Acute and Persistent Post-Craniotomy Pain: A Prospective 6-Month Follow-Up Questionnaire Study

Introduction: The incidence of acute pain after craniotomy differs remarkably in previous studies, and the prevalence of persistent pain is not precisely known. We conducted 6-month follow-up surveys on the incidence and intensity of acute and persistent pain after elective craniotomy. Methods: We carried out a prospective cohort study via a series of structured questionnaires to record acute pain intensity preoperatively and postoperatively, and the incidence of persistent pain 3 and 6 months after a craniotomy in a tertiary care center. Patients scheduled for elective craniotomy were interviewed the day before surgery, postoperatively before discharge from the hospital, and 3 and 6 months after surgery. Pain was assessed on a numeric rating scale (0 - 10) at rest and movement, as well as expectations of pain before surgery, efficacy of pain therapy, and satisfaction with pain treatment. The incidence of adverse events, sleep time and interruptions caused by pain, different pain types, and drugs used for pain treatment were also recorded. Results: A total of 152 patients were enrolled in the study and completed the preoperative questionnaire;123 (81%) completed postoperative questionnaire and 108 (72%) completed the 3- and 6-month follow-ups. The average pain score at the time of the postoperative questionnaire was moderate, 4 at rest and 5 upon movement. The percentage of patients experiencing mild pain at rest and upon movement was 52% and 49%, and moderate pain was 15% and 16%, respectively. Severe postoperative pain was detected in 5% and 8% of patients at rest and upon movement, respectively. Three months after surgery, 6% of patients reported mild pain at rest, 3% moderate pain at rest, and 1% severe pain at rest. Persistent mild and moderate pain at rest after 6 months was reported by 3% and 1% of patients, respectively. The most common adverse events were postoperative nausea and vomiting (11%) and abdominal discomfort (8%). During postoperative pain treatment in the intensive care unit or post-anesthesia care unit, 92% of patients received acetaminophen, 88% fentanyl, and 24% oxycodone. During neurosurgical ward care, ibuprofen was used in 61% of patients. Satisfaction with analgesia was high throughout the study period with a median satisfaction score of 9 postoperatively and 10 at 3 and 6 months on the 0 - 10 scale. Conclusion: The findings indicate that most patients experience moderate or mild pain after craniotomy, but patient satisfaction with pain treatment is high. Persistent pain after 3 and 6 months is rare and mild in nature.

Persistent Post-Surgical Pain after Total Knee Arthroplasty at a Tertiary Care Hospital of a Low-Middle Income Country

Background: Persistent post-surgical pain (PPSP) is pain that lasts for 3 months or more after a surgical intervention, where other causes of pain have been excluded. There is scarce knowledge about the prevalence of PPSP in low- and middle-income countries (LMICs). The aim of our study was to assess the prevalence of PPSP after total knee arthroplasty (TKA) at our university hospital and explore factors associated with it. Methods: It was a prospective cross-sectional study. Approval was obtained from the Ethics Review Committee. Patients undergoing elective unilateral total knee arthroplasty under general or regional anaesthesia were recruited over a six months period. A designated pain nurse called the patients three months after surgery and asked about the presence of pain, its location, type, degree and associated factors. Patients who reported pain at three months were called a year after the surgery and the same questions were asked. Results: Eighty-two patients had TKA during the study period. At the time of discharge, 57 (69.5%) patients were satisfied with their postoperative pain management. Three months after the surgery, 13 (15.8%) patients reported pain. Pain was mild in 11 and moderate in two patients. At one-year follow-up, three patients (3.6%) reported pain that was mild to moderate in intensity. Pain disturbed sleep in all three patients and disturbed daily life routines in one patient. No significant difference was found in any of the variables when compared with patients who did not report pain at three months. Conclusions: Although PPSP is a recognized adverse outcome after TKA, little is known about its prevalence in LMICs. In our patient population, 15.8% reported pain three months after TKA, while at one year, 3.6% of patients reported mild to moderate pain. Multicenter studies are recommended for determining the overall prevalence in our patient population and for getting directions for making targeted efforts towards its prevention and treatment.

Management of procedural pain in the intensive care unit

Pain is a common experience for inpatients,and intensive care unit(ICU)patients undergo more pain than other departmental patients,with an incidence of 50%at rest and up to 80%during common care procedures.At present,the management of persistent pain in ICU patients has attracted considerable attention,and there are many related clinical studies and guidelines.However,the management of transient pain caused by certain ICU procedures has not received sufficient attention.We reviewed the different management strategies for procedural pain in the ICU and reached a conclusion.Pain management is a process of continuous quality improvement that requires multidisciplinary team cooperation,painrelated training of all relevant personnel,effective relief of all kinds of pain,and improvement of patients'quality of life.In clinical work,which involves complex and diverse patients,we should pay attention to the following points for procedural pain:(1)Consider not only the patient's persistent pain but also his or her procedural pain;(2)Conduct multimodal pain management;(3)Provide combined sedation on the basis of pain management;and(4)Perform individualized pain management.Until now,the pain management of procedural pain in the ICU has not attracted extensive attention.Therefore,we expect additional studies to solve the existing problems of procedural pain management in the ICU.

Management of Geriatric Low Back Pain with Tai Chi

Introduction:Chronic low back pain(cLBP)among older adults is a complex,biopsychosocial condition that despite research efforts and innovative interventions remains a prevalent,disabling and costly condition.This case highlights the use of tai chi(TC)for persistent geriatric LBP.Case Presentation:A 68-year-old Caucasian female with cLBP,neuromuscular imbalances,leg weakness and fall risk was treated with a walking program(aerobic),manual therapy(mobility),lumbar stabilization(strength)and group TC class(neuromuscular function).Discussion:Research validates TC for a variety of older adult health conditions,but few studies demonstrated effectiveness for cLBP.This case outlines the use of a simplified Yang-style TC for management of persistent geriatric LBP.Conclusion:The addition of group TC to standard treatment for cLBP resulted in improved functional outcomes,decreased pain ratings and improved leg strength,flexibility and balance as compared to standard treatment for cLBP.Following the group TC class the client reported significant self-perception of recovery,and these functional and confidence gains eliminated the need for physiotherapy services for cLBP for three subsequent years.Level of Evidence:Therapy,level 4.

Ankle Arthroscopy: A Complimentary Adjunct in the Diagnosis and Management of Ankle Fractures

Ankle fractures are one of the most common injuries treated by orthopaedic surgeons. A minority of patients with ankle fractures go on to develop persistent pain following anatomical reduction. These sequelae may arise as a result of untreated ligamentous or chondral injuries. This study aims to correlate acute arthroscopic ankle findings with the Lauge-Hansen fracture pattern classification. We further aim to compare subjective functional outcomes at least one year following surgery between patients who have received Open Reduction and Internal Fixation (ORIF) alone, versus ORIF plus arthroscopy. This is a retrospective case series of patients who have undergone ankle fracture ORIF +/- arthroscopy from July 2014 to July 2017 inclusive. Each patient’s presenting radiograph was classified according to the Lauge-Hansen ankle fracture classification with subsequent correlation to intra-operative arthroscopic findings. Functional outcome at a minimum of one year was evaluated with the American Academy of Orthopaedic Surgeons (AAOS) metric. Twenty two patients underwent ankle ORIF plus arthroscopy (Group A) with a further 26 patients receiving ORIF alone (Group B). 1 in 3 supination-external-rotation type II (SER II) injuries possessed a concomitant syndesmosis injury or osteochondral lesion (OCL) on arthroscopy. 1 in 3 patients with an SER IV injury had an osteochondral lesion. The mean AAOS score achieved for Group A was 89.6 (±7.9) with the mean score for Group B being 82.0 (±13.7). In conclusion, ankle arthroscopy aids the diagnosis and treatment of ligamentous and osteochondral injuries not evident on plain film with subsequent superior short-term outcomes.

AMPA receptor trafficking in inflammation-induced dorsal horn central sensitization

Activity-dependent postsynaptic receptor trafficking is critical for long-term synaptic plasticity in the brain, but it is unclear whether this mechanism actually mediates the spinal cord dorsal hom central sensitization （a specific form of synaptic plasticity） that is associated with persistent pain. Recent studies have shown that peripheral inflammation drives changes in ct-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor （AMPAR） subunit trafficking in the dorsal horn and that such changes contribute to the hypersensitivity that underlies persistent pain. Here, we review current evi- dence to illustrate how spinal cord AMPARs participate in the dorsal hom central sensitization associated with persistent pain. Understanding these mechanisms may allow the development of novel therapeutic strategies for treating persistent pain.