Efficacy of median nerve hydrodissection by hyalase versus midazolam in the treatment of carpal tunnel syndrome.

Background: The objective was to determine which of midazolam or hyalase could improve the pain score and functional disability in median nerve hydrodissection. Methods: In a double-blind study with two groups, both received bupivacaine 15 mg with either 300 IU hyalase in 2 ml of saline (group HA) or 2 mg of midazolam in 2 ml of sterile saline (group MZ). Results: Statistically significantly lower post-injection Visual Analog Scale scores in group MZ compared with group HA at all follow-ups. Group MZ had significantly lower functional disability scores than group HA. Conclusion: Both drugs yielded favorable results. Midazolam was more impactful in alleviating pain and reducing functional disability up to 6 months.

Intra-Carpal Injection of Ozone versus Methylprednisolone in Carpal Tunnel Syndrome of Systemic Sclerosis Patients: A Randomized Single-Blind Clinical Trial.

BACKGROUND: Carpal tunnel syndrome (CTS) is the most entrapment syndrome in general and is the most frequent peripheral nervous system involvement in systemic sclerosis (SSc). Local injection of steroid hydrodissection or ozone-oxygen showed favourable outcome in CTS in general. OBJECTIVES: To compare the clinical efficacy of ozone versus methylprednisolone intracarpal injection upon pain, functional status, and nerve conduction in patients with CTS due to SSc. STUDY DESIGN: A randomized single-blinded trial. SETTING: Anesthesia, pain, and rheumatology clinics in a university hospital. METHODS: Fifty CTS patients with > 3 months duration of SSc were equally randomized into either group O (injection of ozone/oxygen 25 mu-g/mL in 20 mL) or group M (methylprednisolone acetate 40mg, and 40 mg lidocaine in 20 mL). Visual analog scale (VAS) was measured pre-injection, then re-evaluated post-injection at 4 time points (1 week, 1 month, 3 months , and 6 months); Cochin Hand Function Scale (CHFS); and a median nerve electrophysiologic study was done before injection, then by the end of 3 months and 6 months. RESULTS: VAS was significantly lower in group M after 1 week (P = 0.01). Group O showed significantly lower VAS after 3 and 6 month (P < 0.001). Additionally, there was a significant decrease in the VAS during the whole study period within each group, in comparison to its baseline value. CHFS was significantly lower in the ozone group after 6 months (P < 0.001). The sixth month's sensory conduction was significantly higher in group O (P = 0.002). The motor distal latency was significantly lower in the ozone group after 3 and 6 months (P < 0.001). LIMITATIONS: Follow-up period could be furtherly extended. CONCLUSION: Both intracarpal ozone or methylprednisolone afford favorable effects upon CTS in patients with SSc. However, ozone alleviates pain much more, enhances the hand functional status, and improves median nerve conduction in study with over six months duration.

Efficacy of Genicular Nerve Radiofrequency Ablation Versus Intra-Articular Platelet Rich Plasma in Chronic Knee Osteoarthritis: A Single-Blind Randomized Clinical Trial.

BACKGROUND: Chronic knee osteoarthritis is a common problem with increasing of the aging population. Pulsed radiofrequency and intraarticular platelet rich plasma injection are well evidenced beneficial modalities for pain alleviation in such groups of patients. OBJECTIVE: The primary goal in this study was to compare the 2 modalities regarding pain alleviation evaluated by visual analog scale. The secondary goal focused upon the change of the Index of Severity for Osteoarthritis of the Knee by Lequesne. STUDY DESIGN: Single-blind randomized interventional clinical trial. SETTING: University hospitals. METHODS: Two hundred patients with chronic knee osteoarthritis were equally and randomly distributed into 2 groups. Group PRF received pulsed radiofrequency, whereas the group PRP received intraarticular platelet-rich plasma. The visual analog scale and index of severity of osteoarthritis were evaluated before intervention, after one week (for visual analog scale only), then after 3, 6, and 12 months. RESULTS: Visual analog scale was significantly lower in the PRF group compared to the PRP group at 6 and 12 months with P-values of 0.01 and 0.04, respectively. Regarding to the postinterventional index of severity of osteoarthritis, it was significantly lower in the PRF group than the PRP group with P-values of 0.001 at 3, 6, and 12 months follow-up. LIMITATIONS: Physical and analgesic therapy were not included in data collection, and there was no control group. CONCLUSION: Pulsed radiofrequency of the genicular nerves can be considered superior to knee intraarticular platelet-rich plasma injection for sustained pain relief and the lower severity index in patients with chronic knee osteoarthritis.

Efficacy of Hyalase Hydrodissection in the Treatment of Carpal Tunnel Syndrome: A Randomized, Double-Blind, Controlled, Clinical Trial.

BACKGROUND: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy, which results from median nerve compression. A lot of nonsurgical modalities are available for the management of mild to moderate situations. Local Hyalase hydrodissection (HD) of the entrapped median nerve could offer a desirable sustained symptom alleviation. OBJECTIVES: To evaluate the clinical efficacy of Hyalase/saline solution carpal tunnel HD on pain, functional status, and nerve conduction in patients with CTS. STUDY DESIGN: A randomized, double-blinded trial. SETTING: Anesthesia, pain, and rheumatology clinics in a university hospital. METHODS: Patients: 60 patients with CTS (> 6 months' duration). INTERVENTION: patients were allocated equally into either group 1 (HD with Hyalase + 10 mL saline solution injection), or group 2 (HD with 10 mL saline solution only). MEASUREMENTS: assessment of pain using Visual Analog Scale (VAS), functional disability (FD) score, and nerve conduction studies before injection, and over 6 months after injection. Nerve conduction parameters before injection and postinjection by the end of 3 and 6 months were evaluated as well. RESULTS: Statistically significant lower postinjection values of VAS (1 ± 1.8, 2 ± 1.1, 2 ± 1.2, 2 ± 1.1) in group 1 versus (2 ± 1.2, 3 ± 1.7, 4 ± 1.5, 5 ± 2.6) in group 2 by the end of the first week, and the first, third, and sixth months, and significantly lower FD scores (15.3 ± 1.2, 13 ± 1.3, 10.2 ± 1.3, 10.2 ± 1.3) in group 1 versus (17.5 ± 1.8, 16.6 ± 2.8, 19.4 ± 3.2, 21.2 ± 2.5) in group 2 during the same time intervals. Nerve conduction study parameters have shown significantly higher velocity and lower latency in the Hyalase group than in the saline solution group by the 3 and 6 month follow-up. LIMITATION: We suggest a longer period could be reasonable. CONCLUSIONS: Carpal tunnel HD with Hyalase with saline solution is considered as an efficient technique offering a rapid onset of pain relief and functional improvements, and better median nerve conduction in patients with CTS over 6 months follow-up duration. KEY WORDS: Carpal tunnel syndrome, Hyalase, median nerve hydrodissection.

Perineural Platelet-Rich Plasma for Diabetic Neuropathic Pain, Could It Make a Difference?

OBJECTIVE: To evaluate the clinical effect of perineural platelet-rich plasma (PRP) injection for pain and numbness alleviation in diabetic peripheral neuropathy (DPN). STUDY DESIGN: A randomized prospective clinical trial. SETTING: Pain clinic and Rheumatology and Rehabilitation Departments, Assiut University Hospital. METHODS: Sixty adult patients with type II DM accompanied by DPN of at least six months' duration were assessed by modified Toronto Clinical Neuropathy Score (mTCNS) and randomly allocated into two groups. Group I underwent ultrasound-guided perineural PRP injection and medical treatment, and Group II received medical treatment only. Patients were followed up at months 1, 3, and 6 with regard to pain and numbness visual analog scale (VAS) and mTCNS scores. RESULTS: Significant improvement was recorded in pain and numbness VAS scale scores in group I vs group II (P ≤ 0.001 during the whole study period for both parameters); at the same time, mTCNS improved in group I in comparison with group II with P = 0.01, 0.001, and <0.001 at months 1, 3, and 6, respectively. CONCLUSIONS: Perineural PRP injection is an effective therapy for alleviation of diabetic neuropathy pain and numbness and enhancement of peripheral nerve function.

Could Short-Term Perioperative High-Dose Atorvastatin Offer Antiarrhythmic and Cardio-Protective Effects in Rheumatic Valve Replacement Surgery?

OBJECTIVES: To evaluate the role of prophylactic high-dose atorvastatin for prevention of postoperative atrial fibrillation (POAF), inflammatory response attenuation, and myocardial protection after valve replacement cardiac surgery. DESIGN: Randomized controlled trial. SETTING: Assiut University Hospitals. PARTICIPANTS: Sixty-four adult patients undergoing cardiac valve replacement surgery. INTERVENTIONS: The participants were equally divided into 2 groups. Group S received 80 mg of atorvastatin (oral tablets), 12 and 2 hours preoperatively, and on the 2nd, 3rd, 4th, and 5th postoperative days. Control group C received placebo at the same time periods. MEASUREMENTS: The incidence of POAF, postoperative white blood cell count, serum C-reactive protein, interleukin 6, and troponin I. MAIN RESULTS: Group S patients showed a lower incidence of POAF compared with the placebo group (p = 0.031). The white blood cell count showed significant reductions in group S compared with group C on the second, third, fourth, and fifth postoperative days. The C-reactive protein level showed significant reductions on the third, fourth, and fifth postoperative days in group S compared with group C (p = 0.001, 0.001, and 0.001, respectively). The serum level of interleukin 6 showed a significant reduction on the fifth postoperative day in group S compared with group C (p = 0.001). There was no significant difference between the 2 groups regarding the troponin I level and inotropic score. CONCLUSION: Prophylactic use of high dose atorvastatin can decrease the incidence of POAF and attenuate the inflammatory process in adult patients undergoing isolated rheumatic cardiac valve replacement surgery.

Paravertebral Dexmedetomidine in Video-Assisted Thoracic Surgeries for Acute and Chronic Pain Prevention.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is considered as one of the minimally invasive surgeries. Early postoperative pain alleviation is very important to avoid complications, at the same time, proper early pain control is an established fact to decrease the incidence of chronic pain. OBJECTIVES: To evaluate the efficacy of thoracic paravertebral block (PVB) by a bupivacaine/ dexmedetomidine mixture on acute and chronic post-thoracoscopic surgery pain in patients undergoing VATS. STUDY DESIGN: A randomized prospective double-blinded trial. SETTING: Assiut University Hospitals, Orman Cardiology Hospital. METHODS: Sixty adult patients underwent elective VATS surgery under general anesthesia randomly allocated into 2 groups; Group I received thoracic PVB with isobaric bupivacaine 0.5% (0.3 mL/kg) and Group II received PVB with isobaric bupivacaine 0.5% (0.3 mL/kg) and dexmedetomidine (1 mcg/kg). Postoperative pain (at rest, with cough, and with movement) was assessed through a visual analog scale (VAS) every 30 minutes in the first 2 hours, then at the second, fourth, eighth, and 24th hours. Time to first analgesia request and consumption of intravenous rescue analgesia (ketorolac tromethamine 30 mg/dose) was recorded. Follow-up of the patients regarding the incidence of chronic post-thoracoscopic pain by the end of the third and sixth months after the procedure was reviewed through the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale. RESULTS: VAS score was significantly lower in Group II during the early postoperative 90 minute records. Pain with cough and with movement persisted to be significantly lower in Group II up to the second postoperative hour. Time to first analgesia requirement was significantly longer in Group II in comparison to Group (P < 0.001). There was less ketorolac consumption in Group II than in Group I (P = 0.002). At the third month, Group II showed significantly lower incidence of LANSS pain scale than Group I (P = 0.04). LIMITATIONS: There was the heterogeneity of surgical procedures in the patients. CONCLUSIONS: Dexmedetomidine as an adjuvant to bupivacaine PVB offers better pain relief during the early postoperative hours, and it carries a favorable effect on chronic postoperative pain.Clinical trial registry number: NCT03632161. KEY WORDS: Dexmedetomidine, paravertebral block, video-assisted thoracoscopic surgery, postoperative pain, chronic pain.

Effects of terlipressin infusion during hepatobiliary surgery on systemic and splanchnic haemodynamics, renal function and blood loss: a double-blind, randomized clinical trial.

BACKGROUND: Terlipressin, in general, is a vasopressor which acts via V1 receptors. Its infusion elevates mean blood pressure and can reduce bleeding which has a splanchnic origin. The primary outcome was to assess the impact of intraoperative terlipressin infusion on portal venous pressure during hepatobiliary surgery; the 2ry outcomes included effects upon systemic hemodynamics, estimated blood loss, and postoperative renal functions. METHODS: This prospective randomized study involved 50 patients undergoing hepatobiliary surgery who were randomly and equally allocated into terlipressin group, or a control group. The terlipressin group received an initial bolus dose of (1 mg over 30 min) followed by a continuous infusion of 2 µg/kg/h throughout the procedure and gradually weaned over the first four postoperative hours, whereas the control group received the same volumes of normal saline. The portal venous pressure changes were measured directly through a portal vein angiocatheter. RESULTS: Portal pressure was significantly reduced over time in the terlipressin group only (from 17.88 ± 7.32 to 15.96 ± 6.55 mmHg, p < .001). Mean arterial blood pressure was significantly higher in the terlipressin group. Estimated blood loss was significantly higher in the control group than the terlipressin group (1065.7 ± 202 versus 842 ± 145.5 ml; p = 0.004), and the units of packed RBCs transfused were significantly higher in the control group ((0-2) versus (0-4) p = 0.003). There was no significant difference between groups as regards the incidence of acute kidney injury. CONCLUSION: Intraoperative infusion of terlipressin during hepatobiliary surgery was shown to improve intraoperative portal hemodynamics with subsequent reduction in blood loss. TRIAL REGISTRATION: Clinical trial number and registry URL: Trial registration number: NCT02718599 . Name of registry: ClinicalTrials.gov. URL of registry: https://clinicaltrials.gov/ct2/show/NCT02718599 . Date of registration: March 2016. Date of enrolment of the first participant to the trial: April 2016.

Effect of 2 Enteral Feeding Schedules on Intra-abdominal Pressure in Patients Receiving Mechanical Ventilation: A Randomized Controlled Trial.

BACKGROUND: Elevated intra-abdominal pressure is associated with morbidity in critically ill patients. Enteral feeding is important for these patients but may cause complications. OBJECTIVE: To compare the effects of 2 intermittent feeding schedules on intra-abdominal pressure in patients receiving mechanical ventilation. METHODS: A single-blinded, prospective, parallel-group, randomized controlled trial was conducted in an intensive care unit in a teaching hospital in Egypt. Fifty adult patients requiring more than 48 hours of mechanical ventilation were enrolled. Patients were randomly sorted into 2 study groups. The intervention group received intermittent enteral feedings 5 times daily at 4-hour intervals. The control group received intermittent enteral feedings 10 times daily at 2-hour intervals. Both groups fasted for 8 hours overnight. Intra-abdominal pressure was measured 7 times: at admission and before and after the first 3 feedings on the third day of the intensive care unit stay. RESULTS: One-way repeated-measures analysis of variance showed that mean intra-abdominal pressure was higher in the control group before the first feeding (t = 2.27, P = .03) but was higher in the intervention group after the second feeding (t = 2.51, P = .02) and after the third feeding (t = 2.41, P = .02). Vomiting and diarrhea were not significantly different between the groups. More constipation and abdominal distension occurred in the intervention group than in the control group. CONCLUSION: Intra-abdominal pressure was not significantly affected by feeding interval. However, reducing the time interval between intermittent enteral feedings may minimize the risk for constipation and abdominal distension.

Pain alleviation in patients undergoing cardiac surgery; presternal local anesthetic and magnesium infiltration versus conventional intravenous analgesia: a randomized double-blind study.

BACKGROUND: Magnesium is one of the effective, safe local anesthetic adjuvants that can exert an analgesic effect in conditions presenting acute and chronic post-sternotomy pain. We studied the efficacy of continuous infusion of presternal magnesium sulfate with bupivacaine for pain relief following cardiac surgery. METHODS: Ninety adult patients undergoing valve replacement cardiac surgery randomly allocated into three groups. In all patients; a presternal catheter was placed for continuous infusion of either 0.125% bupivacaine and 5% magnesium sulfate (3 ml/h for 48 hours) in group 1, or 0.125% bupivacaine only in the same rate in group 2, versus conventional intravenous paracetamol and ketorolac in group 3. Rescue analgesia was iv 25 µg fentanyl. Postoperative Visual Analog Scale (VAS) and fentanyl consumption during the early two postoperative days were assessed. All patients were followed up over two months for occurrence of chronic post-sternotomy pain. RESULTS: VAS values showed high significant differences during the first 48 hours with the least pain scale in group 1 and significantly least fentanyl consumption (30.8 ± 7 µg in group 1 vs. 69 ± 18 µg in group 2, and 162 ± 3 in group 3 respectively). The incidence of chronic pain has not differed between the three groups although it was more pronounced in group 3. CONCLUSIONS: Continuous presternal bupivacaine and magnesium infusion resulted in better postoperative analgesia than both presternal bupivacaine alone or conventional analgesic groups.

Fluoroscopic Guided Radiofrequency of Genicular Nerves for Pain Alleviation in Chronic Knee Osteoarthritis: A Single-Blind Randomized Controlled Trial.

BACKGROUND: Nowadays, pain and disability due to chronic knee arthritis is a very common problem in middle aged people. A lot of modalities for management are available, including conservative analgesics and up to surgical interventions. Radiofrequency ablation of genicular nerves is assumed to be an effective less invasive and safe pain alleviation modality. OBJECTIVES: To evaluate the efficacy of fluoroscopic guided radiofrequency neurotomy of the genicular nerves for alleviation of chronic pain and improvement of function in patients with knee osteoarthritis. STUDY DESIGN: A single-blind randomized controlled trial. SETTING: Pain management unit, and Rheumatology and Rehabilitation clinics of Assiut University hospitals, Assiut, Egypt. METHODS: This study involved 60 patients with chronic knee osteoarthritis. Radiofrequency neurotomy of the genicular nerves was done for 30 patients (Group A) while the other 30 patients (Group C) received conventional analgesics only. The outcome measures included visual analog scale (VAS), Western Ontario and McMaster Universities Index (WOMAC), and Likert scale for patient satisfaction in the 2nd week,3rd, and 6th months. RESULTS: There were significant differences regarding the VAS in the 2nd week, 3rd, and 6th months between the 2 groups, and a significant difference in total WOMAC index in the 6th month only. There were significant changes when comparing pretreatment values with the values during the whole follow-up period with regard to the VAS and total WOMAC index in both groups. LIMITATIONS: No diagnostic block was done prior to radiofrequency. We recommend the use of such a technique on a larger number of OA patients, with a longer follow-up period. CONCLUSION: RF can ameliorate pain and disability in chronic knee osteoarthritis in a safe and effective manner. KEY WORDS: Chronic pain, radiofrequency (RF), knee osteoarthritis.

Implication of Two Different Doses of Intradiscal Ozone-Oxygen Injection upon the Pain Alleviation in Patients with Low Back Pain: A Randomized, Single-Blind Study.

BACKGROUND: Low back pain (LBP) is mostly induced by disc herniation (DH) or degeneration and has a burden upon social activity and economical aspects of life. An abundance of medical and surgical interventions have evolved to resolve this problem, but one of the newly introduced techniques, which is the minimally invasive, low cost ozone-oxygen mixture (O3-O2) intradiscal injection, offers a rapid onset amelioration of symptoms with a sustained duration of pain relief. OBJECTIVE: We aim to evaluate the quality of pain alleviation using 2 different doses of intradiscal injections of O3-O2 mixture. STUDY DESIGN: A prospectively randomized, single-blind study. SETTING: Pain clinic, anesthesia, intensive care, and pain department in Assiut University Hospitals. METHODS: Sixty patients with symptomatizing single lumbar DH were subjected to O3-O2 intradiscal injection and randomly allocated into one of 2 groups; group A: received 10 mL, 40 µg/mL of O3-O2 and group B: received 10 mL, 30 µg/mL of O3-O2. Pain score and functional ability of the patients using the visual analog scale (VAS) and Oswestry Disability Index (ODI) were evaluated after 1, 6, and 12 months and compared to the basal values. Patient satisfaction and reduction of DH were evaluated after the sixth month. RESULTS: There were no significant differences between the 2 groups regarding the clinical outcome; however both the ODI and VAS evaluations showed highly significant improvement (decreased) (P < 0.01) after injection and during the entire follow-up period. There were highly significant negative correlations between the DH reduction percentage and both the VAS and ODI scores after 6 months in both of the groups. LIMITATIONS: This study was limited by a small sample size; it was also an active control trial, which may explain the insignificant difference in between the groups, in addition to being a single-blind trial. CONCLUSION: Intradiscal injection of O3-O2 mixture is a very valuable maneuver in the reduction of DH size and improvement of pain quality, with either ozone concentrations of 40 µg/mL or 30 µg/mL. KEY WORDS: Low back pain, ozone, disc herniation.