the baseline and postoperative sixth-week pain and Oxford Hip Score, sixth-week Ranawat internal rotation test, and sixth-month acetabular inclination and anteversion angle were recorded. Hospital stay and the duration of surgery were also noted. Results: Implant dislocation occurred in three (1.6%) patients only in the CPA group at six weeks postoperatively (p = 0.104). No differences were noted in surgery time, baseline and postoperative pain, or hip function (p < 0.05). The Ranawat internal rotation test was positive in 89.6% of the PSPA group and 40.1% of the CPA group at six weeks (p = 0.001). The inclination angle was better in the PSPA group (p = 0.001), but there was no difference in anteversion angle (p = 0.523) at the sixth month postoperatively. The PSPA group had a shorter hospital stay (mean = 2.14 days) compared to the CPA group (mean = 2.47 days) (p = 0.006). Conclusions: The absence of dislocation cases in the piriformis-sparing approach suggests that the preservation of the piriformis tendon, especially in the early period, may have reduced the risk of prosthesis dislocation by increasing joint stability from a clinical perspective. Further research is needed to evaluate the long-term impact of the piriformis-sparing posterior approach regarding the dislocation rates and functional outcomes.

Quadratus Lumborum Block for Total Laparoscopic Hysterectomy: A Systematic Review and Meta-analysis

OBJECTIVE

No regional blockade techniques are considered standard of care for total laparoscopic hysterectomy (TLH). Quadratus lumborum block (QLB), a novel fascial plane block, has emerged as a potential option; however, its analgesic efficacy in TLH remains unclear.

DATA SOURCES

We conducted a comprehensive search across multiple databases, including Medline PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science. No filters or language restrictions were imposed.

METHODS OF STUDY SELECTION

The Population, Intervention, Comparison, and Outcomes framework in this review was as follows: (1) adult patients undergoing TLH; (2) QLB as the intervention; (3) comparison with no block or placebo; (4) primary outcome: 24-hour postoperative intravenous morphine-equivalent consumption; secondary outcomes: postoperative pain at 2, 4, 6, 12, and 24 hours, and the incidence of postoperative nausea and vomiting (PONV); (5) randomized controlled trials. Meta-analyses, including subgroup and sensitivity analyses, were conducted using a random-effects model.

TABULATION, INTEGRATION, AND RESULTS

This analysis included 8 trials with 540 patients. QLB significantly reduced postoperative 24-hour intravenous morphine-equivalent consumption following TLH (mean difference: -4.61 mg; 95% confidence interval: -7.13 to -2.09; p <.001; I² = 57%), though the reduction was below the minimal clinically important difference (MCID) of 10 mg. The static pain scores at 2, 6, and 12 hours, as well as dynamic pain scores at 2, 6, and 24 hours postoperatively, were significantly lower in the QLB group than in the control group. However, only the 2-hour postoperative dynamic pain score (mean difference = 1.19) exceeded the MCID of 1. No statistically significant differences were observed in the incidence of PONV.

CONCLUSION

QLB statistically reduced postoperative opioid consumption and pain scores at certain time points after TLH, but only the 2-hour dynamic pain score exceeded the MCID with no improvement in PONV, suggesting limited clinical benefit of QLB in TLH.

Tranexamic Acid Has A Limited Role in Improving Visual Clarity and Pain in Arthroscopic Shoulder Surgery: A Systematic Review and Meta-Analysis

PURPOSE

The purpose of this systematic review was to evaluate the effects of tranexamic acid (TXA) compared to placebo or other comparators with regard to visual clarity, pain, total operative time, and volume of blood loss in patients undergoing arthroscopic shoulder surgery.

METHODS

CENTRAL, EMBASE, and MEDLINE were searched from inception until January 4th, 2025. Study selection and data extraction were carried out in duplicate. Randomized controlled trials that compared TXA versus placebo or another comparator in patients undergoing arthroscopic shoulder surgery were included. All outcomes were assessed in duplicate for risk of bias (RoB) using the RoB-2 tool and for certainty of evidence using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) approach. Results were pooled in a meta-analysis using a random-effects model when appropriate or were synthesized narratively when data could not be pooled.

RESULTS

Overall, 12 randomized controlled trials involving 1009 patients were included. The pooled estimate for visual clarity shows a slight increase in visual clarity (Standardized Mean Difference 0.64 [0.05, 1.24]). The pooled estimate for pain shows a mean difference of a reduction of pain by 0.38 points in the TXA group on a visual analog scale of 0 to 10 (0 = no pain) (Mean Difference -0.38 [-0.76, 0.00]).

CONCLUSIONS

There is moderate-certainty evidence suggesting that TXA likely results in a slight increase in visual clarity. The evidence also suggests that TXA has little to no difference in pain, operative time, and volume of blood loss.

LEVEL OF EVIDENCE

Level I, systematic review of Level I studies.

Letter: effects of dexamethasone combined with vitamin B12 on percutaneous endoscopic interlaminar discectomy early outcomes: a randomized controlled trial

Cheng He et al. evaluated the effect of dexamethasone combined with vitamin B12 on early outcomes following percutaneous endoscopic interlaminar discectomy (PEID). While the study offers valuable insights, we have several constructive suggestions. The lack of a standardized anesthesia protocol (local vs. general anesthesia) may have influenced the results, as patients under local anesthesia were awake during the procedure. Previous studies suggest intraoperative communication and patient awareness can impact pain levels and recovery. To clarify the effect of anesthesia type on recovery, we recommend conducting a subgroup analysis based on the anesthesia method. Although the CT group(combined treatment) showed satisfactory pain control (VAS < 3.3), the observed VAS score between days 1 and 3 may not reflect the actual patient experience. Except for the VAS score for leg pain on the third day after surgery, the net intergroup differences at other time points were less than the minimal clinically important differences recommended in the literature(a change of 10 for the 100 mm pain VAS). Furthermore, the study does not assess patient satisfaction with pain management, making it difficult to determine the clinical importance of the treatment effect.

Rate and Timing of Progression to Total Knee Arthroplasty After Anterior Cruciate Ligament Reconstruction in Patients With Systemic Inflammatory Disease: A Long-term Propensity-Matched Cohort Study

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) is one of the most common orthopaedic procedures and one of the most well studied. Despite extensive research dedicated to ACLR, there is limited understanding of how chronic inflammatory systemic diseases (CIDs) such as rheumatoid arthritis and systemic lupus erythematosus affect outcomes.

PURPOSE

To compare the outcomes of ACLR in cohorts of patients with and without CID.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective query of a regional data set was conducted for all patients who underwent ACLR from 1990 to 2021 for traumatic ACL rupture. All patients with CID were identified and propensity matched to non-CID controls. Baseline characteristics and clinical outcomes were identified through retrospective chart review, and patients were contacted for subjective outcomes.

RESULTS

A total of 30 patients with ACLR and a diagnosis of CID were identified. These patients were propensity matched to 120 non-CID controls. Baseline demographic and surgical characteristics demonstrated no statistical differences. Follow-up duration was similar between the CID and non-CID groups (mean, 14.6 vs 14.2 years; P = .868). The CID cohort had a higher arthrofibrosis rate (16.7% vs 4.3%; P = .031), higher osteoarthritis rate (33.3% vs 16.7%; P = .041), higher total knee arthroplasty (TKA) rate (16.7% vs 3.3%; P = .016), and earlier time to TKA (14.7 vs 23.5 years; P = .032). Knee range of motion, infection rate, retear rate, time to retear, and time to osteoarthritis were not statistically different between the cohorts. The CID cohort had higher visual analog scale pain scores (mean, 2.00 vs 1.20; P = .043) but slightly higher satisfaction (mean, 3.92 vs 3.39; P = .043). There were no differences in preinjury Tegner, postoperative Tegner, change in Tegner, or IKDC score. In a univariate Cox regression model, the CID cohort had a retear hazard ratio of 1.43 (95% CI, 0.46-4.51; P = .537). Kaplan-Meier survival revealed no significant differences in retear-free survival between the CID and non-CID cohorts at 25 years (85.7% vs 87.3%; P = .53). The CID cohort had a TKA hazard ratio of 3.94 (95% CI, 1.05-14.8; P = .042). Kaplan-Meier survival demonstrated significantly decreased TKA-free survival at 25 years in the CID cohort (64.9% vs 91.2%; P = .029).

CONCLUSION

CID increases the incidence of arthrofibrosis, osteoarthritis, and TKA in those undergoing ACLR. Patients with CID also undergo TKA significantly sooner than non-CID counterparts. Notably, the majority of patient-reported outcome measures are no worse in patients who have a CID diagnosis. Thus, ACLR constructs themselves may not necessarily fare worse in patients with CID. Nonetheless, these patients need to be cautiously counseled on the clinical outlook after their ACLR.

A critical approach to research on perioperative pain management

Optimal postoperative pain management is a prerequisite for enhancing functional recovery after surgery. However, many studies assessing analgesic interventions have limitations. Consequently, further improvements in study design are urgently needed. In this focused editorial, we critically review prevalent trial designs and outcome measures including treatment-related adverse events evaluating analgesic interventions. Novel clinical trial designs should improve efficiency and enhance the likelihood of detecting relevant treatment effects. Cohort and database studies using propensity score matching and directed acyclic graphs could provide real-world generalisable information. Procedure-specific and patient-specific trials should allow identification of subpopulations most likely to benefit from a particular intervention after a specific surgical procedure and thus ascertain optimal analgesic strategies in challenging populations.

Is Cystoscopic Intravesical Injection of OnabotulinumtoxinA Acceptable in an Outpatient Clinic?

PURPOSE

Cystoscopic intravesical onabotulinumtoxinA injection is a safe and effective minimally invasive treatment for refractory overactive bladder. While the procedure can be performed in outpatient clinics under local anesthetic, some clinicians still use sedation or general anesthesia in an operating theatre. Our study aimed to assess acceptability of intravesical onabotulinumtoxinA injection versus widely accepted diagnostic cystoscopy in the outpatient setting via the medium of patient experience.

METHODS

A 16-item patient experience survey was administered following diagnostic cystoscopy or intravesical onabotulinumtoxinA injection in an outpatient clinic. Both procedures were performed using a flexible cystoscope with local anesthetic gel. A visual analogue scale (VAS) assessed intraprocedure pain. Dichotomous questions assessed whether significant pain or postprocedure symptoms were experienced and if these required medical attention. A free-text question assessed which symptoms had occurred.

RESULTS

One hundred responses from 188 patients were received (53.2% response rate). Sixty-eight patients underwent cystoscopic intravesical onabotulinumtoxinA injection and 32 diagnostic cystoscopy. Mean VAS scores were higher for onabotulinumtoxinA injection (24 of 100) than diagnostic cystoscopy (11 of 100) (P=0.002). VAS scores were higher among patients reporting preprocedure anxiety (31 of 100 vs. 14 of 100, P=0.0013). Twenty-four percent of onabotulinumtoxinA injection patients experienced symptoms postprocedure versus 41% for cystoscopy. Medical attention was sought more frequently in the diagnostic cystoscopy group (9.4% vs. 1.5%). Common symptoms following both procedures were dysuria, urinary frequency, urgency, abdominal pain and urine discoloration.

CONCLUSION

Cystoscopic intravesical injection of onabotulinumtoxinA appears more painful than diagnostic cystoscopy. However, as VAS scores were relatively low, this is unlikely to represent clinically significant discomfort burdensome to the patient. There were no significant complications postprocedure. Cystoscopic intravesical onabotulinumtoxinA injection is acceptable in an outpatient setting.

Meniscal repair with concomitant suture-augmented ACL repair versus reconstruction: a retrospective cohort study

INTRODUCTION

This study evaluated patient-reported outcome measures (PROM) and reinjury rates in patients undergoing meniscal repair with concomitant suture-augmented (SA) anterior cruciate ligament reconstruction (ACLR) or repair (ACLr).

MATERIALS AND METHODS

We performed a retrospective cohort study of patients who underwent concomitant meniscus and ACL procedures by a single surgeon between 2015 and 2021. Inclusion criteria were meniscal repair with concomitant SA ACLR or SA ACLr, at least two years of follow-up, and participation in postoperative PROM surveys. Exclusion criteria were concomitant meniscectomy, multiligament repair or reconstruction, or other concomitant procedures at the time of the index operation. After a minimum of two years of follow-up, data was collected on reinjury and patient reported outcome measures, including Knee Injury and Osteoarthritis Outcome Score (KOOS), Single Assessment Numeric Evaluation (SANE), Visual Analog Pain Scale, and Veterans Rand 12 Item Survey (VR-12).

RESULTS

39 total patients were identified, 12 ACL repairs and 27 ACL reconstructions. 6 patients were lost to follow-up, with 10 patients in the ACLr cohort and 23 patients in the ACLR cohort included in the study. Meniscus tear laterality was not significantly different between the cohorts (p = 0.3828). There were two meniscal repair failures in the ACLr cohort compared to one in the ACLR cohort (p = 0.2117). There was one ACL reinjury in the ACLr cohort compared to zero reinjuries in the ACLR cohort (p = 0.3030). In a univariate analysis of PROMs, there were no significant differences in postoperative KOOS (p = 0.3308), VAS (p = 0.9955), SANE (p = 0.3449), VR-12M (p = 0.4705), or VR-12P (p = 0.7903) scores between the cohorts. In a multivariable analysis controlling for age, sex, BMI, meniscus tear laterality, and meniscus tear pattern, choice of ACL procedure was not a significant predictor of any postoperative PROM. 23 total patients, 6 ACL repairs and 17 ACL reconstructions had preoperative data available and were evaluated for changes in PROMs after surgery. There were clinically significant improvements in KOOS and SANE scores in both cohorts postoperatively.

CONCLUSION

In this cohort of patients, meniscal repair with SA ACLr was not inferior to meniscal repair with SA ACLR at two years of follow-up.

Perineural dexamethasone added to peripheral nerve block in knee surgery: a systematic review with meta-analysis

The objective of the study was to assess the analgesic effects of dexamethasone (DEX) added to peripheral nerve block in knee surgery. We searched for relevant randomized controlled trials (RCTs) in PubMed and the Cochrane Database of Systematic Reviews. The latest search was done on September 11, 2024. Search terms included knee surgery, regional anesthesia, and DEX. Data extraction, statistical analysis, and risk of bias assessment followed established protocols. Seven RCTs with 551 patients were included. In the DEX 4 mg group, no reduction of pain at rest was found. However, for the DEX 8 mg group, pain management at rest was more effective; the mean difference (MD) with 95% CI was -0.34 [-0.50, -0.18]. For pain with movement, the model favors the DEX 4 mg group (MD with 95% CI was -1.03 [-1.84, -0.22]). Only one study reported the differences in pain intensity scores with movement between the DEX 8 mg and control groups. For morphine consumption, the model did not reveal any reduction in the DEX 4 mg group (MD -0.68 [-1.87, 0.5]) or DEX 8 mg group (MD -10.44 [-23.92, 3.03]). Pain with movement may be reduced with a lower dose, and pain without movement with a higher dose of DEX.

Preoperative thoracic epidural analgesia with and without erector spinae plane block for thoracotomy: A retrospective study

BACKGROUND

Thoracotomy is a highly painful surgical procedure, with thoracic epidural analgesia (TEA) serving as the gold standard for postoperative pain management. However, TEA can induce significant hypotension, especially when combined with general anesthesia. The ultrasound-guided erector spinae plane block (ESPB) has emerged as a complementary technique for enhancing analgesia while minimizing side effects. This study compares the analgesic efficacy and intraoperative hemodynamic outcomes of preoperative TEA with and without ESPB in patients undergoing thoracotomy.

METHODS

This retrospective cohort study was conducted at a tertiary university hospital, including patients who underwent thoracotomy for tumor resection between March 2017 and March 2023. Patients receiving ESPB prior to TEA were compared with those receiving TEA alone. Postoperative pain intensity and intraoperative hemodynamic stability were assessed. The primary outcome was postoperative pain scores, while secondary outcomes included intraoperative mean arterial pressure and postoperative outcomes such as length of hospital stay.

RESULTS

A total of 64 patients were enrolled in the study, including 43 who received TEA alone and 21 who received a combination of TEA and ESPB. After propensity score matching, 21 patients were matched 1:1 in each group for comparative analysis. Patients who received ESPB in addition to TEA had significantly lower pain scores at 1 h and 24 h postoperatively (p < 0.001). Additionally, they demonstrated higher intraoperative mean arterial pressures (p = 0.036) compared to the TEA-only group. However, there were no significant differences in postoperative outcomes.

CONCLUSIONS

The combination of preoperative ESPB and TEA provides superior early postoperative pain control and enhances intraoperative hemodynamic stability in thoracotomy patients compared to TEA alone.

Perioperative Use of Pregabalin vs. Duloxetine for Pain Management of Knee Fracture Surgery: A Double-Blind Randomized Clinical Trial

Background: Effective postoperative pain management, particularly in orthopedic procedures, presents significant challenges. There is increasing evidence supporting the benefits of multimodal analgesia, including the use of gabapentinoids and serotonin norepinephrine reuptake inhibitors (SNRIs), to minimize opioid consumption while effectively managing pain. However, a gold-standard treatment has not been established. Objectives: This study aims to compare the efficacy of duloxetine and pregabalin within a multimodal analgesic regimen for managing postoperative pain and their opioid-sparing effects following knee fracture surgery. Methods: In this double-blind randomized clinical trial (RCT), 54 patients undergoing knee fracture surgery were randomized to receive either 75 mg oral pregabalin or 30 mg duloxetine twice daily, starting at least 24 hours prior to surgery and continuing up to 48 hours postoperatively. Pain severity was assessed at admission and at 6, 12, 24, and 48 hours post-operation. Patients reporting a pain score greater than six on a Numeric Rating Scale (NRS) received intramuscular morphine. Additionally, total opioid dose, associated complications, and drug adverse effects were monitored within the first 48 hours post-surgery. Results: Although there was no statistically significant difference between the duloxetine and pregabalin groups at each time point, the reduction in pain at the 48-hour mark was more pronounced in the duloxetine group compared to the pregabalin group. The duloxetine group required higher doses of morphine on the first day compared to the pregabalin group (3.96 ± 3.20 mg vs. 2.14 ± 2.72 mg, P = 0.022). However, on the second day, opioid rescue was required in three patients in the pregabalin group, whereas no patients in the duloxetine group required rescue. No clinically significant adverse effects were observed in either group. Conclusions: Duloxetine 60 mg per day is an equally effective perioperative alternative to pregabalin 150 mg per day, resulting in a slight increase in rescue opioid administration with equivalent analgesic efficacy during the first 24 hours postoperatively. It demonstrates notable analgesic outcomes with no increased need for opioids between 24 to 48 hours post-surgery.

The analgesic effects of quadratus lumborum block versus caudal block for pediatric patients undergoing abdominal surgery: a systematic review and meta-analysis

Background

Since children cannot express pain, postoperative pain treatment for them is relatively lacking. In this meta-analysis, we compared the postoperative analgesic effects of quadratus lumborum block (QLB) and caudal block (CB) in surgeries involving the lower abdomen, inguinal region, and urogenital system in children.

Objective

This review examined the postoperative analgesic effects of QLB and CB in pediatric patients (0-18 years of age) undergoing abdominal surgery. The primary endpoint was the rate of postoperative rescue analgesia, defined as the proportion of patients who returned to acetaminophen, ibuprofen, and other analgesics when the pain score was greater than the protocol preset value within 24 h after surgery. Secondary outcomes included resting pain scores (0-10) at 30 min, 4 h, 12 h, and 24 h after surgery. Other secondary outcome measures were the time of first rescue analgesia, the incidence of PONV, and the incidence of postoperative complications, such as post-block infection, anaphylaxis to local anesthesia and hematoma.

Evidence review

We systematically reviewed Pubmed, Central, EMBASE, Google Scholar, Web of Science citation index, the US clinical trials register, and abstracts for randomized controlled trials that compared these blocks and reported the rate of postoperative rescue analgesia.

Findings

Seven RCTs (444 patients) were included in the final analysis. In pediatric abdominal surgery, compared with CB, QLB could reduce the rate of postoperative rescue analgesia within 24 h after surgery (RR = 0.37; 95% CI = 0.26 to 0.51; P < 0.01). The pain score in the QLB group at 4 (SMD = -0.11; 95% CI = -0.21 to -0.01; P = 0.02) and 12 h (SMD = -0.11; 95% CI = -0.22 to 0.00; P = 0.06) after surgery was lower, but at 0.5(SMD = 0.42; 95% CI = 0.34 to 0.50; P < 0.01) and 24 h (SMD = 0.30; 95% CI = 0.03 to 0.58; P = 0.03) was higher than that in the CB group. Of note, these pain score differences were not clinically significant. In addition, there was no significant difference in the incidence of complications or side effects between the QLB and the CB group (RR = 0.94; 95% CI = 0.59 to 1.48; P = 0.77).

Conclusion

In conclusion, QLB might have a better postoperative analgesic effect for lower abdominal surgery than CB in pediatric patients. However, due to the relatively few RCTs identified and significant heterogeneity, further research in the future is needed to prove these findings.

Systematic Review Registration

identifier (CRD 42023441447).

Comparative Efficacy of Postoperative Pain Management Techniques Following Costal Cartilage Harvest: A Systematic Review and Network Meta-analysis

BACKGROUND

Efficient pain control is essential in reconstructive surgeries, particularly in procedures involving the harvest of costal cartilage. This study examines and compares different pain relief treatments using a network meta-analysis (NMA) to determine the most effective techniques for managing pain.

METHODS

We performed a systematic review and network meta-analysis (NMA) by scanning several databases such as PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure (CNKI), Wanfang, and Weipu till March 18, 2024. The review analyzed randomized controlled trials and observational studies that evaluated the effectiveness of local anesthetics and multimodal analgesia techniques in treating postoperative pain following costal cartilage harvest. Primary outcomes were pain scores at 6-, 12-, 24-, and 48-h post-surgery, while secondary outcomes included the need for rescue analgesia and opioid-related adverse effects.

RESULTS

Fourteen studies involving 935 participants were included. The analysis revealed that multimodal strategies, particularly 'Methylene Blue and Ropivacaine Intercostal Nerve Block (MB & Ropivacaine ICNB) combined with Patient-Controlled Analgesia (PCA),' were the most effective techniques to reduce pain scores across 6, 24, and 48-h time points. "Pre-operation SAPB & PSB + PCA" was most effective in reducing pain score at 12h and significantly decreased the need for rescue analgesia and opioid-related adverse effects. In contrast, traditional ICNB with single drug consistently showed the least efficacy.

CONCLUSION

The results of our study strongly support the use of multimodal analgesic techniques instead of typical single medication ICNB for managing postoperative pain after costal cartilage harvest. These strategies not only provide superior pain control but also contribute to reducing the dependency on opioids, aligning with current clinical priorities to enhance recovery and minimize opioid-related risks.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effectiveness of pain care intervention combined with traditional Chinese medicine care in the perioperative care of patients with urinary stones

The study investigated the effectiveness of pain care intervention combined with traditional Chinese medicine (TCM) care in the perioperative care of patients with urinary stones.Pain and urinary function recovery before and after postoperative care intervention, and Pittsburgh sleep quality index (PSQI), self-rating anxiety scale (SAS), and self-rating depression scale (SDS) scores before and after care intervention in the two groups were compared. First anal discharge time, catheter retention time, first out of bed activity time, the total number of hospital days, and complications were observed in both groups after surgery, and the satisfaction scores of patients in both groups with the perioperative care were recorded.Compared with the control group, the observation group showed lower first anal discharge time, catheter retention time, first out of bed activity time, the total number of hospital days, and the incidence of complications after surgery, and the patients were more satisfied with the care.Pain care intervention combined with TCM care is beneficial in reducing postoperative pain in patients undergoing urinary stone surgery, speeding up the recovery of urinary function, improving sleep quality, anxiety, and depression, and reducing the incidence of complications.