Was it less painful for knights? Influence of appearance on pain perception

Abstract

Background

Pain perception is a subjective experience shaped by different factors. In this study, we investigated the influence of a visually manipulated appearance of a virtual arm on pain perception. Specifically, we investigated how pain perception and vegetative skin responses were modified by inducing a virtual protection on the right arm by a virtual armour.

Methods

Participants (n = 32) immersed in virtual reality embodied a virtual arm, which appeared in three different versions (uncovered, neutral or protected). During the virtual reality simulation, the participants received electrical stimulations of varying intensities. Skin conductance level (SCL) was analysed for the phase anticipation (from the moment the arm appeared until the electric stimulation) and perception of pain (after the electric stimulation). Pain ratings were acquired after the painful stimuli occurred.

Results

The sense of embodiment was positive for the unprotected and neutral condition and lower for the protected than for the neutral arm. Pain ratings were significantly decreased in the protected arm condition compared with both the unprotected arm and the neutral arm conditions. The SCL measurements showed no significant differences for the three arm types.

Conclusions

According to the pain ratings, participants felt significantly less pain in the covered arm condition compared with the unprotected and the neutral arm condition. Subjective pain perception was decreased by a virtual protection of the arm in VR. The simplicity of the manipulation suggests possible practical uses in pain therapy by strengthening the patients’ own capacities to influence their pain using simple cognitive manipulations via virtual reality.

Significance

A virtual, covered arm causes differences in reported pain ratings. Physiological measurements do not confirm the findings. Visual information about body protection can have an impact on pain perception.

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Altered theta oscillations in resting EEG of fibromyalgia syndrome patients

Abstract

Background

Fibromyalgia syndrome (FM) is a chronic pain disorder characterized by widespread pain, sleep disturbance, fatigue and cognitive/affective symptoms. Functional imaging studies have revealed that FM and other chronic pain syndromes can affect resting brain activity. This study utilized electroencephalographic (EEG) recordings to investigate the relative power of ongoing oscillatory activity in the resting brain.

Methods

A 64-channel EEG was recorded at rest in 19 female FM patients and 18 healthy, age-matched, control subjects. The Manual Tender Point Scale (MTPS) examination was performed to quantify tonic pain and tenderness on the day of testing along with measures of mood, arousal and fatigue. Oscillations in delta, theta, alpha, beta and gamma frequency bands were analysed using Standardised Low-Resolution Brain Electromagnetic Tomography to evaluate sources of spectral activity throughout the whole brain.

Results

FM patients exhibited greater pain, tiredness and tension on the day of testing relative to healthy control participants and augmented theta activity in prefrontal and anterior cingulate cortices. No significant differences were seen in other frequency bands. Augmented frontal theta activity in FM patients significantly correlated with measures of tenderness and mean tiredness scores.

Conclusions

The findings indicate that alterations to resting-state oscillatory activity may relate to ongoing tonic pain and fatigue in FM, and manifest in brain regions relevant for cognitive-attentional aspects of pain processing and endogenous pain inhibition. Enhanced low-frequency oscillations were previously seen in FM and other chronic pain syndromes, and may relate to pathophysiological mechanisms for ongoing pain such as thalamocortical dysrhythmia.

Significance

Increased prefrontal theta activity may contribute to persistent pain in fibromyalgia or represent the outcome of prolonged symptoms. The findings point to the potential for therapeutic interventions aimed at normalizing neural oscillations, while further research utilizing quantitative analysis of resting EEG could benefit our understanding of fibromyalgia pathophysiology.

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Testing the validity of telephone interviews to assess chronic pain in children and adolescents: A randomized cross-over trial

Abstract

Background

Telephone surveys are intended to reduce attrition in longitudinal studies. For paediatric chronic pain patients, the comparability of pain-related information gathered using telephone interviews and postal surveys remain unknown. Furthermore, it remains unknown how social desirability may influence answers.

Methods

To compare data from telephone interviews and postal surveys, a randomized cross-over design with two measure points 2 weeks apart and four conditions (combinations of telephone interviews (T) and postal surveys (P): P-T, T-P, P-P, T-T) was conducted in a sample of N = 323 paediatric chronic pain patients.

Results

In the inter-group comparison, pain-related information did not differ between telephone interviews and postal surveys except for the information on pain location (back and extremities). Agreement measures of the intra-group comparisons suggest substantial to excellent agreements for all items and did not differ between the groups. The internal consistency of a disability scale was excellent for both assessment modes; the number of missing values did not differ. Participation rate was higher for telephone interviews compared to the postal surveys. Across both time points, attrition was lowest for the groups without a switch in assessment mode compared to the groups with a switch in assessment mode. Except for pain-related school absence, no effect of social desirability occurred.

Conclusions

Telephone interviews are a useful method to achieve a high response rate. Pain locations should be asked for separately and not in an open question when interviewing children and adolescents on the telephone.

Significance

Telephone interviews are a good method to achieve a high response rate and obtain valid data in studies with paediatric chronic pain patients.

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Fear of Pain Questionnaire-9: Brief assessment of pain-related fear and anxiety

Abstract

Background

Fear and anxiety are important considerations in both acute and chronic pain. Effectively and efficiently measuring fear and anxiety associated with pain in healthcare settings is critical for identifying vulnerable patients. The length and administration time of current measures of pain-related fear and anxiety inhibit their routine use, as screening tools and otherwise, suggesting the need for a shorter, more efficient instrument.

Methods

A 9-item shortened version of the Fear of Pain Questionnaire – III (FPQ-III), the Fear of Pain Questionnaire-9 (FPQ-9), was developed based upon statistical analyses of archival data from 275 outpatients with chronic pain and 275 undergraduates. Additionally, new data were collected from 100 outpatients with chronic pain and 190 undergraduates to directly compare the standard and short forms. Exploratory and confirmatory factor analyses, and other psychometric analyses, were conducted to examine and establish the FPQ-9 as a reliable and valid instrument.

Results

The original three-factor structure of the FPQ-III was retained in the shortened version; a confirmatory factor analysis produced good model fit (RMSEA = 0.00, CFI = 1.00, TLI = 1.00, SRMR = 0.03). Results suggested a high degree of correlation between the original FPQ-III and the new FPQ-9 (r = 0.77, p < 0.001). Measures of internal consistency for FPQ-9 subscales were high; correlations with other pain and anxiety instruments suggested concurrent, convergent and divergent validity.

Conclusions

The FPQ-9 is a psychometrically sound alternative to longer instruments assessing fear and anxiety associated with pain, for use in both clinical and research situations that only allow brief screening.

Significance

The FPQ-9 has considerable potential for dissemination and utility for routine, brief screening, given its length (completion time ~2 min; scoring time ~1 min), reading level and psychometric properties.

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Tactile acuity testing at the neck: A comparison of methods

Interest in measurement of tactile acuity in musculoskeletal practice has emerged following its link to functional reorganization of the somatosensory cortex in ongoing pain states. Several tactile acuity measurement methods have been described but have not been thoroughly investigated in the cervical region.

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Racial and Socioeconomic Disparities in Disabling Chronic Pain: Findings from the Health and Retirement Study

The U.S. National Pain Strategy calls for increased population research on “high impact chronic pain,” i.e., longstanding pain that substantially limits participation in daily activities. Using data from the nationally-representative Health and Retirement Study (HRS), we investigated the prevalence of high-impact chronic pain in U.S. adults over age 50 overall and within population subgroups. We also explored sociodemographic variation in pain-related disability within specific activity domains.

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Diagnosis and early management of inflammatory arthritis

What you need to knowConsider inflammatory arthritis in anyone with acute or subacute onset of joint pain, early morning stiffness, and soft tissue swellingEarly diagnosis and treatment with disease...

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Do self-efficacy, body mass index, duration of onset and pain intensity determine performance on selected physical tasks in individuals with unilateral knee osteoarthritis?

To investigate the contributions of Pain Self-Efficacy (PSE), Function Self-Efficacy (FSE), Body Mass Index (BMI), duration of onset of Knee OsteoArthritis (KOA) and Present Pain Intensity (PPI) to performance on Stair Task Test (STT), Timed Up-and-Go (TUG) and 20-Meter Walk Test (20-MWT) and explore correlations among the variables in individuals with unilateral KOA.

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VIP cortical conductors set the tone for chronic pain

Nature Neuroscience 20, 1037 (2017). doi:10.1038/nn.4609

Authors: Erika K Harding & Michael W Salter

Loss of inhibition in a circuit in the primary somatosensory cortex that controls the activity of layer 5 neurons drives pain hypersensitivity. Restoring this inhibition resets the inhibitory–excitatory balance, producing analgesia.

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Long-Term Effects of Repeated Injections of Local Anesthetic With or Without Corticosteroid for Lumbar Spinal Stenosis: A Randomized Trial

Comorbidities That Cause Pain and the Contributors to Pain in Individuals With Chronic Obstructive Pulmonary Disease

Dynamic Balance Training Improves Physical Function in Individuals With Knee Osteoarthritis: A Pilot Randomized Controlled Trial

Short-Term Effects of Thoracic Spine Manipulation on Shoulder Impingement Syndrome

Association of Traumatic Brain Injury With Chronic Pain in Iraq and Afghanistan Veterans: Effect of Comorbid Mental Health Conditions

Comparative Effectiveness of Nonoperative Treatments for Chronic Calcific Tendinitis of the Shoulder: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Clinical Utility and Psychometric Characteristics of the Measure of Intermittent and Constant Osteoarthritis Pain in Adults With Hip and Knee Osteoarthritis

Own and partner pain intensity in older couples: longitudinal effects on depressive symptoms

Abstract: Chronic pain has been linked to depression among individuals and their partners. Yet, little is known about long-term mutual influences between pain intensity and depressive symptoms within couples as they age. Using a nationally representative U.S. sample of wives and husbands aged 50 and older (mean = 64.53, SD = 7.86), this study explored the links between own and partner pain intensity and depressive symptoms across an 8-year period. A total of 963 heterosexual married couples drawn from the Health and Retirement Study completed interviews biennially from 2006 to 2014. Dyadic growth curve models examined mutual associations within couples and controlled for sociodemographic characteristics, length of marriage, and marital quality, along with self-rated health, number of chronic health conditions, and functional disability. For wives and husbands, their own greater baseline pain intensity was significantly linked to their own higher levels of depressive symptoms. Unexpectedly, wives with greater baseline pain intensity reported decreases in their depressive symptoms over time. There were also partner effects such that husbands' greater pain intensity at baseline was associated with increases in wives' depressive symptoms over time. Findings highlight the importance of considering both individual and spousal associations between pain intensity and depressive symptoms in later life. Understanding how individual and couple processes unfold may yield critical insights for the development of intervention and prevention efforts to maintain mental health among older chronic pain patients and their spouses.

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Manual therapy, exercise therapy or combined treatment in the management of adult neck pain – A systematic review and meta-analysis

Neck pain is a common and often disabling musculoskeletal condition. Two therapies frequently prescribed for its management are manual therapy (MT) and exercise therapy (ET), and combining these treatment approaches are common.

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Cervical stability training with and without core stability training for patients with cervical disc herniation: A randomized, single-blind study

Abstract

Background

This study aims at evaluating and comparing the effects of cervical stability training to combined cervical and core stability training in patients with neck pain and cervical disc herniation.

Methods

Fifty patients with neck pain and cervical disc herniation were included in the study, randomly divided into two groups as cervical stability and cervical-core stability. Training was applied three times a week in three phases, and lasted for a total duration of 8 weeks. Pain, activation and static endurance of deep cervical flexor muscles, static endurance of neck muscles, cross-sectional diameter of M. Longus Colli, static endurance of trunk muscles, disability and kinesiophobia were assessed.

Results

Pain, activation and static endurance of deep cervical flexors, static endurance of neck muscles, cross-sectional diameter of M. Longus Colli, static endurance of trunk muscles, disability and kinesiophobia improved in both groups following the training sessions (p < 0.05). Comparison of the effectiveness of these two training methods revealed that the cervical stability group produced a greater increase in the right transverse diameter of M. Longus Colli (p < 0.05). However, static endurance of trunk muscles and kinesiophobia displayed better improvement in the cervical-core stability group (p < 0.05).

Conclusions

Cervical stability training provided benefit to patients with cervical disc herniation. The addition of core stability training did not provide any additional significant benefit. Further research is required to investigate the efficacy of combining other techniques with cervical stability training in patients with cervical disc herniation.

Significance

Both cervical stability training and its combination with core stability training were significantly and similarly effective on neck pain and neck muscle endurance in patients with cervical disc herniation.

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A smoker with joint pain

A 45 year old man presented with a 6 month history of painful joints, cough, fever, and weight loss. He had a smoking history of 15 pack years. On examination there was synovitis of the hands, feet,...

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Equimolar mixture of nitroux oxyde and oxygen during post-operative physiotherapy in patients with cerebral palsy: A randomized, double-blind, placebo-controlled study

Abstract

Background

The administration of an equimolar mixture of nitrous oxide and oxygen (N2O) is recommended during painful procedures. However, the evaluation of its use during physiotherapy after surgery has not been reported, although pain may hamper physiotherapy efficiency. This study investigated whether the use of N2O improves the efficacy of post-operative physiotherapy after multilevel surgery in patients with cerebral palsy.

Method

It was a randomized 1:1, double-blind, placebo-controlled study. All patients had post-operative physiotherapy starting the day after surgery. Patients received either N2O or placebo gas during the rehabilitation sessions. All patients had post-operative pain management protocol, including pain medication as needed for acute pain. The primary objective was to reach angles of knee flexion of 110° combined with hip extension of 10°, with the patient lying prone, within six or less physiotherapy sessions. Secondary evaluation criteria were the number of sessions required to reach the targeted angles, the session-related pain intensity and the analgesics consumption for managing post-operative pain.

Results

Sixty-four patients were enrolled. Targeted angles were achieved more often in the N2O group (23 of 32, 72%, vs. Placebo: 13/ of 32, 41%; p = 0.01).

Conclusion

The administration of N2O during post-operative physiotherapy can help to achieve more quickly an improved range of motion, and, although not significant in our study, to alleviate the need for pain medication. Further studies evaluating the administration of N2O in various settings are warranted.

Significance

During this randomized placebo-controlled double-blind study, children receiving nitrous oxide and oxygen (N2O) achieved more often the targeted range of motion during physiotherapy sessions after multilevel surgery. Compared to placebo, nitrous oxide and oxygen (N2O) enabled a better management of acute pain related to physiotherapy procedures.

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Second World War: Paris neurosurgeon's map outwitted Nazis

Second World War: Paris neurosurgeon's map outwitted Nazis

Nature 547, 7663 (2017). doi:10.1038/547281a

Authors: Pierre Bourdillon, Marc Lévêque & Caroline Apra

Neurosurgeon Jean Talairach (1911–2007) created his pioneering brain atlas with his colleague Gabor Szikla in 1967. Almost three decades earlier, he had painstakingly drawn a quite different map — of Paris's subterranean ossuaries (see 'Catacomb network under Paris'), a copy of which we recently unearthed

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Evidence for the modulation of nociception in mice by central mast cells

Abstract

Background

Hyperalgesia that develops following nerve ligation corresponds temporally and in magnitude with the number of thalamic mast cells located contralateral to the ligature. We tested the possibility that mast cells modulate nociception centrally, similar to their role in the periphery.

Methods

We examined the central effect of two hyperalgesic compounds that induce mast cell degranulation and of stabilized mast cells using cromolyn.

Results

Thermal hyperalgesia (tail flick) induced by nerve growth factor (NGF, a neurotrophic compound) and mechanical hyperalgesia (von Frey) induced by dynorphin A (1-17) (opioid compound) each correlated with the per cent of thalamic mast cells that were degranulated. Degranulation of these mast cells by the central injection of compound 48/80, devoid of neurotrophic or opioid activity, was sufficient to recapitulate thermal hyperalgesia. Stabilization of mast cells by central injections of cromolyn produced no analgesic effect on baseline tail flick or von Frey fibre sensitivity, but inhibited thermal hyperalgesia produced by compound 48/80 and tactile hyperalgesia induced by dynorphin and by Freund's complete adjuvant. Finally, chemical nociception produced by the direct activation of nociceptors by formalin (phase I) was not inhibited by centrally injected cromolyn whereas chemical nociception dependent on central sensitization (formalin-phase II and acetic acid-induced abdominal stretches) was.

Conclusions

These convergent lines of evidence suggest that degranulation of centrally located mast cells sensitizes central nociceptive pathways leading to hyperalgesia and tonic chemical sensitivity.

Significance

Hyperalgesia induced by spinal nerve ligation corresponds temporally and in magnitude with degranulation of thalamic mast cells. Here, we provide evidence that hyperalgesia induced by NGF, formalin and dynorphin also may depend on mast cell degranulation in the CNS whereas cromolyn, a mast cell stabilizer, blocks these effects in mice.

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Delta-9-tetrahydrocannabinol decreases masticatory muscle sensitization in female rats through peripheral cannabinoid receptor activation

Abstract

Background

This study investigated whether intramuscular injection of delta-9-tetrahydrocannabinol (THC), by acting on peripheral cannabinoid (CB) receptors, could decrease nerve growth factor (NGF)-induced sensitization in female rat masseter muscle; a model which mimics the symptoms of myofascial temporomandibular disorders.

Methods

Immunohistochemistry was used to explore the peripheral expression of cannabinoid receptors in the masseter muscle while behavioural and electrophysiology experiments were employed to assess the functional effects of intramuscular injection of THC.

Results

It was found that CB1 and CB2 receptors are expressed by trigeminal ganglion neurons that innervate the masseter muscle and also on their peripheral endings. Their expression was greater in TRPV1-positive ganglion neurons. Three days after intramuscular injection of NGF, ganglion neuron expression of CB1 and CB2, but not TPRV1, was decreased. In behavioural experiments, intramuscular injection (10 μL) of THC (1 mg/mL) attenuated NGF-induced mechanical sensitization. No change in mechanical threshold was observed in the contralateral masseter muscles and no impairment of motor function was found after intramuscular injections of THC. In anaesthetized rats, the same concentration of THC increased the mechanical thresholds of masseter muscle mechanoreceptors. Co-administration of the CB1 antagonist AM251 blocked the effect of THC on masseter muscle mechanoreceptors while the CB2 antagonist AM630 had no effect.

Conclusions

These results suggest that reduced inhibitory input from the peripheral cannabinoid system may contribute to NGF-induced local myofascial sensitization of mechanoreceptors. Peripheral application of THC may counter this effect by activating the CB1 receptors on masseter muscle mechanoreceptors to provide analgesic relief without central side effects.

Significance

Our results suggest THC could reduce masticatory muscle pain through activating peripheral CB1 receptors. Peripheral application of cannabinoids could be a novel approach to provide analgesic relief without central side effects.

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Structured pain management reduces patient discomfort after catheter ablation and rhythm device surgery

Abstract

Background

The goal was to test the effectiveness of a structured pain management programme after invasive electrophysiological interventions in cardiology including ablation of atrial fibrillation (AF) or ventricular tachycardia (VT) and implantation, or explantation, of pacemakers or implantable cardioverter defibrillators.

Methods

This was a prospective study with a pre-/post-design where a post-intervention group (116 consecutive patients) was compared to a pre-intervention group (102 consecutive patients) after implementation of a structured pain-management programme using the numeric rating scale (NRS 0–10) and classified as moderate-to-severe if NRS > 3. Measurements were recorded every two hours during the first 24 h post-operatively. The location of the pain and the amount of analgesic used were also recorded.

Results

The proportion of patients who experienced moderate-to-severe pain after the procedure decreased after initiation of the pain-management program: 47% versus 61%; p = 0.048. This difference was driven primarily by reduced pain late (8–24 h) after the procedure; 16% versus 39%; p < 0.001. The risk to develop late (8–24 h) post-procedural pain was reduced approximately three-fold after implementation of the pain-management programme (OR = 0.32, 95% CI 0.16–0.64, p = 0.001). Multivariate analysis indicated chronic pain, early pain (0–6 h), and type of intervention were associated with late post-interventional pain. In contrast, age, diabetes mellitus, BMI, gender and procedure time were not related.

Conclusion

The findings illustrate the potential value of a structured pain-management programme. The proportion of patients who experienced moderate-to-severe pain after these electrophysiological procedures decreased significantly.

Significance

This is the first exploratory study that evaluates the impact of a multidisciplinary pain-management programme after cardiac electrophysiological interventions. It demonstrates that significant quality improvement is achievable following simple rules together with patient and staff education. The programme reduces the proportion of patients with moderate-to-severe pain after electrophysiological procedures significantly.

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Association between chronic musculoskeletal pain and executive function in community-dwelling older adults

Abstract

Background

We examined the association of chronic musculoskeletal pain with executive function in community-dwelling older adults.

Method

This cross-sectional study recruited 234 community-dwelling older adults in Japan (mean age: 72.7, women: 62.8%). Chronic musculoskeletal pain was defined as having moderate or more severe pain lasting ≥ 3 months. Executive function was assessed using the Digit Symbol Substitution Test (DSST), Trail Making Test (TMT) parts A and B, Letter Verbal Fluency Test (LVFT) and Category Verbal Fluency Test (CVFT).

Results

Prevalence of chronic musculoskeletal pain was 19% (n = 44). In the univariate analysis, the DSST and CVFT scores were significantly lower in the chronic musculoskeletal pain group than in the control group (DSST: chronic musculoskeletal pain group vs. control group, 40.2 vs. 45.4, respectively, p < 0.05; CVFT: 13.7 vs. 15.6, respectively, p < 0.05), whereas the TMT parts A and B and LVFT scores were not. The multivariate linear regression models adjusted for covariates showed that the chronic musculoskeletal pain group had significantly lower DSST (adjusted β = –0.13, p < 0.05) and CVFT scores (adjusted β = –0.17, p < 0.05) than the control group.

Conclusion

Chronic musculoskeletal pain may interfere with the elements of executive function, processing speed and semantic fluency, in community-dwelling older adults. The association of chronic musculoskeletal pain with executive function requires further investigation.

Significance

Our results suggest an association between moderate-severe chronic musculoskeletal pain and impairments of semantic fluency and processing speed in community-dwelling older adults.

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Ecological momentary assessment of pain, fatigue, depressive and cognitive symptoms reveals significant daily variability in multiple sclerosis

How do pain, fatigue, depressive, and cognitive symptoms relate to well-being and social and physical functioning in the daily lives of individuals with multiple sclerosis?

Pain, fatigue, and cognitive symptoms are temporally associated within- but not across-days in multiple sclerosis

Exercise Therapy in Juvenile Idiopathic Arthritis: A Systematic Review and Meta-analysis

An Overview of Chronic Spinal Pain: Revisiting Diagnostic Categories and Exploring an Evolving Role for Neurostimulation

Study Design. Topic overview. Objective. To describe the varied etiologies resulting in chronic spinal pain and review the current available evidence for treatments. Summary of Background Data. Chronic pain conditions, especially those that affect the axial back and radiate to the extremities, affect a large population. This results in pronounced disability and a high socioeconomic burden. Our understanding of the underlying mechanisms for chronic pain is limited. This prevents a comprehensive diagnostic approach. Evidence from high-level clinical trials supporting treatments for chronic spinal pain is also limited. Methods. Articles were identified through PubMed searches or already known to the author. The literature was reviewed and summarized, indicating the strength of evidence available for many treatment modalities. Results. There are very few studies published that evaluate behavioral modifications for chronic spinal pain and only one long-term study investigating chronic pharmacological treatments. The data on the success of spinal surgeries to relieve chronic spinal pain suggest an unacceptably high failure rate. The best evidence (Level I) currently available suggests that spinal cord stimulation is a safe, effective, and durable treatment for chronic spinal pain. Recent clinical data support further investigation of new innovations and earlier therapeutic consideration of currently employed approaches. Conclusion. Currently, physicians are limited in the practice of evidence-based medicine regarding chronic spinal pain treatments due to both the paucity of data available and an inconsistent diagnostic nomenclature. The introduction of new neurostimulation modalities is promising but requires better characterization through ongoing prospective clinical investigation. Level of Evidence: 5

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Treatment Options for Failed Back Surgery Syndrome Patients With Refractory Chronic Pain: An Evidence Based Approach

Study Design. A significant number of lumbar postsurgical patients continue to suffer persistent pain and limited function and are termed to have “Failed back surgery syndrome” (FBSS). This review evaluates clinical trial data for the treatment of FBSS patients. Objective. Using an evidence-based approach to evaluate FBSS treatments will assist clinicians in choosing the most effective options for FBSS patients. Furthermore, reducing the utilization of less effective therapies may result in substantial financial savings for this patient population. Summary of Background Data. Treatments for FBSS may be generally categorized as physical therapy and exercise, medications, interventional procedures, neuromodulation, and reoperation. Careful review and classification of the level of evidence available for each category of treatment for FBSS patients will help guide clinical decision-making. Methods. A literature review was performed for FBSS treatments. The publications were arranged hierarchically according to the North American Spine Society's guidelines as randomized controlled trials (RCTs), prospective studies, retrospective chart, and systematic reviews. Book chapters, nonsystematic reviews, and expert opinions were excluded. The review focused on studies with at least 20 FBSS patients and 6-month follow-up. Results. Evidence is weak for medications and reoperation, but strong for active exercise and interventional procedures such as adhesiolysis. The strongest evidence for long-term treatment is for spinal cord stimulation (SCS), showing favorable Level I RCT results compared with conventional medical management and reoperation. In addition, high-frequency SCS at 10 kHz has demonstrated superiority over traditional, low-frequency SCS for treating low back and leg pain in a recent Level I RCT. Conclusion. Clinicians may increasingly utilize levels of evidence during their evaluation of each FBSS patient to render the best therapeutic plan, likely resulting in improved long-term pain control and reducing costs by avoiding less effective modalities. New directions in SCS show promising results for the treatment of FBSS. Level of Evidence: 1

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Spinal Cord Stimulation in Chronic Pain: Mode of Action

Study Design. Literature review. Objective. A review of the literature that presents a perspective on mechanisms of actions behind spinal cord stimulation (SCS) therapy for chronic pain. Summary of Background Data. SCS is an effective therapeutic alternative for the treatment of intractable chronic pain. Its application has been mostly based on the gate control theory of pain. Computational models have been fundamental on the understanding of clinical observations and the design of therapies that provide optimal neuromodulation. Research has provided insight into the involvement of specific neurotransmitters that support segmental and supraspinal mechanisms of action. Methods. A literature review was performed with emphasis on mechanisms of action for SCS including the effects of electrical fields on spinal cord structures based on computational models and preclinical and clinical explorations. Results. This review provides background on the development of SCS, which has been driven around a paresthesia-based paradigm as a result of the gate control theory. A review of computational models emphasizes their importance on our current understanding of the mechanism of action and clinical optimization of therapy. Electrophysiology and molecular biology have provided a closer, yet narrow, view of the effect of SCS on neurotransmitters and their receptors, which have led to the formulation of segmental and supraspinal mechanisms. Literature supporting the involvement of glial cells in chronic pain and their characteristic response to electrical fields should motivate further investigation of mechanisms involving neuroglia. Finally, a review of recent results paresthesia-free strategies should encourage research on mechanisms of action. Conclusion. The mechanisms of SCS have been extensively studied and several consistent phenomena have emerged. The activation of A-beta fibers to induce paresthesia also involve neurotransmitter release via segmental and supraspinal pathways. Despite advancements, much remains to be understood, particularly as new stimulation strategies are developed. Level of Evidence: N /A

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Clinical Evidence for Spinal Cord Stimulation for Failed Back Surgery Syndrome (FBSS): Systematic Review

Study Design. A systematic review. Objective. A systematic literature review of the clinical data from prospective studies was undertaken to assess the efficacy of spinal cord stimulation (SCS) in the treatment of failed back surgery syndrome (FBSS) in adults. Summary of Background Data. For patients with unrelenting back pain due to mechanical instability of the spine, degenerative disc disease, spinal injury, or deformity, spinal surgery is a well-accepted treatment option; however, even after surgical intervention, many patients continue to experience chronic back pain that can be notoriously difficult to treat. Clinical evidence suggests that for patients with FBSS, repeated surgery will not likely offer relief. Additionally, evidence suggests long-term use of opioid pain medications is not effective in this population, likely presents additional complications, and requires strict management. Methods. A systematic literature review was performed using several bibliographic databases, prospective studies in adults using SCS for FBSS were included. Results and Conclusion. SCS has been shown to be a safe and efficacious treatment for this patient population. Recent technological developments in SCS offer even greater pain relief to patients’ refractory to other treatment options, allowing patients to regain functionality and improve their quality of life with significant reductions in pain. Level of Evidence: N/A

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Best Practices in Spinal Cord Stimulation

Study Design. A review of clinical best practices for spinal cord stimulation (SCS). Objective. The aim of this study is to summarize published and evidence based guidelines with regards to utilizing SCS, including patient selection, disease indication, perioperative management, complication mitigation strategies, and device selection. Additional focus has been provided on quality care to individual patients by acknowledging the importance of durable outcomes and care delivery costs. Summary of Background Data. For more than 30 years, SCS has successfully alleviated patient suffering and enhanced the lives of patients with refractory pain conditions. Prospective studies of SCS have consistently demonstrated benefits through reduction of pain, improvement in function, and reduced healthcare expenditures in select patient diagnosis groups. Although the benefits of SCS are well-supported, the clinical application of this therapy varies widely based on physician training and experience, regional clinical practice variations, and insurance coverage. Methods. This article provides a summary of published studies, case reports, evidence-based guidelines and expert consensus, with the intent of increasing physician competency and enhancing patient care through improved clinical outcomes. Results. A guide to SCS implantation, appropriate patient selection, ranked recommendations for diseases that may most benefit for SCS treatment, complication mitigation strategies, and finally, indications for choosing the most efficacious modality of SCS therapy for specific patients and pain conditions. Conclusion. Although SCS has been shown to be safe and effective for a number of pain conditions, emerging SCS modalities promise even greater efficacy over traditional SCS. To achieve this promise, physicians must carefully select and manage their patients and the SCS device. Level of Evidence: N\A

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Cost-Effectiveness Data Regarding Spinal Cord Stimulation for Low Back Pain

Study Design. Review of published literature pertaining to spinal cord stimulation (SCS) cost data analysis. Objective. To acquire, organize, and succinctly summarize the available literature regarding the costs associated with, and the cost-effectiveness of, SCS. Summary of Background Data. Chronic back and limb pain is a pervasive complaint in modern society, with estimated annual costs of medical care greater than $100 billion. The traditional standard medical management with or without intermittent surgical decompression/fusion has been plagued by high costs and inconsistent results, leading to poor patient satisfaction and functional outcome, and questions from policy makers regarding use of limited healthcare resources. Neuromodulation techniques, including SCS have recently become more common in the treatment of chronic back/leg pain, with clinical studies showing a high degree of efficacy in alleviating otherwise intractable pain. Given the relatively high upfront costs associated with the hardware and implantation, policy makers have, however, questioned their use in the framework of cost-containment and resource utilization. We reviewed the available literature summarizing cost data of SCS in chronic back and limb pain, as an understanding of these data will be vital to justify continued payment for this expensive, but often very effective, treatment modality. Methods. We performed a PubMed literature search utilizing the following terms: “spinal cord stimulation,” “SCS,” “financial,” “cost,” “cost-effectiveness,” and “cost-utility.” All studies published in English and containing complete or partial cost evaluations of SCS for chronic back and limb pain were included. Results. The search revealed 21 studies that evaluated cost data, with or without outcomes analysis and cost-utility analysis, for patients with chronic back and limb pain. The overwhelming majority of data presented shows that SCS is not only an effective treatment option for these patients, but also represents cost savings and efficient use of healthcare resources relative to current standards of care. Although not all studies performed cost-utility analyses, those that did tended to show SCS falling well within accepted thresholds of “willingness-to-pay” on the part of third-party payers. That being said, the articles included in this review were almost all small, retrospective, single-institution studies. In addition, many of them relied on modeling for their analyses, and published literature values for cost and/or outcomes data rather than prospectively collected patient data. Although the data presented in this review are encouraging, it should serve as a foundation for a thorough, prospective, cost-utility analysis of SCS in chronic back and limb pain so that the role of this important treatment modality may be cemented in the treatment paradigm for these patients without questions from third-party payers. Conclusion. The large majority of data covering costs of SCS argue in favor of the cost-effectiveness of this treatment modality for chronic neuropathic pain, especially in comparison to reoperation and medical management. Although most of the higher-quality evidence is relatively short-term, clinical experience with the durability of treatment benefit of SCS in these patients is promising. Given the pushback regarding high upfront costs of implantation, longer-term, prospective, randomized studies evaluating this topic will be important to help maintain third-party payer reimbursements for SCS. Level of Evidence: 5

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Evidence Gaps in the Use of Spinal Cord Stimulation for Treating Chronic Spine Conditions

Study Design. A review of literature. Objective. The aim of this study was to define and explore the current evidence gaps in the use of spinal cord stimulation (SCS) for treating chronic spine conditions. Summary of Background Data. Although over the last 40 years SCS therapy has undergone significant technological advancements, evidence gaps still exist. Methods. A literature review was conducted to define current evidence gaps for the use of SCS. Areas of focus included 1) treatment of cervical spine conditions, 2) treatment of lumbar spine conditions, 3) technological advancement and device selection, 4) appropriate patient selection, 5) the ability to curb pharmacological treatment, and 6) methods to prolong efficacy over time. New SCS strategies using advanced waveforms are explored. Results. The efficacy, safety, and cost-effectiveness of traditional SCS for chronic pain conditions are well-established. Evidence gaps do exist. Recently, advancement in waveforms and programming parameters have allowed for paresthesia-reduced/free stimulation that in specific clinical areas may improve clinical outcomes. New waveforms such as 10-kHz high-frequency have resulted in an improvement in back coverage. To date, clinical efficacy data are more prevalent for the treatment of painful conditions originating from the lumbar spine in comparison to the cervical spine. Conclusion. Evidence gaps still exist that require appropriate study designs with long-term follow-up to better define and improve the use of this therapy for the treatment of chronic spine pain in both the cervical and lumbar regions. Level of Evidence: N/A

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Trial Design and Endpoint Evaluation in Clinical Studies Addressing Chronic Back Pain

Study Design. A review of the literature evaluating clinical trials of chronic back pain. Objective. To assist physicians in assessing the quality of clinical trial data to make the most informed treatment decisions. Summary of Background Data. Chronic pain is a tremendous public health issue, affecting close to 100 million adults in the United States, and costs the American people billions of dollars. One traditional treatment approach, the long-term use of opiate medications, has recently come under intense scrutiny for problems with complications, diversion, abuse, addiction, and lack of efficacy.1 In addition, the Centers for Disease Control and Prevention has recognized that overprescribing opiates has enabled an overdose crisis, and written guidelines that are intended to limit their use. It is for this reason that physicians must have a comprehensive understanding of the range of drug-free alternative therapies available and have the tools needed to rigorously evaluate the chronic pain literature so they can make appropriate treatment decisions. Methods. An evaluation of how clinical trials are designed and ranked, outcome measures, and costs for a variety of therapies is necessary to determine which treatment option is the most efficacious for an individual patient. Results. Clinical trial data demonstrate that spinal cord stimulation (SCS) is a safe and effective treatment option for many types of chronic pain, including back pain. The last 10 years has brought tremendous advances in the field of neuromodulation. Today, several treatment modalities exist for SCS requiring the physician to be able to critically evaluate and interpret the literature and determine which modality has the strongest evidence. When evaluating clinical trial data of patients with chronic back pain, emphasis must be placed on well designed, randomized controlled trials with long-term follow-up producing level I evidence. These data are obtained in a rigorous manner and are likely to have less bias when compared with lower level studies. Conclusion. The level I studies performed to date have provided evidence that treatment with SCS results in sustainable pain reduction and improvements in scores measuring quality of life and patient functioning in those patients with chronic intractable back pain. Level of Evidence: 5

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Improvements in Neck and Arm Pain Following an Anterior Cervical Discectomy and Fusion

Study Design. A retrospective analysis. Objective. The aim of this study was to quantify improvements in Visual Analogue Scale (VAS) neck and arm pain, Neck Disability Index (NDI), and Short Form-12 (SF-12) Mental (MCS) and Physical (PCS) Composite scores following an anterior cervical discectomy and fusion (ACDF). Summary of Background Data. ACDF is evaluated with patient-reported outcomes. However, the extent to which these outcomes improve following ACDF remains poorly defined. Methods. A surgical registry of patients who underwent primary, one- or two-level ACDF during 2013 to 2015 was reviewed. Comparisons of VAS neck and arm, NDI, and SF-12 MCS and PCS scores were performed using paired t tests from preoperative to each postoperative time point. Analysis of variance (ANOVA) was used to estimate the reduction in neck and arm pain over the first postoperative year. Subgroup analyses were performed for patients with predominant neck (pNP) or arm (pAP) pain, as well as for one- versus two-level ACDF. Results. Eighty-nine patients were identified. VAS neck and arm, NDI, and SF-12 PCS improved from preoperative scores at all postoperative time points (P < 0.05 for each). Across the first postoperative year, patients reported a 2.7-point (44.2%) reduction in neck and a 3.1-point (54.0%) reduction in arm pain (P < 0.05 for each). Sixty-one patients with pNP and 28 patients with pAP reported reductions in neck and arm pain over the first 6 months and 12 weeks postoperatively, respectively (P < 0.05 for each). Patients who underwent one-level ACDFs experienced a 47.2% reduction in neck pain and 55.1% reduction in arm pain over the first postoperative year (P < 0.05 for each), while those undergoing two-level ACDF experienced 39.7% and 49.2% for neck and arm, respectively (P < 0.05 for each). Conclusion. This study suggests that patients experience significant improvements in neck and arm pain following ACDF regardless of presenting symptom. In addition, patients undergoing one-level ACDF report greater reductions in neck and arm pain than patients undergoing two-level fusion. Level of Evidence: 4

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Which Technique Is Better Option for C3 Segment in Multilevel Open-Door Laminoplasty of the Cervical Spine?: Laminectomy Versus Laminoplasty

Study Design. A post-hoc comparative study. Objective. To evaluate postoperative clinical, radiological, and surgical outcomes after laminoplasty (LP) involving the C3 segment and to compare outcomes with those of patients who underwent LP with C3 laminectomy (LN). Summary of Background Data. In many of the pathologies that require LP involving C3 segment, most spine surgeons perform LP at C3 and other cervical segments. Considering the peculiarities of the C2-C3 level, spine surgeons should take into account those in LP involving the C3 segment, but the particular aspects of the C2-C3 levels have not been fully evaluated. Methods. Of 93 patients, 66 patients (39 in group A, LP involving C3; 27 in group B, LP with C3 LN) were enrolled in the study. The primary outcome measure was pain intensity of the posterior neck measured with visual analog scale. Secondary endpoints included the following: (1) radiologic outcomes based on the cervical range of motion and rate of bony impingement and spontaneous fusion between C2 and C3, (2) clinical outcomes based on the 12-item short-form health survey and Japanese Orthopedic Association scale, and (3) surgical outcomes. Results. The primary end-point of the present study, posterior neck pain, exhibited a greater improvement in the group with C3 LN than in the group with C3 LP at 6 months and 1 year after surgery (P = 0.03 and 0.01, respectively). The cervical range of motion of C3 LN group was significantly greater than C3 LP group at postoperative 1 year (P = 0.02). Radiologic evidences of bony impingement and spontaneous fusion between C2 and C3 were significantly greater in C3 LP group than in C3 LN group. Clinical outcomes and surgical outcomes did not differ significantly between groups. Conclusion. We recommend performing LN instead of LP for the C3 segment in cases requiring multilevel LP surgery involving C3. Level of Evidence: 3

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Intramuscular Local Anesthetic Infiltration at Closure for Postoperative Analgesia in Lumbar Spine Surgery: A Systematic Review and Meta-Analysis

Study Design. Systematic Review and Meta-Analysis Objective. To identify whether intramuscular local anesthetic infiltration prior to wound closure was effective in reducing postoperative pain and facilitating early discharge following lumbar spine surgery. Summary of Background Data. Local anesthetic infiltration prior to wound closure may form part of the multimodal strategy for postoperative analgesia, facilitating early mobilization and discharge. Although there are a number of small studies investigating its utility, a quantitative meta-analysis of the data has never been performed. Methods. This review was conducted according the PRISMA statement and was registered with the PROSPERO database. Only randomized controlled trials were eligible for inclusion. Key outcomes of interest included time to first analgesic demand, total postoperative opiate usage in the first 24 hours, visual analogue score (VAS) at 1, 12 and 24 hours and postoperative length of stay. Results. Eleven publications fulfilled the inclusion criteria. A total of 438 patients were include; 212 in the control group and 226 in the intervention group. Local anesthetic infiltration resulted in a prolonged time to first analgesic demand (mean difference (MD) 65.88 minutes, 95% confidence interval (95% CI) 23.70 to 108.06, P.0.002) as well as a significantly reduced postoperative opiate demand (M.D. −9.71 mg, 95% CI −15.07, −4.34, p = 0.0004). There was a small but statistically significant reduction in postoperative visual analogue score (VAS) at 1 hour (M.D. −0.87 95%CI −1.55, −0.20, p = 0.01), but no significant reduction at 12 or 24 hours (p = 0.93 and 0.85 respectively). Conclusion. This systematic review and meta-analysis provides evidence that postoperative intramuscular local anaesthetic infiltration reduces postoperative analgesic requirements and the time to first analgesic demands for patients undergoing lumbar spine surgery. Key research priorities include optimization of the choice and strength of local anaesthetic agent and health-economic analyses to strengthen the case for routine use of postoperative local anesthetics in lumbar spine surgery. Level of Evidence: 1

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Reoperation for Recurrent Intervertebral Disc Herniation in the Spine Patient Outcomes Research Trial: Analysis of Rate, Risk Factors, and Outcome

Study Design. This study was a post-hoc subgroup analysis of prospectively collected data in the Spine Patient Outcomes Research Trial (SPORT). Objective. The aim of this study was to determine the risk factors for and to compare the outcomes of patients undergoing revision disc excision surgery in SPORT. Summary of Background Data. Risk factors for reherniation and outcomes after revision surgery have not been well-studied. This information is critical for proper patient counseling and decision-making. Methods. Patients who underwent primary discectomy in the SPORT intervertebral disc herniation cohort were analyzed to determine risk factors for undergoing revision surgery. Risk factors for undergoing revision surgery for reherniation were evaluated using univariate and multivariate analysis. Primary outcome measures consisted of Oswestry Disability Index (ODI), the Sciatica Bothersomeness index (SBI), and the Short Form 36 (SF-36) at 6 weeks, 3 months, 6 months, and yearly to 4 years. Results. Of 810 surgical patients, 74 (9.1%) received revision surgery for reherniation. Risk factors for reherniation included: younger age (hazard ratio [HR] 0.96 [0.94–0.99]), lack of a sensory deficit (HR 0.61 [0.37–0.99]) lack of motor deficit (HR 0.54 [0.32–0.91]), and higher baseline ODI score (HR 1.02 [1.01–1.03]). The time-adjusted mean improvement from baseline to 4 years was less for the reherniation group on all outcome measures (Bodily Pain Index [BP] 39.5 vs. 44.9, P = 0.001; Physical Function Index [PF] 37.1 vs. 44.5, P < 0.001; ODI 33.9 vs. 38.3, P < 0.001; SBI 8.7 vs. 10.5, P < 0.001). At 4 years, only SBI (−9 vs. −11.4, P = 0.002) was significantly lower in the reherniation group. Conclusion. Younger patients with higher baseline disability without neurological deficit are at increased risk of undergoing revision surgery for reherniation. Those considering revision surgery for reherniation will likely improve significantly following surgery, but possibly not as much as with primary discectomy. Level of Evidence: 3

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Development of the Parent Responses to School Functioning Questionnaire

Parents play an important role in supporting school functioning in youth with chronic pain, but no validated tools exists to assess parental responses to child and adolescent pain behaviors in the school context. Such a tool would be useful in identifying targets of change to reduce pain-related school impairment. The goal of this study was to develop and preliminarily validate the Parent Responses to School Functioning (PRSF) Questionnaire, a parent self-report measure of this construct. After initial expert review and pilot testing, the measure was administered to 418 parents of children (ages 6-17) seen for initial multidisciplinary chronic pain clinic evaluation.

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Prevalence, patterns, and predictors of massage practitioner utilization: Results of a US nationally representative survey

The use of massage therapy is common, especially in patients with musculoskeletal pain. The purpose of this study was to examine the prevalence, utilization, socio-demographic and health-related predictors of massage practitioner consultations in the US population.

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[Department of Error] Department of Error

Avidan MS, Maybrier HR, Abdallah AB, et al. Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. Lancet 2017; 390: 267–275—In this Article, the eighth author's name should have read “Hilary P Grocott”. This correction has been made to the online version as of July 13, 2017, and the printed Article is correct.

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Severe chest pain in an asthmatic patient

A 20 year old woman with a history of asthma presented to the emergency department complaining of shortness of breath and sharp pains in her chest and neck. The pain was worse on deep inspiration....

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Factors Influencing Long-Term Opioid Use Among Opioid Naïve Patients: an Examination Of Initial Prescription Characteristics and Pain Etiologies

The relationships of characteristics of the initial opioid prescription and pain etiology with the probability of opioid discontinuation were explored in this retrospective cohort study using health insurance claims data from a nationally representative database of commercially insured patients in the U.S. We identified 1,353,902 persons aged ≥14 with no history of cancer or substance abuse, with new opioid use episodes and categorized them into 11 mutually exclusive pain etiologies. Cox Proportional Hazards models were estimated to identify factors associated with time to opioid discontinuation.

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A new pupillary measure to assess pain: a prospective study

The Variation Coefficient of Pupillary Diameter (VCPD) allows for an objective assessment of pain in laboring women. It could allow for an easy assessment of pain in non-communicating patients: newborns or very old patients, patients with serious psychological conditions, assessment during the immediate post-operatory period or in intensive care units.

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Can primary care for back and/or neck pain in the Netherlands benefit from stratification for risk groups according to the STarT Back Tool-classification?

The Kinematics and Spondylosis of the Lumbar Spine Vary Depending on the Levels of Motion Segments in Individuals With Low Back Pain

Study Design. A prospective cohort study. Objective. The aim of this study was to identify associations of spondylotic and kinematic changes with low back pain (LBP). Summary of Background Data. The ability to characterize and differentiate the biomechanics of both the symptomatic and asymptomatic lumbar spine is crucial to alleviate the sparse literature on the association of lumbar spine biomechanics and LBP. Methods. Lumbar dynamic plain radiographs (flexion-extension), dynamic computed tomography (CT) scanning (axial rotation, disc height), and magnetic resonance imaging (MRI, disc and facet degeneration grades) were obtained for each subject. These parameters were compared between symptomatic and control groups using Student t test and multivariate logistic regression, which controlled for patient age and sex and identified spinal parameters that were independently associated with symptomatic LBP. Disc grade and mean segmental motion by level were tested by one-way analysis of variance (ANOVA). Results. Ninety-nine volunteers (64 asymptomatic/35 LBP) were prospectively recruited. Mean age was 37.3 ± 10.1 years and 55% were male. LBP showed association with increased L5/S1 translation [odds ratio (OR) 1.63 per mm, P = 0.005], decreased flexion-extension motion at L1/L2 (OR 0.87 per degree, P = 0.036), L2/L3 (OR 0.88 per degree, P = 0.036), and L4/L5 (OR 0.87 per degree, P = 0.020), increased axial rotation at L4/L5 (OR 2.11 per degree, P = 0.032), decreased disc height at L3/L4 (OR 0.52 per mm, P = 0.008) and L4/L5 (OR 0.37 per mm, p < 0.001), increased disc grade at all levels (ORs 2.01–12.33 per grade, P = 0.001–0.026), and increased facet grade at L4/L5 (OR 4.99 per grade, P = 0.001) and L5/S1 (OR 3.52 per grade, P = 0.004). Significant associations were found between disc grade and kinematic parameters (flexion-extension motion, axial rotation, and translation) at L4/L5 (P = 0.001) and L5/S1 (P < 0.001), but not at other levels (P > 0.05). Conclusion. In symptomatic individuals, L4/L5 and L5/S1 levels were affected by spondylosis and kinematic changes. This study clarifies the relationships between kinematic alterations and LBP, mostly observed at the above-mentioned segments. Level of Evidence: N/A

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Intermittent Cervical Traction for Treating Neck Pain: A Meta-analysis of Randomized Controlled Trials

Study Design. A meta-analysis. Objective. The aim of this study was to perform a comprehensive search of current literature and conduct a meta-analysis of randomized controlled trials (RCTs) to assess the neck pain relieving effect of intermittent cervical traction (ICT). Summary of Background Data. Neck pain is a common and disabling problem with a high prevalence in general population. It causes a considerable burden on the health care system with a substantial expenditure. ICT is a common component of physical therapy for neck pain in the outpatient clinic. However, the evidence regarding the effectiveness of ICT for neck pain is insufficient. Methods. Data were obtained from the PubMed, Cochrane Library, Embase, and Scopus databases from the database inception date to July 02, 2016. RCTs reporting the effects of ICT on neck pain, including those comparing the effects of ICT with those of a placebo treatment, were included. Two reviewers independently reviewed the studies, conducted a risk of bias assessment, and extracted data. The data were pooled in a meta-analysis by using a random-effects model. Results. The meta-analysis included seven RCTs. The results indicated that patients who received ICT for neck pain had significantly lower pain scores than those receiving placebos did immediately after treatment (standardized mean difference = −0.26, 95% confidence interval = −0.46 to −0.07). The pain scores during the follow-up period and the neck disability index scores immediately after treatment and during the follow-up period did not differ significantly. Conclusion. ICT may have a short-term neck pain-relieving effect. Some risks of bias were noted in the included studies, reducing the evidence level of this meta-analysis. Additional high-quality RCTs are required to clarify the long-term effects of ICT on neck pain. Level of Evidence: 1

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Stand-alone Lateral Recess Decompression Without Discectomy in Patients Presenting With Claudicant Radicular Pain and MRI Evidence of Lumbar Disc Herniation: A Prospective Study

Study Design. A prospective study. Objective. The aim of this study was to analyze the outcomes of stand-alone lateral recess decompression without discectomy in patients with claudicant radicular pain and magnetic resonance imaging (MRI) showing LRS (lateral recess stenosis) with lumbar disc herniation. Summary of Background Data. Discectomy is the gold standard treatment for symptomatic lumbar disc herniations refractory to conservative care. Typically, patients with positive SLR (Straight leg raising test) and flexion dominant leg pain are the ideal candidates who can be benefited from discectomy. There is a subset of patients with morphological features of lumbar disc herniation with LRS on MRI and presenting with diametrically opposite symptoms such as claudicant leg pain, extension dominant leg pain, relief on flexion, and a negative SLR. Until now, no focused prospective study in the literature highlights stand-alone lateral recess decompression in this group of patients. Methods. From January 2007 to June 2013, 55 patients having unilateral claudicant radicular pain were selected to undergo stand-alone lateral recess decompression with tubular retractors. Intraoperatively, disc consistency and presence of sequestrated fragments were analyzed. Visual Analogue Scale (VASleg), Oswestry Disability Index (ODI) score, and Macnab criteria were used to measure outcomes. Results. Out of 55 patients, stand-alone lateral recess decompression was successfully executed in 51 patients and remaining four patients had sequestrated discs that required removal. Mean age at presentation was 54.5 years (41–67 years), male:female ratio was 1.12:1, and mean follow-up was 3.8 years (3–5.8 years). Significant improvement (P < 0.0001) was noticed between preoperative and postoperative VASleg score (8.39 ± 0.84 vs. 2.5 ± 0.48) and ODI score (46.79 ± 1.85 vs. 18.71 ± 2.41). As per Macnab criteria, 94% patients were satisfied with surgery. Conclusion. Stand-alone lateral recess decompression without discectomy is clinically effective for a large majority of patients with claudicant radicular pain and MRI evidence of LRS with associated lumbar disc herniation. The ability to perform it with minimal invasive techniques makes it focused and targeted with minimal morbidity. Level of Evidence: 4

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Selective Anterior Thoracolumbar Fusion in Adolescent Idiopathic Scoliosis: Long-Term Results After 17-Year Follow-Up

Study Design. Prospectively updated long-term data and retrospective case series analysis. Objective. To report the long-term results of selective anterior instrumented thoracolumbar (ThL) fusion in adolescent idiopathic scoliosis (AIS). Summary of Background Data. The results of anterior selective fusion in AIS have been reported up to 2 and 5 years follow-up. However, there is a lack of evidence of long-term results of this surgical approach. Methods. Forty-two consecutive patients with main thoracolumbar/lumbar AIS who had undergone surgery for a selective anterior ThL instrumented fusion with more than 12 years of follow-up met inclusion criteria. Preoperative, postoperative (1-yr), and final updated radiographic parameters were recorded. Final ODI and SRS-22 questionnaires were evaluated. Results. Thirty-five patients were finally recruited (5 were lost and 2 refused). The mean age at surgery was 16.6 years. The mean final follow-up was 17.3 years (12–24 yr). The ThL preoperative Cobb was 49.5° ± 9, obtaining a postoperative correction of 79%±13 and final correction of 72% ± 18. The preoperative thoracic curve (31.4° ± 14.2) obtained a spontaneous postoperative correction to 18.4° ± 11.9, maintained at final follow-up (17.8° ± 10.8). Apical vertebral rotation improved from 25.8° ± 7.8 to 9.2° ± 5.5 and finally to 8° ± 5.2 (P = 0.001). Sagittal parameters (T5-T12 = 27.2° and L1-S1=56.9°) did not change significantly postoperatively nor by final follow-up. Coronal balance improved from 2.4 cm to 1.6 cm postoperatively and 0.8 cm at final follow-up (P = 0.006). The disc angulation below the last instrumented vertebra improved with follow-up from 7.6° to 5.7° (P = 0.012). There were no revision surgeries or infections. One patient showed a symptomatic lower disc degeneration requiring lumbar pain surgery. Final SRS-22 global score was 4.3/5. The final ODI scored 6/100. Conclusion. In the long term, selective anterior thoracolumbar instrumentation with a single solid rod in AIS maintained good corrections on the three planes with no major complications or infections, no revision surgeries, and with satisfactory final functional and clinical outcomes. Level of Evidence: 4

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A Normative Baseline for the Srs-22 From Over 1000 Healthy Adolescents in India: Which Demographic Factors Affect Outcome?

Study Design. A prospective analysis. Objective. This study aims to 1) establish a baseline for the SRS-22 in South East Asia and 2) evaluate the influence of patient demographics on the SRS-22. Summary of Background Data. Previous studies have established a baseline for the SRS-22 in the US and described the impact of patient demographics. While the SRS-22 is used internationally, limited normative data are available. Methods. After approval from the local hospital and school board, 1200 adolescents (age 10–18 years) were asked to anonymously complete the SRS-22 in English. The following demographic factors were assessed: height, weight, age, gender, household income (range <$30K to >$200K), and household status (single/dual parent income). Participants with a prior spine history or active medical problems were excluded. Statistical analysis was done with a Pearson correlation followed by an analysis of variance (ANOVA). Results. One thousand nineteen unaffected adolescents completed the SRS-22 (mean age 14.4 ± 1.6 years). Demographics were as follows: gender (42%F, 58%M), household status (640 single/379 dual), height (157 ± 12 cm), weight (46 ± 11.2 kg), body mass index (BMI; 18.5 ± 3.6). SRS-22 score for all patients and by gender: Mean [4.0 ± 0.4, (F)4.0 ± 0.4, (M)3.9 ± 0.4, P < 0.0001], Activity [3.9 ± 0.4, (F)4.0 ± 0.5, (M)3.9 ± 0.6], Pain [4.3 ± 0.6; (F)4.4 ± 0.6, (M)4.2 ± 0.7, P < 0.001], Image [3.9 ± 0.6, (F)3.9 ± 0.6, (M)3.9 ± 0.6], and Mental [3.7 ± 0.6, (F)3.8 ± 0.6, (M)3.7 ± 0.6, P < 0.001]. Male gender was associated with worse pain (-0.15), mental health (-0.11), and overall SRS-22 score (−0.11). Age was correlated with a worse image (r = −0.17, P = < 0.000), while higher BMI was associated with less pain (0.07/0.02). Conclusion. Younger age, female gender, and higher BMI correlated with a better SRS-22 score. Income and household status did not affect SRS-22. These findings contrast data gathered in the US but should be considered in conjunction with the minimal clinically important difference (MCID). This study establishes the first normative baseline for the SRS-22 in SE Asia and analyzed the effect of demographics on the outcome score. Level of Evidence: 2

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