The United States and Canada are in the midst
of an epidemic of the use, misuse and overdose of opioids, and deaths
related to overdose. This is the direct result of overstatement
of the benefits and understatement of the risks of using opioids
by advocates and pharmaceutical companies. Massive amounts of prescription
opioids entered the community and were often diverted and misused.
Most other parts of the world achieve comparable pain
Aims. Cervical spondylosis is often accompanied by dizziness. It has
recently been shown that the ingrowth of Ruffini corpuscles into
diseased cervical discs may be related to cervicogenic dizziness.
In order to evaluate whether cervicogenic dizziness stems from the
diseased cervical disc, we performed a prospective cohort study
to assess the effectiveness of anterior cervical discectomy and
fusion on the
We have examined the
1. A method of denervating the elbow joint, based upon observations on the articular branches of the main nerve trunks, is presented. 2. In a small group of cases with post-traumatic arthritis and osteoarthritis,
We investigated the effect of delay before nerve repair on neuropathic pain after injury to the brachial plexus. We studied 148 patients, 85 prospectively and 63 retrospectively. The mean number of avulsed spinal nerves was 3.2 (1 to 5). Pain was measured by a linear visual analogue scale and by the peripheral nerve injury scale. Early repair was more effective than delayed repair in the
Aims. The aim of this study was to compare the effectiveness of a femoral
nerve block and a periarticular infiltration in the management of
early post-operative pain after total knee arthroplasty (TKA). Patients and Methods. A pragmatic, single centre, two arm parallel group, patient blinded,
randomised controlled trial was undertaken. All patients due for
TKA were eligible. Exclusion criteria included contraindications
to the medications involved in the study and patients with a neurological
abnormality of the lower limb. Patients received either a femoral
nerve block with 75 mg of 0.25% levobupivacaine hydrochloride around
the nerve, or periarticular infiltration with 150 mg of 0.25% levobupivacaine
hydrochloride, 10 mg morphine sulphate, 30 mg ketorolac trometamol
and 0.25 mg of adrenaline all diluted with 0.9% saline to make a
volume of 150 ml. Results. A total of 264 patients were recruited and data from 230 (88%)
were available for the primary analysis. Intention-to-treat analysis
of the primary outcome measure of a visual analogue score for pain
on the first post-operative day, prior to physiotherapy, was similar
in both groups. The mean difference was -0.7 (95% confidence interval
(CI) -5.9 to 4.5; p = 0.834). The periarticular group used less
morphine in the first post-operative day compared with the femoral nerve
block group (74%, 95% CI 55 to 99). The femoral nerve block group
reported 39 adverse events, of which 27 were serious, in 31 patients
and the periarticular group reported 51 adverse events, of which
38 were serious, in 42 patients up to six weeks post-operatively.
None of the adverse events were directly attributed to either of
the interventions under investigation. Conclusion . Periarticular infiltration is a viable and safe alternative to
femoral nerve block for the early post-operative
The intra-articular injection of local anaesthetic is frequently used for pain
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
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
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
1. A case of cervical cord compression due to a congenital anomaly of the arch of the axis, treated successfully by decompressive laminectomy twenty-six years after the onset of symptoms, is described. 2. The significance of bony abnormalities of the cervical spine as a treatable cause of spastic tetraparesis is stressed.
We have studied 58 patients with pain from osteoporotic vertebral fractures which did not respond to conservative treatment. These were 53 women and five men with a mean age of 72.5 years. They received a nerve-root injection with lidocaine, bupivicaine and DepoMedrol. The mean follow-up period was 13.5 months. The mean pain scores before treatment, at one and six months after treatment and at the final follow-up were 85, 24.9, 14.1, and 17.4, respectively. According to our modified criteria for grading results, six patients were considered to have an excellent result, 42 good and ten fair. A newly developed compression fracture was noted in three patients. There were no complications related to the injection. Our study suggests that nerve-root injections are effective in reducing pain in patients with osteoporotic vertebral fractures and that these patients should be considered for this treatment before percutaneous vertebroplasty or operative intervention is attempted.
We report a prospective double-blind trial of the efficacy of a single epidural dose of buprenorphine on pain after spinal decompression. Postoperative pain was assessed by a linear analogue pain chart and by the additional requirement for analgesia. The patients receiving buprenorphine were significantly more comfortable (p less than 0.005) and required less analgesia in the first 12 hours after operation (p less than 0.05) than the control group. This simple procedure is recommended as an effective and safe method of reducing pain.
1. Three cases of traumatic arterial spasm are reported. 2. In each case there was increased tension in a neighbouring myofascial compartment. 3. The cause of this tension was oedema, possibly supplemented in one case by haematoma. 4. Release of tension by splitting the sheath was followed by relaxation of the artery. 5. It is suggested that tension in a fascial compartment may provide the stimulus that maintains arterial spasm and that the consequent ischaemia aggravates the oedema, so that a vicious circle is established. 6. It is further suggested that if spasm persists in spite of the usual measures, including exploration of the artery, the distal myofascial compartment should be decompressed. Division of the deep fascia of the cubital or the popliteal fossa is not enough. 7. Such persistent arterial spasm is uncommon, and further observations are needed to define the significance of increased tension in a distal myofascial compartment.
We performed intercostal nerve transfer in 19 patients to relieve pain from preganglionic injury to the brachial plexus. The procedure was successful in 16 patients at a mean of 28.6 months (12 to 68) after the injury.
Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears. The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane – anterior to the rib cage – is clearly different and does not allow it to function as an ideal transfer. Consistent
Aims. The aim was to assess whether robotic-assisted total knee arthroplasty (rTKA) had greater knee-specific outcomes, improved fulfilment of expectations, health-related quality of life (HRQoL), and patient satisfaction when compared with manual TKA (mTKA). Methods. A randomized controlled trial was undertaken (May 2019 to December 2021), and patients were allocated to either mTKA or rTKA. A total of 100 patients were randomized, 50 to each group, of whom 43 rTKA and 38 mTKA patients were available for review at 12 months following surgery. There were no statistically significant preoperative differences between the groups. The minimal clinically important difference in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score was defined as 7.5 points. Results. There were no clinically or statistically significant differences between the knee-specific measures (WOMAC, Oxford Knee Score (OKS), Forgotten Joint Score (FJS)) or HRQoL measures (EuroQol five-dimension questionnaire (EQ-5D) and EuroQol visual analogue scale (EQ-VAS)) at 12 months between the groups. However, the rTKA group had significantly (p = 0.029) greater improvements in the WOMAC pain component (mean difference 9.7, 95% confidence interval (CI) 1.0 to 18.4) over the postoperative period (two, six, and 12 months), which was clinically meaningful. This was not observed for function (p = 0.248) or total (p = 0.147) WOMAC scores. The rTKA group was significantly (p = 0.039) more likely to have expectation of ‘Relief of daytime pain in the joint’ when compared with the mTKA group. There were no other significant differences in expectations met between the groups. There was no significant difference in patient satisfaction with their knee (p = 0.464), return to work (p = 0.464), activities (p = 0.293), or pain (p = 0.701). Conclusion. Patients undergoing rTKA had a clinically meaningful greater improvement in their knee pain over the first 12 months, and were more likely to have fulfilment of their expectation of daytime pain