Efficacy of subcutaneous and topical local anaesthesia for pain relief after resection of malignant breast tumours.

OBJECTIVE: Infiltration and topical application of local anaesthetics close to the surgical wound may be used to prevent postoperative pain. We evaluated the efficacy of these treatments after breast surgery for cancer. DESIGN: Double-blind randomised trial with two treatment groups and one control group. SETTING: University hospital, Sweden. INTERVENTIONS: Patients were allocated to treatment with bupivacaine infiltration (n = 29), topical application of lignocaine/prilocaine (n = 31), or no local treatment (n = 30). MAIN OUTCOME MEASURES: Difference and time related patterns in pain scores measured on a visual analogue scale (VAS), and morphine consumption. RESULTS. None of the local anaesthetics significantly reduced the VAS score or morphine consumption. However, fewer patients in the anaesthetic groups had high VAS scores than controls, the 75 centile for the mean score after operation being 2.7, 2.0 and 2.1 for the controls, infiltration, and topical anaesthetic groups, respectively. The controls had higher scores from 6 hours postoperatively onwards. The corresponding median morphine consumption was 24.5, 18.5, and 16.2 mg. CONCLUSIONS. Local anaesthesia slightly reduced the overall pain scores and the morphine consumption, but was of potential clinical value only in the patients who had the highest pain scores.     

Predicting Postoperative Pain by Preoperative Pressure Pain Assessment

Background: The goal of this study was to evaluate whether preoperative pressure pain sensitivity testing is predictive of postoperative surgical pain.

Methods: Female subjects undergoing lower abdominal gynecologic surgery were studied. A pressure algometer was used preoperatively to determine the pressure pain threshold and tolerance. A visual analog scale (VAS) was used to assess postoperative pain. A State-Trait Anxiety Inventory was used to assess patients' anxiety. Subjects received intravenous patient-controlled analgesia for postoperative pain control. The preoperative pain threshold and tolerance were compared with the postoperative VAS pain score and morphine consumption.

Results: Forty women were enrolled. Their preoperative pressure pain threshold and tolerance were 141 +/- 65 kPa and 223 +/- 62 kPa, respectively. The VAS pain score in the postanesthesia care unit and at 24 h postoperatively were 81 +/- 24 and 31 +/- 10, respectively. Highly anxious patients had higher VAS pain scores in the postanesthesia care unit (P < 0.05). Pressure pain tolerance was significantly correlated with the VAS at 24 h postoperatively (P < 0.001, r = -0.52). Pressure pain tolerance after fentanyl administration (mean, 272 +/- 68 kPa) correlated significantly with morphine consumption in the first 24 h postoperatively (P < 0.002, r = -0.48).     

Effectiveness of analgesic techniques after breast surgery: a meta-analysis

OBJECTIVE: To evaluate the effectiveness of locoregional analgesic techniques (thoracic paravertebral block (TPVB), wound infiltration (WI)) after breast surgery. STUDY DESIGN: Meta-analysis. METHODS: Searches of Medline and Cochrane were performed using the search terms "breast surgery" and "local anaesthetics" and "infiltration" or "paravertebral block". Manual searches were also performed. Two independent investigators assessed the publications and extracted the data. Inclusion criteria were randomised controlled trials that evaluated effectiveness of single-injection TPVB or WI with local anaesthetics after breast surgery. Postoperative pain scores evaluated by visual analogic scale (VAS) during the first six hours (H6), at twelve hours (H12) and incidence of postoperative nausea and vomiting (PONV) were collected. RESULTS: Nine studies met inclusion criteria with five trials that evaluated paravertebral block (N=253) and 4 studies that evaluated wound infiltration (N=174). TPVB decreased significantly VAS at H6 (Weighted mean difference (WMD)=-18 [-5;-32] ; P=0.007) and at H12 (WMD=-12[-20;-4] ; P=0.001) and the risk of PONV (relative risk=0.39 [0.26; 0.57] ; P<0.00001). WI did not decrease significantly VAS for postoperative pain and PONV. CONCLUSION: Single injection TPVB in contrast to WI is effective for analgesia after breast surgery and decreases PONV.     

The influence of injection speed on pain during injection of local anaesthetic

Study objective: To determine the influence of injection speed on pain during injection of local anaesthetics. Methods: In a blinded randomised study with 36 healthy volunteers, each volunteer received three injections of 4.5 ml lidocaine subcutaneously on the abdomen. The injections were given during 15 seconds (0.3 ml/s), 30 seconds (0.15 ml/s), and 45 seconds (0.1 ml/s). The needle tip remained beneath the skin for 45 seconds during all three injections. Participants rated the pain experienced on a 100 mm visual analogue scale (VAS) immediately after each injection. After the last injection, they were asked which injections were the least and most painful. Results: The mean VAS pain score for the 15 seconds injections was 26 (SD = 19), for the 30 seconds injections 24 (SD = 19), and for the 45 seconds injections also 24 (SD = 18) (ns). Eight subjects preferred the 15 seconds injection, 15 preferred the 30 seconds injection, and 10 preferred the 45 seconds injection (ns). Conclusion: It is concluded that varying the injection speed between 0.3 ml/s and 0.1 ml/s has no influence on the pain experienced during subcutaneous injection of 4.5 ml lidocaine.     

Epidural fentanyl, adrenaline and clonidine as adjuvants to local anaesthetics for surgical analgesia: meta-analyses of analgesia and side-effects

Background: The risk/benefit ratio of adding fentanyl, adrenaline and clonidine to epidural local anaesthetics for improving intraoperative analgesia is unclear. This meta-analysis was performed to clarify this issue.
Methods: Trials retrieved by search were considered if they were prospective, controlled, epidural analgesia (without combining general anaesthesia) was planned and occurrence of pain during surgery or side-effects were reported. Papers entered meta-analysis if they reached a predefined minimum quality score. Pooled odds ratios (OR) and confidence intervals (CI) were computed. P <0.05 was considered as significant.
Results: Eighteen trials were included in the analysis for fentanyl. Fentanyl decreased the likelihood of pain (OR=0.21, 95% CI=0.15–0.30, P <0.001) and increased the incidence of pruritus (OR=5.59, 95% CI=3.12–10.05, P <0.001) and sedation (OR= 1.88, 95% CI=1.19–2.98, P =0.003), compared to control (local anaesthetic without fentanyl). Fentanyl had no effect on respiratory depression, nausea, vomiting and Apgar score. One case of respiratory depression of a newborn was observed. Because of the very low number of trials selected, evaluation of adrenaline and clonidine was not feasible.
Conclusion: The analysis of current literature shows that the addition of fentanyl to local anaesthetics for intraoperative epidural analgesia is safe and advantageous. The reduction in the incidence of pain during surgery is quantitatively high and therefore clinically significant. Side-effects are mild. Randomized, controlled trials have to be performed in order to clarify the role of adrenaline and clonidine as epidural adjuvants for surgical analgesia.     

Jet injection of local anesthetic decreases pain of arterial cannulation in awake neurosurgical patients

Arterial cannulation through the standard skin wheal of local anesthetic raised with a needle may be painful. The authors compared the efficacy of local anesthetic injected via a 25G needle versus a Bioject jet injector for arterial cannulation in awake neurosurgical patients. After institutional review board approval, 40 patients were randomized to receive 0.3 mL 1% lidocaine adjusted to pH 7.0 with NaHCO3 by Bioject with a 2-cm spacer between the syringe and skin or by 25G needle injection. Two pain assessments were used at the time of local anesthetic injection and at arterial cannulation. Patients rated their pain on a visual analog scale (VAS) (0 = no pain, 100 = worst pain). Observers scored patient response as 0 (no response), 1 (flinch), or 2 (withdrawal). The VAS at injection was 23 +/- 19 for the needle group and 3 +/- 6 for the Bioject group (P < 0.001). The VAS at arterial cannulation was 39 +/- 25 for the needle group and 15 +/- 22 for the Bioject group (P < 0.001). Median observer scores at injection and cannulation were 1 (range 0-2) for the needle group and 0 (range 0-2) for the Bioject group (P < 0.001). Patients in the Bioject group experienced significantly less pain during lidocaine administration and at the time of arterial cannulation by their own and by an observer's assessment than the needle injection group. Jet injection of local anesthetic should be considered prior to arterial cannulation in awake patients.     

Predicting postoperative pain by preoperative pressure pain assessment

BACKGROUND: The goal of this study was to evaluate whether preoperative pressure pain sensitivity testing is predictive of postoperative surgical pain. METHODS: Female subjects undergoing lower abdominal gynecologic surgery were studied. A pressure algometer was used preoperatively to determine the pressure pain threshold and tolerance. A visual analog scale (VAS) was used to assess postoperative pain. A State-Trait Anxiety Inventory was used to assess patients' anxiety. Subjects received intravenous patient-controlled analgesia for postoperative pain control. The preoperative pain threshold and tolerance were compared with the postoperative VAS pain score and morphine consumption. RESULTS: Forty women were enrolled. Their preoperative pressure pain threshold and tolerance were 141 +/- 65 kPa and 223 +/- 62 kPa, respectively. The VAS pain score in the postanesthesia care unit and at 24 h postoperatively were 81 +/- 24 and 31 +/- 10, respectively. Highly anxious patients had higher VAS pain scores in the postanesthesia care unit (P < 0.05). Pressure pain tolerance was significantly correlated with the VAS at 24 h postoperatively (P < 0.001, r = -0.52). Pressure pain tolerance after fentanyl administration (mean, 272 +/- 68 kPa) correlated significantly with morphine consumption in the first 24 h postoperatively (P < 0.002, r = -0.48). CONCLUSIONS: Assessment of preoperative pressure pain tolerance is significantly correlated with the level of postoperative pain. Pain tolerance assessment after fentanyl was administered and fentanyl sensitivity predicted the dose of analgesics used in the first 24 h after surgery. The algometer is thus a simple, useful tool for predicting postoperative pain and analgesic consumption.     

Topical anaesthesia of intact skin: liposome-encapsulated tetracaine vs EMLA

In this randomized, double-blind study, we have compared the ability of 5% liposome-encapsulated tetracaine (amethocaine) (LET) vs 5% eutectic mixture of local anaesthetics (EMLA) to produce local anaesthesia of intact skin in 40 healthy volunteers. Volunteers had both preparations applied to their forearms under an occlusive dressing for 1 h. Superficial anaesthesia was measured by a total of nine 1-mm pinpricks on each arm. Deeper anaesthesia was assessed by single insertion of a sterile 22-gauge needle to a depth of 3 mm and pain was reported on a visual analogue scale (VAS). If the volunteer perceived greater than four of the 1-mm pinpricks, the 3-mm insertion was not performed. Results showed that the number of pinpricks perceived was significantly less (P < 0.01) for LET (median 1.0; range 0-9) vs EMLA (1.5; 0-9). In volunteers who had deeper anaesthesia assessed, there was no significant difference (P = 0.065) in VAS scores for LET (mean 1.5 (SD 1.4); n = 34) vs EMLA (2.4 (2.1); n = 28). Overall anaesthetic effect, as ranked by all of the subjects, was significantly better for LET compared with EMLA (P = 0.024). We have demonstrated that when applied in equal volumes, 5% LET produced better superficial local anaesthesia than EMLA.      

A high initial VAS score and sedation afteriv morphine titration are associated with the need for rescue analgesia

PURPOSE: Administration of sc morphine has been recommended two hours after the end of iv morphine titration in the postanesthesia care unit (PACU), but in some cases patients complain of pain earlier than this. We assessed pain after the end of iv morphine titration and studied the characteristics of patients who needed rescue sc morphine. METHODS: Postoperative pain was assessed using the visual analogue scale (VAS; 0 to 100) and the threshold required to administer morphine in the PACU was a score of 30. VAS was measured every 15 min up to two hours after the end of iv morphine titration. Patients were divided into two groups, those who required sc morphine before two hours and those who did not. Data are expressed as mean +/- SD or odds ratio (OR; 95% confidence interval). RESULTS: Four hundred and two patients were analyzed. Mean age was 51 +/- 19 yr, initial VAS 69 +/- 19, and the dose of iv morphine 11.7 +/- 6.6 mg. The number of patients requiring sc morphine within two hours was 84 (21%). These patients had more severe initial postoperative pain (73 +/- 20 vs 68 +/- 19, P < 0.05), and experienced sedation more frequently during morphine titration (45 vs 25%, P < 0.001). Using a multivariate analysis, occurrence of sedation during titration [OR 2.3 (1.4-3.8), P < 0.001] and an initial pain score > or = 60 [OR 1.9 (1.0-3.4), P < 0.05] were significantly associated with the need for rescue sc morphine. CONCLUSION: Sedation during titration and an initial VAS > or = 60 are characteristics of the patients who require rescue (less than two hours) sc morphine after iv morphine titration.     

Randomized clinical trial of the influence of local water-filtered infrared A irradiation on wound healing after abdominal surgery

BACKGROUND: Postoperative local water-filtered infrared A (wIRA) irradiation improves tissue oxygen partial pressure, tissue perfusion and tissue temperature, which are important in wound healing. METHODS: The effect of wIRA irradiation on abdominal wound healing following elective gastrointestinal surgery was evaluated. Some 111 patients undergoing moderate to major abdominal surgery were randomized into one of two groups: wIRA and visible light irradiation (wIRA group) or visible light irradiation alone (control group). Uncovered wounds were irradiated twice a day for 20 min from days 2-10 after operation. RESULTS: Irradiation with wIRA improved postoperative wound healing in comparison to visible light irradiation alone. Main variables of interest were: wound healing assessed on a visual analogue scale (VAS) by the surgeon (median 88.6 versus 78.5 respectively; P < 0.001) or patient (median 85.8 versus 81.0; P = 0.040), postoperative pain (median decrease in VAS score during irradiation 13.4 versus 0; P < 0.001), subcutaneous oxygen tension after irradiation (median 41.6 versus 30.2 mmHg; P < 0.001) and subcutaneous temperature after irradiation (median 38.9 versus 36.4 degrees C; P < 0.001). The overall result, in terms of wound healing, pain and cosmesis, measured on a VAS by the surgeon (median 79.0 versus 46.8; P < 0.001) or patient (79.0 versus 50.2; P < 0.001) was better after wIRA irradiation. CONCLUSION: Postoperative irradiation with wIRA can improve normal postoperative wound healing and may reduce costs in gastrointestinal surgery.     

Applicability of tools to assess pain in elderly patients after cardiac surgery

Background: Post-operatively, elderly patients with impaired vision and cognitive dysfunction may experience difficulties understanding standard pain assessment tools such as the 10-cm Visual Analogue Scale (VAS) and the Verbal Rating Scale (VRS). Thus, there is a need to identify more feasible post-operative pain assessments for elderly patients. With this goal in mind, we compared the VAS and VRS with two more expressive tools: the 50-cm Red Wedge Scale (RWS) and the Facial Pain Scale (FPS).
Methods: Cardiac surgery patients (73 ± 5 years, mean ± SD) were allocated to an RWS ( n =80) or an FPS ( n =80) group. Pain was assessed at rest and after movement during the first 4 days after tracheal extubation. The RWS or FPS assessments were repeated after 10 min. All patients completed the VRS and VAS.
Results: The rates of successful pain measurement on study day 1 were: VRS 86%, VAS 62%, RWS 78%, and FPS 60%. Pain measurements with the RWS correlated with the VAS ( r =0.758, P <0.001) and weaker with the VRS ( r =0.666, P <0.001) measurements. Pain measurements with the FPS correlated well with the VAS ( r =0.873, P <0.001) and weaker with the VRS ( r =0.583, P <0.001) measurements. With all scales, success rates improved during the study period.
Conclusion: In elderly patients, immediately after cardiac surgery, the VRS is the most feasible pain scale, followed by the RWS. The traditional 10-cm VAS is unsuitable for pain measurement in this population.     

Cosmetic outcomes following head and neck melanoma reconstruction: The patient’s perspective

BACKGROUND:While studies have compared aesthetic outcomes following wide local excision of head and neck melanoma, none have evaluated this important outcome from the patient’s perspective. Indeed, one could argue that the psychosocial impact of head and neck melanoma excision and reconstruction is more accurately assessed by deriving patient-based as opposed to surgeon-based outcome measures.OBJECTIVE:To evaluate aesthetic outcomes following wide local excision of head and neck melanoma from the patient’s perspective.METHODS:Fifty-one patients who underwent excision of 57 head and neck melanomas followed by immediate closure by primary repair, skin grafting, local flap coverage or free tissue transfer were asked to complete a written survey at least six months after their surgery. A visual analogue scale (VAS) was used to assess the patient’s perception of appearance alteration, satisfaction with his or her appearance, and emotional impairment. An ordinal scale was used to evaluate several criteria of the reconstructive outcome (pain, itching, colour, scarring, stiffness, thickness and irregularity).RESULTS:Forty-two patients (82.4%) completed the survey. There were significant correlations between VAS scores reported for appearance alteration, satisfaction with outcome and emotional impairment (P=0.001). Patients who received skin grafts reported significantly unfavourable VAS scores compared with other methods of reconstruction (P=0.046). Moreover, skin grafts received significantly worse ordinal scale ratings for itching (P=0.043), colour (P=0.047), scarring (P=0.003) and stiffness (P=0.041) compared with other methods of reconstruction. Both skin grafts and free flaps were reported to have significantly less favourable thickness (P=0.012) and irregularity (P=0.036) than primary closure or local tissue transfer. There was no significant difference between patients undergoing primary closure with local tissue transfer (P>0.413). Other factors related to the patient’s VAS scores included location of the melanoma (P=0.033), size of defect (P=0.037) and recurrence of melanoma (P=0.042).CONCLUSION:The degree of emotional impairment following reconstruction of head and neck melanoma excision defects was correlated with the patient’s perception of appearance alteration. From the patient’s perspective, primary closure and local tissue transfer appeared to result in the highest aesthetic satisfaction.     

Patient discomfort following periapical surgery.

OBJECTIVE: The aim of the study was to assess patient discomfort following periapical surgery. STUDY DESIGN: Forty-two patients with apical periodontitis were allocated to apicectomy with either smoothening of the gutta-percha root filling or a retrograde root filling with mineral trioxide aggregate (MTA). RESULTS: Pooling all patients, VAS score for pain peaked 3 hours postoperatively (mean VAS = 29). The VAS score for swelling peaked 1 day postoperatively (mean VAS = 41). Patients' overall perception of postoperative discomfort was induced by (questions asked at the day for suture removal): Oral awareness (36 yes, 6 no); swelling (30 yes, 12 no); compromised chewing ability (18 yes, 24 no); pain (15 yes, 27 no). There was no correlation between the operating time and VAS scores for pain and swelling (r < or = .25, P > .11). CONCLUSIONS: Patients experienced little pain and moderate swelling after periapical surgery. Oral awareness was the most reported reason for postoperative discomfort. The operating time was not a decisive factor in relation to postoperative discomfort.     

Which patients are less likely to improve after arthroscopic rotator cuff repair?

ObjectiveThe aim of this study was to evaluate which specific factors influence the improvement in function and to estimate the time to obtain pain relief following arthroscopic rotator cuff repair.MethodsA total of 97 patients (57 men and 40 women; mean age: 55.5 ± 9.3 years) who had arthroscopic rotator cuff repair between 2013 and 2016 were included into the study. Multivariable stepwise analysis included preoperative variables (age, gender, body mass index, comorbidities, occupation and participation in sports, Oxford shoulder score at baseline, preceding injury and duration of preoperative symptoms) and arthroscopic findings (size of rotator cuff tear, pathology of the long head of the biceps and cartilage lesions). The change in the Oxford shoulder score at the last follow-up was modeled as a function of the above predictor variables. The time to regain a visual analogue scale (VAS) under two points following surgery was considered the time to regain substantial pain relief.ResultsThe mean follow-up time was 33.2 ± 14.4 months. Twenty three patients had partial thickness and seventy four had full thickness supraspinatus tears. In third of the patients the tears were defined as large full thickness. At the last follow-up the mean Oxford shoulder score improved from 13.8 ± 4.8 to 42.1 ± 7.2 points (P < 0.001). The mean VAS improved from a preoperative score of 6.7 ± 1.3 points to 1.5 ± 0.6 points postoperatively (P < 0.001) and 80 (83%) patients declared they were satisfied to have had the operation. The mean time interval for substantial pain relief was 4.9 ± 3.6 months. Patients with higher preoperative Oxford shoulder score and larger tear size were correlated with lesser improvement in Oxford shoulder score (R = 0.5, P = 0.001).ConclusionArthroscopic rotator cuff repair improved pain and function at an average follow-up of three years. A substantial pain relief was regained within five months from surgery. Larger rotator cuff tear size and more favorable preoperative function were predictors of worse postoperative function.Level of evidenceLevel IV, Therapeutic study.     

Randomized clinical trial of the influence of intraperitoneal local anaesthesia on pain after laparoscopic surgery

BACKGROUND: There is controversy about the effectiveness of intraperitoneal local anaesthesia (LA) in laparoscopic surgery. The aim of the present randomized clinical trial was to compare the analgesic effect of pre-emptive (preoperative) versus postoperative intraperitoneal LA in two different types of laparoscopic surgery. METHODS: Between July 2004 and January 2005, 133 consecutive patients scheduled to undergo laparoscopic fundoplication or hernia repair were randomly assigned to one of three treatments: placebo solution (50 ml 0.9 per cent saline) or LA (50 ml 0.5 per cent lidocaine) administered immediately after creation of the pneumoperitoneum, or LA (50 ml 0.5 per cent lidocaine) at the end of the operation. Analgesic requirements were analysed, and pain was assessed using a visual analogue scale (VAS) from 0 to 100 at 6, 12, 24 and 48 h after surgery. RESULTS: The duration of pneumoperitoneum (median 66 versus 46 min respectively; P < 0.001) and overall pain intensity (median VAS score 46.7 versus 6.5; P < 0.001) were higher for laparoscopic fundoplication than for hernia repair. Preoperative application of LA reduced abdominal pain (median 28.6 versus 74.9; P < 0.005), shoulder pain (median 24.3 versus 43.8; P = 0.004) and analgesic consumption (mean(s.d.) 11.1(5.0) versus 18.5(5.4) mg piritramide per 48 h; P = 0.002) after fundoplication, but had no analgesic effects after hernia repair. CONCLUSION: Pre-emptive application of LA reduced postoperative pain and analgesic requirements after laparoscopic fundoplication.     

Sex- and Age-related Differences in Morphine Requirements for Postoperative Pain Relief

Background: Sex-related differences in the perception of pain and susceptibility to opioids remain a matter of debate. Intravenous morphine titration used to obtain pain relief in the immediate postoperative period is a unique clinical model for assessing the effect of sex on reported pain. Because of the wide variation in dose requirements for pain management, the authors conducted a prospective study in a large population and also assessed the effect of aging.

Methods: Intravenous morphine titration was administered as a bolus of 2 (body weight << 60 kg) or 3 mg (body weight > 60 kg) during the immediate postoperative period. The interval between each bolus was 5 min. The visual analog pain scale (VAS) threshold required to administer morphine was 30, and pain relief was defined as a VAS score of 30 or less. Data are expressed as mean +/- SD.

Results: Data from 4,317 patients were analyzed; 54% of the patients were male, and 46% were female. The mean morphine dose required to obtain pain relief was 11.9 +/- 6.8 mg or 0.173 +/- 0.103 mg/kg. Women had a higher initial VAS score (74 +/- 19 vs. 71 +/- 19; P < 0.001) and required a greater dose of morphine (0.183 +/- 0.111 vs. 0.165 +/- 0.095 mg/kg; P < 0.001). In contrast, no significant difference was noted in elderly (aged > 75 yr) patients (0.163 +/- 0.083 vs. 0.157 +/- 0.085 mg/kg).     

Back pain and disability after lumbar laminectomy: is there a relationship to muscle retraction?

OBJECTIVE: Preliminary studies have suggested that prolonged retraction of the paraspinal muscle during spinal surgery may produce ischemic damage. We report the continuous measurement of intramuscular pressure (IMP) during decompressive lumbar laminectomy and its relationship to subsequent back pain and disability. METHODS: Twenty patients undergoing two-level decompressive lumbar laminectomy for lumbar canal stenosis were recruited. Back pain and disability were assessed by use of the Visual Analog Score (VAS), Oswestry Disability Index (ODI), and Short-Form 36 (SF-36) Health Survey. During surgery, IMP was recorded continuously from the multifidus muscle by use of a pressure transducer. The intramuscular perfusion pressure (IPP) was estimated as the difference between the patient's mean arterial pressure and IMP. RESULTS: Two muscle retractors were used: the Norfolk and Norwich (n = 10) and the McCulloch (n = 10). The mean duration of deep muscle retraction was 62.7 +/- 8 minutes (range, 19-133 min). On application of deep muscle retraction, there was a rapid and sustained increase in IMP (P < 0.001), and overall, the calculated mean IPP approached 0 mm Hg or less during this period (P < 0.001). On release of deep muscle retraction, there was a rapid decrease in IMP to preoperative levels. The IPP was greater with the Norfolk and Norwich than the McCulloch retractor (P < 0.001). Compared with preoperative values, there was a decrease in ODI (P < 0.001) and VAS for back pain (P < 0.001) at discharge and 4 to 6 weeks and 6 months after surgery. In addition, there was a decrease in SF-36 scores at 6 months compared with preoperative values (P < 0.001). Total duration of muscle retraction greater than 60 minutes was associated with worse VAS scores for back pain and ODI and SF-36 scores for disability at 6 months after surgery (P < 0.05). There was no relationship between the VAS, ODI, and SF-36 scores and other parameters measured, including the mean IPP, retractor type, operating surgeon, and wound length. CONCLUSION: The McCulloch retractor generates a higher IMP than the Norfolk and Norwich retractor. However, postoperative improvement in VAS, ODI, and SF-36 scores in these patients was associated with a shorter duration of muscle retraction and not the degree of IMP or IPP generated. In this respect, periodic relaxation of the paraspinal muscle retractors during surgery to allow muscle perfusion may help to reduce postoperative back pain and disability.     

Randomised clinical trial of Hydrofiber dressing with silver versus povidone-iodine gauze in the management of open surgical and traumatic wounds

This prospective, randomised clinical trial compared pain, comfort, exudate management, wound healing and safety with Hydrofiber dressing with ionic silver (Hydrofiber Ag dressing) and with povidone-iodine gauze for the treatment of open surgical and traumatic wounds. Patients were treated with Hydrofiber Ag dressing or povidone-iodine gauze for up to 2 weeks. Pain severity was measured with a 10-cm visual analogue scale (VAS). Other parameters were assessed clinically with various scales. Pain VAS scores decreased during dressing removal in both groups, and decreased while the dressing was in place in the Hydrofiber Ag dressing group (n = 35) but not in the povidone-iodine gauze group (n = 32). Pain VAS scores were similar between treatment groups. At final evaluation, Hydrofiber Ag dressing was significantly better than povidone-iodine gauze for overall ability to manage pain (P < 0.001), overall comfort (P < or = 0.001), wound trauma on dressing removal (P = 0.001), exudate handling (P < 0.001) and ease of use (P < or = 0.001). Rates of complete healing at study completion were 23% for Hydrofiber Ag dressing and 9% for povidone-iodine gauze (P = ns). No adverse events were reported with Hydrofiber Ag dressing; one subject discontinued povidone-iodine gauze due to adverse skin reaction. Hydrofiber Ag dressing supported wound healing and reduced overall pain compared with povidone-iodine gauze in the treatment of open surgical wounds requiring an antimicrobial dressing.     

Pain management in a rheumatology department: a satisfaction survey

OBJECTIVES: To evaluate the quality of pain management in a teaching hospital rheumatology department. METHODS: We conducted a satisfaction survey among all the patients admitted to the conventional rheumatology department of our teaching hospital over a 1-month period (88 patients with a mean length of stay of 5 d). The patients were asked to complete a questionnaire on the day of discharge. The professional staff was not informed of the survey. RESULTS: The mean pain severity score at admission (visual analog scale, VAS) was 7.76 +/- 1.76 and the mean score decrease with treatment was 7.27 +/- 2.81. Expected pain relief and actual pain relief were correlated (R = 0.39; P = 0.001). Nearly all the patients (96.1%) reported have been encouraged to communicate about their pain. Information on the treatment was given to 89.3% of the patients; no significant differences in pain severity or pain relief were found between the patients who did and did not receive this information. The patients were satisfied with their management by the physicians (VAS: 8.83 +/- 2.07) and nurses (VAS: 8.68 +/- 1.72). CONCLUSION: Satisfaction with pain management (a subjective criterion) was good in our patients. However, no validated tools for measuring satisfaction are available, and measurements should be repeated to look for improvements over time. Limitations to these results include the placebo effect, the influence of memory, and the effects of the behavior of hospitalized patients. A repeat survey is needed.     

Functional and oncological outcomes after total claviculectomy for primary malignancy

Primary malignancies of the clavicle are very rare, and scarce data are available regarding the functional and oncologic outcome after total claviculectomy. This is a retrospective review of 9 patients with primary clavicular malignancy, between 2000 and 2010, treated with total claviculectomy. There were 5 females and 4 males with a mean age of 29 years (range, 16 to 56). After a mean follow-up period of 46 months (range, 24-102 months) all patients were alive and without local recurrence or metastases. Patients had almost a full range of motion without pain, without significant functional deficit. The mean Constant-Murley score (best possible score = 100) improved from 26 to 79 (p < 0.001), while the VAS for pain improved from 8.7 to 2.4 (p < 0.001). Therefore, total claviculectomy may be a useful salvage procedure for primary clavicular malignancy.