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OBJECTIVE: We aimed to evaluate the analgesic efficacy as well as the postoperative quality of recovery of preoperative oral duloxetine a serotonin and norepinephrine reuptake inhibitor for patients undergoing major abdominal cancer surgery. MATERIALS AND METHODS: Sixty-two patients, undergoing major abdominal cancer surgery were divided into 2 equal groups, received oral duloxetine 60 mg (2 h preoperative) or placebo. Postoperative 48 hours morphine consumption, visual analog scale pain score, and quality of recovery were measured. RESULTS: The cumulative 48 hours morphine consumption was significantly reduced in the duloxetine group compared with the placebo group (mean±SD) (5.2±3.2 vs. 12.9±3.4 mg), mean difference (95% confidence interval) 7.6 mg (5.9-9.3) P<0.001. The time to first morphine request was delayed significantly in the duloxetine group, median (interquartile range), 25 (19 to 38) versus 8 (4 to 9) hours, P<0.001. The duloxetine group had lower pain scores than the placebo group at 8, 12, 16, and 24 hours postoperatively, however, nonsignificant changes were observed at 0, 2, 4, 36, and 48 hours postoperatively. Participants in the duloxetine group had a better postoperative quality of recovery than the placebo group. The median (interquartile range) of the global quality of recovery-40 scoring system for the duloxetine group was 185 (180 to 191) compared with 170 (163 to 175) in the placebo group (P<0.001). DISCUSSION: A single preoperative dose of oral duloxetine, 60 mg for patients subjected to major abdominal cancer surgery reduced postoperative pain, decreased opioid consumption, and improved the quality of recovery.

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AIM: Evaluation of the analgesic efficacy of radiofrequency thoracic sympathectomy for sympathetically maintained post-mastectomy pain syndrome (PMPS). METHODS: Patients with PMPS randomized to Group TS (n = 33) received radiofrequency thoracic sympathectomy, and those randomized to Group Sham (n = 33) received no radiofrequency current. Postoperative pain treatment consisted of duloxetine, pregabalin, and tramadol for both groups. The outcome variables were the proportion of patients who showed >50% reduction in their VAS pain score, the pain intensity measured by VAS score, and the global perceived effect (GPE) evaluated during the 6-month follow-up period. RESULTS: A significantly higher proportion of patients experienced >50% reduction in pain in Group TS (Group TS 25/30 [83.3%] vs. Group Sham 18/31 [58%], P = 0.032); the proportion of patients who experienced >50% reduction in their pain without analgesics was significantly higher in Group TS (Group TS 10/25 [40%] vs. Group Sham 0/18 [0%], P = 0.001). Furthermore, the proportion of patients treated with tramadol + duloxetine + pregabalin who experienced >50% reduction in their pain was significantly lower in Group TS (Group TS 0/25 [0%] vs. Group Sham 13/18 [75%], P = 0.001). The VAS pain score was significantly lower in Group TS at 2 weeks and at 1, 2, 3, and 6 months following the procedure. The GPE was significantly higher in Group TS (Group TS median GPE [interquartile range]) 7 [5, 7] vs. Group Sham median GPE [interquartile range]) 5 [4, 6]) P < 0.001). CONCLUSIONS: Radiofrequency thoracic sympathectomy for sympathetically maintained PMPS decreased VAS pain scores and reduced the need for anti-neuropathic drugs, particularly opioid medications, and provided better patient satisfaction.

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OBJECTIVE: Duloxetine has been recently used as a part of multimodal analgesia in perioperative settings, yet the optimal dose of Duloxetine is not determined. DESIGN: A parallel, randomized, placebo-controlled trial. SETTING: Tertiary level oncology center. PATIENTS: 88 female patients with breast cancer were subjected to modified radical mastectomy (MRM) with ASA class I and II were recruited. INTERVENTION: Participants were randomly allocated into 4 equal groups received 2 h preoperatively, placebo (D0, N = 22), Duloxetine 30 mg (D30, N = 22), Duloxetine 60 mg (D60, N = 22) and Duloxetine 90 mg (D90, N = 22) tablet. MEASUREMENTS: The primary outcome; 24 h cumulative postoperative morphine consumption and the secondary outcomes; VAS score of pain intensity, quality of recovery (QoR-40), time to Aldrete 9, and side effects (sedation and vomiting) were measured. RESULTS: The median (IQR) consumption of morphine (mg) in the first postoperative 24 h was significantly decreased in both (D60 and D90) groups compared to (D0 and D30) groups, P < 0.001(Bonferroni corrected), however, a non-significant reduction was observed between D90 group vs. D60 group and D30 group vs. D0 group, P = 0.595 and P = 0.462 respectively, D60 vs. D0; 0(0-6) vs. 10(9-12), D60 vs. D30; 0(0-6) vs. 9(8-11), D90 vs. D0; 0(0-5) vs. 10(9-12), D90 vs. D30; 0(0-5) vs. 9(8-11), D90 vs. D60; 0(0-5) vs. 0(0-6), D30 vs. D0; 9(8-11) vs. 10(9-12), patients in D90 group took longer time to recover from anesthesia " time to Aldrete 9" and showed an increased level of sedation in comparison with other groups, vomiting was more frequent in the D90 group. CONCLUSION: Preoperative oral Duloxetine of 60 mg, for patients subjected to MRM is the optimal dose considering its analgesic efficacy and side effects. TRIAL REGISTRATION: The trial was registered at Clinical Trials.gov with unique ID number; NCT03468348.

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BACKGROUND: Superior hypogastric plexus neurolytic (SHP-N) block is the mainstay management for pelvic cancer pain of visceral origin when oral opioids fail due to inefficacy or intolerance to side effects. Unfortunately, SHP-N has the potential to control pelvic pain in 62%-72% of patients at best, because chronic pelvic pain may assume additional characteristics other than visceral. OBJECTIVE: Combining SHP-N with pulsed radiofrequency (PRF) of the sacral roots might block most of the pain characteristics emanating from the pelvic structures and improve the success rate of SHP-N in controlling pelvic and perineal cancer pain. STUDY DESIGN: This study was a prospective randomized controlled clinical trial. SETTINGS: The research took place in the interventional pain unit of a tertiary center in the university hospital. METHODS: Fifty-eight patients complaining of cancer-related chronic pelvic and perineal pain were randomized to either the PRF + SHP group (n = 29), which received SHP-N combined with PRF of the sacral roots S2-4, or the SHP group (n = 29), which received SHP-N alone. The outcome variables were the percentage of patients who showed a > 50% reduction in their Visual Analog Scale (VAS) pain score, the VAS pain score, and global perceived effect evaluated during a 3-month follow-up period. RESULTS: The percentage of patients who showed a > 50% reduction in their VAS pain score was significantly higher in the SHP + PRF group compared to the SHP group when assessed at one month (92.9% [n = 26] vs 57.7% [n = 15]; P = .003) and 3 months (85.7% [n = 24) vs 53.8% [n = 14]; P = .01) post procedure, respectively. However, no significant difference was observed between the 2 groups at the 6-month evaluation (SHP + PRF [57.1% (n = 16)] vs SHP [50% (n = 13)]; P = .59). There was a statistically significant reduction of VAS in the SHP + PRF group in comparison to the SHP group at one month (2.8 ± 0.9 vs 3.5 ± 1.2 [mean difference, -0.7 (95% confidence interval [CI], -1.29 to -0.1), P = .01]), 2 months (2.8 ± 0.9 vs 3.5 ± 1.2 [mean difference, -0.64 (95% CI, -1.23 to -0.05), P = .03]), and 3 months (2.7 ± 1 vs 3.4 ± 1.2 [mean difference, -0.67 (95% CI, -1.29 to -0.05)], P = .03]) post procedure, respectively; however, the 2 groups did not significantly differ at 2 weeks, 4, 5, and 6 months post procedure. Regarding postprocedural analgesic consumption, there were trends towards reduced opioid consumption at all postprocedural measured time points in the SHP+PRF group compared to the SHP group; these differences reached statistical significance at 2 months (median, 30 [interquartile range (IQR), 0.00-30] vs median, 45 [IQR, 30-90]; P = .046) and 3 months (median, 0.00 [IQR, 0.00-30] vs median, 30 [IQR, 0.00-67.5]; P = .016) post procedure, respectively. LIMITATIONS: The study follow-up period is limited to 6 months only. CONCLUSIONS: SHP-N combined with PRF of the sacral roots (S2, 3, 4) provided a better analgesic effect than SHP-N alone for patients with chronic pelvic and perineal pain related to pelvic cancer. TRIAL REGISTRY: ClinicalTrials.gov. NCT03228316. KEY WORDS: Pelvic pain, pulsed radiofrequency, sacral roots, superior hypogastric plexus.

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BACKGROUND: Pharmacologic treatment is not successful in all cases of postmastectomy pain syndrome (PMPS). Some patients continue suffering pain while taking their medications, and others cannot tolerate the side effects of antineuropathic analgesics. Radiofrequency technology has provided promising results in the management of chronic neuropathic pain. OBJECTIVES: Considering that affection of intercostobrachial nerves are the main reason behind PMPS, we aimed to evaluate and compare the analgesic efficacy of pulsed radiofrequency (PRF) when delivered either on thoracic dorsal root ganglion (DRG) of intercostobrachial nerves (thoracic DRG 2, 3, and 4) or their corresponding thoracic paravertebral nerves (PVNs). STUDY DESIGN: Prospective randomized-controlled clinical trial. SETTINGS: Interventional pain unit, tertiary center, university hospital. METHODS: Sixty-four patients complaining of PMPS were randomized to either group DRG (n = 32) that received PRF on thoracic DRG, or group PVN (n = 32) that received PRF on thoracic PVN. The outcome variables were that the patients showed > 50% reduction in their visual analog scale (VAS) pain score; the VAS pain score and global perceived effect (GPE) was evaluated during a 6-month follow-up period. RESULTS: The percentage of patients who showed > 50% reduction of their VAS pain score was significantly higher in group DRG compared with group PVN, assessed at 4 and 6 months postprocedure (23/29:79.3% vs. 13/29:44.8%; P = 0.007) and (22/29:75.9% vs. 7/29:24.1%; P < 0.001), respectively, however, the 2 groups did not significantly differ at 1, 2, and 3 months postprocedure (DRG vs. PVN), (21/29: 72.4% vs. 21/29: 72.4%; P = 0.542), (24/29: 82.8% vs. 23/29: 79.9%; P = 0.778), and (24/29: 82.8% vs. 19/29: 65.5%; P = 0.136), respectively. There was a statistically significant reduction of VAS pain score at 4 and 6 months (DRG vs. PVN, mean ± standard deviation, 2.9 ± 2 vs. 3.9 ± 1.5; mean difference (95% confidence interval), 1 (0.06:1.9); P = 0.038; 3 ± 1.94 vs. 5.1 ± 1.5; mean difference (95% confidence interval), 1.9 (1:2.9); P < 0.001, respectively), however, the 2 groups did not significantly differ at 1, 2, and 3 months postprocedure. With regard to the patient's satisfaction (i.e., GPE), assessed at 3 and 6 months postprocedure, there was a significantly higher satisfaction in group DRG compared with group PVN (median [interquartile range (IQR)], 6 (5:7) vs. 3 (2:4);P < 0.001), however, the patient's satisfaction was similar between groups at 3 months postprocedure: median (IQR), 6 (4:7) vs. 6 (5:6); P = 0.327. LIMITATIONS: The study follow-up period is limited to 6 months only. CONCLUSIONS: PRF of both the thoracic DRG and the thoracic PVN are effective treatments for PMPS; however, PRF of DRG provided a better long-term analgesic effect. Nevertheless, given the inherent risk of performing thoracic foraminal interventions and the technical difficulty of targeting thoracic DRG, we recommend that PRF of DRG should be reserved for cases that failed to gain adequate response to PRF of thoracic PVN in conjunction with medical treatment. KEY WORDS: Postmastectomy pain syndrome, radiofrequency, dorsal root ganglion, paravertebral nerve.

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BACKGROUND: The atlantoaxial joint (AAJ) plays a pivotal role in the cervical spine motion. Unfortunately, it is the most common cervical spine joint that is affected in patients with rheumatoid arthritis. Inflammation of the AAJ results in neck disability, nerve root compression, and finally spinal cord compression. OBJECTIVES: We aim to evaluate the efficacy of intraarticular triamcinolone injection of the AAJ on neck pain and disability. STUDY DESIGN: A prospective randomized, controlled clinical trial. SETTING: An interventional pain unit in a tertiary center at a university hospital in Egypt. METHODS: Sixty patients with rheumatoid arthritis complaining of AAJ arthritis were randomized into 2 groups. Group AAJI (n = 30) received AAJ injection with 1.0 mL of a mixture of 0.5 mL of bupivacaine 0.5% and 0.5 mL of 20 mg of triamcinolone, in addition to oral placebo tablets (2 tablets every 8 hours for one week). Group SS (n = 30) received systemic steroids, oral prednisolone tablets (5 mg, 2 tablets every 8 hours for one week), in addition to AAJ injection with 1.0 mL of a mixture of 0.5 mL of bupivacaine 0.5% and 0.5 mL of normal saline solution. The percentage of patients who showed >/= 50% reduction of their visual analog scale (VAS) pain score (measured at 1, 2, and 3 months postoperatively), VAS pain score and neck disability index (NDI) (measured at 2, 4, 6, 8, and 12 weeks postoperatively), and the magnetic resonance imaging (MRI) changes of AAJ (assessed 4 weeks postoperatively) were all evaluated. RESULTS: There was significant reduction in the percentage of patients who showed ≥50% reduction of their VAS pain score postoperatively in group AAJI compared with group SS at one month (75% vs. 46.45%; P = 0.033), 2 months (60.7% vs. 25%; P = 0.009), and 3 months (53.6% vs. 17.9%; P = 0.007). There was significant reduction in overall VAS and overall NDI in group AAJI compared with group SS (mean ± standard error) (41.5 ± 2.6 vs. 52.1 ± 2.6; P = 0.005) and (43.7 ± 3.1 vs. 52.4 ± 3.1; P = 0.040), respectively. Analysis of postoperative MRI findings revealed significant improvement of bone marrow edema in group AAJI (AAJI vs. SS) (71.4% vs. 42.9%; P = 0.033), also the synovial enhancement disappeared significantly in group AAJI compared with group SS, (16/22 [72.7%] vs. 10/23 [43.5%]; P = 0.026), moreover, there was a significant reduction in pannus size in group AAJI compared with group SS, (6/10 [60%] vs. 1/9 [11%]; P = 0.041). LIMITATIONS: The study follow-up period was limited to only 3 months. CONCLUSIONS: For acutely inflamed AAJ due to rheumatoid arthritis, AAJ steroid injection is a potential therapeutic option; it decreased cervical neck pain, improved neck mobility, and hastened recovery of the joint from an acute inflammatory stage. KEY WORDS: Rheumatoid arthritis, atlantoaxial joint injection.

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OBJECTIVE: To assess the postoperative analgesic efficacy of epidural dexmedetomidine added to bupivacaine infusion for patients undergoing major abdominal cancer surgery. METHODS: Patients scheduled for major upper abdominal cancer surgery were allocated to group bupivacaine (n =32), in which patients received epidural bupivacaine infusion (6 mL/h bupivacaine 0.1%) for 48 hours postoperatively, or group bupivacaine + dexmedetomidine (n=32), in which patients received epidural dexmedetomidine added to bupivacaine infusion (6 mL/h of bupivacaine 0.1% + dexmedetomidine, 0.5 µg/mL) for 48 hours postoperatively. The cumulative morphine consumption, the time to first analgesic request, and the VAS pain score were evaluated. RESULTS: The cumulative morphine consumption was significantly reduced in group bupivacaine + dexmedetomidine compared with group bupivacaine: mean ± SD of 10.40±5.16 mg vs 23.23±8.37 mg with an estimated difference (95% CI) of -12.83 (-16.43, -9.24), (P<0.001). The time to the first analgesic demand was significantly delayed in group bupivacaine + dexmedetomidine compared with group bupivacaine: median (IQR) of 6 (1.75, 8.25) h vs 1 (0, 4)h, (P<0.001). The mean collapsed over time of overall VAS pain scores at rest and movement was significantly reduced in group bupivacaine + dexmedetomidine compared with group bupivacaine : mean ± SE of 1.6±0.08 vs 2.38±0.08 with an estimated difference (95% CI) of -0.8 (-1, -0.86), (P<0.001), and mean ± SE of 2.17±0.07 vs 3.25±0.07 with an estimated difference (95% CI) of -1.1 (-1.27, - 0.89), (P<0.001), respectively. CONCLUSION: Epidural infusion of dexmedetomidine added to bupivacaine for patients undergoing major abdominal cancer surgery significantly reduced morphine consumption, delayed time to first analgesic supplementation, and decreased pain intensity during the first 48 hours postoperatively without harmful derangement on hemodynamics.

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BACKGROUND: Chronic post-surgical pain in the groin region represents a challenge for the managing physician and is a burden on the quality of life of the patient. None of the existing interventions or medical treatment is satisfactory. OBJECTIVES: We aim to evaluate the analgesic efficacy of pulsed radiofrequency (PRF) applied to the ilioinguinal nerve and the genital branch of the genitofemoral nerve for patients suffering from chronic post-surgical orchialgia. STUDY DESIGN: A prospective randomized, controlled clinical trial. SETTING: An interventional pain unit in a tertiary center at a university hospital in Egypt. METHODS: Seventy patients complaining of chronic post-surgical orchialgia were randomized into 2 groups: PRF group (n = 35), received pulsed radiofrequency on the ilioinguinal nerve and genital branch of the genitofemoral nerve, or sham group (n = 35). The percentage of patients that showed > 50 % reduction of their visual analog scale (VAS) pain score as well as the percentage of patients that did not require additional analgesic drugs was assessed. The VAS pain score and the global perceived effect (GPE) were reported during the 3-month follow-up period. RESULTS: The percentage of patients that showed > 50% reduction of their VAS pain score was 80% (24/30) in the PRF group versus 23.33% (7/30) in the sham group. The percentage of patients that did not require analgesic drugs was 50% (15/30) in the PRF group versus 3.3% (1/30) in the sham group. There was a significant reduction of the mean post-procedural VAS pain score at 2, 4, 6, 8, and 12 weeks (P = 0.001) in the PRF group in comparison to the sham group. Likewise, there was a significant improvement of the GPE in the PRF group in comparison to the sham group (P = 0.00). LIMITATIONS: The study's follow-up period was limited to 3 months only. CONCLUSIONS: For patients suffering from chronic post-surgical orchialgia, PRF applied to the ilioinguinal nerve and the genital branch of the genitofemoral nerve is an effective treatment modality. It provides long-lasting pain relief and decreases the demand for pain medications. KEY WORDS: Orchialgia, groin pain, radiofrequency, ilioinguinal nerve, genitofemoral nerve.

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STUDY OBJECTIVE: The objective of this study was to evaluate the effect of adding dexmedetomidine (DEX) to bupivacaine on the quality of spermatic cord block anesthesia and postoperative analgesia. DESIGN: This is a randomized, double-blind study. SETTING: This study was performed in an educational and research hospital. PATIENTS: One hundred twenty adult males were scheduled for intrascrotal surgeries. INTERVENTIONS: Patients were divided into two groups: group B received 10 mL of bupivacaine 0.25% for spermatic cord block and intravenous 50 µg of DEX and group BD received 10 mL of bupivacaine 0.25% added to 50 µg of DEX (9.5 mL bupivacaine 0. 25% + 0.5 mL [50 µg] DEX) for spermatic cord block, and for masking purposes, the patients received isotonic saline intravenously. MEASUREMENTS: Time to first analgesic request, analgesic consumption, and visual analog scale (VAS) pain score in the first 24 hours postoperatively were assessed. MAIN RESULTS: Time to first rescue analgesic was significantly delayed in group BD in comparison with group B, median (interquartile) range, 7 (6-12) hours versus 6 (5-7) hours, (p=0.000), the mean cumulative morphine consumption (mg) in the first postoperative 24 hours was significantly lower in group BD compared with group B, 8.13±4.45 versus 12.7±3.79, with a mean difference (95% CI) of -4.57 (-6.06 to -3.07) (p=0.000); also, there was a significant reduction of VAS pain score in group BD in comparison with group B at all measured time points, VAS 2 hours (1.28±0.9 vs 1.92±0.8), VAS 6 hours (2.62±1.5 vs 3.93±1.2), VAS 12 hours (2.40±1.1 vs 3.57±0.65), VAS 24 hours (1.90±0.68 vs 2.53±0.62) (p=0.000). CONCLUSION: The addition of 50 µg of DEX to bupivacaine 0.25% in spermatic cord block for intrascrotal surgeries resulted in delay of first analgesic supplementation, reduction of postoperative analgesic consumption as well as improvement of the success rate of the block.

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STUDY OBJECTIVE: The aim of this study was to evaluate the analgesic efficacy and safety of pectoralis-serratus interfascial plane block in comparison with thoracic paravertebral block for postmastectomy pain. DESIGN: A prospective randomized controlled study. SETTING: Tertiary center, university hospital. PATIENTS: Sixty-four adult women, American Society of Anesthesiologists physical status classes I, II, and III, scheduled for unilateral modified radical mastectomy with axillary evacuation. INTERVENTIONS: Patients were randomized to receive either pectoralis-serratus interfascial plane block, PS group (n=32), or thoracic paravertebral block, PV group (n=32). MEASUREMENTS: Twenty-four-hour morphine consumption and the time to rescue analgesic were recorded. The pain intensity evaluated by visual analog scale (VAS) score at 0, 2, 4, 8, 16, and 24hours postoperatively was also recorded. MAIN RESULTS: The median (interquartile range) postoperative 24-hour morphine consumption was significantly increased in PS group in comparison to PV group (PS vs PV), 20 mg (16-23 mg) vs 12 mg (10-14 mg) (P<.001). The median postoperative time to first analgesic request was significantly shorter in PS group compared to PV group (PS, 6 hours [5-7 hours], vs PV, 11 hours [9-13 hours]) (P<.001). The intensity of pain was low in both groups in VAS 0, 2, and 4hours postoperatively. However, there was significant reduction in VAS in PV group compared to PS group at 8, 16, and 24hours postoperatively. CONCLUSIONS: Pectoralis-serratus interfascial plane block was safe and easy to perform and decreased intensity of postmastectomy pain, but it was inferior to thoracic paravertebral block.

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STUDY OBJECTIVE: We hypothesized that oral administration of a single dose of pregabalin 2 hours before modified radical mastectomy (MRM) would produce dose-related reduction in postoperative opioid consumption. DESIGN: Prospective randomized controlled clinical trial. SETTING: Postanesthesia care unit. PATIENTS: One hundred twenty adult women scheduled for unilateral (MRM) with axillary evacuation. INTERVENTIONS: Patients were randomized to receive either, placebo capsule, pregabalin 75 mg, pregabalin 150 mg, or pregabalin 300 mg. MEASUREMENTS: The assessment parameters were the postoperative analgesic effect using visual analog scale (VAS) pain scores, the subsequent 24-hour morphine consumption, and the systemic adverse effects of pregabalin doses. MAIN RESULTS: The VAS score at rest and movement was significantly decreased only in group P300 and group P150 in comparison to group P0 and group P75 at 0 hour (P<.01). The median (interquartile range) consumption of morphine in the first postoperative 24 hours was significantly decreased in group P300 in comparison to group P0 and group P75 (P300 vs P0: 6.5 [5-6.5] vs 20.5 [15.8-20.5] [P<.001]; P300 vs P75: 6.5 [5-6.5] vs 20 [14-20] [P<.001]), but there was no significant difference between group P300 and group P150. In addition, there was a significant decrease in consumption of morphine in group P150 in comparison to group P0 and group P75 (P150 vs P0: 7 [5-7] vs 20.5 [15.8-20.5] [P<.001]; P150 vs P75: 7 [5-7] vs 20 [14-20] [P<.001]). There were statistical significant increase in dizziness and blurred vision in group P300 in comparison to other groups (P<.05). CONCLUSIONS: A single preoperative oral dose of pregabalin 150 mg is an optimal dose for reducing postoperative pain and morphine consumption in patients undergoing MRM.

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