Maximum pain on visual analog scales in spinal disorders

Effect of Preoperative Opiate Use on Outcomes After Posterior Lumbar Surgery

Introduction

The prescription opioid epidemic and widespread use of narcotic medications have introduced new challenges when treating patients undergoing spine surgery. Given the ubiquity of preoperative opioid consumption amongst patients undergoing spine surgery, further research is needed to characterize perioperative risks. Our goal is to compare outcomes following primary lumbar decompression, instrumentation, and fusion based on preoperative opioid prescriptions.

Methods

Patients older than 18 years of age who underwent a primary one- to two-level lumbar decompression, instrumentation, and fusion were included in the study. Patients with known malignancy, surgery involving three or more lumbar levels, current or previous use of neuromodulation, revision surgery, anterior or far lateral interbody fusions, acute fractures, or other concurrent procedures were excluded. Patients were divided into chronic opioid therapy (COT; over six months), acute opioid therapy (AOT; up to six months), and opiate-naïve groups. Opioid prescriptions, demographics, smoking status, readmission rates within one year, and reoperation rates within two years were recorded based on electronic medical record documentation.

Results

Out of 416 patients identified, 114 patients met the inclusion criteria. Thirty-eight patients (33.3%) were on COT, 38 patients (33.3%) were on AOT, and 38 patients (33.3%) were opioid naïve preoperatively. Readmission rates within one year for COT, AOT, and opioid naïve patients were 34.2%, 26.3%, and 10.5%, respectively (p=0.047). Reoperation rates within two years for COT, AOT, and opioid naïve patients were 34.2%, 15.8%, and 13.2%, respectively (p=0.049). We also found current or former smokers were more likely to be on AOT or COT than never smokers (78.4% vs. 57.1%; p=0.017). 

Conclusion

Long-term opiate use is associated with an increased risk for readmission within one year and revision within two years. Physicians should discuss the increased risks of readmission and revision surgery associated with lumbar decompression and fusion seen in patients on preoperative opioid therapy.

Management of High-Pressure Injection Hand Injuries: A Multicentric, Retrospective, Observational Study

Hand injuries after high-pressure injection are a medical emergency. These events occur frequently in workers during industrial cleaning, painting, and lubrication, and may have devastating consequences, leading to eventual amputation and poor functional outcomes. The authors have investigated the evolution, management, and outcome. Medical records of occupational medicine units and hand surgery units were collected in order to spot the high-pressure gear accident cases. Records were analyzed by dividing the subjects into two groups: those treated within 6 h and after 6 h of the trauma. A follow-up was carried out at least 1 year after treatment; the post-treatment outcomes were assessed. Of the 71 (100%) subjects, 26 (37%) were treated ≤6 h and 45 (63%) >6 h. A total of 28% (n = 20) underwent amputation. In 61% of cases, accidents had occurred in the iron and steel sector. High viscosity materials with a delayed treatment beyond 6 h seemed to determine compartmental syndrome and following amputation. A significantly better outcome was reported among subjects treated ≤6 h compared to those treated >6 h, 20% (n = 7) versus 26% (n = 9), respectively. Early management of this type of injury is crucial. The results of this study may contribute to providing guidelines to occupational physicians in order to best manage this type of emergency.

Use of pre-operative anxiety score to determine the precise dose of butorphanol for intra-operative sedation under regional anesthesia: A double-blinded randomized trial

A randomized double-blinded controlled trial was performed to explore the association between pre-operative anxiety and intra-operative butorphanol requirement to evaluate the precise sedative requirement and to confirm the sedative effect of butorphanol in patients receiving lower-limb orthopedic surgery. The Amsterdam pre-operative anxiety and information scale and the Ramsay sedation score (RSS) were used to assess the patients' pre-operative anxiety score and sedation state during surgery. Patients were divided into two groups according to their pre-operative anxiety score prior to administration of pre-medication. Patients in each group were randomly divided into a butorphanol group and a 0.9% saline group. A total of 142 patients were enrolled and 131 patients were analyzed. The sedation scores of patients with high pre-operative anxiety in the 0.9% saline group were lower than those in the butorphanol group at each time-point after infusion. An increased pre-operative anxiety score predicted an increased duration to reach an RSS of 4 for an acceptable level of sedation (r²=0.887, P<0.0001). In conclusion, butorphanol had a good sedative effect on patients with pre-operative anxiety. The following formula was proposed: Precise dose of butorphanol (µg/kg)=15.26 + (0.14× pre-operative anxiety score), which may provide an improvement for patients exhibiting a high level of pre-operative anxiety. The trial was registered prior to patient enrollment at clinicaltrials.gov on 20.01.2018 (trial registration no. NCT03429179).

[An age-stratified follow-up of complications and clinical benefit of posterior lumbar intervertebral fusion procedure in middle-aged and older patients]

Objective

To compare the complications and clinical scores of posterior lumbar intervertebral fusion (PLIF) in middle-aged and older patients of different ages, and to assess the risk of complications of PLIF in different ages, providing a reference for clinical treatment.

Methods

The clinical data of 1 136 patients, who were more than 55 years old and underwent PLIF between June 2013 and June 2016, were retrospectively analyzed. According to the age of patients undergoing surgery, they were divided into 3 groups as 55-64 years old, 65-74 years old, and ≥75 years old. The general characteristics, comorbidities, and surgical data of the three groups were compared, with comparison the morbidity of complications. According to the minimal clinical important difference (MCID), the improvement of patient's pain visual analogue scale (VAS) score and the Oswestry disability index (ODI) score were compared. Univariate logistic regression analysis was used to analyze the difference of complications and the improvement of VAS and ODI scores. Multivariate logistic regression analysis was performed for the risk factors of complications.

Results

There were significant differences in the number of surgical fusion segments and osteoporosis between groups ( P<0.05); there was no significant difference in gender, body mass index, operation time, preoperative American Society of Anesthesiologists (ASA) classification, and comorbidities between groups ( P>0.05). All patients were followed up 6-62 months with an average of 27.4 months. Among the results of postoperative complications, there were significant differences in the total incidence of intraoperative complications, systemic complications, minor complications, and the percentage of improvement of ODI score to MCID between groups ( P<0.05); but there was no significant difference in the total incidence of complications at the end of long-term follow-up and the percentage of improvement of VAS score to MCID between groups ( P>0.05). Univariate logistic regression analysis showed that after adjusting the confounding factors, there were significant differences in intraoperative complications and the percentage of improvement of ODI score to MCID between 55-64 and 65-74 years old groups ( P<0.05); systemic complications, minor complications, complications at the end of long-term follow-up, and the percentage of improvement of ODI score to MCID in ≥75 years old group were significantly different from those in the other two groups ( P<0.05). Multivariate logistic regression analysis showed that age was a risk factor for systemic complications, minor complications, and complications at the end of long-term follow-up. Except for age, long operation time was a risk factor for intraoperative complications, increased number of fusion segments was a risk factor for systemic complications, the number of comorbidities was a risk factor for minor complications, and osteoporosis was a risk factor for complications at the end of long-term follow-up.

Conclusion

The risk of surgical complications is higher in the elderly patients (≥75 years) with lumbar degenerative diseases than in the middle-aged and older patients (<75 years), while the improvements of postoperative VAS and ODI scores were similar. Under the premise of fully assessing surgical indications, PLIF has a positive effect on improving the elderly patients' quality of life.

Comparison of Transforaminal Percutaneous Endoscopic Lumbar Discectomy with and without Foraminoplasty for Lumbar Disc Herniation: A 2-Year Follow-Up

Background

Both transforaminal percutaneous endoscopic lumbar discectomy with foraminoplasty (TF PELF) and transforaminal percutaneous endoscopic lumbar discectomy without foraminoplasty (TF PELD) were developed for lumbar disc herniation (LDH) patients. However, the safety and effectiveness between the TF PELF and TF PELD have not been investigated.

Methods

Of the included 140 LDH patients, 62 patients received TF PELF (PELF group) and 78 patients received TF PELD (PELD group). The operation time, the duration of staying at the hospital, and complication incidences were recorded. All patients were followed up for 2 years, where low back and leg visual analogue scale (VAS) pain ratings and Oswestry Disability Index (ODI) were compared between the 2 groups before and after surgery. Modified Macnab criterion was estimated for all patients at postoperative 2 years.

Results

There were no significant difference of the operation time, number of days staying at the hospital, and the incidence of complications between the 2 groups (P > 0.05). Two cases in the PELF group and 1 case in the PELD group received a second surgery due to unrelieved symptoms postoperatively. Low back and leg VAS and ODI scores decreased in both groups after operation (P < 0.01), respectively, but were not significant between the 2 groups over time (P > 0.05). Six patients in the PELF group and 3 patients in the PELD group did not continue the follow-up; thus, only 131 patients completed Macnab evaluation. The satisfactory rate was reported as 80.4% in the PELF group and 90.7% in the PELD group (P > 0.05).

Conclusions

This study suggested that the safety and effectiveness of TF PELF are comparable to TF PELD for LDH patients.

A clinical study on acupuncture in combination with routine rehabilitation therapy for early pain recovery of post-stroke shoulder-hand syndrome

The clinical effect of acupuncture in combination with rehabilitation therapy for post-stroke shoulder-hand syndrome (SHS) was explored. Patients (178) with post-stroke SHS who received treatment in the Dalian Second Hospital from March 2012 to March 2016 were included in this study. The patients were divided into experimental group (89 cases) and control group (89 cases). Patients in the control group received rehabilitation therapy, while those in the treatment group received acupuncture treatment in addition to rehabilitation therapy. Visual analogue scale (VAS) was applied to assess the pain degree of patients. Fugl-Meyer assessment (FMA), functional comprehensive assessment (FCA) and assessment of quality of life (QoL) were used to evaluate rehabilitation condition of the patients. Early pain relief, rehabilitation of upper extremity motor function and improvement of QoL after treatment were compared between the two groups. The scores of VAS, FMA, FCA and QoL showed obvious differences between the two groups after treatment (P<0.05). The scores of the experimental group were significantly better than those of the control group, and the improvement in upper extremity motor function of the patients in the experimental group was better than that of the patients in the control group. The total effective rate of the patients in the experimental group was higher than that of control group (P<0.05). The effect in improving the upper extremity motor function of the patients in the experimental group was better than that of control group. The scores of QoL of the patients in the experimental group were better than that of the patients in the control group (P<0.05). In conclusion, acupuncture in combination with rehabilitation therapy can improve early pain and rehabilitation significantly and enhance QoL for patients with post-stroke SHS, which is worthy of being widely used in clinical practice.

Metrics and Acquisition Modes for Fixation Stability as a Visual Function Biomarker

Purpose

To compare different metrics and acquisition modes of fixation stability as a new visual function biomarker in a large cohort of patients with ABCA4-related Stargardt disease from the multicenter prospective ProgStar study.

Methods

Fixation was tested during a separate fixation exam and also dynamically during a sensitivity exam, using fundus-tracking microperimetry (Nidek MP-1). Fixation data were analyzed using the bivariate contour ellipse area (BCEA), the 2/4 degree method, and the Fujii classification.

Results

In a total of 235 patients, the mean BCEA was larger when measured during the sensitivity exam (418 eyes; 12.5 vs. 4.6 deg2 during the fixation task in 427 eyes). Correlations between the two tests were generally weak. Fixation stability during the sensitivity test was significantly correlated with visual acuity. Comparing the BCEA values and the corresponding Fujii categories for these eyes revealed ranges of overlap where an eye with one defined BCEA value can fall into each of the three Fujii categories.

Conclusions

Patients may have limited ability to fixate over defined time periods, which leads to significant differences between shorter and longer measurements of fixation stability. The most appropriate way to use this functional biomarker appears to be using continuous metrics for fixation stability, such as the BCEA, during a macular sensitivity test.

Comprehensive comparing percutaneous endoscopic lumbar discectomy with posterior lumbar internal fixation for treatment of adjacent segment lumbar disc prolapse with stable retrolisthesis: A retrospective case-control study

The study was to comprehensively compare the postoperative outcome and imaging parameter characters in a short/middle period between the percutaneous endoscopic lumbar discectomy (PELD) and the internal fixation of bone graft fusion (the most common form is posterior lumbar interbody fusion [PLIF]) for the treatment of adjacent segment lumbar disc prolapse with stable retrolisthesis after a previous lumbar internal fixation surgery.In this retrospective case-control study, we collected the medical records from 11 patients who received PELD operation (defined as PELD group) for and from 13 patients who received the internal fixation of bone graft fusion of lumbar posterior vertebral lamina decompression (defined as control group) for the treatment of the lumbar disc prolapse combined with stable retrolisthesis at Department of Spine Surgery, the Third Hospital of Hebei Medical University (Shijiazhuang, China) from May 2010 to December 2015. The operation time, the bleeding volume of perioperation, and the rehabilitation days of postoperation were compared between 2 groups. Before and after surgery at different time points, ODI, VAS index, and imaging parameters (including Taillard index, inter-vertebral height, sagittal dislocation, and forward bending angle of lumbar vertebrae) were compared.The average operation time, the blooding volume, and the rehabilitation days of postoperation were significantly less in PELD than in control group. The ODI and VAS index in PELD group showed a significantly immediate improving on the same day after the surgery. However, Taillard index, intervertebral height, sagittal dislocation in control group showed an immediate improving after surgery, but no changes in PELD group till 12-month after surgery. The forward bending angle of lumbar vertebrae was significantly increased and decreased in PELD and in control group, respectively.PELD operation was superior in terms of operation time, bleeding volume, recovery period, and financial support, if compared with lumbar internal fixation operation. Radiographic parameters reflect lumber structure changes, which could be observed immediately after surgery in both methods; however, the recoveries on nerve function and pain relief required a longer time, especially after PLIF operation.