[Perspectives] The body as image: image as body

Pain is invisible and its experience highly subjective, making it hard to communicate. This essay grew out of the Encountering Pain Conference at University College London that shared the findings of the face2face and Pain: Speaking the Threshold projects with patients, clinicians, academics, and artists. We explore narratives triggered by images co-created with pain patients and placed between doctor and patient in the pain clinic during the face2face project.

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A boy with fever and arthralgia

An eight year old boy was admitted to the emergency department with a seven day history of medium grade fever with mild headache, sore throat, arthralgia in his wrists, and pain in the soles of his...

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Epiploic appendagitis

A 47 year old healthy man presented to the emergency department with two days of abdominal pain, which localised to the right iliac fossa on examination. Blood results were normal. The initial...

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Prevalence and predictors of chronic postsurgical pain in children: A systematic review and meta-analysis

Emerging research suggests that pain may persist longer-term for many children after major surgery, with significant impact on their health outcomes. This systematic review identified the prevalence of chronic postsurgical pain (CPSP) in children after surgery, and determined presurgical biomedical and psychosocial risk factors associated with CPSP prevalence or severity. Prospective studies assessing CPSP 3-12 months after surgery in children 6-18 years of age published in English in MEDLINE, EMBASE, PsycINFO, and Cochrane Database of Systematic Reviews since 1996 were eligible for inclusion.

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Predicting the pain continuum after adolescent idiopathic scoliosis surgery: A prospective cohort study

Abstract

Background

Chronic postsurgical pain (CPSP) affects half a million children annually in the United States, with dire socioeconomic consequences, including long-term disability into adulthood. The few studies of CPSP in children are limited by sample size, follow-up duration, non-homogeneity of surgical procedure and factors evaluated.

Methods

In a prospective study of 144 adolescents undergoing a single major surgery (spine fusion), we evaluated demographic, perioperative, surgical and psychosocial factors as predictors of a continuum of postsurgical pain: immediate, pain maintenance at 2–3 months (chronic pain/CP) and persistence of pain a year (persistent pain/PP) after surgery.

Results

We found an incidence of 37.8% and 41.8% for CP and PP. CP and acute pain were both significant predictors for developing PP (p-value <0.001 and 0.003). Preoperative pain and higher postoperative opioid requirement was significantly associated with CP (p = 0.015, p = 0.002), while Childhood Anxiety Sensitivity Index (p = 0.002) and surgical duration (p = 0.014) predicted PP. The final regression models had reasonable predictive accuracy (c-statistic of 0.73 and 0.83 for CP and PP, respectively). Anxiety scores and catastrophizing for child and parent were found to be significantly correlated (p = 0.005, p = 0.013 respectively). Pain trajectories revealed that 65% of patients who developed PP reported CP and high pain trends; however, 33% of those who developed PP could not be identified using solely pain criteria.

Conclusion

Persistent postsurgical pain in children is a significant problem. It can be predicted in part by combinations of psychological and clinical variables, which may provide evidence-based measures to prevent development of CPSP in the future.

Significance

In a homogeneous cohort of adolescents undergoing spine fusion, we report a high incidence of persistent postsurgical pain (41.8%) predicted by child anxiety, perioperative pain, and surgical duration. Our results stress timely preventive and therapeutic strategies.

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Predictors of prescription opioid use 4 months after traumatic musculoskeletal injury and corrective surgery: A prospective study

The aim of the present study was to examine the incidence and predictors of persistent prescription opioid use 4-months after traumatic injury. Adults who sustained a traumatic musculoskeletal injury were recruited to participate in this observational prospective, longitudinal study within 14 days of injury (T1) and followed for 4-months (T2). Measures included questionnaires on pain, opioid consumption, pain disability, anxiety, depression, and posttraumatic stress symptoms as well as a chart review for injury related information.

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Systematic review of self-report measures of pain intensity in 3- and 4-year-olds: Bridging a period of rapid cognitive development

Claims are made for the validity of some self-report pain scales for 3- and 4-year-old children, but little is known about their ability to use such tools. This systematic review identified self-report pain intensity measures used with 3- and/or 4- year-old participants (3-4yo) and considered their reliability and validity within this age span. The search protocol identified research articles that included 3-4yo, reported use of any pain scale, and included self-reported pain intensity ratings. A total of 1,590 articles were screened and 617 articles met inclusion criteria.

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Twin peaks? No evidence of bimodal distribution of outcomes in clinical trials of non-surgical interventions for spinal pain: An exploratory analysis

The presence of bimodal outcome distributions has been used as a justification for conducting responder analyses, in addition to, or in place of analyses of mean difference, in clinical trials and systematic reviews of interventions for pain. The aim of this study was to investigate the distribution of participants’ pain outcomes for evidence of bimodal distribution.

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Remote ischaemic conditioning decreases blood flow and improves oxygen extraction in patients with early complex regional pain syndrome

Abstract

Background

Remote ischaemic conditioning (RIC) is the cyclic application of non-damaging ischaemia leading to an increased tissue perfusion, among others triggered by NO (monoxide). Complex regional pain syndrome (CRPS) is known to have vascular alterations such as increased blood shunting and decreased NO blood-levels, which in turn lead to decreased tissue perfusion. We therefore hypothesized that RIC could improve tissue perfusion in CRPS.

Method

In this proof-of-concept study, RIC was applied in the following groups: in 21 patients with early CRPS with a clinical history less than a year, in 20 age/sex-matched controls and in 12 patients with unilateral nerve lesions via a tourniquet on the unaffected/non-dominant upper limb. Blood flow and tissue oxygen saturation (StO₂) were assessed before, during and after RIC via laser Doppler and tissue spectroscopy on the affected extremity. The oxygen extraction fraction was calculated.

Results

After RIC, blood flow declined in CRPS (p < 0.01). StO₂ decreased in CRPS and healthy controls (p < 0.01). Only in CRPS, the oxygen extraction fraction correlated negatively with the decreasing blood flow (p < 0.05).

Conclusion

Contrary to our expectations, RIC induced a decrease of blood flow in CRPS, which led to a revised hypothesis: the decrease of blood flow might be due to an anti-inflammatory effect that attenuates vascular disturbances and reduces blood shunting, thus improving oxygen extraction. Further studies could determine whether a repeated application of RIC leads to a reduced hypoxia in chronic CRPS.

Significance

Remote ischaemic conditioning leads to a decrease of blood flow. This decrease inversely correlates with the oxygen extraction in patients with CRPS.

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Nucleus accumbens dopamine receptors mediate hypothalamus-induced antinociception in the rat formalin test

Abstract

Background

Lateral hypothalamus (LH) involves in modulation of tonic pain. Regarding the direct and indirect neural connections between the LH and nucleus accumbens (NAc), we aimed to examine the pain modulatory role of NAc dopamine receptors in modulation of LH-induced analgesia in the formalin test.

Methods

Vehicle-control groups received saline or DMSO into the NAc and saline into the LH. Carbachol-control groups received carbachol (250 nmol/L) into the LH, 5 min after saline or DMSO injection into the NAc. In treatment groups, intra-NAc administration of SCH-23390 or sulpiride (D1-and D2-like dopamine receptor antagonists, respectively) was performed 5 min before carbachol injection. Formalin test was done in all rats 5 min after the second injection.

Results

The blockade of NAc dopamine receptors reduced carbachol-induced antinociception during both phases of formalin test and reduction in LH-induced analgesia during the late phase was more than that during the early phase. Furthermore, contribution of D2-like dopamine receptors to mediation of anti-hyperalgesic effect of carbachol was greater than that of D1-like dopamine receptors during the late phase.

Conclusions

The findings suggest that LH-VTA-NAc circuit is contributed to the modulation of formalin-induced pain. These findings demonstrate that transmission at D1- and D2-like dopamine receptors mediates the LH-induced analgesia.

Significance

Blockade of accumbal dopamine receptors attenuated analgesia induced by carbachol injection into the lateral hypothalamus during both phases of formalin test. Effect of blockade of D1- and D2-like dopamine receptors on reduction in antinociception was more during the late phase. Contribution of D2-like dopamine receptors to mediation of antinociception during the late phase was greater than the early phase.

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Predictors of Acute Post-Surgical Pain Following Inguinal Hernioplasty

Acute post-surgical pain (APSP) is a common and anticipated problem after surgery with detrimental consequences if not appropriately managed. This study examined the independent and joint contribution of pre-surgical demographic, clinical and psychological variables as predictors of APSP intensity, evaluated through an 11-point numerical rating scale, after inguinal hernioplasty, one of the most performed surgeries worldwide. In a prospective observational cohort study, a consecutive sample of 135 men undergoing hernioplasty was assessed before (T1) and 48 hours after (T2) surgery.

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Facilitated Pro-Nociceptive Pain Mechanisms in Radiating Back Pain Compared with Localized Back Pain

Facilitated pain mechanisms and impaired pain inhibition are often found in chronic pain patients. This study compared clinical pain profiles, pain sensitivity, as well as pro-nociceptive and anti-nociceptive mechanisms in patients with localized low back pain (n=18), localized neck pain (n=17), low back and radiating leg pain (n=18), or neck and radiating arm pain (n=17). It was hypothesized that patients with radiating pain had facilitated pain mechanisms and impaired pain inhibition compared with localized pain patients.

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Cost-utility of Group Acceptance and Commitment Therapy for Fibromyalgia versus recommended drugs: An economic analysis alongside a 6-month randomised controlled trial conducted in Spain (EFFIGACT study)

The aim of this study was to analyse the cost-utility of a group-based form of Acceptance and Commitment Therapy (GACT) in patients with fibromyalgia (FM) compared to patients receiving recommended pharmacological treatment (RPT) or on a waiting list (WL). The data were derived from a previously published study, an RCT that focused on clinical outcomes. Health economic outcomes included health-related quality of life and healthcare use at baseline and at 6-month follow-up using the EuroQol (EQ-5D-3L) and the Client Service Receipt Inventory (CSRI), respectively.

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Less Exercise and More Drugs: How a Low Income Population Manages Chronic Pain

Mechanical effects of traction on lumbar intervertebral discs: A magnetic resonance imaging study

Although traction has long been used for treating patients with low back pain (LBP), its effects are still inconclusive mainly because of limited high-quality evidence.

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Inflammatory ‘double hit’ model of temporomandibular joint disorder with elevated CCL2, CXCL9, CXCL10, RANTES and behavioural hypersensitivity in TNFR1/R2−/− mice

Abstract

Background

Patients with temporomandibular joint disorders (TMD), reactive arthritis and rheumatoid arthritis often have combined etiology of hereditary and microenvironmental factors contributing to joint pain. Multiple clinical and animal studies indicate ‘double-hit’ inflammatory insults can cause chronic inflammation. The first inflammatory insult primes the immune system and subsequent insults elicit amplified responses. The present ‘double hit’ study produced a chronic orofacial pain model in mice with genetic deletion of both TNFα receptors (TNFR1/R2−/−), investigating the main nociceptive signalling pathways in comparisons to wild type mice.

Methods

An initial inflammatory insult was given unilaterally into the temporomandibular joint (TMJ). Secondary hypersensitivity was tested on the skin over the TMJ throughout the experiment. Three weeks later after complete reversal of hypersensitivity, a second inflammatory insult was imposed on the colon. Pharmacological interventions were tested for efficacy after week 10 when hypersensitivity was chronic in TNFR1/R2−/− mice. Serum cytokines were analysed at Days 1, 14, and Week 18.

Results

The double hit insult produced chronic hypersensitivity continuing through the 4-month experimental timeline in the absence of TNFα signalling. P2X7 and NMDA receptor antagonists temporarily attenuated chronic hypersensitivity. Serum cytokine/chemokine analysis on Day 14 when CFA induced hypersensitivity was resolved identified increased levels of pro-inflammatory cytokines CCL2, CXCL9, CXCL10, RANTES and decreased levels of anti-inflammatory cytokines IL-1ra and IL-4 in TNFR1/R2−/− compared to WT mice.

Conclusions

These data suggest a causal feed-forward signalling cascade of these little studied cytokines have the potential to cause recrudescence in this orofacial inflammatory pain model in the absence of TNFα signalling.

Significance

Using a mouse model of chronic inflammatory temporomandibular joint disorder, we determined that absence of functional TNFR1/R2 induces aberrant inflammatory signalling caused by other increased pro-inflammatory and decreased anti-inflammatory cytokines that could serve as blood biomarkers and may predict disease progression.

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“Effects of exergames on quality of life, pain and disease impact in women with Fibromyalgia: A randomized controlled trial”

Feasibility and safety of a powered exoskeleton for assisted walking for persons with multiple sclerosis: a single-group preliminary study

The Role of Spinal GABAB Receptors in Cancelr-Induced Bone Pain in Rats

Cancer-induced bone pain (CIBP) remains a major challenge in advanced cancer patients due to our lack of understanding of its mechanisms. Previous studies have demonstrated the vital role of GABAB receptors (GABABRs) in regulating nociception and various neuropathic pain models have shown diminished activity of GABABRs. However, the role of spinal GABABRs in CIBP remains largely unknown. In this study, we investigated the specific cellular mechanisms of GABABRs in the development and maintenance of CIBP in rats.

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[Correspondence] Lessons from the controversy over statins

Jane Armitage and colleagues, led by senior author Rory Collins, (Nov 5, p 2237)1 and Richard Horton (Nov 5, p 2237)2 appear to believe that retraction of an article from The BMJ will end the debate about statins and primary prevention. Even were there grounds for retraction, I fear they would be disappointed. Questions about the evidence base for statins continue to emerge from many quarters: how strong is the evidence, how large is the benefit for individuals at lowest risk of heart disease, how well did the trials record common minor side-effects, how representative were the trials of women and the elderly, what was the effect of active run-in periods and composite endpoints, how does taking a statin affect a person's diet and exercise patterns, why is there a discrepancy between the real-life experience of muscle pain and what was reported in the trials, why have the data for harms not yet been given the same levels of scrutiny as the data for benefits, and is cholesterol a reliable surrogate endpoint to guide prevention of cardiovascular disease?3,4

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Midgut volvulus

A 56 year old man with no history of surgery presented with acute epigastric pain and nausea. He had experienced episodes of epigastric pain after eating during several months, but upper endoscopy...

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A woman with lower back pain

A 52 year old woman presented with a two day history of lower back pain that was radiating into her left leg with weakness in that leg. She had a history of chronic back pain. Neurological...

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Clinical characteristics and outcomes of treatment of the cervical spine in patients with persistent post-concussion symptoms: A retrospective analysis

Concussion is typically defined as a mild brain injury, and yet the brain is unlikely to be the only source of persistent post-concussion symptoms. Concurrent injury to the cervical spine in particular is acknowledged as a potential source of common persistent symptoms such as headache, dizziness and neck pain.

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Eye stabilization reflexes in traumatic and non-traumatic chronic neck pain patients

Many chronic neck pain patients experience problems with vision. These problems are possibly induced by deviations of the eye stabilization reflexes. It is not known whether these eye reflex alterations occur both in traumatic and non-traumatic neck pain patients.

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Do older adults with chronic low back pain differ from younger adults in regards to baseline characteristics and prognosis?

Abstract

Background

Low back pain (LBP) in older adults is poorly understood because the vast majority of the LBP research has focused on the working aged population. The aim of this study was to compare older adults consulting with chronic LBP to middle aged and young adults consulting with chronic LBP, in terms of their baseline characteristics, and pain and disability outcomes over 1 year.

Methods

Data were systematically collected as part of routine care in a secondary care spine clinic. At initial presentation patients answered a self-report questionnaire and underwent a physical examination. Patients older than 65 were classified as older adults and compared to middle aged (45–65 years old) and younger adults (17–44 years old) for 10 baseline characteristics. Pain intensity and disability were collected at 6 and 12 month follow-ups and compared between age groups.

Results

A total of 14,479 participants were included in the study. Of these 3087 (21%) patients were older adults, 6071 (42%) were middle aged and 5321 (37%) were young adults. At presentation older adults were statistically different to the middle aged and younger adults for most characteristics measured (e.g. less intense back pain, more leg pain and more depression); however, the differences were small. The change in pain and disability over 12 months did not differ between age groups.

Conclusions

This study found small baseline differences in older people with chronic LBP compared to middle aged and younger adults. There were no associations between age groups and the clinical course.

Significance

Small baseline differences exist in older people with chronic low back pain compared to middle aged and younger adults referred to secondary care for chronic low back pain. Older adults present with slightly less intense low back pain but slightly more intense leg pain. Changes in pain intensity and disability over a 12 month period were similar across all age groups.

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Effectiveness of manual therapy versus surgery in pain processing due to carpal tunnel syndrome: A randomized clinical trial

Abstract

Background

People with carpal tunnel syndrome (CTS) exhibit widespread pressure pain and thermal pain hypersensitivity as a manifestation of central sensitization. The aim of our study was to compare the effectiveness of manual therapy versus surgery for improving pain and nociceptive gain processing in people with CTS.

Methods

The trial was conducted at a local regional Hospital in Madrid, Spain from August 2014 to February 2015. In this randomized parallel-group, blinded, clinical trial, 100 women with CTS were randomly allocated to either manual therapy (n = 50), who received three sessions (once/week) of manual therapies including desensitization manoeuvres of the central nervous system, or surgical intervention (n = 50) group. Outcomes including pressure pain thresholds (PPT), thermal pain thresholds (HPT or CPT), and pain intensity which were assessed at baseline, and 3, 6, 9 and 12 months after the intervention by an assessor unaware of group assignment. Analysis was by intention to treat with mixed ANCOVAs adjusted for baseline scores.

Results

At 12 months, 95 women completed the follow-up. Patients receiving manual therapy exhibited higher increases in PPT over the carpal tunnel at 3, 6 and 9 months (all, p < 0.01) and higher decrease of pain intensity at 3 month follow-up (p < 0.001) than those receiving surgery. No significant differences were observed between groups for the remaining outcomes.

Conclusions

Manual therapy and surgery have similar effects on decreasing widespread pressure pain sensitivity and pain intensity in women with CTS. Neither manual therapy nor surgery resulted in changes in thermal pain sensitivity.

Significance

The current study found that manual therapy and surgery exhibited similar effects on decreasing widespread pressure pain sensitivity and pain intensity in women with carpal tunnel syndrome at medium- and long-term follow-ups investigating changes in nociceptive gain processing after treatment in carpal tunnel syndrome.

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Pain characteristics as important contribution factors to upper limb dysfunctions in breast cancer survivors at long term

The aim of this study was to explore the treatment, patient, and impairment-related risk factors associated with upper limb dysfunctions in breast cancer survivors.

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Painful After-Sensations in Fibromyalgia are Linked to Catastrophizing and Differences in Brain Response in the Medial Temporal Lobe

Fibromyalgia (FM) is a complex syndrome characterized by chronic widespread pain, hyperalgesia, and other disabling symptoms. While the brain response to experimental pain in FM patients has been the object of intense investigation, the biological underpinnings of painful after-sensations (PAS), and their relation to negative affect have received little attention. In this cross-sectional cohort study, subjects with FM (n=53) and healthy controls (n=17) were assessed for PAS by exposure to a sustained, moderately painful cuff stimulus to the leg, individually calibrated to a target pain intensity of 40/100.

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Sleep Fragmentation Hypersensitizes Healthy Young Women to Deep and Superficial Experimental Pain

Our findings that pain-free, young women develop hyperalgesia to superficial and deep-muscle pain after short-term sleep disruption highlight the need for effective sleep management strategies in patients with pain. Findings also suggest the possibility that short-term sleep disruption associated with recurrent acute pain could contribute to increased risk for future chronic pain conditions

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The influence of a depressed scapular alignment on upper limb neural tissue mechanosensitivity and local pressure pain sensitivity

A depressed scapula alignment could lead to prolonged and repetitive stress or compression of the brachial plexus, resulting in sensitization of neural tissue. However, no study has investigated the influence of alignment of the scapulae on sensitization of upper limb neural tissue in otherwise asymptomatic people. In this case-control study, we investigate the influence of a depressed scapular alignment on mechanosensitivity of the upper limb peripheral nervous system as well as pressure pain thresholds (PPT).

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Does the acromiohumeral distance matter in chronic rotator cuff related shoulder pain?

The relation between acromiohumeral distance (AHD) and severity of pain, disability and range of movement (ROM) in patients with chronic rotator cuff related shoulder pain (RCRSP) has not been reported.

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Rumination induces a pattern of attention characterized by increased vigilance followed by avoidance of affective pain words

Abstract

Background

This study examined the effects of rumination on attentional processes in relation to an acute experimental pain task. In keeping with recent theory and research, it was hypothesized that we would identify a pattern of attentional bias characterized by enhanced initial vigilance followed by avoidance of pain-related stimuli.

Method

Undergraduate students were randomized to a rumination condition, which received threat-inducing information about the cold pressor task, or a distraction condition. Using the dot probe task, attentional biases to sensory and affective pain words were assessed at two presentation intervals (500 and 1250 ms).

Results

Those in the rumination condition did not show differences in attentional biases compared to the control group, however, they did respond more quickly to pain congruent trials compared to neutral/neutral trials when affective pain words were presented for 500 ms. In addition, those in the rumination group responded more slowly in congruent trials to neutral/neutral trials than affective/neutral trials indicating avoidance at 1250 ms. Although those in the rumination condition exhibited higher levels of distress and reported higher levels of pain when they withdrew their hands from the cold pressor task, the congruency biases did not predict these results.

Conclusion

These results suggest that experimentally manipulating rumination changes attentional processes consistent with the vigilance-avoidance hypothesis.

Significance

The rumination manipulation led to increased worry about pain and induced to an attentional pattern of vigilance-avoidance for affective pain words. The induction also led to more distress and pain. Rumination and worry appear to increase unhelpful patterns of attention and could be an appropriate focus of intervention.

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Dynamic balance training improves physical function in individuals with knee osteoarthritis: a pilot randomized controlled trial

Beliefs about pharmaceutical medicines and natural remedies explain individual variation in placebo analgesia

This study examined whether placebo responses were predicted by a theoretical model of specific and general treatment beliefs. Using a randomised cross-over, experimental design (168 healthy individuals) we assessed whether responses to a cold pressor task were influenced by two placebo creams described as Pharmaceutical vs Natural origin. We assessed whether placebo responses were predicted by pre-treatment beliefs about the treatments (placebo) and by beliefs about the pain. The efficacy of both Pharmaceutical and Natural Placebos in reducing Pain Intensity was predicted by aspects of pain catastrophizing including Feelings of Helplessness (Pharmaceutical: B=0.03, p<0.01, Natural: B=0.02, p<0.05) and Magnification of Pain (Pharmaceutical: B=0.04, p<0.05, Natural: B=0.05, p<0.05) but also by pre-treatment Necessity beliefs (Pharmaceutical: B=0.21, p<0.01, Natural: B=0.16, p<0.05) and, for the Pharmaceutical condition, by more general beliefs in personal sensitivity to pharmaceuticals (B=0.14, p<0.05).

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Lower placebo responses after long-term exposure to fibromyalgia pain

Knowledge about placebo mechanisms in patients with chronic pain is scarce. Fibromyalgia syndrome (FM) is associated with dysfunctions of central pain inhibition, and since placebo analgesia entails activation of endogenous pain inhibition, we hypothesized that long-term exposure to FM pain would negatively affect placebo responses. Here we examined the placebo-group (n=37, mean age 45 years) from a 12-week, randomized, double-blind, placebo-controlled trial investigating the effects of milnacipran or placebo.

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Body mass index and distribution of body fat can influence sensory detection and pain sensitivity

Abstract

Background

The aim of this study was to investigate the influence of body fat percentage and its distribution on sensory detection and pain sensitivity responses to experimentally induced noxious stimuli in otherwise pain-free individuals.

Methods

Seventy-two participants were divided into three equal groups according to their body mass index (BMI: normal, overweight and obese). Percentage body fat was estimated using a four-site skinfold method. Measurements of cold pressor pain threshold, tolerance and intensity; contact thermal sensory detection and heat pain threshold and tolerance (TSA-II – NeuroSensory Analyzer, Medoc); and blunt pressure pain threshold (algometer, Somedic SenseLab AB) were taken at the waist and thenar eminence.

Results

Mean ± SD pressure pain threshold of the obese group (620.72 ± 423.81 kPa) was significantly lower than normal (1154.70 ± 847.18 kPa) and overweight (1285.14 ± 998.89 kPa) groups. Repeated measures ANOVA found significant effects for site for cold detection threshold (F_1,68 = 8.3, p = 0.005) and warm detection threshold (F_1,68 = 38.69, p = 0.001) with waist having lower sensory detection thresholds than thenar eminence. For heat pain threshold, there were significant effects for site (F_1,68 = 4.868, p = 0.031) which was lower for waist compared with thenar eminence (mean difference = 0.89 °C).

Conclusion

Obese individuals were more sensitive than non-obese individuals to pressure pain but not to thermal pain. Body sites may vary in their response to different types and intensities of stimuli. The inconsistency of findings within and between research studies should catalyse further research in this field.

Significance

This study provided evidence that body mass index and distribution of body fat can influence sensory detection and pain sensitivity. Obese individuals were more sensitive than normal range body mass index individuals to pressure pain but not to thermal pain. Pain response varied according to subcutaneous body fat at different body sites. These findings strengthen arguments that weight loss should be a significant aspect of a pain management programme for obese pain patients.

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Bilateral analgesic effects of abobotulinumtoxinA (Dysport®) following unilateral administration in the rat

Abstract

Background

In addition to inhibition of muscle and glandular hyperactivity, botulinum neurotoxin (BoNT) type A also interferes with pain processing. Previously, in a rat model of paclitaxel-induced polyneuropathy, abobotulinumtoxinA (aboBoNT-A) elicited analgesic effects not only in the injected paw, but also in the contralateral, non-injected paw.

Methods

Here, we assessed bilateral analgesic effects of unilateral aboBoNT-A in several chronic pain models in Sprague-Dawley rats. Effects of aboBoNT-A on the paw withdrawal threshold in response to mechanical pressure was assessed in models of streptozotocin-induced diabetic polyneuropathy, chronic constriction injury (CCI)-associated mononeuropathy, and bilateral carrageenan-induced inflammatory pain.

Results

In diabetic polyneuropathy, aboBoNT-A (15, 20 U/kg) reversed hyperalgesia in the toxin-injected and non-injected paws. In unilateral CCI-exposed animals, 20 U/kg aboBoNT-A given ipsilateral to the injury reversed mechanical hyperalgesia, while 30 U/kg aboBoNT-A given contralateral to the injury had no effect. In carrageenan-induced bilateral inflammatory pain, aboBoNT-A (20, 30 U/kg) reversed hyperalgesia in both toxin-injected and non-injected paws.

Discussion

These results suggest that unilateral administration of aboBoNT-A results in bilateral reduction in mechanical hyperalgesia across neuropathic and inflammatory pain conditions, bilateral activation of sensory neurons being prerequisite for its expression. Future studies involving effects on other sensory modalities as well as those evaluating diffusion and migration of the toxin away from the injection site can shed light on mechanisms of this phenomenon.

Significance

The results expand evidence on bilateral analgesic effects of aboBoNT-A following unilateral administration across pain modalities, as the phenomenon is seen in more than one model of polyneuropathy as well as in a model of chronic inflammatory pain when the latter is rendered bilateral. The mechanism of bilateral analgesic effects of aboBoNT-A may require activation of the peripheral sensory neurons and involve retrograde axonal transport of the toxin into the spinal cord.

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Slow brushing reduces heat pain in humans

Abstract

Background

C-tactile (CT) afferents are unmyelinated low-threshold mechanoreceptors optimized for signalling affective, gentle touch. In three separate psychophysical experiments, we examined the contribution of CT afferents to pain modulation.

Methods

In total, 44 healthy volunteers experienced heat pain and CT optimal (slow brushing) and CT sub-optimal (fast brushing or vibration) stimuli. Three different experimental paradigms were used: Concurrent application of heat pain and tactile (slow brushing or vibration) stimulation; Slow brushing, applied for variable duration and intervals, preceding heat pain; Slow versus fast brushing preceding heat pain.

Results

Slow brushing was effective in reducing pain, whereas fast brushing or vibration was not. The reduction in pain was significant not only when the CT optimal touch was applied simultaneously with the painful stimulus but also when the two stimuli were separated in time. For subsequent stimulation, the pain reduction was more pronounced for a shorter time interval between brushing and pain. Likewise, the effect was more robust when pain was preceded by a longer duration of brush stimulation. Strong CT-related pain reduction was associated with low anxiety and high calmness scores obtained by a state anxiety questionnaire.

Conclusions

Slow brushing – optimal for CT activation – is effective in reducing pain from cutaneous heating. The precise mechanisms for the pain relief are as yet unknown but possible mechanisms include inhibition of nociceptive projection neurons at the level of the dorsal horn as well as analgesia through cortical mechanisms.

Significance

Slow brushing stimuli – optimal for activation of C-tactile fibres – can reduce pain from cutaneous heating. No such effect was seen with fast brushing or vibration. These observations indicate the role of C-tactile fibres in pain modulation.

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Effects of short-term oxycodone maintenance on experimental pain responses in physically dependent opioid abusers

A common clinical problem with opioid analgesics is the loss of analgesic efficacy after repeated dosing; when this occurs, it is not clear what principles should guide providing effective analgesia among opioid-dependent individuals. This within-subject inpatient study aimed to determine if physically dependent opioid abusers (n=11) experience changes in oxycodone-induced analgesia during two oxycodone maintenance (30mg p.o./q.i.d.) phases: Initial Stabilization (Days 1 – 3) and after 6 weeks of Chronic Dosing.

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Pain catastrophizing and negative mood states following spinal cord injury: transitioning from inpatient rehabilitation into the community

Chronic pain is prevalent in people with spinal cord injury (SCI). This research investigated how chronic pain intensity and catastrophizing varies in adults with SCI during inpatient rehabilitation up to 12 months post-injury after transitioning into the community. Eighty-eight participants with SCI were assessed for pain intensity and catastrophizing, depressive mood states and cognitive performance. Participants were divided into sub-groups of clinically elevated depressive mood and anxiety versus those with normal mood state levels.

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Morphological and physiological differences in the upper trapezius muscle in patients with work-related trapezius myalgia compared to healthy controls: A systematic review

Trapezius myalgia is a common musculoskeletal complaint, characterized by pain, stiffness and tightness of the trapezius muscle. It is often work-related and caused by prolonged static and repetitive work tasks. It is hypothesized that this leads to various morphological and physiological alterations in muscle tissue but the pathophysiology is poorly understood. These alterations can be investigated by analysing muscle biopsies in order to reveal the underlying cellular mechanisms.

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Reconceptualising manual therapy skills in contemporary practice

With conflicting evidence regarding the effectiveness of manual therapy calls have arisen within some quarters of the physiotherapy profession challenging the continued use of manual skills for assessment and treatment. A reconceptualisation of the importance of manual examination findings is put forward, based upon a contemporary understanding of pain science, rather than considering these skills only in terms of how they should “guide” manual therapy interventions. The place for manual examination findings within complex, multidimensional presentations is considered using vignettes describing the presentations of five people with low back pain.

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Psychometric evaluation of the Pain Attitudes Questionnaire-Revised for people with advanced cancer

Pain-related stoicism and cautiousness are theorized to be more prevalent in older than younger patients and to lead to greater pain underreporting and consequently inadequate pain management in older patients. The Pain Attitudes Questionnaire-Revised (PAQ-R), which measures five pain-related stoicism (fortitude, concealment, superiority) and cautiousness (self-doubt, reluctance) factors in chronic pain, can help test this hypothesis in advanced cancer but requires validation. We conducted a psychometric evaluation of the PAQ-R in 155 younger (< 60 years) and 114 older (≥ 60 years) patients with advanced cancer.

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Intrathecal Versus Intravenous Morphine in Minimally Invasive Posterior Lumbar Fusion: A Blinded Randomized Comparative Prospective Study

Study Design. A blinded, randomized, comparative prospective study. Objective. The aim of this study was to compare the use of intrathecal morphine to endovenous morphine on postoperative pain after posterior lumbar surgery. Summary of Background Data. Intrathecal morphine can provide significant safe analgesia for at least 12 hours and up to 24 hours in patients undergoing major surgery. Its dosages have been decreasing in the last 30 years, but currently, the optimal dose remains unknown. As of today, there are no studies comparing the efficacy and the side effects of this technique with intravenous morphine administration after minimally invasive lumbar fusion surgery. Methods. We randomized and compared two groups of 25 patients, who were given either 100 μg intrathecal (ITM group) or 5 ± 2 mg intravenous morphine delivered intravenously for 24 hours at 2 mL/h (IVM group) after minimally invasive posterior lumbar fusion. VAS score at 0, 6, 12, 24 hours, mobilization out of bed at 6 hours, hospitalization duration and complications as lower limbs paresthesia, urinary retention at 6 and 12 hours, nausea, vomit, itch, and constipation were evaluated. Results. Data showed a lower VAS score, a reduction of constipation, lower limbs paresthesia, or urinary retention at 12 hours in ITM rather than in the IVM group. None suffered of vomit, itch, or nausea in both groups. Urinary retention was observed more frequently in ITM group at 6 hours. Patients of ITM group were mobilized out bed earlier than those from IVM group. Conclusion. A low dosage of intrathecal morphine is safe and effective after minimally invasive lumbar fusion surgery. The reduction of pain in the study group permitted a shorter hospitalization and earlier mobilization out of bed, augmenting patients’ comfort. Level of Evidence: 2

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Cost-Effectiveness of Primary Care Management With or Without Early Physical Therapy for Acute Low Back Pain: Economic Evaluation of a Randomized Clinical Trial

Study Design. Economic evaluation of a randomized clinical trial. Objective. Compare costs and cost-effectiveness of usual primary care management for patients with acute low back pain (LBP) with or without the addition of early physical therapy. Summary of Background Data. Low back pain is among the most common and costly conditions encountered in primary care. Early physical therapy after a new primary care consultation for acute LBP results in small clinical improvement but cost-effectiveness of a strategy of early physical therapy is unknown. Methods. Economic evaluation was conducted alongside a randomized clinical trial of patients with acute, nonspecific LBP consulting a primary care provider. All patients received usual primary care management and education, and were randomly assigned to receive four sessions of physical therapy or usual care of delaying referral consideration to permit spontaneous recovery. Data were collected in a randomized trial involving 220 participants age 18 to 60 with LBP <16 days duration without red flags or signs of nerve root compression. The EuroQoL EQ-5D health states were collected at baseline and after 1-year and used to compute the quality adjusted life year (QALY) gained. Direct (health care utilization) and indirect (work absence or reduced productivity) costs related to LBP were collected monthly and valued using standard costs. The incremental cost-effectiveness ratio was computed as incremental total costs divided by incremental QALYs. Results. Early physical therapy resulted in higher total 1-year costs (mean difference in adjusted total costs = $580, 95% CI: $175, $984, P = 0.005) and better quality of life (mean difference in QALYs = 0.02, 95% CI: 0.005, 0.35, P = 0.008) after 1-year. The incremental cost-effectiveness ratio was $32,058 (95% CI: $10,629, $151,161) per QALY. Conclusion. Our results support early physical therapy as cost-effective relative to usual primary care after 1 year for patients with acute, nonspecific LBP. Level of Evidence: 2

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Collar Fixation Is Not Mandatory After Cervical Laminoplasty: A Randomized Controlled Trial

Study Design. Prospective randomized controlled study. Objectives. To determine the effect of collar-aided fixation on outcomes after laminoplasty for cervical compressive myelopathy. Summary of Background Data. Patients are often placed in a Philadelphia collar for weeks after cervical laminoplasty. However, the benefit of postoperative collar use remains controversial. We hypothesized that treatment outcomes in postoperative pain in patients without collars would not be inferior to the outcomes in patients using Philadelphia collars for 2 weeks. Methods. This trial analyzed 74 patients (52 males, 22 females, mean age 72.7 years) with cervical compressive myelopathy who had undergone double-door laminoplasty. Before surgery, we randomly assigned patients to the collar-fixation (CF) group (postoperative Philadelphia collar for 2 weeks) or the no-collar (NC) group. The primary outcome was the visual analog scale (VAS) for cervical pain up to 1 year after surgery. Secondary outcomes were Japanese Orthopedics Association score, Short Form 36 score (SF-36), cervical range of motion (ROM), lordotic angle, and complications. Results. VAS scores up to 1 year after operation were similar with or without collar fixation (P = 0.487, two-way ANOVA). JOA scores improved significantly in both groups (P = 0.002 in CF, P < 0.001 in NC). There was no statistically significant difference between groups with regard to the improvement of JOA scores (54.9% in CF, 47.0% in NC, P = 0.80). The improvement in SF-36 was similar in both groups. Loss of ROM and lordotic angle of the cervical spine did not differ between groups (P = 0.61 in CF, P = 0.82 in NC). The incidence of complications was similar in both groups. Conclusion. The VAS scores of cervical pain with the postoperative treatment without collar fixation were not inferior to those when using Philadelphia collars for 2 weeks. Moreover, other outcomes such as JOA scores, SF-36, ROM, lordotic angle, and complications were similar in both groups. Level of Evidence: 2

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Management of Symptomatic Cervical Disk Herniation: A Survey Among Dutch Neurosurgeons

Study Design. A questionnaire survey. Objective. To assess the preferred surgical technique, the optimal timing of surgery, and the expectations of different surgical techniques of neurosurgeons in the Netherlands, regarding patients with cervical disc herniation (CDH). Summary of Background Data. To treat CDH, multiple surgical techniques are performed. Due to the lack of consensus, the daily routine management may vary. Methods. All 134 neurosurgeons of the Dutch Association of Neurosurgery were sent a survey, evaluating the operative management as well as the attitude towards different surgical treatments for CDH. Results. Ninety-six (74.4%) of the neurosurgeons treating CDH completed the survey. Anterior cervical discectomy with fusion (ACDF) was the standard procedure for the majority of neurosurgeons (76.3%). ACDF was expected to have the highest effectiveness on arm pain, yet also a higher risk for complications as compared with anterior cervical discectomy (ACD). Approximately, 47.9% of the surgeons regarded a minimal duration of 8 to 12 weeks of radicular arm pain before deciding to perform surgery. Regarding the risk of recurrent CDH, DCF was expected to give the highest risk, whereas ACDF the lowest. Conclusion. Despite the lack of solid evidence in favor for ACDF this survey showed that ACDF is the preferred technique to treat cervical radiculopathy. A minimum duration of 8 to 12 weeks of radicular arm pain was considered the optimal timing to perform surgery for CDH by the majority of the neurosurgeons. Whether to fuse or not remains a controversial subject in degenerative spinal surgery. This study emphasizes the need of high-quality evidence on the optimal surgical management of CDH. Level of Evidence: N/A

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Feasibility of Posterior Cervical Foraminotomy in Cervical Foraminal Stenosis: Prediction of Surgical Outcomes by the Foraminal Shape on Preoperative Computed Tomography

Study Design. A retrospective cohort study. Objective. The aim of this study was to compare the feasibility of posterior cervical laminoforaminotomy (PCF) for V- or parallel-shaped foraminal stenosis (FS). Summary of Background Data. During PCF, the need for extensive facet resection would depend on the extent of any pathology. When resection is extensive, the possibilities of instability and incomplete decompression should be considered. Methods. From March 2004 to March 2015, we enrolled 36 patients following single-level PCF procedures for FS. We classified patients by foraminal shape on preoperative computed tomography (CT) scan into V-shaped and parallel-shaped groups. We then compared arm and neck pain using a numeric rating scale (NRS) and clinical outcomes using Odom criteria. Radiological evaluation included dynamic X-rays for instability and CT scans for facet resection. Result. We enrolled 16 and 20 patients in the V-shape and parallel-shape groups, respectively. By Odom criteria, no patient was graded fair or poor in the V group, but five patients were graded as fair and one patient as poor in the parallel group. Continued postoperative arm pain at 1 year, which was related to incomplete decompression, was significantly higher in parallel group. Only one patient complained of postoperative neck pain with an NRS >5, and another five patients sustained radiculopathy with an NRS >5. Among five patients who complained sustained radiculopathy, one patient required revision surgery for incomplete decompression. The amount of facet removal was not different significantly between groups, and no patient had postoperative instability. Conclusion. Although PCF seems to be a good surgical option for V-shaped FS, we experienced worse outcomes for patients with parallel-shaped FS. We recommend that ACDF or more aggressive posterior foraminotomy be performed with fusion when presented with parallel neuroforaminal compression. Level of Evidence: 4

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Prognostic Factors for Persistent Leg-Pain in Patients Hospitalized With Acute Sciatica

Study Design. Prospective cohort study. Objective. To identify potential prognostic factors for persistent leg-pain at 12 months among patients hospitalized with acute severe sciatica. Summary of Background Data. The long-term outcome for patients admitted to hospital with sciatica is generally unfavorable. Results concerning prognostic factors for persistent sciatica are limited and conflicting. Methods. A total of 210 patients acutely admitted to hospital for either surgical or nonsurgical treatment of sciatica were consecutively recruited and received a thorough clinical and radiographic examination in addition to responding to a comprehensive questionnaire. Follow-up assessments were done at 6 weeks, 6 months, and 12 months. Potential prognostic factors were measured at baseline and at 6 weeks. The impact of these factors on leg-pain was analyzed by multiple linear regression modeling. Results. A total of 151 patients completed the entire study, 93 receiving nonrandomized surgical treatment. The final multivariate models showed that the following factors were significantly associated with leg-pain at 12 months: high psychosocial risk according to the Örebro Musculosceletal Pain Questionnaire (unstandardized beta coefficient 1.55, 95% confidence interval [CI] 0.72–2.38, P < 0.001), not receiving surgical treatment (1.11, 95% CI 0.29–1.93, P = 0.01), not actively employed upon admission (1.47, 95% CI 0.63–2.31, P < 0.01), and self-reported leg-pain recorded 6 weeks posthospital admission (0.49, 95% CI 0.34–0.63, P < 0.001). Interaction analysis showed that the Örebro Musculosceletal Pain Questionnaire had significant prognostic value only on the nonsurgically treated patients (3.26, 95% CI 1.89–4.63, P < 0.001). Conclusion. The results suggest that a psychosocial screening tool and the implementation of a 6-week postadmission follow-up has prognostic value in the hospital management of severe sciatica. Level of Evidence: 2

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Accuracy and Safety of Pedicle Screw Placement in Adolescent Idiopathic Scoliosis Patients: A Review of 2020 Screws Using Computed Tomography Assessment

Study Design. Retrospective review of CT scan. Objective. To investigate the accuracy and safety of pedicle screws placed in adolescent idiopathic scoliosis (AIS) patients. Summary of Background Data. The reported pedicle screws perforation rates for corrective AIS surgery vary widely from 1.2% to 65.0%. Knowledge regarding the safety of pedicle screws in scoliosis surgery is very important in preventing complications. Methods. This study investigates the accuracy and safety of pedicle screws placed in 140 AIS patients. CT scans were used to assess the perforations that were classified according to Rao et al (2002): grade 0, grade 1 (<2 mm), grade 2 (2–4 mm), and grade 3 (>4 mm). Anterior perforations were classified into grade 0, grade 1 (<4 mm), grade 2 (4–6 mm), and grade 3 (>6 mm). Grade 2 and 3 (excluding lateral grade 2 and 3 perforation over thoracic vertebrae) were considered as critical perforations. Results. A total of 2020 pedicle screws from 140 patients were analyzed. The overall total perforation rate was 20.3% (410 screws) with 8.2% (166 screws) grade 1, 2.9% (58 screws) grade 2 and 9.2% (186 screws) grade 3 perforations. Majority of the perforations was because of lateral perforation occurring over the thoracic region, as a result of application of extrapedicular screws at this region. When the lateral perforations of the thoracic region were excluded, the perforation rate was 6.4% (129 screws), grade 2, 1.4% (28 screws) and grade 3, 0.8% (16 screws). There were only two symptomatic left medial grade 2 perforations: one screw at T12 presented with postoperative iliac crest numbness and another screw at L2 presented with radicular pain that subsided with conservative treatment. There were six anterior perforations abutting the right lung, four anterior perforations abutting the aorta, two anterior perforations abutting the esophagus, and one abutting the trachea was noted. Conclusion. Pedicle screws insertion in AIS has a total perforation rate of 20.3%. After exclusion of lateral thoracic perforations, the overall perforation rate was 8.6% with a critical perforation rate of 2.2% (44/2020). The rate of symptomatic screw perforation leading to radicular symptoms was 0.1%. There was no spinal cord, aortic, esophageal, or lung injuries caused by malpositioned screws in this study. Level of Evidence: 4

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Patients’ Attitudes Toward Nonphysician Screening of Low Back and Low Back Related Leg Pain Complaints Referred for Surgical Assessment

Study Design. A questionnaire survey. Objective. The aim of this study was to explore patient attitudes toward screening to assess suitability for low back surgery by nonphysician health care providers. Summary of Background Data. Canadian spine surgeons have shown support for nonphysician screening to assess and triage patients with low back pain and low back related leg pain. However, patients’ attitudes toward this proposed model are largely unknown. Methods. We administered a 19-item cross-sectional survey to adults with low back and/or low back related leg pain who were referred for elective surgical assessment at one of five spine surgeons’ clinics in Hamilton, Ontario, Canada. The survey inquired about demographics, expectations regarding wait time for surgical consultation, as well as willingness to pay, travel, and be screened by nonphysician health care providers. Results. Eighty low back patients completed our survey, for a response rate of 86.0% (80 of 93). Most respondents (72.5%; 58 of 80) expected to be seen by a surgeon within 3 months of referral, and 88.8% (71 of 80) indicated willingness to undergo screening with a nonphysician health care provider to establish whether they were potentially a surgical candidate. Half of respondents (40 of 80) were willing to travel >50 km for assessment by a nonphysician health care provider, and 46.2% were willing to pay out-of-pocket (25.6% were unsure). However, most respondents (70.0%; 56 of 80) would still want to see a surgeon if they were ruled out as a surgical candidate, and written comments from respondents revealed concern regarding agreement between surgeons’ and nonphysicians’ determination of surgical candidates. Conclusion. Patients referred for surgical consultation for low back or low back related leg pain are largely willing to accept screening by nonphysician health care providers. Future research should explore the concordance of screening results between surgeon and nonphysician health care providers. Level of Evidence: 3

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Effect of Load Magnitude and Distribution on Lumbar Spine Posture in Active-duty Marines

Study Design. Repeated measures. Objective. The purpose of this study was to quantify the effect of operationally relevant loads and distributions on lumbar spine (LS) in a group of active-duty Marines. Summary of Background Data. Low-back pain has been associated with heavy load carriage among military personnel. Although there are data describing the LS posture in response to load, the effect of varying load characteristics on LS posture remains unknown. Methods. Magnetic resonance images of Marines (n = 12) were acquired when standing unloaded and when carrying 22, 33, and 45 kg of load distributed both 50% to 50% and 20% to 80% anteriorly and posteriorly. Images were used to measure LS and pelvic postures. Two-way repeated-measures ANOVA and posthoc tests were used to compare LS posture across load magnitudes and distributions (α = 0.05). This project was founded by the US Army Medical Research Acquisition Activity, Award No. W81XWH-13–2–0043, under Work Unit No. 1310. Results. No changes in LS posture were induced when load was evenly distributed. When load was carried in the 20% to 80% distribution lumbosacral flexion increased as a result of sacral anterior rotation and overall reduced lumbar lordosis. This pattern was greater as load was increased between 22 and 33 kg, but did not increase further between 33 and 45 kg. We observed that the inferior LS became uniformly less lordotic, independently of load magnitude. However, the superior LS became progressively more lordotic with increasing load magnitude Conclusion. Postural adaptations were found only when load was carried with a posterior bias, suggesting that load-carriage limits based on postural changes are relevant when loads are nonuniformly distributed. Although the tendency would be to interpret that loads should be carried symmetrically to protect the spine, the relationship between postural changes and injury are not clear. Finally, the operational efficiency of carrying load in this distribution needs to be tested. Level of Evidence: 3

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Outcomes Following Arthrodesis for Atlanto-Axial Osteoarthritis

Study Design. Retrospective analysis. Objective. We set out to evaluate the radiographic and patient-reported outcomes following C1-C2 arthrodesis for atlantoaxial osteoarthritis (AAOA) using modern instrumentation and techniques. Summary of Background Data. Few studies have evaluated outcomes following C1-C2 arthrodesis for AAOA using modern surgical fixation techniques. Methods. Retrospective analysis of all patients following C1-C2 arthrodesis with recalcitrant AAOA from a single center, single surgeon from 2002 to 2012. Preoperative, immediate and final follow-up postoperative radiographic images were evaluated. Patient-reported outcomes scores were assessed preoperative, 1-year, and final postoperative follow-up. Results. We found a total of 14 patients (13 female, 1 male) with average follow-up of 2.96 ± 2.26 years and mean age at surgery of 71.8 ± 9.3 years old. The most common construct was posterior C1-C2 bilateral screw-rod construct (SRC) (n = 9), and there were 3 patients with transarticular screw (TAS) constructs, and 2 patients with hybrid fixation (unilateral SRC and contralateral TAS). Mean change from baseline to final follow-up for Numeric Pain Rating Scale (NRS) was −4.7 ± 2.1, and Neck Disability Index (NDI) was −21.0 ± 13.6, with 11 (78.6%) patients demonstrated a substantial clinical benefit (change in NDI ≥ 10). There were no differences from baseline to all follow-up time points for SF-12 Physical and Mental Component Scores. All patients had evidence of solid C1-C2 arthrodesis and stable fixation at final follow-up, with no significant change in subaxial sagittal alignment. There were no perioperative or postoperative complications. Conclusion. We report one of the largest series evaluating patient-reported outcomes in patients following arthrodesis for AAOA using modern C1-C2 fixation techniques. Our study found C1-C2 arthrodesis for AAOA to be safe and effective, with a significant improvement in patient-reported pain and neck disability and most patients reporting substantial clinical benefit. Level of Evidence: 4

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