Aims. The aim of this study was to describe the prevalence and patterns of neuropathic pain over one year in a cohort of patients with chronic post-surgical pain at three months following total knee arthroplasty (TKA). Methods. Between 2016 and 2019, 363 patients with troublesome pain, defined as a score of ≤ 14 on the Oxford Knee Score pain subscale, three months after TKA from eight UK NHS hospitals, were recruited into the Support and Treatment After Replacement (STAR) clinical trial. Self-reported neuropathic pain and postoperative pain was assessed at three, nine, and 15 months after surgery using the painDETECT and Douleur Neuropathique 4 (DN4) questionnaires collected by postal survey. Results. Symptoms of neuropathic pain were common among patients reporting chronic pain at three months post-TKA, with half reporting neuropathic pain on painDETECT (191/363; 53%) and 74% (267/359) on DN4. Of those with neuropathic pain at three months, half continued to have symptoms over the next 12 months (148/262; 56%), one-quarter had improved (67/262; 26%), and for one-tenth their neuropathic symptoms fluctuated over time (24/262; 9%). However, a subgroup of participants reported new, late onset neuropathic symptoms (23/262; 9%). Prevalence of neuropathic symptoms was similar between the screening tools when the lower cut-off painDETECT score (≥ 13) was applied. Overall, mean neuropathic pain scores improved between three and 15 months after TKA. Conclusion. Neuropathic pain is common in patients with chronic pain at three months after TKA. Although neuropathic symptoms improved over time, up to half continued to report painful neuropathic symptoms at 15 months after TKA. Postoperative care should include screening, assessment, and treatment of neuropathic pain in patients with early chronic postoperative pain after TKA. Cite this article: Bone Joint J 2024;106-B(6):582–588

Abstract. Introduction. Total knee replacement (TKR) is a successful operation for many patients, however 15–20% of patients experience chronic post-surgical pain (CPSP). Many will experience neuropathic characteristics. We describe the prevalence and patterns of neuropathic pain in a cohort of patients with CPSP three months after TKR. Methodology. Between 2016–2019, 363 patients with troublesome pain, ≤14 on Oxford Knee score pain subscale, at three months after TKR from eight NHS hospitals were recruited into the Support and Treatment After Replacement (STAR) trial. Self-reported neuropathic pain was assessed at three, nine and fifteen months after surgery using painDETECT and Douleur Neuropathique 4 (DN4). Results. At three months post-operative, 53% reported neuropathic pain on painDETECT and 74% on DN4. Half (56%) remained in neuropathic pain over the twelve-month follow-up period, 26% reported improvement, and 9% reported new neuropathic symtpoms or fluctuated in and out of neuropathic pain (9%). Overall mean neuropathic pain scores improved between three and 15 months after TKR. When the painDETECT cut-off score of ≥13(ambiguous/possible) was used, DN4 and painDETECT measures showed similar prevalence rates at each timepoint. Conclusion. Neuropathic pain is common among patients with CPSP at three months after TKR. Although symptoms improved over time, one quarter to one half of our cohort continued to report symptoms at fifteen months. We propose a painDETECT cutoff score of ≥13 be used to identify neuropathic features in the TKR population. Postoperative care should include identification, assessment, and treatment of neuropathic pain in patients with CPSP after TKR

Background. Patients with low back-related leg pain (LBLP) can present with neuropathic pain; it is not known but is often assumed that neuropathic pain persists over time. This research aimed to identify cases with neuropathic pain that persisted at short, intermediate and longer-term time points, in LBLP patients consulting in primary care. Methods. LBLP patients in a primary care cohort study (n=606) completed the self-report version of Leeds Assessment for Neurological Symptoms and Signs (s-LANSS, score of ≥12 indicates possible neuropathic pain) at baseline, 4-months, 12-months and 3-years. S-LANSS scores and percentages of patients with score of ≥12 are described at each time-point. Multiple imputation was used to account for missing data. Results. At baseline, 48.3% (293/606) of patients presented with neuropathic pain, 25.0% (94/376) at 4-months, 22.6% (79/349) at 12-months and 21.6% (58/268) at 3-years. A small proportion (6.6%) scored ≥ 12 at all four time-points. Those who scored ≥ 12 at baseline and 4-months reported higher disability (RMDQ (0–23) 15.2) and depression scores (HADS (0–21) 8.6), and lower pain self-efficacy (PSEQ (0–60) 27.2), compared to those with neuropathic pain at one other time-point at most. Conclusion. Few LBLP patients in primary care present with long-term persistent neuropathic pain. Patients with neuropathic pain at baseline and short-term follow-up present with greater morbidity in terms of disability, depression and lower confidence to manage their pain. This is important because these patients may benefit the most from early intervention using neuropathic pain medication. These findings will inform research investigating potential prognostic indicators of persistent neuropathic pain. Conflicts of interest: None. Sources of funding: Support for SA Harrisson, a National Institute for Health Research (NIHR) Clinical Doctoral Fellow and NE Foster, an NIHR Senior Investigator, was provided by an NIHR Research Professorship awarded to NE Foster (NIHR-RP-011-015). K Konstantinou is supported by a Higher Education Funding Council for England/ NIHR Senior Clinical Lectureship. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health

Purpose of study: Pain mechanisms underlying the majority of low back and leg pain remain to be elucidated. A recently developed neuropathic pain questionnaire (PainDETECT) was used to assess for the presence of probable neuropathic pain in a group of patients with low back ± leg pain and the effect this has on them. Method: Patients with low back ± leg pain referred to an Extended Scope Practitioner Physiotherapy clinic who consented to take part completed the PainDETECT questionnaire, and the Roland Morris Disability Questionnaire, and the Fear Avoidance Beliefs Questionnaire. Patients were then grouped by the PainDETECT score into probable neuropathic pain, unlikely neuropathic pain or pain of uncertain underlying mechanism. In patients imaged subsequent to assessment in the clinic (MRI) the PainDETECT scores were compared to evidence of compression of nerve roots. Results: 17% of patients had probable neuropathic pain, in 47% neuropathic pain unlikely and 36% uncertain. Those with probable neuropathic pain when compared to unlikely neuropathic pain were more disabled (p> .001), scored higher on a visual analogue scale (p=0.013), but were no different on the Fear avoidance scale (p=0.08). Those with neuropathic components to their pain always reported leg pain (93% below knee), whereas 63% of unlikely neuropathic pain patients had leg pain (38% below knee). The relationship between nerve root compression and neuropathic pain score was uncertain. Conclusion: Patients with a neuropathic component to their back pain report higher levels of pain, more leg pain and are more disabled by their problem

A subgroup of patients that undergo TKR surgery have evidence of neuropathic pain and central sensitization that may predispose to severe postoperative pain. This study assesses the correlation of MRI detected bone marrow lesions (BMLs) and synovitis with markers of neuropathic pain and central sensitization in patients undergoing TKR surgery and healthy volunteers. 31 patients awaiting TKR and 5 healthy volunteers were recruited. Each subject underwent a 3-T knee MRI scan that was graded for BMLs (0–45) and synovitis (0–3) using subsets of the MRI Osteoarthritis Knee Score (MOAKS). All subjects were asked to complete the PainDetect questionnaire to identify nociceptive pain (< 13), unclear pain (13–18) and neuropathic pain (>18). Correlation between BMLs and PainDetect score was the primary outcome measure. Secondary outcomes included the correlation of synovitis to PainDetect and temporal summation (TS) a measure of central sensitization to the PainDetect score. TS was determined using a monofilament to evoke pain. Pilot histological analysis of the prevalence of osteoclasts (TRAP. +. ) within BMLs versus normal subchondral bone was performed, implying a role in BML pathology. Increasing BML MOAKS score correlated with neuropathic pain (painDetect), r. s. = 0.38, p=0.013 (one-tailed). There was a positive correlation between synovitis and PainDetect score, τ =0.23, p= 0.031 (one-tailed). TS was greater in the neuropathic pain than in nociceptive pain patients, U = 18.0, p=0.003 (one-tailed). TRAP staining identified more osteoclasts within BMLs than contralateral condyle lesion free subchondral bone, z = −2.232, p = 0.026 (Wilcoxon Signed Rank Test, one-tailed). BMLs and synovitis are more prevalent in neuropathic pain and central sensitization in knee OA. Higher osteoclast prevalence was seen within BMLs which may help explain the association with BMLs and pain in OA

Purpose of study and background. Neuropathic pain is a challenging pain syndrome to manage. Low back-related leg pain (LBLP) is clinically diagnosed as either sciatica or referred leg pain and sciatica is often assumed to be neuropathic. Our aim was to describe the prevalence and characteristics of neuropathic pain in LBLP patients. Methods. Analysis of cross-sectional data from a prospective, primary care cohort of 609 LBLP patients. Patients completed questionnaires, and received clinical assessment including MRI. Neuropathic characteristics (NC) were measured using the self-report version of the Leeds Assessment of Neuropathic Symptoms and Signs scale (SLANSS; score of ≥12 indicates pain with NC). Results. 52% of the patients diagnosed with sciatica and 39% of those diagnosed with referred leg pain presented with pain with NC. Irrespective of LBLP diagnosis, patients with NC reported significantly worse leg pain (mean 5.8 vs 4.7), back pain intensity (0.0 vs 0.0), disability (RMDQ 15.2 vs 12.4), high risk of persistent disabling pain (47.5% vs 31.5%), depression (HADS 7.3 vs 5.4) and anxiety (8.9 vs 6.7), compared to patients without NC. Sciatica patients with NC presented with higher leg pain (6.0 vs 4.8) and disability but less anxiety (8.6 vs 10.2) and depression compared to patients with referred pain with NC. Conclusion. LBLP patients with NC present with more severe pain, disability and psychological morbidity, but these characteristics differ according to clinical diagnosis, suggesting potential subgroups. The data will inform future research on the clinical course and prognosis of these patients. No conflicts of interest. Sources of funding: Support for SA Harrisson, a National Institute for Health Research (NIHR) Clinical Doctoral Fellow and NE Foster, an NIHR Senior Investigator, was provided by an NIHR Research Professorship awarded to NE Foster (NIHR-RP-011-015). K Konstantinou is supported by a Higher Education Funding Council for England/ NIHR Senior Clinical Lectureship. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health

Purpose of the study: The favourable outcome with knee arthroplasty can be compromised by persistent unexplained pain. Postoperative pain accounts for about 30% of the complaints of chronic pain present in 25% of the general population and would be to a large extent of neuropathic origin (DCN). The purpose of this work was to evaluate pain before and after knee arthroplasty in terms of intensity and clinical expression. Material and methods: A prospective monocentric epidemiology study was conducted to validate self-administrated questionnaires which, over a six month period, were completed by knee arthroplasty patients. A numerical scale (Nu) from 0 to 10, a 7-item questionnaire screening for neuropathic pain (burns, painful cold, electrical discharge, tingling, pins and needles, numbness, itching) scored 0 or 1 and positive if the score is ≥3 (DN4), an abridged qualitative pain questionnaire (QDSA) divided into a sensorial score (QDSAs) and an affective score (QDSAa), and a scale evaluating anxiety and depression (HAD) were recorded preoperatively, (T0), at 3rd postoperative day (PO), 1st (M1), 3rd (M2) and 6th (M6) postoperative month. Outcome was expressed as mean±SD or median and range. Results: Eight men and 39 women, mean age 66.6±10.7 years were included. These patients. Fourteen of 47 (25.9%) had DCN postoperatively (2 DN4 successively ≥3). The “tingles” item for postoperative DN4 was significantly predictive of DCN (specificity 88.9%, sensitivity 83.3%). Preoperatively, the median intensity of pain was 6 (5–10) and was significantly higher in patients with DCN compared with those without DCN at M1 (4 [1–8] vs 3 [0–7]) and M3 (4 [1–8] vs 2 [0–6]) (p < 0,009) including 3/14 patients with Nu > 7 at M3. At M6, 12.7 % (n = 6/47) patients still had DN4 ≥3. The QDSAs score was higher in patients with DCN at M1 (11.8±4.4 vs 4.8±4.5; p < 0.001) and M3 (10.2±6 vs 3.5±3.2; p < 0.001). There was no significant difference between the QDSAa scores and the HAD. Conclusion: The persistence of unusually intense pain after knee arthroplasty would suggest the pain could result from a neuropathological source which would require specific treatment because of the general insensitivity to analgesics

Background. There is a paucity of prognosis research in patients with neuropathic low back-related leg pain (LBLP) in primary care. Purpose. To investigate the clinical course and prognostic factors in primary care LBLP patients consulting with neuropathic pain (NP). Methods. LBLP patients in a primary-care cohort study (n=606) completed the self-report version of Leeds Assessment for Neurological Symptoms and Signs (s-LANSS, score of ≥12 indicates possible NP) at baseline and 4-months. Mixed effects models compared pain-intensity (highest of mean leg or mean back pain - 0–10 NRS at baseline, 4-months, 12-months and 3-years) between those with persistent NP (s-LANSS ≥12 at baseline and 4-months) and those without (s-LANSS ≥12 at baseline and <12 at 4-months). Univariable and multivariable binary logistic regression examined association between potential prognostic factors (chosen from baseline self-report questionnaires, clinical examination, MRI scan findings) and persistent NP. Multiple imputation was used to account for missing data. Results. 44% (72/164) of patients with NP at baseline had persistent NP at 4-months. Mean pain intensity of patients with persistent NP was higher at 4-months, 12-months and 3-years compared to those without. In univariable analysis, only pain self-efficacy was significantly associated with persistent NP (OR 0.98, 95% CI 0.96 to 0.998). In multivariable analysis, none of the 7 investigated factors were significantly associated with persistent NP. Conclusion. Patients with persistent NP were consistently worse-off up to 3-years follow-up compared to those without. It was difficult to identify those patients with NP at baseline who would have persistent NP at 4-months. No conflicts of interest. Sources of funding: Sarah Harrisson is a Clinical Doctoral Fellow funded through a National Institute for Health Research (NIHR) Research Professorship for Nadine Foster (NIHR-RP-011-015). Nadine Foster is a NIHR Senior Investigator. Kika Konstantinou is supported by a Higher Education Funding Council for England/ National Institute for Health Research Senior Clinical Lectureship. The views expressed in this publication are those of the author(s), not necessarily those of the NHS, NIHR or the Department of Health and Social Care. This work relates to an Education and Continued Professional Development (level 2) award by the Musculoskeletal Association of Chartered Physiotherapists to Sarah Harrisson (June 2016)

Introduction. Nociceptive and neuropathic components both contribute to chronic pain. Since these components require different pain management strategies, correct pain diagnosis before and during treatment is important. Freynhagen et al. (2006) reported that they had developed and validated the pain-DETECT questionnaire (PD-Q) to detect neuropathic components in chronic low back pain patients. They also reported that 37% of unselected cohort of chronic LBP patients had predominantly neuropathic pain. However, the extent to which neuropathic components relate to the pathomechanism of pain deriving from osteoarthritis of hip joint remains unknown. The purpose of this study was to utilize PD-Q to investigate the relationship between neuropathic components and pain deriving from osteoarthritis of the hip joint. Methods. Between March and August 2010, 125 patients with osteoarthritis of hip joint completed PD-Qs about their pain. From this data set, we investigated whether or not the patients’ pain contained neuropathic components. Results. Only 6.4% of the patients had a score 19, indicating that a neuropathic component was likely (90%). Conversely, 79.2 % had a score 12, indicating that a neuropathic component was unlikely (15%). For the remaining 14.4% with an intermediate score (13–18), the presence of a neuropathic component remained uncertain. Conclusion. In this set of patients with osteoarthritis of hip joint, the PD-Q responses indicated that only a small percentage (6.4%) were likely to have a neuropathic component to their hip pain

Aims. The aims of this study were to report the outcomes of patients with a complex fracture of the lower limb in the five years after they took part in the Wound Healing in Surgery for Trauma (WHIST) trial. Methods. The WHIST trial compared negative pressure wound therapy (NPWT) dressings with standard dressings applied at the end of the first operation for patients undergoing internal fixation of a complex fracture of the lower limb. Complex fractures included periarticular fractures and open fractures when the wound could be closed primarily at the end of the first debridement. A total of 1,548 patients aged ≥ 16 years completed the initial follow-up, six months after injury. In this study we report the pre-planned analysis of outcome data up to five years. Patients reported their Disability Rating Index (DRI) (0 to 100, in which 100 = total disability), and health-related quality of life, chronic pain scores and neuropathic pain scores annually, using a self-reported questionnaire. Complications, including further surgery related to the fracture, were also recorded. Results. A total of 1,015 of the original patients (66%) provided at least one set of outcome data during the five years of follow-up. There was no evidence of a difference in patient-reported disability between the two groups at five years (NPWT group mean DRI 30.0 (SD 26.5), standard dressing group mean DRI 31.5 (SD 28.8), adjusted difference -0.86 (95% CI -4.14 to 2.40; p = 0.609). There was also no evidence of a difference in the complication rates at this time. Conclusion. We found no evidence of a difference in disability ratings between NPWT compared with standard wound dressings in the five years following the surgical treatment of a complex fracture of the lower limb. Patients in both groups reported high levels of persistent disability and reduced quality of life, with little evidence of improvement during this time. Cite this article: Bone Joint J 2024;106-B(8):858–864

Introduction. Pain after trauma has received relatively little research attention compared with surgical techniques and functional outcomes, but is important to patients. We aimed to describe nerve dysfunction and pain characteristics using tibial fractures as a model. We hypothesized that early nerve dysfunction was associated with neuropathic and chronic pain. Materials and Methods. Adult patients with isolated open or closed tibial diaphyseal fractures were prospectively observed for 1-year in 5 Major Trauma Centres. Nerve dysfunction was assessed using Semmes-Weinstein monofilaments, acute pain with the visual numerical rating scale (VNRS), neuropathic pain with the doleur neuropathique-4 score and quality of life (QOL) using the EQ-5D score. Results. Of 77 included patients, twenty-six (33.8%) had Gustilo-Anderson grade II or worse injuries. Forty-six (63.0%) had operative repair; 0 operation notes reported nerve injury. Mean VNRS pain scores one week post-injury were 4.6/10 (SD 2.4). Seventeen patients (23.3%) presented with impaired sensation, persisting in 11 (15.1%) at 3-months. Neuropathic pain affected 16 (20.8%) patients one week post-injury; a further 20 (26.0%) had >2 symptoms of nerve pain. Only four (11.1%) received anti-neuropathic drugs. At 6-months, twenty-three (31.5%) reported mobility problems, 21 (28.8%) difficulty completing normal activities, 25 (34.2%) pain and 15 (20.5%) anxiety and depression. Conclusions. Nerve dysfunction and neuropathic pain are common early features in patients with tibial fractures, but are poorly recognised and inadequately treated. Pain has long-term effects on patients’ QOL. Future work should aim to improve identification and management of neuropathic pain

Abstract. Introduction. There is a need to develop approaches to reduce chronic pain after total knee replacement. There is an established link between disturbed sleep and pain. We tested the feasibility of a trial evaluating the clinical and cost-effectiveness of a pre-operative sleep assessment and complex intervention package for improving long-term pain after TKR. Methodology. REST was a feasibility multi-centre randomised controlled trial with embedded qualitative study and health economics. Participants completed baseline measures and were randomised to usual care or the intervention, a tailored sleep assessment and behavioural intervention package delivered by an extended scope practitioner three months pre-operatively with a follow-up call up at four-weeks. Patient reported outcomes were assessed at baseline, one-week pre-surgery, and 3-months post-surgery. Results. 57 patients were randomised and 20 had surgery within the study timelines. All patients allocated the intervention attended an appointment and most engaged with treatment. The intervention group reported improvements in sleep (Sleep Conditions Indicator) and neuropathic pain (painDETECT) scores. Participants found the sleep treatments and study processes to be acceptable. The mean cost of the intervention was estimated at £134.45 per patient. Conclusion. The feasibility study has shown that patient recruitment is feasible, engagement with and adherence to the intervention is high, and the intervention is acceptable to patients and clinicians. Preliminary findings show that the intervention group had improved sleep quality and had reduced levels of pre-operative neuropathic pain. This study has demonstrated that a full RCT is feasible and identified areas for improvement to optimize the trial design

Purpose of study and background. This study aimed to investigate if the PD-Q classification was predictive of outcomes at 3 and 12-months follow-up in LBP patients with associated leg pain. Identification of clinically important subgroups and targeted treatment is believed to be important in low back pain (LBP) care. The PainDETECT Questionnaire (PD-Q) is designed to classify whether a person has neuropathic pain, based on their self-reported pain characteristics. However, it is unknown whether this classification is a prognostic factor and/or predicts treatment response. Method and results. 145 participants were recruited in secondary care. Inclusion criteria were 3-12 months LBP and leg pain. Baseline PD-Q scores classified participants into three groups (likely to have neuropathic pain, uncertain, unlikely) but did not affect treatment decisions. The outcome measures were LBP, leg pain, activity limitation and self-reported general health. Scores were compared between those with ‘likely’ neuropathic pain (neuropathic group) and ‘unlikely’ (non-neuropathic group), using Mann-Whitney, Friedman and Chi Square tests. At baseline, the neuropathic group had worse scores on all outcome measures, and analgesic use, sick leave, sense of coherence and psychological profile (p=.000 to .044). At 3-months and 12-months both groups improved (p=.001 to .032). However, the groups remained different at each time point on all outcome measures (p=.000 to .033) except LBP (p=.054 to .214). Conclusions. The PD-Q classification was a prognostic factor but was not predictive of response to generic care. Further studies should investigate whether PD-Q groups are predictive of response to neuropathic pain targeted treatment

Pain is a common presenting symptom of patients with shoulder conditions, yet there has been little work done to accurately describe its distribution and nature. We studied all patients attending the Royal Devon and Exeter Hospital shoulder clinic from August 2012 – 2013. Patients completed a questionnaire detailing their Oxford Shoulder Score and a validated neuropathic pain questionnaire. Patients were given diagrams to draw on their perceived location of pain or abnormal sensation. We analysed all patients with frozen shoulder (48), osteoarthritis (37) and rotator cuff arthropathy (17). We found that neuropathic pain is common in patients with shoulder conditions identified in 39% of OA patients, 42% with rotator cuff arthropathy and 57% with frozen shoulder. Pain outside the shoulder was reported in over 50% of patients, commonly the forearm, hand, neck and chest. Frozen shoulder was especially associated with pain outside of the shoulder with 39% describing symptoms in the neck or chest, 21% into the forearm and 18% into the hand. Interestingly, neuropathic pain radiating down the arm was not described in the rotator cuff arthropathy group. The high prevalence of neuropathic symptoms and pain felt outside the shoulder aids diagnosis and more accurately identifies these conditions

The December 2014 Knee Roundup. 360 . looks at: national guidance on arthroplasty thromboprophylaxis is effective; unicompartmental knee replacement has the edge in terms of short-term complications; stiff knees, timing and manipulation; neuropathic pain and total knee replacement; synovial fluid α-defensin and CRP: a new gold standard in joint infection diagnosis?; how to assess anterior knee pain?; where is the evidence? Five new implants under the spotlight; and a fresh look at ACL reconstruction

Peripheral nerve injuries (PNI) occur in 10% of combat casualties. In the immediate field-hospital setting, an insensate limb can affect the surgeon's assessment of limb viability and in the long-term PNI remain a source of considerable morbidity. Therefore the aims of this study are to document the recovery of combat PNI, as well as report on the effect of current medical management in improving functional outcome. In this study, we present the largest series of combat related PNI in Coalition troops since World War II. From May 2007 – May 2010, 100 consecutive patients (261 nerve injuries) were prospectively reviewed in a specialist PNI clinic. The functional recovery of each PNI was determined using the MRC grading classification (good, fair and poor). In addition, the incidence of neuropathic pain, the results of nerve grafting procedures, the return of plantar sensation, and the patients' current military occupational grading was recorded. At mean follow up 26.7 months, 175(65%) of nerve injuries had a good recovery, 57(21%) had a fair recovery and 39(14%) had a poor functional recovery. Neuropathic pain was noted in 33 patients, with Causalgia present in 5 cases. In 27(83%) patients, pain was resolved by medication, neurolysis or nerve grafting. In 35 cases, nerve repair was attempted at median 6 days from injury. Of these 62%(22) gained a good or fair recovery with 37%(13) having a poor functional result. Forty-two patients (47 limbs) initially presented with an insensate foot. At final follow up (mean 25.4 months), 89%(42 limbs) had a return of protective plantar sensation. Overall, 9 patients were able to return to full military duty (P2), with 45 deemed unfit for military service (P0 or P8). This study demonstrates that the majority of combat PNI will show some functional recovery. Adherence to the principles of war surgery to ensure that the wound is clear of infection and associated vascular and skeletal injuries are promptly treated will provide the optimal environment for nerve recovery. Although neuropathic pain affects a significant proportion of casualties, pharmacological and surgical intervention can alleviate the majority of symptoms. Finally, the presence of an insensate limb at initial surgery, should not be used as a marker of limb viability. The key to recovery of the PNI patient lies in a multi-disciplinary approach. Essential to this is regular surgical review to assess progress and to initiate prompt surgical intervention when needed. This approach allows early determination of prognosis, which is of huge value to the rehabilitating patient psychologically, and to the whole rehabilitation team

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

Radiofrequency (RF) lesions have been used for over 25 years in the treatment of intractable pain of spinal origin. The conventional understanding of this technique is that the heat which is produced in the tissue surrounding the electrode tip causes destruction of nervous tissue, which in turn reduces the input of noxious nerve stimuli and alleviates pain. Neuropathic pain is usually a contra-indication to the use of RF nerve lesioning. For treatment of patients with severe radicular pain we use pulsed radiofrequency who has been recently described as a technique to apply a relatively high voltage near a nerve but without the usual effects of rise in temperature or subsequent nerve injury. This study reports the effect of pulsed RF in 21 patients with severe radicular pain who had previously failed to respond to conventional therapy. Patients and Methods: From December 2000 to August 2001, 18 patients underwent pulsed RF Rhizotomy of Dorsal Root Ganglion (DRG) of segmental N. Root of the painful dermatome. Out of them, 16 passed treatment in the lumbar area and 2 in the neck. The age of the patients ranged from 20 to 75 years (m=55.7 years). Male/female ratio was 1.4/1. 50% was previously operated (discectomy, laminectomy). No complications were seen either in the procedure or in the follow-up. Results: Out of 21 patients, 3 (14.3%) did not respond to treatment. In the remaining 18 patients Rhizotomy was successful at 3 months follow-up. Mean VAS score before procedures was 8.85 (range 7–10), after treatment 3.8 (range 0–10). Conclusion: Pulsed RF treatment is a safe, simple procedure to control radicular, neuropathic pain in the cervical, thoracic and lumbar regions. Advantages of this method:. It is non-destructive procedure and it can therefore be used for different indication which were not suitable for conventional RF. Post-procedure discomfort does occur but it is less pronounced than following conventional RF. Although permanent sensory loss is a rare complication of RF it does occur. Pulsed RF does not have this complication

Background. Medication prescribing patterns for patients with neuropathic low back-related leg pain (LBLP) in primary care are unknown. Purpose. To estimate the proportion of patients prescribed pain medications, describe baseline characteristics of patients prescribed neuropathic pain (NP) medication and estimate the proportion of LBLP patients with refractory NP. Methods. General practice electronic medical and prescribing records of a large (n=609), prospective, primary-care cohort of LBLP patients were analysed. Cases of NP were identified using the self-report version of the NP scale, Leeds Assessment for Neurological Symptoms and Signs (score of ≥12 indicates possible NP) (n=293). Patients with leg pain intensity ≥ 5 (mean of three 0–10 NRSs) or <30% reduction in disability (RMDQ 0–23) at 4-months compared to baseline and who were prescribed ≥ 2 NP medications were considered to have refractory NP. Results. 82% (223/273) of patients with NP were prescribed at least one pain medication; 29% (80/273) of patients were prescribed one first-line NP medication (for example Amitriptyline). Patients who were prescribed NP medication(s) had higher leg pain intensity and disability. There was evidence that patients improved with (61%, 41/67) and without (75%, 76/102) having been prescribed NP medication. Few patients (4%, 7/169) met the criteria for refractory NP suggesting that the scale of the problem in primary care is limited. Conclusion. Patients with NP were commonly prescribed pain medication, under a third were prescribed NP medication and many patients improved without such medication. Future research is needed to determine the effectiveness of NP medication. No conflicts of interest. Sources of funding: Sarah Harrisson is a Clinical Doctoral Fellow funded through a National Institute for Health Research (NIHR) Research Professorship awarded to Nadine Foster (NIHR-RP-011-015). Nadine Foster is a NIHR Senior Investigator. Kika Konstantinou is supported by a Higher Education Funding Council for England/ National Institute for Health Research Senior Clinical Lectureship. The views expressed in this publication are those of the author(s), not necessarily those of the NHS, NIHR or the Department of Health and Social Care. This work relates to an Education and Continued Professional Development (level 2) award by the Musculoskeletal Association of Chartered Physiotherapists to Sarah Harrisson (June 2016)

Aim. To examine the mid-term survival, clinical and patient reported outcomes of the silastic 1. st. metatarsophalangeal joint replacement for the treatment of end stage hallux rigidus. Methods. We reviewed 83 consecutive silastic arthroplasties performed in 79 patients for end stage hallux rigidus. There were 3 men and 76 women; mean age 63 years (range 45–78 years). No patient was lost to follow up. Average follow-up was 5.3 years (1.1–11.3 years). The EQ 5D–5L Health index, Manchester-Oxford Foot Questionnaire (MOXFQ), visual analogue scale (VAS) of pain and overall satisfaction rate (Likert scale) were collected for patient reported outcomes. Results. 2 patients required revision; 1 for early infection (2 months) and 1 for stem breakage (10 years 1 month). 5 patients reported lateral metatarsalgia, 2 patients reported neuropathic pain, 6 patients developed superficial infection which fully responded to oral antibiotics, and 1 patient developed interphalangeal joint pain. 2 patients died in the cohort. Pre-operative mean MOXFQ was 44, mean EQ5D Index was 0.564 and VAS was 6.97. At mean follow-up of 5.3 years, the mean MOXFQ was 12.7 (0–57), the mean EQ5D Index was 0.851 (−0.02–1) and the mean VAS was 1.67 (0–8). The mean range of motion was 35° (30° dorsiflexion and 5° plantarflexion). The overall satisfaction rate was 90.2%. The implant survival rate was 97.6%. Conclusions. The silastic big toe arthroplasty offers excellent clinical mid term survival and functional outcomes and could be considered as an attractive alternative to traditional fusion for end stage hallux rigidus