What Is the Medication Iatrogenic Risk in Elderly Outpatients for Chronic Pain?

PURPOSE: Medication iatrogeny is a major public health problem that increases as the population ages. Therapeutic escalation to control pain and associated disorders could increase polypharmacy and iatrogeny. This study aimed to characterize the medication iatrogenic risk of elderly outpatients with chronic pain. METHODS: This was a prospective cohort study recruiting patients 65 years or older with chronic pain. A medication iatrogenic assessment was performed based on the best possible medication history to record risk of adverse drug events (Trivalle score), STOPP (Screening Tool of Older Person's Prescriptions)/START (Screening Tool to Alert doctors to Right Treatment) criteria, and potentially inappropriate medications. RESULTS: We recruited 100 patients with an average age of 71 years. The median number of medications before pain consultation was 8 (interquartile range = [7;11]). Trivalle score showed that 43% of patients were at moderate or high medication iatrogenic risk. Before consultation, 79% and 75% of patients had at least 1 STOPP or START criterion on their orders, respectively. One-third of orders mentioned benzodiazepine prescribed for more than 4 weeks. At least 1 potentially inappropriate medication was prescribed for 54% of the patients, with a median of 1 per patient (interquartile range = [0;1]). A combination of several anticholinergics was prescribed in 23% of patients. CONCLUSION: Elderly patients with chronic pain are at risk of medication iatrogeny. Preventive measures as multidisciplinary medication review could reduce the iatrogenic risk in these outpatients.This study is registered at clinicaltrials.gov as NCT04006444 on July 3, 2019.

eDOL mHealth App and Web Platform for Self-monitoring and Medical Follow-up of Patients With Chronic Pain: Observational Feasibility Study.

BACKGROUND: Chronic pain affects approximately 30% of the general population, severely degrades quality of life (especially in older adults) and professional life (inability or reduction in the ability to work and loss of employment), and leads to billions in additional health care costs. Moreover, available painkillers are old, with limited efficacy and can cause significant adverse effects. Thus, there is a need for innovation in the management of chronic pain. Better characterization of patients could help to identify the predictors of successful treatments, and thus, guide physicians in the initial choice of treatment and in the follow-up of their patients. Nevertheless, current assessments of patients with chronic pain provide only fragmentary data on painful daily experiences. Real-life monitoring of subjective and objective markers of chronic pain using mobile health (mHealth) programs can address this issue. OBJECTIVE: We hypothesized that regular patient self-monitoring using an mHealth app would lead physicians to obtain deeper understanding and new insight into patients with chronic pain and that, for patients, regular self-monitoring using an mHealth app would play a positive therapeutic role and improve adherence to treatment. We aimed to evaluate the feasibility and acceptability of a new mHealth app called eDOL. METHODS: We conducted an observational study to assess the feasibility and acceptability of the eDOL tool. Patients completed several questionnaires using the tool over a period of 2 weeks and repeated assessments weekly over a period of 3 months. Physicians saw their patients at a follow-up visit that took place at least 3 months after the inclusion visit. A composite criterion of the acceptability and feasibility of the eDOL tool was calculated after the completion of study using satisfaction surveys from both patients and physicians. RESULTS: Data from 105 patients (of 133 who were included) were analyzed. The rate of adherence was 61.9% (65/105) after 3 months. The median acceptability score was 7 (out of 10) for both patients and physicians. There was a high rate of completion of the baseline questionnaires and assessments (mean 89.3%), and a low rate of completion of the follow-up questionnaires and assessments (63.8% (67/105) and 61.9% (65/105) respectively). We were also able to characterize subgroups of patients and determine a profile of those who adhered to eDOL. We obtained 4 clusters that differ from each other in their biopsychosocial characteristics. Cluster 4 corresponds to patients with more disabling chronic pain (daily impact and comorbidities) and vice versa for cluster 1. CONCLUSIONS: This work demonstrates that eDOL is highly feasible and acceptable for both patients with chronic pain and their physicians. It also shows that such a tool can integrate many parameters to ensure the detailed characterization of patients for future research works and pain management. TRIAL REGISTRATION: ClinicalTrial.gov NCT03931694; http://clinicaltrials.gov/ct2/show/NCT03931694.

Treatment Impact on Patient-Reported Outcomes in Peripheral Neuropathic Pain: Comparing Single Intervention With Topical High-Concentration Capsaicin to Daily Oral Pregabalin.

BACKGROUND: Peripheral neuropathic pain (PNP) is a complex, subjective experience affecting both physical and psychological aspects of functioning. Assessing patient-reported outcomes (PROs) beyond pain relief is important and aligns with the recommendations of IMMPACT (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials). Moreover, PRO data are key to clinical decision-making when evaluating treatment options. However, direct comparisons between such options are scarce. High-concentration capsaicin 179 mg (8% w/w) cutaneous patch (HCCP) is applied to the skin at minimum intervals of 90 days under physician supervision; alternative recommended treatments for PNP are mostly orally administered on a daily basis. The ELEVATE study directly compared HCCP with pregabalin and found noninferior efficacy of HCCP to pregabalin in relieving pain after 8 weeks, with a significantly faster onset of action and fewer systemic side effects. OBJECTIVES: The objective of this analysis was to compare PRO outcomes defined as secondary objectives of the ELEVATE study after a single intervention with HCCP to daily oral pregabalin for 8 weeks. STUDY DESIGN: ELEVATE was an open-label, randomized (1:1) multicenter study. SETTING: The study included 92 sites in 22 countries in Europe and Asia. METHODS: Five hundred fifty-nine non-diabetic  patients with PNP received a single intervention with HCCP (n = 282; 1-4 patches at baseline) or oral daily pregabalin (n = 277; 150-600 mg, 8 weeks). At baseline (Day 0) and Week 8, patients completed the following PROs in addition to the regular pain assessments: Patient Global Impression of Change (PGIC), Medical Outcomes Study Cognitive Functioning scale (MOS-Cog), Medical Outcomes Study Sleep scale (MOS-Sleep), Treatment Satisfaction Questionnaire for Medication (TSQM), and EuroQol 5-Dimensions 5-levels (EQ-5D-5L) Utility Index (EQ-UI) and Visual Analog Scale (EQ-VAS). RESULTS: At Week 8, 76% and 75.9% of patients on HCCP and pregabalin, respectively, reported to be very much/much/minimally improved on the PGIC. HCCP application was associated with significant improvements from baseline vs. pregabalin in MOS-Cog (mean difference: 4.28 [95% CI: 2.90-5.66]; P < 0.001), EQ-VAS (3.11 [0.30-5.92]; P = 0.030), and TSQM global satisfaction (6.74 [2.29-11.20]; P = 0.029), particularly the side-effects dimension (21.23 [17.55-24.94]; P < 0.0001). No significant differences in improvements were noted for the MOS-Sleep, TSQM convenience, and EQ-UI. LIMITATIONS: The ELEVATE study has an open-label design, with only one comparator (pregabalin); it was limited to 8 weeks. The sample size was determined for the primary endpoint. CONCLUSIONS: A single intervention with HCCP showed benefits vs. daily pregabalin at Week 8 on several PROs. While HCCP has been approved in the United States for PNP treatment in diabetic and PHN patients, these observations provide information on how patients perceive the effects of distinct PNP treatments. They are complementing already existing knowledge on efficacy and safety of different treatment options with data on patient preferences and may help identify the appropriate treatment option in dialogue with the patients and shared decision-making.IRB Approval: At the time of the study, the trial was approved either nationally or at site level. All approvals were granted prior to the initiation of the trial. A list of Ethics Committees that approved the trial is included as a supplemental file. CLINICAL TRIAL REGISTRATION NUMBER: NCT01713426.

Characterisation of pragmatic postoperative PAin Trajectories over seven days and their association with CHronicity after 3 months: a prospective, pilot cohort study (PATCH study).

BACKGROUND: Reliable outcome measurement providing information both on early and late postoperative pain outcomes are still lacking. The purpose of this study was: 1) to characterise postoperative pain trajectories according to an innovative pragmatic concept: ideal pain trajectory (rapid and sustained pain relief) vs non-ideal pain trajectories (late, transient, or no pain relief); and 2) to assess the incidence of persistent post-surgical pain (PPSP) and the potential association between non-ideal pain trajectories and PPSP. METHODS: This prospective observational pilot cohort study was performed from March until June 2016. A total of 344 patients undergoing major general surgery were invited to complete a self-assessment of pain intensity using numerical rating scale (NRS; 0 = no pain to 10 = worst pain) from day 1 until day 7 after surgery, in order to establish their pain trajectory. Three months after surgery, patients were screened for PPSP. RESULTS: Rest pain score was analysed in 308 participants. Among them, 210 (68% - 95% CI: 63-73) had an "ideal" pain trajectory, while 98 (32% - 95% CI: 27-37) had "non-ideal" pain trajectories. Three months after surgery, 31% (95% CI: 26-37) reported PPSP. Multivariable analysis showed that "non-ideal" pain trajectories [OR 2.25; (95% CI: 1.26-4.01) P = 0.006] were significantly associated with PPSP. CONCLUSIONS: The present study proposes an innovative pragmatic concept of postoperative pain trajectories: ideal vs non-ideal pain trajectories, providing information both on acute postoperative pain resolution and early identification patients at risk for developing PPSP. TRIAL REGISTRATION: NCT02599233; November, 6, 2015, with clinicaltrials.gov.

Safety and efficacy of an equimolar mixture of oxygen and nitrous oxide: a randomized controlled trial in patients with peripheral neuropathic pain.

ABSTRACT: Nitrous oxide (N2O) is an odorless and colorless gas routinely used as an adjuvant of anesthesia and for short-duration analgesia in various clinical settings mostly in the form of an N2O/O2 50%-50% equimolar mixture (EMONO). Experimental studies have suggested that EMONO could also induce long-lasting analgesic effects related to the blockade of N-methyl-D-aspartate receptors. We designed the first international multicenter proof of concept randomized, placebo-controlled study to assess the efficacy and safety of a 1-hour administration of EMONO or placebo (medical air) on 3 consecutive days up to 1 month after the last administration in patients with chronic peripheral neuropathic pain. A total of 240 patients were recruited in 22 centers in France and Germany and randomly assigned to 1 study group (120 per group). Average pain intensity (primary outcome), neuropathic pain characteristics (Neuropathic Pain Symptom Inventory), Patient Global Impression of Change, anxiety, depression, and quality of life were systematically assessed before and after treatment. The changes in average pain intensity between baseline and 7 days after the last administration were not significantly different between the 2 groups. However, evoked pain intensity (predefined secondary endpoint) and Patient Global Impression of Change (exploratory endpoint) were significantly improved in the EMONO group, and these effects were maintained up to 4 weeks after the last treatment administration. Mostly transient side effects were reported during the treatment administration. These encouraging results provide a basis for further investigation of the long-term analgesic effects of EMONO in patients with neuropathic pain.

Fractal properties in sensorimotor variability unveil internal adaptations of the organism before symptomatic functional decline.

If health can be defined as adaptability, then measures of adaptability are crucial. Convergent findings across clinical areas established the notion that fractal properties in bio-behavioural variability characterize the healthy condition of the organism, and its adaptive capacities in general. However, ambiguities remain as to the significance of fractal properties: the literature mainly discriminated between healthy vs. pathological states, thereby loosing perspective on the progression in between, and overlooking the distinction between adaptability and effective adaptations of the organism. Here, we design an experimental tapping paradigm involving gradual feedback deprivation in groups of healthy subjects and one deafferented man as a pathological-limit case. We show that distinct types of fractal properties in sensorimotor behaviour characterize, on the one hand impaired functional ability, and on the other hand internal adaptations for maintaining performance despite the imposed constraints. Findings may prove promising for early detection of internal adaptations preceding symptomatic functional decline.

[Drug management of cancer-related peripheral neuropathic pain: A systematic review of the literature]. / Prise en charge médicamenteuse des douleurs neuropathiques périphériques liées au cancer : une revue systématique de la littérature.

The objective of the present systematic literature review was to provide an update on medical treatment of neuropathic pain in cancer patients. The number of cancer patients is steadily increasing. Pain is frequent in cancer patients. Few studies have focused on medical treatment of pain, and especially of neuropathic pain, in current or former cancer patients. The present systematic review of all studies published between December 2012 and August 2018 was intended to estimate the scale of this lack. In all, 27 articles were identified on a systematic PubMed search and from the authors' personal knowledge, confirming that scant data have been published. The heterogeneity of cancer patients, of cancer, and of pain go some way toward explaining this scarcity. Guidelines, founded mainly on results from non-cancer patients, recommend tricyclic antidepressants and antiepileptic drugs; local treatments have the advantage of good systemic tolerance. Larger-scale studies taking account of the etiology of neuropathic pain, its characteristics (strictly neuropathic or mixed) and patient characteristics (awaiting treatment, under treatment, recent or non-recent survivor, or in terminal phase) along the care pathway are needed to improve knowledge. The results of the present literature analysis can help future research.

French clinical guidelines for peripheral motor nerve blocks in a PRM setting.

INTRODUCTION: Motor nerve blocks with anesthetic drug for local anesthesia are commonly used in physical and rehabilitation medicine (PRM), especially in the field of spasticity. Guidelines in this context are currently lacking. METHOD: Eighteen experts selected on the basis of their recognized experience by the scientific committees of the French PRM (SOFMER) and Anesthesia and Intensive care (SFAR) societies were invited to work and propose guidelines for the use of loco-regional anesthetic drug for motor nerve blocks in PRM setting. Eight issues were addressed: which neural blocks for which indications; drugs and contraindications; medical survey and attitude in case of adverse event; injection and guidance material; patient preparation and pain relief; efficacy assessment; patient information; education of PRM physiatrists. The Medline, Cochrane and Embase databases for the period 1999 to 2018 were consulted and 355 papers analyzed. The drafts were commented then approved by the whole group using electronic vote, before final approval by scientific committee of each society. RESULTS: No scientific evidence emerged from the literature. Thus, these guidelines are mainly based on the opinion of the expert panel. Guidelines for each issue are reported with the main points of arguments. The main question deals with the recommendation about doses for each drug: for lidocaine - up to 2mg/kg - "check contraindications, emergency truck available, no need of previous anesthetic consultation nor presence of anesthetic physician"; for ropivacaine - up to 1.5mg/kg, with a maximum of 100mg - the same but after intravenous line. Beyond these doses, SFAR guidelines have to be applied with the need of anesthetic physician. CONCLUSION: These are the first organizational guidelines devoted to increase the security of motor nerve block use in PRM settings.

The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales.

Unlike wards, where chronic and acute pain are regularly managed, comparisons of the most commonly used self-report pain tools have not been reported for the intensive care unit (ICU) setting. The objective of this study was to compare the feasibility, validity and performance of the Visual Analog Scale (horizontal (VAS-H) and vertical (VAS-V) line orientation), the Verbal Descriptor Scale (VDS), the 0-10 oral Numeric Rating Scale (NRS-O) and the 0-10 visually enlarged laminated NRS (NRS-V) for pain assessment in critically ill patients. One hundred and eleven consecutive patients admitted into a medical-surgical ICU were included as soon as they became alert and were able to follow simple commands. Pain was measured using the 5 scales in a randomized order upon enrollment-(T1) and after-(T2) administration of an analgesic or, in absence of pain upon enrollment, after a nociceptive procedure. The rate of any response obtained both at T1 and T2 (success rate) was significantly higher for NRS-V (91%) compared with NRS-O (83%), VDS (78%), VAS-H (68%) and VAS-V (66%). Pain intensity changed significantly between T1 and T2, showing a good validity and responsiveness for the 5 scales, which correlated well between each other. The negative predictive value calculated from true and false negatives defined by real and false absence of pain was highest for NRS-V (90%). In conclusion, the NRS-V should be the tool of choice for the ICU setting, because it is the most feasible and discriminative self-report scale for measuring critically ill patients' pain intensity.

Anaesthesia for cataract surgery.

Cataract surgery is the most frequent surgical procedure requiring anaesthesia in developed countries. It is performed mainly in elderly patients, who present with many coexisting diseases that induce subsequent hazards from general anaesthesia. Cataract anaesthesia is performed following various techniques of regional anaesthesia, which are detailed in this review. Needle block carries a low but real risk of complications, mainly because of needle misplacement. Correct teaching and training are mandatory to prevent complications. The main patient risk factor for inadvertent globe perforation is the presence of a myopic staphyloma. Retrobulbar block has been progressively phased out and replaced by peribulbar block, sub-Tenon's block (STB) or topical anaesthesia (TA). The requirement for very deep block with total akinesia has greatly decreased with the use of phacoemulsification for cataract surgery, allowing for use of TA or low-volume STB. However, non-akinesia techniques may give rise to impaired surgical conditions, which have the potential to result in surgical complications. A surgical approach to accessing sub-Tenon's space avoids needle block, but does not totally prevent complications. When deep anaesthesia is required, low-volume STB, performed using either the needle technique or a surgical approach, appears to be the technique of choice in terms of efficacy. Increasing the anaesthetic volume provides reproducible akinesia. Various local anaesthetics may be used, depending on their availability and respective properties. The most useful adjuvant to local anaesthetic is hyaluronidase.

Assessing pain in non-intubated critically ill patients unable to self report: an adaptation of the Behavioral Pain Scale.

PURPOSE: To validate an adaptation of the Behavioral Pain Scale (BPS) for its use in non-intubated intensive care unit (ICU) patients unable to self-report their pain because of the occurrence of delirium. The "vocalization" domain was inserted to construct the BPS-non intubated (BPS-NI) scale, ranging from 3 (no pain) to 12 (most pain). DESIGN: Prospective psychometric study in a medical-surgical ICU. METHODS: The same physician and one bedside nurse rated pain in non-intubated patients unable to self-report their pain during four conditions: before and after a catheter dressing change (non-nociceptive procedure) and before and after turning the patient (nociceptive procedure). Delirium was assessed by the Confusion Assessment Method for the ICU (CAM-ICU). RESULTS: A total of 120 paired evaluations were performed in 30 consecutive adult patients, 84% with delirium (CAM-ICU positive). BPS-NI scores were higher during painful procedures than at rest [6.0 (5.0-8.0) vs. 3.0 (3.0-3.8); P < 0.001], while no changes in BPS-NI scores were found during non-nociceptive procedures (discriminative validity). The BPS-NI had good internal consistency (standardized Cronbach alpha = 0.79), and each domain reflected the pain expression factor in a balanced way (coefficients between 0.57 and 0.59). The BPS-NI had a good inter-rater reliability (weighted kappa coefficient = 0.89 for the four conditions and 0.82 during nociceptive procedures) and a good responsiveness, with an effect size ranging from 1.5 to 3.6. CONCLUSIONS: Pain during procedures is perceived even in non-intubated ICU patients with delirium. In those patients, pain level can be assessed with the BPS-NI scale since this instrument exhibited good psychometric properties. Electronic supplementary material The online version of this article (doi:10.1007/s00134-009-1590-5) contains supplementary material, which is available to authorized users.

[Peripheral nerve blocks and spasticity. Why and how should we use regional blocks?]. / Prise en charge des spasticités douloureuses: pourquoi et comment utiliser les blocs locorégionaux?

Muscle spasticity causes pain, disability, and difficulties in the rehabilitation of patients with cerebrovascular lesions, head, brain or spine trauma, coma, or neurologic diseases such as multiple sclerosis, amyotrophic lateral sclerosis, or cerebral palsy. Regional blocks have a threefold use in patients with painful spasticity: diagnostic, prognostic, and therapeutic. Blocks are feasible on an outpatient or day-hospital basis. Blocks are applied most often to 4 peripheral sites: the pectoral nerve loop, median, obturator, and tibial nerves. The main indication is debilitating or painful spasticity. Peripheral blocks with local anesthetics are used as tests, to mimic the effects of motor blocks and determine their potential adverse effects, transiently and reversibly. Peripheral neurolytic blocks are easy to perform, effective, and inexpensive.

Postoperative Analgesic THerapy Observational Survey (PATHOS): a practice pattern study in 7 central/southern European countries.

Surveys evaluating pain in hospitals keep on showing that postoperative pain (POP) remains undertreated. At the time when guidelines are edited and organisational changes are implemented, more recent data are necessary to check the impact of these measures on daily practice and needs for improvement. This prospective, cross-sectional, observational, multi-centre practice survey was performed in 2004-2005 in 7 European countries. It was conducted in surgical wards of a randomised sample of hospitals. Data on POP management practices following surgery in adult in-patients were collected anonymously via a standardised multiple choice questionnaire. Among 1558 questionnaires received from 746 European hospitals, 59% were provided by anaesthetists and 41% by surgeons. There are no regular on-site staff training programmes on POP management in the institution for 34% of the respondents, patients are systematically provided with POP information before surgery for 48% of respondents; balanced analgesia following major surgery and regular administration of analgesics are largely used; 25% of respondents have specific written POP management protocols for all patients in their ward; 34% of respondents say that pain is not assessed and 44% say that pain scores are documented in the patient's chart. This largest ever performed survey confirms the extensive body of evidence that current POP management remains suboptimal and identifies needs for improvement on European surgical wards. However, the wide use of balanced analgesia and the regular administration of analgesics are indicators of ongoing change.

Quality control programme for acute pain management in emergency medicine: a national survey.

OBJECTIVE: This national survey was carried out to evaluate the quality programme for acute pain management in the emergency department (ED) and in pre-hospital emergency medical services (EMS). METHODS: Two types of questionnaires were sent to the chief consultant and the chief nurse of all ED and EMS. Data collected were: the type of structure, quality programme organization, acute pain management, and the training needs to initiate a pain quality programme. RESULTS: A total of 363 questionnaires were recorded (198 from chief consultants) with 98% of questionnaires being usable. A pain management committee existed in 71% of cases, a quality committee in 83%. A complete quality control procedure existed in 53% of units. An audit on pain management was carried out in only 23% of cases. Training in quality was performed for 64% of physicians and 68% of nurses. Training specifically for pain management was carried out for physicians in 56% of cases and for nurses in 68% of cases. Pain therapeutics protocols existed in 69% of cases. Pain intensity was evaluated 'systematically or often' in 64% at the beginning of patient management, and in 56% at the end of patient management. The staff was 'not very motivated' for a pain management quality programme in less than 3% of responses. A total of 61% of chief consultants and 58% of chief nurses requested advice. CONCLUSION: Most ED and EMS units seem to master the quality control programme methodology. Units are highly motivated to initiate a quality control programme on pain. Nevertheless, its implementation could benefit from some external support.

Tramadol added to 1.5% mepivacaine for axillary brachial plexus block improves postoperative analgesia dose-dependently.

UNLABELLED: Adjuncts to local anesthetics for peripheral plexus blockade may enhance the quality and duration of anesthesia and postoperative analgesia. The analgesic, tramadol, has a unique mechanism of action that suggests efficacy as such an adjunct. It displays a central analgesic and peripheral local anesthetic effect. We designed a prospective, randomized, controlled and double-blind clinical trial to assess the effect of tramadol added to brachial plexus anesthesia. One-hundred patients scheduled for carpal tunnel release surgery under brachial plexus anesthesia were randomized into four groups. All patients received 1.5% mepivacaine 40 mL plus a study solution containing either isotonic sodium chloride (Group P, n = 17), tramadol 40 mg (Group T(40), n = 22), tramadol 100 mg (Group T(100), n = 20) or tramadol 200 mg (Group T(200), n = 20). We evaluated the time of onset of anesthesia, duration of sensory and motor blockade, duration and quality of postoperative analgesia, and occurrence of adverse effects. Onset and duration of sensory and motor blocks were not different among groups. The number of patients requesting analgesia in the postoperative period was significantly less in the 3 tramadol groups compared with the placebo group (P = 0.02); this was also noted with the placebo and T(40) groups compared with the T(200) group. No statistical significance was demonstrated between the placebo and the T(40) group or the T(100) group and the T(200) group. Furthermore, there was a significant trend effect among groups applying the Cochran-Armitage tendency test (P = 0.003), suggesting a dose-dependent decrease for additional postoperative analgesia requirements when tramadol was added. Side effects did not differ among groups, although they were more frequently recorded in the T groups. Our study suggests that tramadol added to 1.5% mepivacaine for brachial plexus block enhances in a dose-dependent manner the duration of analgesia with acceptable side effects. However, the safety of tramadol has to be investigated before allowing its use in clinical practice. IMPLICATIONS: Tramadol's unique mechanism of action suggests efficacy as a local anesthetic adjunct for peripheral plexus blockade. Our study demonstrates that tramadol, added to mepivacaine for brachial plexus anesthesia, extends the duration and improves the quality of postoperative analgesia in a dose dependent fashion with acceptable side effects.

Neurolytic blockade of the obturator nerve for intractable spasticity of adductor thigh muscles.

Neurolytic blockade is one of the therapeutic possibilities to treat spasticity of various muscles. In patients with spasticity of the adductor thigh muscles, a percutaneous approach to the obturator nerve is often difficult. We describe a new approach to the obturator nerve and we examine its feasibility. The second objective was to assess the efficacy of obturator neurolysis for the management of adductor thigh muscle pain and spasticity associated with hemiplegia or paraplegia. Nerve blocks were performed via a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve. Neurolysis was performed by injection of 65% ethanol. We performed 27 blocks in 23 patients. Technical evaluation was achieved in terms of number of attempted needle insertions, time to accurate location of the nerve and success rate. The efficacy of the block was assessed using four scores: degree of alleviation of muscle spasm and triple flexion of the lower limb, improvement of gait and facilitation of hygienic care. Success rate of the technique was 100% with a time to accurate nerve location of 130+/-35 s. Compared with scores measured immediately before the block, all studied parameters were significantly improved. Efficiency was significant on adductor muscle spasticity (p<0.001 at 1 day and p<0.01 at 60 and 120 months). Triple flexion was also significantly improved (p<0.05 from 1 to 120 days), as well as gait (p<0.02) and hygiene (p<0.01) scores. No complications occurred. The combined approach of the obturator nerve represents a new technique which proved to be accurate, fast, simple, highly successful and reproducible. Obturator neurolysis was confirmed as an efficient and cost-effective technique to reduce adductor muscle spasm and related pain and to improve gait and hygienic care in patients with neurological sequelae of stroke, head trauma or any lesion of the motor neurone.