Background. Over 55,000 spinal operations are performed annually in the NHS. Effective postoperative analgesia facilitates early mobilisation and assists rehabilitation and hospital discharge, but is difficult to achieve with conventional, opioid-based, oral analgesia. The clinical and cost-effectiveness of two alternative techniques, namely intrathecal opioid and the more novel erector-spinae plane blockade, is unknown. The Pain Relief After Instrumented Spinal Surgery (PRAISE) trial aims to evaluate these techniques. Methods. PRAISE is a multicentre, prospective, parallel group, patient-blinded, randomised trial, seeking to recruit 456 adult participants undergoing elective, posterior lumbar-instrumented spinal surgery from up to 25 NHS hospitals. Participants will be randomised 1:1:1 to receive (1) Usual Care with local wound infiltration, (2) Intrathecal Opioid plus Usual Care with local wound infiltration or (3) Erector Spinae Plane blockade plus Usual Care with no local wound infiltration. The primary outcome is pain on movement on a 100mm visual analogue scale at 24 hours post-surgery. Secondary outcomes include pain at rest, leg pain, quality of recovery (QoR-15), postoperative opioid consumption, time to mobilisation, length of hospital stay, health utility (EQ-5D-5L), adverse events and resource use. Parallel economic evaluation will estimate incremental cost-effectiveness ratios. Results. Differences in the primary outcome at 24 hours will be estimated by mixed-effects linear regression modelling, with fixed effects for randomisation factors and other important prognostic variables, and random effects for centre, using the as-randomised population. Treatment effects with 95% confidence intervals will be presented. Conclusion. The study is due to open in May 2024 and complete in 2026. Conflicts of Interest. No conflicts of interest declared. Sources of Funding. NIHR Health Technology Award – grant number NIHR153170. Trial presentations so far. APOMP 2023 and 2024; RCOA conference, York, November 2023; Faculty of Pain Management training day, London, February 2024

Purpose. Prospectively evaluate the timescale of leg pain resolution after lumbar discectomy and decompression, in the immediate post-operative period and identify possible risk factors for failure/delay in leg pain resolution. Materials and Methods. A prospective observational study of 100 consecutive patients undergoing lumbar discectomy or decompression. Patients recorded their leg and back pain in VAS and disability in ODI preoperatively. Patients rated their leg pain relief just prior to discharge after surgery. Telephone follow-up at 1-2 week and 3-4 week post-op was followed by clinic review at 6 and 12 weeks, to assess the timescale of leg pain resolution and improvement in function (ODI score). Results. Immediately before discharge from hospital 67% patients reported relief of leg pain. 33% reported no relief or were unsure. Of these, 26 (80%) reported pain relief subsequently. At 1-2 weeks, 81 patients reported pain relief. 14 reported persistent pain, but six of them (45%) improved subsequently. By six weeks 91% reported leg pain relief and only two of the unimproved nine patients subsequently experienced relief of leg pain. Failure to improve the leg pain was clearly associated with failure to improve disability by ODI score. But the ODI score did not improve in 11 patients reporting relief of leg pain. Decompression in older age and women had a relatively higher risk of poor result. Conclusion. After lumbar discectomy and decompression, leg pain relief is immediate in 67%, in 81% by one week and in 91% by six weeks. Improvement is unlikely after this period. Non-resolution of leg pain resulted in persistent/worsened disability, but 11% patients did not improve functionally despite experiencing leg pain relief. Decompression, older age and female sex were negative risk factors

Abstract. Introduction. Local anaesthetic injections are regularly used for perioperative pain relief for shoulder arthroscopies. In our practice all shoulder arthroscopies were performed under general aneasthesia supplemented by perioperative subacromial local anaesthetic injections or landmark guided axillary nerve together with suprascapular nerve injections. We compared pain relief achieved with these two methods. We hypothesized that the selective nerve blocks would provide better post operative pain relief as described in literature. Methods. We conducted a retrospective cohort study on two patient groups with 17 patients each. Group one patients received 20mls 50:50 mixture of 1% lignocaine and 0.5% chirocaine injections before and after start of procedure and group two patients received 20 mls of chirocaine around the axillary and suprascapular nerves. VAS scores were collected at 1 and 4 hours and analgesia taken during the first 24 hours was recorded. Results. No significant difference in pain scores was noted but analgesia requirements in the nerve block group were higher. Conclusion. Landmark guided nerve blocks did not show any advantage over subacromial local anaesthetic in our study. This is in contrast to published literature and we believe subacromial injections are more reliable and reproducible. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Abstract. Objectives. To determine the effectiveness of LIA compared to ACB in providing pain relief and reducing opiates usage in hamstring graft ACL reconstructions. Materials and Methods. In a consecutive series of hamstring graft ACL reconstructions, patients received three different regional and/or anaesthetic techniques for pain relief. Three groups were studied: group 1: general anaesthetic (GA)+ ACB (n=38); group 2: GA + ACB + LIA (n=31) and group 3: GA+LIA (n=36). ACB was given under ultrasound guidance. LIA involved infiltration at skin incision site, capsule, periosteum and in the hamstring harvest tunnel. Analgesic medications were similar between the three groups as per standard multimodal analgesia (MMA). Patients were similar in demographics distribution and surgical technique. The postoperative pain and total morphine requirements were evaluated and recorded. The postoperative pain was assessed using the visual analogue scores (VAS) at 0hrs, 2hrs, 4hrs, weight bearing (WB) and discharge (DC). Results. There was no statistically significant difference in opiates intake amongst the three groups. When comparing VAS scores; there were no statistical difference between the groups at any of the time intervals that VAS was measured. However, the GA+LIA group hospital's LOS (m=2.31hrs, SD=0.75) was almost half that of GA+ACB group (m=4.24hrs, SD=1.08); (conditions t(72)=8.88; p=0.000). There was no statistical significance in the incidence of adverse effects amongst the groups. Conclusion. The LIA technique provided equally good pain relief following hamstring graft ACL reconstructions when compared to ACB, while allowing for earlier rehabilitation, mobilisation and discharge

Purpose of the study. The aims of the study were to explore the experiences of sciatica sufferers, their perceptions of physiotherapy and healthcare service provision. Methods. This was the qualitative element of a mixed methods study investigating the feasibility of early physiotherapy for sciatica. Participants in the pilot trial consented to take part in semi-structured interviews before and after they had undertaken an individualised physiotherapy programme. Data from the interviews was examined line by line using a thematic analysis approach with key themes and sub-themes emerging. Results. Thirty-three participants were recruited and a total of 45 interviews being carried out. 7 central themes and 17 sub-themes were generated from thematic analysis. The first-line treatment administered to all participants by their G.P was a combination of analgesia. The drugs used included paracetamol, ibuprofen, nefopam, diclofenac, tramadol, morphine, diazepam and baclofen. Neuropathic pain modulating medication such as amitriptyline, gabapentin or pregabalin was widely used. Participants reported that medication simply didn't provide sufficient pain relief at a dose where side-effects were acceptable. Twenty-four interviewees described the negative side-effects of the drugs including nausea, dizziness, confusion, constipation, drowsiness, impotence and bloating. Furthermore, participants were concerned about their ability to carry out normal day to day tasks such as childcare, work and driving due to the side-effects of the drugs. Conclusion. Sciatica can be all encompassing, with severe pain and disability. A range of medication is commonly used for pain relief. The results from this study suggest that the drugs don't provide significant pain relief without deleterious side-effects in some patients. No conflicts of interest for any authors. Sources of funding: MR is the recipient of a HEE/NIHR Clinical Doctoral Research Fellowship which funded the study

Abstract. Objectives. To determine the effectiveness of LIA compared to ACB in providing pain relief and reducing opiates usage in hamstring graft ACL reconstructions. Materials and Methods. In a consecutive series of hamstring graft ACL reconstructions, patients received three different regional and/or anaesthetic techniques for pain relief. Three groups were studied: group 1: general anaesthetic (GA)+ ACB (n=38); group 2: GA + ACB + LIA (n=31) and group 3: GA+LIA (n=36). ACB was given under ultrasound guidance. LIA involved infiltration at skin incision site, capsule, periosteum and in the hamstring harvest tunnel. Analgesic medications were similar between the three groups as per standard multimodal analgesia (MMA). Patients were similar in demographics distribution and surgical technique. The postoperative pain and total morphine requirements were evaluated and recorded. The postoperative pain was assessed using the visual analogue scores (VAS) at 0hrs, 2hrs, 4hrs, weight bearing (WB) and discharge (DC). Results. There was no statistically significant difference in opiates intake amongst the three groups. When comparing VAS scores; there were no statistical difference between the groups at any of the time intervals that VAS was measured. However, the GA+LIA group hospital's LOS (m=2.31hrs, SD=0.75) was almost half that of GA+ACB group (m=4.24hrs, SD=1.08); (conditions t(72)=8.88; p=0.000). There was no statistical significance in the incidence of adverse effects amongst the groups. Conclusion. The LIA technique provided equally good pain relief following hamstring graft ACL reconstructions when compared to ACB, while allowing for earlier rehabilitation, mobilisation and discharge

Introduction and Objective. Objectives: To determine the effectiveness of LIA compared to ACB in providing pain relief and reducing opiates usage in hamstring graft ACL reconstructions. Materials and Methods. In a consecutive series of hamstring graft ACL reconstructions, patients received three different regional and/or anaesthetic techniques for pain relief. Three groups were studied: group 1: general anaesthetic (GA)+ ACB (n=38); group 2: GA + ACB + LIA (n=31) and group 3: GA+LIA (n=36). ACB was given under ultrasound guidance. LIA involved infiltration at skin incision site, capsule, periosteum and in the hamstring harvest tunnel. Analgesic medications were similar between the three groups as per standard multimodal analgesia (MMA). Patients were similar in demographics distribution and surgical technique. The postoperative pain and total morphine requirements were evaluated and recorded. The postoperative pain was assessed using the visual analogue scores (VAS) at 0hrs, 2hrs, 4hrs, weight bearing (WB) and discharge (DC). Results. There was no statistically significant difference in opiates intake amongst the three groups. When comparing VAS scores; there were no statistical difference between the groups at any of the time intervals that VAS was measured. However, the GA+LIA group hospital's LOS (m=2.31hrs, SD=0.75) was almost half that of GA+ACB group (m=4.24hrs, SD=1.08); (conditions t(72)=8.88; p=0.000). There was no statistical significance in the incidence of adverse effects amongst the groups. Conclusions. The LIA technique provided equally good pain relief following hamstring graft ACL reconstructions when compared to ACB, while allowing for earlier rehabilitation, mobilisation and discharge

Aim. The primary aim of this pilot study was to assess and evaluate the SpineCor Pain Relief Brace as a method of reducing the pain experienced by patients diagnosed with degenerative scoliosis. Method. Participants (n=24) with an average age of 67 (+/− 8) old that fulfilled the study inclusion criteria were randomly allocated into either a treatment or control group. Both sets of participants received questionnaires (ODI, SF 36v2 and EQ5D-5L) at 1,3,6,9 and 18 months. In addition to the questionnaires the treatment group also received the SpineCor Pain Relief Brace and took part in a semi structured interview. Results. The results from the trial were mixed; repeated measures analysis on the quantitative data showed the brace had a small effect on reducing reported pain and increasing activity. Results from the semi-structured interviews were more informative. Analysis revealed the brace enabled patients' to participate in activities at a higher intensity. Problems with the functionality of the brace such as toileting that ultimately limited the amount of time they could wear the brace were also identified. Conclusion. Overall, mild pain relief and improvements in functionality and activity levels were reported in addition to several functional problems with the brace. These problems could be attributed to the average age of the participants. No prior work has examined issues related to wearing a brace from the patient perspective. Further work is needed to develop a better understanding of the benefits and limitations of bracing for Degenerative scoliosis. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

The aim was to assess the effect of caudal block on patients who have had proximal femoral &/or pelvic osteotomy compared to patients who have had epidural anaesthesia with regards to pain relief and hospital stay. We looked at two patient cohorts; epidural & caudal pain relief in aforementioned procedures. Interrogation of our clinical database (WinDip, BlueSpeir&clinical notes) identified 57 patients: 33 proximal femoral osteotomy, 13 pelvic osteotomy and 11 combined(25 Males 32 Females), aged 1–18 years-old between 2012–2014, in two institutions. A database of demographics, operative indications, associated procedures, analgesia and type of anaesthesia was constructed in relation to daily pain score and length of hospital stay. 39 patients had epidural anaesthesia, and 18 had caudal block. Cerebral palsy with unstable hips was the commonest indication(21), followed by dysplastic hip(10), Perthes disease(8) and other causes(18). The Face, Legs, Activity, Cry, Consolability(FLACC) scale was used to assess pain. Length of hospital stay in caudal block patients was 3.1 days(1–9), in epidural anaesthesia patients stay was 4.46 days(2–13). Paediatrics high dependency unit after an epidural was needed in 20(Average stay 3.4 days) compared to 1 who received caudal block. Caudal block FLACC pain score in the first 36 hours was 1.23(0–4) compared to 0.18(0–2) in patients who had an epidural. Caudal block is associated with less hospital stay and fewer admissions to the high dependency unit, it also provides adequate pain relief post osteotomies when compared to epidural, therefore could be performed at units lacking epidural facilities. A change in related practice however should be cautious and supported by further studies

We performed a randomised double-blind controlled study in patients undergoing elective knee arthroscopy to assess the effect of intra-articular morphine on postoperative pain relief. Patients in the study group (n = 10) received 5 mg of morphine in a 25 ml dilution intra-articularly while those in the control group (n = 10) received 25 ml of saline. Postoperative pain was assessed at intervals by a visual analogue scale and the requirement for supplementary analgesia was recorded. Those in the study group had significantly lower pain scores and required less systemic analgesics than those in the control group. Plasma profiles for morphine and its metabolites were assayed and showed that they were too low to produce effective analgesia. Evidence suggests that analgesia was mediated by local action within the joint

Introduction: We present the results of a controlled randomized trial of the use of a popliteal block for pain relief in ankle and hindfoot surgery. Materials and methods: We studied 47 patients over period of nine months in 2007 to 2008. Patients undergoing an ankle or hindfoot procedure were included in the trial. The trial was explained to the patients. Written information leaflets were also used in the preoperative clinics. Patients were randomized on the day of surgery. A sealed envelope randomizing the patient to block (A), or no block (B) was opened in the anaesthetic room before the patient was anaesthetised. Patients were subjective pain scores were recorded at 30 min, 6, 12 and 24 hours after surgery. The amount of analgesia required and time to first dose was documented. One foot and ankle consultant and one trained fellow gave the popliteal blocks. The block was administered in the lateral position at 0.8 mAmp stimulus to detect the nerve. Group A and B data was compared statistically. Results: The average pain scores in group A were reported to be 1.2 at 30min, 1.23 at 6, 2.1 at 12 and 3 at 24 hours. In group B it was 1.2 at 30min, 7.2, 8.1 and 4 at 6, 12 and 24 hours. There was a statistical significant difference in the pain scores at 6 and 12 hours. There was no statistical significant difference in the pain scores at 30 min and 24 hours. Conclusion: Popliteal block gives effective pain relief in ankle and hindfoot surgery. We believe that it may reduce anaesthetic and analgesic drug requirement as well

We performed resection of part of an injured peripheral nerve in 20 patients with post-traumatic neuralgia, after conservative treatment had failed. All had burning pain, paraesthesia and dysaesthesia in the area innervated by the injured nerve. We resected the nerve in the area in which the patient felt pain, and a further 3 cm proximal to the site of injury. In all cases, the local pain disappeared or markedly decreased. The areas of pain relief and of nerve resection coincided completely in 17 patients and partially in three. The results were assessed as excellent by five patients, good by 11, and fair by four. There were no poor results. Histological examination of the resected nerves showed Wallerian degeneration and immunohistochemical tests indicated that substance P, a polypeptide which may contribute to nociceptive transmission, was present in the tissue around the degenerated nerves

Introduction. We hereby present results of controlled randomized trial of use of popliteal block for pain relief in ankle and hind foot surgery. Materials and methods. We have studied 63 patients over period of 9 months. Patients who needed ankle or hind foot procedure were selected for trial. Patients were explained about the trial and popliteal block along with leaflets at preoperative clinics. Patients were randomized on the day of surgery. A sealed envelop stating whether patient will go to block group (A) or no block group (B) was opened in the anaesthetic room before the patient was anaesthetized. Patients were evaluated for subjective pain scores at 30 min, 6 hrs, 12 hrs and 24 hrs after surgery. Amount of anaelgesic required and time to first dose was documented. Popliteal blocks were given by one foot and ankle consultant and one trained fellow. The block was administered in lateral position at 0.8 mA stimulus to detect the nerve. The data was compared statistically between group A and B. Results. The average pain scores in Group A (33 pts) were 0.72, 1.60, 1.51 and 1.03 at 30 min, 6 hrs, 12 hrs and 24 hrs respectively. While in Group B (30 pts) it was 2.73, 5.5, 6.03 and 3.33 at 30 min, 6 hrs, 12 hrs and 24 hrs respectively. There was statistically significant difference in pain scores at 6 and 12 hrs. There was no statistically significant difference in pain scores at 30 min and 24 hrs. Time to the request for first analgesic was statistically longer in Group A. Conclusion. Popliteal block offers an effective way of pain relief in ankle and hind foot surgery. We believe that it may reduce amount of anaesthetic or anaelgesic drug requirement as well

Substance P is readily detected in the synovial fluid of the knee in which it acts as a powerful inflammatory agent in response to injury and disease. It may be an objective predictor of pain after knee replacement surgery. The level of substance P was measured in the synovial fluid in both knees of 114 patients having unilateral and in 86 patients having bilateral total knee replacement for osteoarthritis. All had severe pain in the knee to be replaced and joint destruction. Substance P was elevated in 73% of replaced knees but not in normal or asymptomatic knees. Good or excellent pain relief was achieved in 97% of patients with an elevated preoperative level of substance P and in 61% of those with a normal preoperative level (p < 0.05 compared with preoperative values)

The multimodal management of canal stenosis is increasing, and inhibitors of central sensitization are playing a crucial role in central sensitization processes. Pregabalin and gabapentin are antiepileptic drugs that reduce presynaptic excitability. The objective of this study was to investigate whether the use of pregabalin and gabapentin is effective in the symptomatic management of canal stenosis.

A literature search was conducted in four databases. The inclusion criteria were studies that compared pregabalin or gabapentin with a control group in lumbar canal stenosis. Randomized clinical trials and a comparative retrospective cohort study were included. The main clinical endpoints were VAS/NRS, ODI, and RDQ (Roland Morris Disability Questionnaire) at 2, 4, 8 weeks, and 3 months, adverse events, and walking distance were also collected. Data were combined using Review Manager 5.4 software.

Six studies and 392 patients were included. The mean age was 60.25. No significant differences were observed in VAS at 2, 4, and 8 weeks: (MD: 0.23; 95% CI: −0.63-1.09), (MD: −0.04; 95% CI: −0.64 to −0.57), and (MD: −0.6; 95% CI: −1.22 to 0.02). Significant differences were observed in favor of pregabalin with respect to VAS at three months: (MD: −2.97; 95% CI: −3.43 to −2.51). No significant differences were observed in ODI (MD: −3.47; 95% CI: −7.15 to −0.21). Adverse events were significantly higher in the pregabalin/gabapentin group (OR 5.88, 95%CI 1.28-27.05). Walking distance and RDQ could not be compared, although the results were controversial.

Gabapentinoids have not been shown to be superior to other drugs used in the treatment of LSS or to placebo. However, they have shown a higher incidence of adverse effects, improved results in VAS at 3 months, and a slight improvement in ambulation at 4 months in combination with NSAIDs compared to NSAIDs in monotherapy.

Background: To assess the safety and efficacy of intrathecal diamorphine for the postoperative pain relief in patients having lumbar decompressive surgery. Methods: Retrospective study of case records of 39 consecutive patients who underwent lumbar decompression surgery, carried out by the same surgeon. There were 39 (24 males & 15 females, age range 19–75 years) healthy patients (23 ASA 1, 13 ASA 2 and 3 ASA 3). All patients having lumbar microdiscetomy or decompression for spinal stenosis were treated by a single intrathecal injection of diamrphine, performed by the surgeon prior to wound closure. All were prescribed regular paracetamol, and a NSAID if there were no contraindications. Oral opiates were prescribed for “rescue” analgesia. Retrospective analysis of the case notes of these patients was carried out and visual analogue pain scores, sedation scores and side effects/complications were evaluated. Results: Five patients required rescue analgesia in the first six hours after surgery. None was required subsequenty. Nausea occurred in 2 patients, 1 patient had vomiting and one pruritus requiring piriton. Respiratory depression and sedation were not found in any of the patients. None of the patients had neurological complications. Conclusion: Intrathecal diamorphine proved to be safe, effective and eliminated the need for opioid infusions following lumbar decompression surgery

Aim of the study: Mason type I radial head fractures are non-displaced fractures and are treated conservatively with early mobilization and excellent results. The aspiration of the accompanying haematoma is advocated by several authors in order to achieve an analgesic effect. The aim of this study was to investigate the effect of haematoma aspiration on intraarticular pressure and on pain relief after Mason I radial head fractures. Materials and Methods: 10 patients (6 men and 4 women, age 23–47 y), who presented in the emergency department after an elbow trauma. Following plain radiographs that showed a Mason I radial head fracture, the patients were subjected to haematoma paracentesis. Initially, the intraarticular pressure was measured by using the Stryker Intra-Compartmental Pressure Monitor System. Afterwards, aspiration of the haematoma was performed, followed by a new pressure measurement without moving the needle. Finally, a brachial-elbow-wrist back slab was placed and a questionnaire was completed, including among others pain evaluation before and after haematoma aspiration by using an analogue ten point pain scale. Results: The intraarticular elbow pressure prior to haematoma aspiration varied from 49 mmHg to 120 mmHg (mean 76.9 mmHg), while following aspiration it ranged from 9 mmHg to 25 mmHg (mean 16.7 mmHg). The mean quantity of the aspired blood was 3.45 ml (0.5 ml to 8.5 ml). Finally, the patients reported a pain decrease from 5.5 (4 to 8) before aspiration to 2.8 (1 to 4) after haematoma aspiration. Decrease for both pressure and pain was statistically significant (p< 0.001). Conclusion: The built of an intraarticular haematoma in the elbow joint following an undisplaced Mason I radial head fracture leads to a pronounced increase of the intraarticular pressure accompanied by intense pain for the patient. The aspiration of the haematoma results in an acute pressure decrease and an immediate patient relief

Purpose

Total and partial joint arthroplasty has been clinically proven to successfully relieve pain and improve function in patients with hip and knee degenerative arthrosis. It has been shown that early return to ambulation correlates well with functional scores. Moreover, the benefits of reduced narcotic use are multi-fold and range from reduced risk of addiction, gastrointenstinal and cardiopulmonary side effects. Establishing realistic pre-operative expectations regarding functional improvement and pain control will nevertheless impact patient satisfaction. Thus, the purpose of this study was to establish safe, achievable and data-driven benchmarks for post-operative ambulation and pain control in patients undergoing elective total joint arthroplasty.