Management of catastrophising and kinesiophobia improves rehabilitation after fusion for lumbar spondylolisthesis and stenosis. A randomised controlled trial

Purpose

To evaluate the effect of a rehabilitation programme including the management of catastrophising and kinesiophobia on disability, dysfunctional thoughts, pain, and the quality of life in patients after lumbar fusion for degenerative spondylolisthesis and/or lumbar spinal stenosis.

Methods

This was a parallel-group, randomised, superiority-controlled study in which 130 patients were randomly assigned to a programme consisting of exercises and cognitive-behavioural therapy (experimental group, 65 subjects) or exercises alone (control group, 65 subjects). Before treatment (T1), 4 weeks later (post-treatment analysis, T2) and 12 months after the end of treatment (follow-up, T3), all the patients completed a booklet containing the Oswestry Disability Index (ODI, primary outcome), the Tampa Scale for Kinesiophobia, the Pain Catastrophising Scale, a pain Numerical Rating Scale, and the Short-Form Health Survey. A linear mixed model for repeated measures was used for each outcome measure.

Results

The ODI linear mixed model revealed significant main effects of group (F(1,122.8) = 95.78, p < 0.001) and time (F(2,120.1) = 432.02, p < 0.001) in favour of the experimental group. There was a significant group × time interaction effect (F(2,120.1) = 20.37, p < 0.001). The analyses of all of the secondary outcome measures revealed a significant effect of time, group and interaction in favour of the experimental group.

Conclusion

The rehabilitation programme, including the management of catastrophising and kinesiophobia, was superior to the exercise programme in reducing disability, dysfunctional thoughts, and pain, and enhancing the quality of life of patients after lumbar fusion for degenerative spondylolisthesis and/or LSS. The effects lasted for at least 1 year after the intervention ended.     

Does a Program Based on Cognitive Behavioral Therapy Affect Kinesiophobia in Patients Following Total Knee Arthroplasty? A Randomized,Controlled Trial With a 6-Month Follow-Up

Background

To evaluate the effects of a cognitive behavioral therapy (CBT) program on kinesiophobia, knee function, pain and pain catastrophizing in patients following total knee arthroplasty (TKA).

Predictive factors for successful clinical outcome 1 year after an intensive combined physical and psychological programme for chronic low back pain

Purpose

The aim of this longitudinal study is to determine the factors which predict a successful 1-year outcome from an intensive combined physical and psychological (CPP) programme in chronic low back pain (CLBP) patients.

Methods

A prospective cohort of 524 selected consecutive CLBP patients was followed. Potential predictive factors included demographic characteristics, disability, pain and cognitive behavioural factors as measured at pre-treatment assessment. The primary outcome measure was the oswestry disability index (ODI). A successful 1-year follow-up outcome was defined as a functional status equivalent to ‘normal’ and healthy populations (ODI ≤22). The 2-week residential programme fulfills the recommendations in international guidelines. For statistical analysis we divided the database into two equal samples. A random sample was used to develop a prediction model with multivariate logistic regression. The remaining cases were used to validate this model.

Results

The final predictive model suggested being ‘in employment’ at pre-treatment [OR 3.61 (95 % CI 1.80–7.26)] and an initial ‘disability score’ [OR 0.94 (95 % CI 0.92–0.97)] as significant predictive factors for a successful 1-year outcome (R ² = 22 %; 67 % correctly classified). There was no predictive value from measures of psychological distress.

Conclusion

CLBP patients who are in work and mild to moderately disabled at the start of a CPP programme are most likely to benefit from it and to have a successful treatment outcome. In these patients, the disability score falls to values seen in healthy populations. This small set of factors is easily identified, allowing selection for programme entry and triage to alternative treatment regimes.     

Oral oxycodone plus intravenous acetaminophen versus intravenous morphine sulfate in acute bone fracture pain control: a double-blind placebo-controlled randomized clinical trial

Objectives

Bone fracture is a common cause of acute pain in emergency and orthopedics departments. Targeting the multifaceted mechanisms of pain with combinations of multiple analgesics (multimodal analgesia) can increase the pain control efforts efficacy and decrease the adverse effects of each medication.

Methods

One hundred and fifty-three patients with acute bone fracture were randomly allocated to two groups receiving intravenous morphine sulfate (74 patients) or oral oxycodone plus intravenous acetaminophen (79 patients). Pain scores and drugs’ adverse effects were assessed 10, 30 and 60 min after treatment.

Results

Pain scores were similar between groups before, 30 and 60 min after medication but patients in morphine sulfate group experienced less pain 10 min after medication. Eight (10.8 %) patients in morphine sulfate group and 26 (32.9 %) patients in acetaminophen/oxycodone group experienced nausea that was statistically significant higher (P value = 0.001). Itching was seen in 12 (15.1 %) patients of acetaminophen/oxycodone group and three (4.0 %) patients of patients in morphine sulfate group (P value = 0.02).

Conclusion

Intravenous acetaminophen plus oral oxycodone is as effective as intravenous morphine sulfate in acute pain control in emergency department but with a less desirable safety profile.     

Gabapentin reduces preoperative anxiety and pain catastrophizing in highly anxious patients prior to major surgery: a blinded randomized placebo-controlled trial

Introduction

Gabapentin is increasingly being used for the treatment of postoperative pain and a variety of psychiatric diseases, including chronic anxiety disorders. Trials have reported mixed results when gabapentin has been administered for the treatment of preoperative anxiety. We tested the hypothesis that gabapentin 1,200 mg vs placebo would reduce preoperative anxiety in patients who exhibit moderate to high preoperative anxiety.

Methods

A blinded randomized controlled trial was conducted from September 2009 to June 2011 at the Toronto General Hospital. Following ethics approval and informed consent, 50 female patients with a 0-10 numeric rating scale (NRS) anxiety score of greater than or equal to 5/10 consented to receive either gabapentin 1,200 mg (n = 25) or placebo (n = 25) prior to surgery. Randomization was computer generated, and the Investigational Pharmacy was responsible for the blinding and dispensing of medication. All patients and care providers, including physicians, nurses, and study personnel, were blinded to group allocation. Before administering the study medication, baseline anxiety levels were measured using a NRS, the Spielberger State-Trait Anxiety Inventories, the Pain Catastrophizing Scale, and the Pain Anxiety Symptoms Scale-20. Baseline pain intensity (0-10 NRS) and level of sedation (0-10 NRS and Richmond Agitation-Sedation Scale [RASS]) were also measured. Two hours after the administration of gabapentin or placebo (prior to surgery), patients again rated their anxiety, pain, and sedation levels using the same measurement tools as at baseline. The main outcome was a reduction in preoperative anxiety.

Results

Forty-four patients (22 treated with gabapentin 1,200 mg and 22 treated with placebo) were included in the analysis of the primary outcome. Analysis of covariance in which pre-drug NRS anxiety scores were used as the covariate showed that post-drug preoperative NRS anxiety (Effect size, 1.44; confidence interval [CI] 0.19 to 2.70) and pain catastrophizing (Effect size, 0.43; CI 0.12 to 0.74) scores were significantly lower in the gabapentin group than in the placebo control group, respectively. Post-drug sedation (Effect size, ?3.02; CI ?4.28 to ?1.77) and RASS (Effect size, 0.41; CI 0.12 to 0.71) scores were significantly higher in the gabapentin group than in the placebo group, respectively.

Conclusions

Administration of gabapentin 1,200 mg prior to surgery reduces preoperative NRS anxiety scores and pain catastrophizing scores and increases sedation prior to entering the operating room. These results suggest that gabapentin 1,200 mg may be a treatment option for patients who exhibit high levels of preoperative anxiety and pain catastrophizing; however, the sedative properties of the medication and the possibility of delayed postoperative discharge in the elective ambulatory population need to be considered.     

Intravenous administration of granulocyte colony-stimulating factor for treating neuropathic pain associated with compression myelopathy: a phase I and IIa clinical trial

Objective

To confirm the feasibility and safety of granulocyte colony-stimulating factor (G-CSF) for treating spinal neuropathic pain associated with compression myelopathy, we have initiated an open-label single-center prospective clinical trial.

Methods

Between January 2009 and February 2011, 17 patients were accrued and were divided into two groups. One group included 7 patients who complained of pain associated with worsening symptoms of myelopathy (progressing myelopathy-related pain group). The other group included 10 patients who complained of pain that persisted after surgery for compression myelopathy (post-operative persistent pain group). All patients underwent intravenous administration of G-CSF (10 μg/kg/day) for 5 consecutive days. Pain severity was evaluated using a visual analog scale (VAS) before and after G-CSF administration.

Results

In 14 of the 17 patients, pain was relieved within several days after G-CSF administration. Pain disappeared completely in 3 patients. In the progressing myelopathy-related pain group, the mean VAS score was 71.4/100 before G-CSF administration, and decreased to 35.9/100 at 1 week after G-CSF administration (p < 0.05). In the post-operative persistent pain group, the mean VAS score was 72.0/100 before G-CSF administration, and decreased to 51.7/100 at 1 week after G-CSF administration (p < 0.05). No severe adverse events occurred during or after G-CSF administration.

Conclusions

The present results provide us with the possibility that G-CSF has a pain-relieving effect for neuropathic pain in patients with compression myelopathy.     

Significant differences of brain blood flow in patients with chronic low back pain and acute low back pain detected by brain SPECT

Background

The aim of this study was to examine and compare the areas of brain blood flow in patients with chronic low back pain (CLBP) without structural abnormality and acute low back pain (ALBP) with lumber disc herniation (LDH). Functional neuroimaging studies provide evidence of abnormalities in the regional cerebral blood flow during low back pain. Recent studies have shown that CLBP is associated with plastic, pathophysiological changes in the brain. However, there has been no report yet statistically or by neuro-images on the compared brain single photon-emission computed tomography (SPECT) findings between CLBP and ALBP patients.

Methods

The subjects comprised 14 patients, 7 CLBP and 7 ALBP patients. The CLBP group included the patients who had no or minor structural abnormality in the lumbar spine on magnetic resonance imaging (MRI) and met the criteria for a classification of “pain disorder” (chronic) according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. The ALBP group included the patients who had symptoms within 3 months of onset and LDH revealed by MRI. All patients were assessed using brain SPECT. We then performed a two-tailed view analysis using the easy Z score imaging system, determined the mean Z scores, and performed vBSEE software (Fujifilm RI Pharma, Tokyo, Japan) for both CLBP and ALBP patients.

Results

The CLBP group showed significantly reduced blood flow in the bilateral prefrontal cortex of the frontal lobe and increased blood flow in the bilateral posterior lobe of the cerebellum.

Conclusions

SPECT images and statistical analyses revealed the brain blood flow alterations in the patients with ALBP and CLBP. These results may suggest that the dysfunction of the prefrontal cortex could lead to the appearance of unconscious pain behavior controlled by the cerebellum in the patients with CLBP.     

Adults with idiopathic scoliosis improve disability after motor and cognitive rehabilitation: results of a randomised controlled trial

Purpose

To evaluate the effects of motor and cognitive rehabilitation on disability in adults with idiopathic scoliosis at lower risk of progression.

Methods

130 adults with idiopathic scoliosis (main curve <35°) were randomly assigned to a 20-week rehabilitation programme consisting of active self-correction, task-oriented exercises and cognitive–behavioural therapy (experimental group, 65 subjects, mean age of 51.6, females 48) or general physiotherapy consisting of active and passive mobilizations, stretching, and strengthening exercises of the spinal muscles (control group, 65 subjects, mean age of 51.7, females 46). Before, at the end, and 12 months after treatment, each participant completed the Oswestry disability index (ODI) (primary outcome), the Tampa scale for kinesiophobia, the pain catastrophizing scale, a pain numerical rating scale, and the Scoliosis Research Society-22 Patient Questionnaire. Radiological (Cobb angle) and clinical deformity (angle of trunk rotation) changes were also investigated. A linear mixed model for repeated measures was used for each outcome.

Results

Significant effects of time, group, and time by group interaction were found for all outcome measures (P < 0.001). After training, the primary outcome showed a clinically significant between-group change (12 % points), which was preserved at follow-up. At follow-up, the radiological deformities showed a significant, although not clinically meaningful, between-group difference of 4° in favour of the experimental group.

Conclusion

The experimental programme was superior to general physiotherapy in reducing disability of adults with idiopathic scoliosis. Motor and cognitive rehabilitation also led to improvements in dysfunctional thoughts, pain, and quality of life. Changes were maintained for at least 1 year.

     

Magnesium sulfate attenuates tourniquet pain in healthy volunteers

Purpose

Preoperative administration of an N-methyl-d-aspartate (NMDA) receptor antagonist has been shown to attenuate tourniquet-induced blood pressure increase under general anesthesia, suggesting that the mechanism of this blood pressure increase includes NMDA receptor activation. The attenuation of this increase may be associated with the pain relief induced by NMDA receptor antagonism. We tested the hypothesis that magnesium sulfate, an NMDA receptor antagonist, attenuates tourniquet pain.

Methods

Twenty-four healthy volunteers were randomly assigned to four groups (n = 6 each): control (normal saline), M1 (magnesium, 1 g), M2 (magnesium, 2 g), and M4 (magnesium, 4 g). Normal saline or magnesium solution was given intravenously over a 15-min period, in a double-blind fashion, before tourniquet inflation, which was continued for 60 min or until the “pain score” (0 = no pain, 100 = highest tolerable pain) reached 100. Pain scores were recorded before and every 5 min during tourniquet inflation. If subjects reported a pain score of 100 before the end of the 60-min period, we adopted a pain score of 100 for the remaining period.

Results

The duration of tourniquet inflation in the M4 group was significantly longer than that in the control group (54.3 ± 8.3 vs. 42.9 ± 9.9 min, P = 0.03). Pain scores in the M4 group were significantly lower than those in the control group from 10 through 50 min after the start of tourniquet inflation. The area under the curve for pain scores in the M4 group was significantly smaller than the areas in the other groups.

Conclusion

Magnesium sulfate, 4 g, significantly attenuated tourniquet pain in healthy awake volunteers, suggesting that NMDA receptor activation is involved in tourniquet pain.     

Prospective,randomized-controlled trial comparing postoperative pain after plug and patch open repair with totally extraperitoneal inguinal hernia repair

Purpose

The aim of this study was to compare postoperative pain between the open tension-free plug and patch (PP) technique and the totally extraperitoneal patch (TEP) hernioplasty.

Methods

One hundred and fifty-four male patients with unilateral inguinal hernia were randomized to undergo PP and TEP from 2005 to 2009. Pain assessment was conducted using the numerical rating scale (NRS) and the McGill Pain Questionnaire preoperatively, 6, 12 and 24 months postoperatively. All patients received the same analgesic regimen and documented pain in a NRS-based 4-week diary.

Results

Of the 154 patients 77 underwent TEP and 77 PP. Median follow-up was 3.8 years. One recurrent hernia was observed in the TEP and two in the PP group (p = 0.56). Median preoperative NRS scores were 2 and 2, 0.3 and 0.4 at 6 months, 0.1 and 0.3 at 12 months, 0.2 and 0.1 at 24 months postoperatively in the PP and TEP groups, respectively (p > 0.05). Data from the 4-week pain diaries revealed significant differences in pain intensity between the two different techniques from the second postoperative week (p < 0.05). Patients in the PP group required more additional analgesics on day four and five postoperatively (p = 0.037 and 0.015, respectively).

Conclusions

Our data favor the TEP technique concerning postoperative pain as primary endpoint between tension-free PP and TEP hernia repair.     

A Randomized, Prospective, Double-blind, Placebo-Controlled Trial of the Effect of Diltiazem Gel on Pain After Hemorrhoidectomy

Background

Spasm of the internal anal sphincter is considered to be one of the causes of pain in anal diseases. We have evaluated the effects of topical diltiazem on postoperative pain after hemorrhoidectomy.

Methods

Sixty-two patients were randomly assigned to receive a 2 % diltiazem gel (n = 32) or a placebo gel (n = 30) after hemorrhoidectomy. Patients applied the gel to the anal region three times per day for 14 days. Pain both in the resting state and on defecation ranged from 0 to 10 on a numerical rating scale, and the number of prescribed loxoprofen tablets (Loxonin) were recorded and confirmed daily by telephone. Any morbidity during the follow-up period was recorded.

Results

Both pain scores during defecation and the number of analgesic tablets consumed tended to be lower in the diltiazem group, although they did not reach statistical significance (P = 0.09, P = 0.12, respectively). Total number of complications was significantly higher in the diltiazem group, but each incidence of complications, including itching sensation, headache, and dizziness was not statistically different.

Conclusions

Perianal application of 2 % diltiazem gel after hemorrhoidectomy has the potential to reduce postoperative pain during defecation.     

Female gender is a risk factor for pain, discomfort, and fatigue after laparoscopic groin hernia repair

Purpose

Female gender is a risk factor for early pain after several specific surgical procedures but has not been studied in detail after laparoscopic groin hernia repair. The aim of this study was to compare early postoperative pain, discomfort, fatigue, and nausea and vomiting between genders undergoing laparoscopic groin hernia repair.

Methods

Prospective consecutive enrollment of women and age-matched (±1 year) and uni-/bilateral hernia-matched male patients undergoing elective transabdominal preperitoneal hernia repair (TAPP). Patients in the two groups received a similar anesthetic, surgical, and analgesic treatment protocol.

Results

Between August 2009 and August 2010, 25 women and 25 men undergoing elective TAPP were prospectively included in the analysis (n = 50) with no significant difference between groups in psychological status regarding anxiety, depression, and catastrophizing. On day 0, women had significantly more pain during rest (p = 0.015) and coughing (p = 0.012), discomfort (p = 0.001), and fatigue (0.020) compared with men. Additionally, cumulative overall postoperative pain during coughing, discomfort, and fatigue on day 0–3 was significantly higher in women compared with men (all p values < 0.05). Women required significantly more opioids (p = 0.015) and had a significantly higher incidence of vomiting on days 0 and 1 (p = 0.002).

Conclusions

Women experienced more pain, discomfort, and fatigue compared with men after laparoscopic groin hernia repair.

Trial registration

Registration number NCT00962338 (www.clinicaltrials.gov).     

Warmed,humidified carbon dioxide insufflation versus standard carbon dioxide in laparoscopic cholecystectomy: a double-blinded randomized controlled trial

Background

During laparoscopic cholecystectomy (LCHE), the insufflation with warmed and humidified carbon dioxide (CO₂) may reduce postoperative pain. The aim of the study was to evaluate the positive effects of heated and humidified carbon dioxide gas on patients with regard to postoperative pain after LCHE.

Patients and methods

This is a prospective, randomized, double-blinded, controlled clinical trial. 148 patients (female = 98, male = 50) scheduled for elective LCHE were randomized into two groups: receiving either heated humidified carbon dioxide, or standard gas. Intraoperative core temperature was measured. The perioperative management was identical for both groups. Postoperative pain intensity was assessed using a visual analog pain scale, and the amount of analgesic consumption was recorded. The postoperative pain management was also standardized and equal for both groups.

Results

67 out of 148 received standard gas (group A), and 81 received warmed, humidified gas (group B). The groups were comparable demographically. The amount of analgesic consumption was recorded. Intraoperative core temperature was significant higher in group B than in group A. Pain was significantly less in group B (p = 0.025) 6 h postoperatively. On the first postoperative day, no significant difference in pain between the two groups was detectable (p = 0.437).

Conclusion

The use of warmed and humidified carbon dioxide during LCHE reduces postoperative pain at the day of operation.     

Local warming at injection site helps alleviate pain after rocuronium administration

Purpose

Various strategies have been proposed to reduce discomfort of pain after rocuronium injection. These studies have shown pretreatment of drugs such as fentanyl and lidocaine to be effective. In a prospective randomized study, we evaluated whether pretreatment with local warming at injection site using an air-warming device could effectively alleviate pain induced by rocuronium.

Methods

Ninety patients undergoing spinal surgeries were randomly divided into two groups: group C (control) and group T (treatment). Patients in group T were subjected to warming at 40°C for 1 min prior to injecting 1 ml (10 mg) of rocuronium at the site of venous access. Patients were then assessed for any discomfort and to quantify their discomfort on a 5-point scale.

Results

Age, sex, and weight were comparable between the two groups. Pain on rocuronium administration was reported by 88.9% patient in group C versus 66.7% in group T (p < 0.05). Severe pain was significantly less in group T (35.6% vs. 8.9%).

Conclusion

Application of warmth over the vascular access prior to rocuronium administration effectively reduces injection-related pain.     

Outcomes of pregabalin in lumbar-disease patients with depression

Background

The anti-seizure drug pregabalin is currently used for peripheral neuropathic pain, including degenerative lumbar disease with a neuropathic component. Although there are many reports associated with pregabalin, treatment outcome in low back pain (LBP) patients with depression remains uncertain. This study investigated the outcomes of pregabalin in LBP patients with depression.

Methods

We assessed 64 patients (29 men and 35 women) using a Visual Analogue Scale, a Self-Rating Depression Scale (SDS) and the Oswestry Disability Index (ODI). Mean age was 63.3 years (range 20–81), and mean duration of disease was 69.8 months (range 3–576). The patients were divided into two groups according to SDS: normal (n = 37) and depressed group (n = 27).

Results

Pregabalin significantly reduced both SDS and ODI in the depressed group (p < 0.05). Effect size was larger for both SDS and ODI in the depressed group than in the normal group. Pain was significantly relieved, even in the depressed group (p < 0.01). Pain reduction was achieved by the direct effect of pregabalin, as well as indirect effects attributed to change in depressive symptoms. Although both somnolence and dizziness were detected, the use of hypnotic agents was decreased in half of cases. Somnolence did not influence the analgesic effects of the drug or psychotic state.

Conclusions

This investigation indicated that pregabalin is safe and effective for reducing both LBP and mood disturbance in patients with depression.     

Comparing the outcomes between Chopart,Lisfranc and multiple metatarsal shaft fractures

Objectives

Complex midfoot injuries could lead to severe functional impairment of mobility and quality of daily living. Aim of this study was to compare the clinical and functional outcomes of Chopart, Lisfranc fractures and multiple metatarsal shaft fractures.

Design

Retrospective case series.

Setting

Level one trauma center.

Intervention

Open or closed reduction and internal fixation with screws, K-wires, plates, external fixation or combination of different technics.

Main outcome measurements

The American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score and the Maryland Foot Score were used to assess pain and functional outcome. 3D gait analysis, pedobarographic analysis and radiologic examinations were performed. The activity level was measured by a step counting accelerometer. All results were compared to an age-matched healthy control group.

Results

24 patients with a median age of 44 years (16–72) were included: 12 patients with multiple metatarsal shaft fractures, 6 patients with Chopart and 6 patients with Lisfranc fractures. The median follow-up was 2.6 years. The pedobarographic analysis reports reduced contact time of the total foot (p = 0.08), the forefoot (p = 0.008) and the hallux (p = 0.015) for the injured foot. A median score of 64 for the SF-36, 64 for the AOFAS Midfoot Score and 73 for the Maryland Foot Score indicated a poor restoration of foot function. Multiple metatarsal shaft fractures presented a significantly lower walking speed (p = 0.03) and cadence (p = 0.04).

Conclusion

The worst results were reported for multiple metatarsal shaft fractures on outcome scores, pedobarography, gait analysis and activity. Metatarsal serial fractures should not be underestimated as well as Chopart and Lisfranc fractures.

Level of evidence

Level IV.     

Long-term follow-up after mesh removal and selective neurectomy for persistent inguinal postherniorrhaphy pain

Purpose

Persistent inguinal pain, influencing daily activities, is seen in about 5 % of patients following inguinal herniorrhaphy. Surgical treatment of patients with persistent postherniorrhaphy pain has been associated with pain relief and improvement in functional status. However, the detailed long-term outcome effects remain to be clarified. The aim of this study was to determine the long-term effects of mesh removal and selective neurectomy in patients with persistent postherniorrhaphy pain after previous open repair.

Methods

The study consecutively included 54 inguinal postherniorrhaphy pain patients treated with mesh removal and aimed neurectomy. Patients completed questionnaires evaluating pain intensity with a numerical rating scale (NRS) and pain-related functional impairment preoperatively, and, 3, 6, 12, 24, and 36 months postoperatively. Endpoints were changes in pain intensity and functional ability when comparing preoperative and postoperative assessments.

Results

Pain intensities (average, maximum, and during activity) were significantly lower at all time points during follow-up compared to preoperative values (p < 0.01 for all) with a reduction in median (IQR) average pain intensity from 6.0 (5.0–7.0) preoperatively to 3.0 (1.0–5.5) at 36-month follow-up. There was no association between positive pain outcome and intraoperative nerve identification (p = 0.47). The number of patients who reported a long-term negative effect of the operation (≥25 % increase in average pain intensity at 36-month follow-up) was 1 of 8. The functional ability was improved at 3 months after the operation (p < 0.01), but the improvement was not statistically significant in the follow-up period. Preoperative signs of depression, anxiety, and catastrophizing had no influence on outcome.

Conclusions

Mesh removal and attempted neurectomy may provide long-lasting analgesic effects in most patients and with a small proportion being worse, without relation to pain history and operative findings. Detailed multicenter collaboration is required to define preoperative diagnostics and the indication for mesh removal and neurectomy, the exact surgical procedure (type of neurectomy) and with detailed follow-up.     

TEP under general anesthesia is superior to Lichtenstein under local anesthesia in terms of pain 6 weeks after surgery: results from a randomized clinical trial

Background

Persistent pain is common after inguinal hernia repair. The methods of surgery and anesthesia influence the risk. Local anesthesia and laparoscopic procedures reduce the risk for postoperative pain in different time perspectives. The aim of this study was to compare open Lichtenstein repair under local anesthesia (LLA) with laparoscopic total extraperitoneal repair (TEP) with respect to postoperative pain.

Methods

Between 2006 and 2010, a total of 389 men with a unilateral primary groin hernia were randomized, in an open-label study, to either TEP (n = 194) or LLA (n = 195). One patient in the TEP group and four in the LLA group were excluded due to protocol violation. Details about the procedure and patient and hernia characteristics were registered. Patients completed the Inguinal Pain Questionnaire (IPQ) 6 weeks after surgery. [The study is registered in ClinicalTrials.gov (No. NCT01020058)].

Results

A total of 378 (98.4 %) patients completed the IPQ. One hundred forty-eight patients (39.1 %) reported some degree of pain, 22 of whom had pain that affected concentration during daily activities. Men in the TEP group had less risk for pain affecting daily activities (6/191 vs. 16/187; odds ratio [OR] 0.35; 95 % CI 0.13–0.91; p = 0.025). Pain prevented participation in sporting activities less frequently after TEP (4.2 vs. 15.5 %; OR 0.24; 95 % CI 0.09–0.56; p < 0.001). Twenty-nine patients (7.7 %) reported sick leave exceeding 1 week due to groin pain, with no difference between the treatment groups.

Conclusions

Patients who underwent the laparoscopic TEP procedure suffered less pain 6 weeks after inguinal hernia repair than those who underwent LLA. Groin pain affected the LLA patients’ ability to perform strenuous activities such as sports more than TEP patients.     

Five-year follow-up of total disc replacement compared to fusion: a randomized controlled trial

Purpose

To evaluate long-term clinical results of lumbar total disc replacement (TDR) compared with posterior lumbar fusion.

Methods

This prospective randomized controlled trial comprised 152 patients; 80 were randomized to TDR and 72 to fusion. All patients had chronic low back pain (CLBP) and had not responded to nonsurgical treatment. Primary outcome measure was global assessment of back pain (GA), secondary outcome measures were back and leg pain, Oswestry Disability Index (ODI), EQ5D, and SF-36. All measures were collected from SweSpine (Swedish national register for spinal surgery) at 1, 2, and 5 years. Follow-up rate at 5 years was 99.3 %.

Results

Both groups showed clinical improvement at 5-year follow-up. For GA, 38 % (30/80) in the TDR group were totally pain free vs. 15 % (11/71) in the fusion group (p < 0.003). Back pain and improvement of back pain were better in the TDR group: VAS back pain at 5 years 23 ± 29 vs. 31 ± 27, p = 0.009, and VAS improvement of back pain at 5 years 40 ± 32 vs. 28 ± 32, p = 0.022. ODI and improvement in ODI were also better in the TDR group: ODI at 5 years 17 ± 19 vs. 23 + 17, p = 0.02 and ODI improvement at 5 years 25 ± 18 vs. 18 ± 19 (p = 0.02). There was no difference in complications and reoperations between the two groups.

Conclusions

Global assessment of low back pain differed between the two surgical groups at all follow-up occasions. Significant differences between groups concerning back pain, pain improvement, and ODI were present at 1 year and disappeared at 2 years, but reappeared at the 5-year follow-up.