Effect of epidural methylprednisolone on post-operative pain and length of hospital stay in patients undergoing lumbar microdiscectomy

Effect of local epidural application of methylprednisolone acetate on time to ambulation in non-ambulatory dogs with thoracolumbar intervertebral disc disease: A prospective randomised, blinded control trial

BACKGROUND

The objective of this study was to analyse the potential benefit of the epidural application of steroids on time to ambulation in non-ambulatory dogs affected by intervertebral disc disease (IVDD) treated with decompressive surgery.

METHODS

This prospective, randomised, blinded control trial involved 41 dogs with thoracolumbar disc extrusion, which were randomly allocated into two groups. In the control group, saline was locally applied after surgical decompression of the spinal cord (n = 23). In the treatment group (n = 18), local epidural application of methylprednisolone acetate (1 mg/kg) was used. Ambulation time was the primary outcome measure, defined as the ability to take 10 independent steps.

RESULTS

The median number of days to ambulation was 7 days (range: 1‒17 days) for the control group and 3 days (range: 1‒8 days) for the treatment group. One dog from the treatment group developed discospondylitis and abscess formation.

LIMITATIONS

The study's heterogeneity in dog breeds, ages and pre-existing health conditions could affect the generalisability of the findings.

CONCLUSION

Epidural methylprednisolone acetate applied locally at the time of surgery may accelerate recovery in dogs following IVDD surgery.

Does Intra-Operative Methylprednisolone Improve Outcomes of Surgery for Degenerative Cervical Myelopathy? - A Prospective Randomized Study

STUDY DESIGN

Randomized controlled trial.

OBJECTIVES

In this study, we hypothesize administering fixed-dose intravenous steroid (Methylprednisolone) intraoperatively would reduce neuroinflammation and enhance functional and radiological outcomes in decompressive surgeries for DCM. Primary objectives were to assess effect of intraoperative MP on modified Japanese Orthopedic Association (mJOA) score, Nurick grade, and MRI signal changes.

METHODS

This prospective triple-blinded randomized controlled trial included 65 patients allocated into MP (n = 33) and control (n = 32) groups. MP (dose-1g) was administered intraoperatively at the beginning of decompression. Clinical outcome measures included mJOA score, Nurick grading, mJOA recovery rate (mJOA RR), Nurick recovery rate (NRR), and complication rates in both groups at 1-, 3-and 24-month follow-up. Radiological outcome was assessed by analyzing regression of T2W and T1W SI changes on MRI scans as per Chen's grading at 24-months follow-up.

RESULTS

MP group exhibited greater improvement in mJOA scores at 24-months (mean improvement: +6.69 vs +6.42; difference: +0.27, 95% CI: -0.37 to +0.91) but was statistically insignificant (P = .107). Similarly, mJOA-RR showed a moderate effect size of 0.42 (95% CI: 0.04 to 0.80) and 0.37 (95% CI: -0.01 to 0.75) at 1-and 3-months follow-up respectively. NRR improvements were observed, with effect sizes of 0.40 (95% CI: 0.02 to 0.78) and 0.49 (95% CI: 0.11 to 0.87) at 1- and 3-months respectively, but not statistically significant (P = .28). At 24-months, MP group had significantly better MRI outcome (Chen grading: mean change +1.15 vs +0.83; effect size: -0.71, 95% CI: -1.09 to -0.33; P = .038).Complication rates were comparable between both groups, emphasizing safety of MP administration.

CONCLUSION

Although null hypothesis was not proven, intraoperative MP administration in DCM surgery demonstrated safety and suggested potential neuroprotective benefits to enhance clinical recovery and reduce spinal cord signal changes. However, further large-scale, multicentric studies are needed to validate these findings and optimize its dose.

Effects of Intraoperative Epidural Steroid-Soaked Gelatin Sponge in Lumbar Spine Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This systematic review and meta-analysis evaluated the impact of intraoperative epidural steroid-soaked gelatin sponge in lumbar spine surgery for conditions like spinal stenosis and nerve root compression. Surgery often involves removing structures to decompress the nerves. Steroids are used to alleviate inflammation and pain, with gelatin sponges serving as carriers to extend their effect. While epidural steroid injections have been effective, the combined use of gelatin sponges remains controversial. The study systematically searched databases including PubMed, MEDLINE, and Cochrane Central Registry of Controlled Trials databases involving lumbar surgeries using steroid-soaked gelatin sponges. Seven studies with 620 patients were included, focusing on postoperative pain scores, analgesic use, hospital stay, and complications. The quality of the studies was assessed using the Cochrane Risk of Bias 2 tool. Results showed no significant difference in pain scores between the steroid and control groups on postoperative day 1 and at three months. However, there was a trend toward reduced pain in the steroid group. Notably, patients in the steroid group required fewer analgesics, indicating a significant reduction in postoperative pain medication use. Other factors, such as surgery time, blood loss, and hospital stay, showed no statistically significant differences between the groups. The findings suggest that while the use of steroid-soaked gelatin sponges does not significantly change immediate postoperative pain levels, it may contribute to improved pain management. This approach is safe, with minimal risk of complications, and may provide prolonged, localized effects due to the slow release of steroids. Future large-scale randomized trials are needed to further validate these findings. In conclusion, the use of steroid-soaked gelatin sponges in lumbar spine surgery is a feasible option to consider, with potential benefits in postoperative pain management and reduced analgesic consumption.

Methylprednisolone Following Minimally Invasive Lumbar Decompression: A Large Prospective Single-Institution Study

STUDY DESIGN

Prospective randomized.

OBJECTIVE

Intraoperative methylprednisolone is a common adjunct following microscopic laminectomy/microdiscectomy. The goal of epidural instillation is a rapid symptomatic reduction in irritation of neural elements. There is inconsistent data supporting its use intraoperatively. To understand whether this maneuver results in any clinical effect, we performed a multiyear prospective study.

SUMMARY OF BACKGROUND DATA

Previous work has demonstrated equivocal effects on pain with a suggestion of an increased risk of complication. These studies tend to suffer from small sample sizes and short follow-ups.

MATERIALS AND METHODS

Study obtained IRB approval. During the study period from 2013 to 2019, nearly equivalent numbers of patients who had received steroids during MIS decompressions were followed. Primary outcomes included pain (visual analog scale) and disability [Oswestry Disability Index (ODI)] at 2 weeks and 4 months. Secondary outcomes included complications, readmissions, and reoperation rates during the study period.

RESULTS

Four hundred eighty-six patients were followed for a mean follow-up of 5.17 years. The index case was more likely to be a revision surgery in the steroid group. Across all patients, there was no difference in pain at 2 weeks or 4 months. Disability was reduced at 2 weeks in the steroid group (ODI: 16.71 vs . 21.02, P = 0.04) but not at 4 months. By subgroup analysis, this is largely explained by ODI reduction in patients with high preoperative ODI (13.00 vs . 43.43, P = 0.03). Patients in the steroid cohort were more likely to undergo subsequent spinal surgery during the study period.

CONCLUSION

Methylprednisolone instillation is associated with a large, transient reduction in ODI for patients with high preoperative ODI; there is no measurable effect on pain. There is equivocal effect on risk of subsequent reoperation. This issue was clarified in peer review but changes did not make it to the abstract. Therefore, the technique is likely best reserved for patients with significant preoperative disability.

A Randomized Controlled Trial Using Epidural Analgesia for Pain Relief After Lumbar Interlaminar Decompressive Spine Surgery: The RAPID trial

STUDY DESIGN

Prospective, double-blind randomized controlled trial.

OBJECTIVE

If an intraoperative single bolus of epidural bupivacaine can result in less postoperative pain following lumbar spinal decompression surgery.

SUMMARY OF BACKGROUND DATA

Adequate postoperative pain management following lumbar spinal decompression surgery is important, as it will lead to early mobilization, less complications, and a shorter hospital stay. Opioid consumption should be limited due to their frequently accompanied side effects and their addictive nature. During the final phase of lumbar decompression surgery, the epidural space becomes easily accessible. This might be an ideal moment for surgeons to administer an epidural bolus of analgesia as a safe and effective method for postoperative pain relief.

MATERIALS AND METHODS

In this trial, we compared a single intraoperative bolus of epidural analgesia using bupivacaine 0.25% to placebo (NaCl 0.9%) and its effect on postoperative pain following lumbar spinal decompression surgery. The primary outcome was the difference in Numeric (Pain) Rating Scale between the intervention and placebo groups during the first 48 hours after surgery.

RESULTS

Both the intervention group and the placebo group consisted of 20 randomized patients (N=40). Statistically significant lower mean Numeric (Pain) Rating Scale pain scores were observed in the intervention group in comparison with the control group (main effect group: -2.35±0.77, P =0.004). The average pain score was lower in the intervention group at all postoperative time points. No study-related complications occurred.

CONCLUSION

This randomized controlled trial shows that administrating a bolus of intraoperative epidural bupivacaine is a safe and effective method for reducing early postoperative pain following lumbar decompression surgery.

Preoperative epidural steroid injections do not increase the risk of postoperative infection in patients undergoing lumbar decompression or fusion: a systematic review and meta-analysis

PURPOSE

Epidural corticosteroid injections (ESI) are a mainstay of nonoperative treatment for patients with lumbar spine pathology. Recent literature evaluating infection risk following ESI after elective orthopedic surgery has produced conflicting evidence. Our primary objective was to review the literature and provide a larger meta-analysis analyzing the temporal effects of steroid injections on the risk of infection following lumbar spine surgery.

METHODS

We conducted a query of the PubMed, Embase, and Scopus databases from inception until April 1, 2022 for studies evaluating the risk of infection in the setting of prior spinal steroid injections in patients undergoing lumbar spine decompression or fusion. Three meta-analyses were conducted, (1) comparing ESI within 30-days of surgery to control, (2) comparing ESI within 30-days to ESI between 1 and 3 months preoperatively, and (3) comparing any history of ESI prior to surgery to control. Tests of proportions were utilized for all comparisons between groups. Study heterogeneity was assessed via forest plots, and publication bias was assessed quantiatively via funnel plots and qualitatively with the Newcastle-Ottawa Scale.

RESULTS

Nine total studies were included, five of which demonstrated an association between ESI and postoperative infection, while four found no association. Comparison of weighted means demonstrated no significant difference in infection rates between the 30-days ESI group and control group (2.67% vs. 1.69%, p = 0.144), 30-days ESI group and the > 30-days ESI group (2.34% vs. 1.66%, p = 0.1655), or total ESI group and the control group (1.99% vs. 1.70%, p = 0.544). Heterogeneity was low for all comparisons following sensitivity analyses.

CONCLUSION

Current evidence does not implicate preoperative ESI in postoperative infection rates following lumbar fusion or decompression. Operative treatment should not be delayed due to preoperative steroid injections based on current evidence. There remains a paucity of high-quality data in the literature evaluating the impact of preoperative ESI on postoperative infection rates.

LEVEL OF EVIDENCE

II.

Effects of local intraoperative epidural use of triamcinolone acetonide-soaked Gelfoam on postoperative outcomes in patients undergoing posterolateral lumbar spinal fusion surgery: a randomized, placebo-controlled, double-blind trial

OBJECTIVE

Prior evidence has supported the use of local intraoperative epidural steroids in lumbar discectomy for improvements in postoperative pain and outcomes. However, currently there is a paucity of data regarding the efficacy of local epidural steroids in spinal fusion procedures. The present investigation aimed to evaluate the impact of local epidural administration of triamcinolone acetonide-soaked Gelfoam on postoperative pain and patient-reported outcomes in patients undergoing instrumented posterolateral lumbar spinal fusion.

METHODS

In this randomized, double-blind, placebo-controlled trial, patients were randomly divided into two groups (treatment and control). Patients in the treatment group received a Gelfoam carrier soaked in 1 ml of triamcinolone acetonide (40 mg), which was placed over the nerve roots in the epidural space before the closure. Patients in the control group received a Gelfoam carrier soaked in normal saline in a similar fashion to the treatment group. Patients were followed up during their hospital stay and at 4 and 12 weeks postoperatively. The primary outcome measure was early postoperative visual analog scale (VAS) scores for pain both at rest and with movement.

RESULTS

A total of 100 patients were recruited in this study and were randomly allocated to the treatment or control group. No significant difference was found in baseline demographic, clinical, and surgical characteristics between the two groups. Postoperative VAS scores for pain both at rest and with movement were comparable between the treatment and control groups. Cumulative morphine consumption, length of hospital stay, and incidence of postoperative complications such as surgical site infection were also similar between the two groups. There was no significant difference in patient-reported outcomes including VAS scores for back and leg pain as well as the Oswestry Disability Index at 4 and 12 weeks postoperatively. The proportion of patients who achieved a minimum clinically important difference for patient-reported outcomes were also similar between the two groups.

CONCLUSIONS

In contrast to the existing literature on the beneficial use of local intraoperative epidural steroids in conventional lumbar discectomy, the present study did not demonstrate such significant efficacy for the use of local epidural steroids in instrumented posterolateral lumbar spinal fusion. However, there is still a lack of evidence in this regard and further high-quality clinical trials are required to evaluate the efficacy of local epidural steroids in this group of patients.

Intraoperative epidural analgesia for pain relief after lumbar decompressive spine surgery: A systematic review and meta-analysis

Introduction

During lumbar decompressive spine surgery, the epidural space is easily accessible. This intraoperative situation allows surgeons to apply an epidural bolus of analgesia at the end of the surgical procedure. In literature, several papers about the methods and effectiveness of delivering local analgesia during lumbar decompressive spine surgery have been published.

Research question

This systematic review and meta-analysis aims to summaries the current literature on the effectiveness and safety of intraoperative epidural analgesia in lumbar decompressive surgery, delivered as a bolus.

Material and method

A systematic search was conducted according to the PRISMA guidelines. Inclusion criteria were randomized controlled trials or comparative cohort studies of patients aged 18 years or older who underwent decompressive lumbar spine surgery. Nonsteroidal epidural analgesia had to be administered as a bolus, intraoperatively, as an adjunct to standard analgesia therapy. Primary outcome measures were reduction in postoperative pain scores, analgesics consumption and length of hospital stay. Secondary outcomes were adverse events.

Results

Eight studies evaluating the effectiveness of intraoperative epidural analgesia were included. Seven studies reported statistically significant reductions in postoperative VAS-pain scores. Six studies reported a statistically significant decrease in postoperative analgesics consumption. Four studies reported on the length of hospital stay, with no statistically significant difference between study groups.

Discussion and conclusion

This systematic review and meta-analysis suggests that additional intraoperative epidural nonsteroidal analgesia, delivered as a bolus, can reduce postoperative pain and postoperative analgesics consumption in patients undergoing decompressive spinal surgery. Further well-powered research is needed to bolster the evidence.

Efficacy of gelatin sponge impregnated with ropivacaine on postoperative pain after transforaminal lumbar interbody fusion: a comparative study

BACKGROUND

The purpose of this study was to investigate the efficacy of gelatin sponge impregnated with ropivacaine on postoperative pain after transforaminal lumbar interbody fusion (TLIF) in patients with lumbar degenerative diseases.

METHODS

We retrospectively reviewed patients who underwent TLIF in our department between August 2018 and January 2020. Patients were divided to ropivacaine group and saline group. A ropivacaine group whom received gelatin sponge impregnated with ropivacaine during operation, and a saline group whom were intraoperatively administered by gelatin sponge impregnated with saline. The two groups were compared in reference to postoperative hospital stay, postoperative complications and visual analog scale (VAS) scores. The consumption of postoperative diclofenac sodium suppository use was also recorded. The Oswestry Disability Index (ODI) scores and Japanese Orthopedic Association (JOA) scores were used for functional evaluation at 1 year postoperatively.

RESULT

A total of 127 patients were evaluated in this retrospective study. The mean postoperative hospital stay in the ropivacaine group was significantly lower than saline group. The VAS score was significantly lower in patients receiving gelatin sponge impregnated with ropivacaine as compared with patients in saline group on postoperative day 1, 2, 3 and 4. The number of patients who need the administration of diclofenac sodium suppository and the mean consumption of postoperative diclofenac sodium suppository was significantly lower in the ropivacaine group as compared with saline group.

CONCLUSION

The application of gelatin sponge impregnated with ropivacaine around the nerve root in patients undergoing TLIF can effectively control the postoperative pain and reduce postoperative hospital stay.

Epidural steroids following percutaneous endoscopic interlaminar discectomy: A protocol for systematic review and meta-analysis

BACKGROUND

Percutaneous endoscopic interlaminar discectomy (PEID) has been widely used in the treatment of lumbar disc herniation and spinal stenosis, epidural steroids following PEID in an effort to reduce the incidence and duration of postoperative pain. Although steroids are widely thought to reduce the effect of surgical trauma, the observation index is not uniform, so the issue is still controversial. Therefore, the purpose of this paper is to systematically evaluate the efficacy and safety of local epidural steroids application following PEID.

METHODS

We will search the following databases from their inception to August 2020, PubMed, Embase, Medline, Chinese National Knowledge Infrastructure, Chinese Biomedical Literature Database, Web of Science, Wan Fang Database, Cochrane Library. The search strategy includes the MeSH terms. Meta-analysis will be performed using Rev Man V.5.3.5 statistical software.

RESULTS

This study will provide a high-quality synthesis to evaluate the efficacy and safety of local epidural steroids following PEID.

CONCLUSION

This systematic review will provide evidence to judge whether local epidural steroids application following PEID is an effective and safe intervention for patients. It will provide reliable evidence for its extensive application.

REGISTRATION NUMBER

INPLASY2020100085.

Clinical efficacy of single intraoperative 500 mg methylprednisolone management therapy for thoracic myelopathy caused by ossification of the ligamentum flavum

Background

The objective of our study was to compare clinical outcome and postoperative complications between patients with thoracic myelopathy caused by ossification of the ligamentum flavum (OLF) treated with and without intraoperative methylprednisolone (MP).

Methods

This retrospective study enrolled 101 patients who underwent posterior approach surgery for OLF and were followed up at least 1 year. Patients were divided into two groups according to MP use in the operation: MP group (n = 47) and non-MP group (n = 54). Clinical outcomes and complications were evaluated before and after operation and at the last follow-up.

Results

Significant differences were found in modified Japanese Orthopedics Association (mJOA) scores and proportion of Frankel grade (A-C) between the two groups immediately after surgery and at 2-week follow-up. No significant differences were found between the two groups in mJOA score before operation and at the final follow-up. Moreover, no significant differences were observed in recovery rate according to mJOA score at any time points, and there was no significant difference in the proportion of Frankel grade (A-C) between the two groups at final follow-up. There were 13 documented infections: 10 in the MP group and 3 in the non-MP group (P = 0.034).

Conclusion

Management therapy with intraoperative 500 mg MP showed better recovery of nerve function within 2 weeks in patients with thoracic myelopathy caused by OLF compared with those did not receive MP. However, long-term follow-up results showed that there was no significant difference in neurological recovery between patients with intraoperative MP or not. Moreover, intraoperative MP increased the rate of wound infection.

Degenerative cervical myelopathy: Recent updates and future directions

Advances in patient selection, surgical techniques, and postoperative care have facilitated spine surgeons to manage complex spine cases with shorter operative times, reduced hospital stay and improved outcomes. We focus this article on a few areas which have shown maximum developments in management of degenerative cervical myelopathy and also throw a glimpse into the future ahead. Imaging modalities, surgical decision making, robotics and neuro-navigation, minimally invasive spinal surgery, motion preservation, use of biologics are few of them. Through this review article, we hope to provide the readers with an insight into the present state of art in cervical myelopathy and what the future has in store for us.

Degenerative Cervical Myelopathy; A Review of the Latest Advances and Future Directions in Management

The assessment, diagnosis, operative and nonoperative management of degenerative cervical myelopathy (DCM) have evolved rapidly over the last 20 years. A clearer understanding of the pathobiology of DCM has led to attempts to develop objective measurements of the severity of myelopathy, including technology such as multiparametric magnetic resonance imaging, biomarkers, and ancillary clinical testing. New pharmacological treatments have the potential to alter the course of surgical outcomes, and greater innovation in surgical techniques have made surgery safer, more effective and less invasive. Future developments for the treatment of DCM will seek to improve the diagnostic accuracy of imaging, improve the objectivity of clinical assessment, and increase the use of surgical technology to ensure the best outcome is achieved for each individual patient.

Impact of Patient's Pain and Fatigue on Decision of Discharge After Laparoscopic Surgery for Colorectal Cancer

Purpose

Hospital stays after laparoscopic surgery for colorectal cancer tend to be much shorter than those after conventional open surgery. Many factors, including surgical outcomes and complications, are associated with patient discharge planning. However, few studies have analyzed the impact of patient subjective discomfort (including pain and fatigue) on the decision to discharge after surgery. Therefore, the purpose of this study was to determine how patient pain and fatigue play a role in the decision to discharge after laparoscopic surgery for colorectal cancer.

Methods

Between March 2014 and February 2015, we conducted a questionnaire survey of 91 patients who underwent laparoscopic surgery for colorectal cancer to estimate the expectation criteria for discharge and patient subjective discomfort at that time. Patients were divided into the following 2 groups: group A, those who complied with the medical professional’s decision to discharge; and group B, those who refused discharge despite the medical professional’s decision. The participants’ subjective factors were analyzed.

Results

Preoperatively, 78 of 91 patients (85.7%) identified activity level, amount of food (tolerance), and bowel movements as important factors that should be considered in the decision to discharge a patient postoperatively. Postoperatively, 17 patients (18.7%) refused discharge despite a discharge recommendation. Subjective pain and fatigue were significantly different in linear-by-linear association between the group of patients who agreed to be discharge and those who disagreed. Despite this difference, there was no significant difference in mean length of hospital stay between the 2 groups.

Conclusion

A patient’s subjective feelings of pain and fatigue can impact their decision regarding hospital discharge.

Methylprednisolone treatment enhances early recovery following surgical decompression for degenerative cervical myelopathy without compromise to the systemic immune system

Background

Degenerative cervical myelopathy (DCM) is caused by degenerative or congenital changes to the discs and soft tissues of the cervical spine, which leads to chronic compression of the spinal cord. The current treatment for moderate to severe DCM consists of surgical decompression, which, while effective in most cases, can result in neuroinflammation and spinal cord reperfusion injury, leading to perioperative neurological complications and suboptimal neurological recovery. The primary objective of this study was to assess, in a translationally relevant animal model of DCM, the efficacy of perioperative methylprednisolone (MP) in enhancing neurological recovery and to evaluate its effect on the inflammatory response following decompression.

Methods

DCM was induced in C57BL/6 mice. Briefly, an aromatic polyether material was implanted underneath the C5-C6 laminae to cause progressive compression of the cervical spinal cord due to focal ossification. Decompressive surgery was undertaken at 12 weeks post initial biomaterial implantation. Animals received one dose of MP (30 mg/kg) or vehicle 30 min before decompression and at 2 weeks after decompression. Acute analysis of secreted cytokines and spinal cord microvasculature was complemented with immunohistochemistry for glial and neuronal cell markers. Locomotor outcomes were measured using the CatWalk system. The composition of circulating white blood cells was analyzed by flow cytometry.

Results

A single dose of MP before decompression significantly sped locomotor recovery (*p < 0.05) and reduced the incidence of perioperative motor complications, without affecting the composition of circulating white blood cells. Histological assessment of the spinal cord showed significant neuronal preservation and a modest reduction in parenchymal inflammation.

Conclusions

Our data suggest that MP reduces perioperative neurological complications following decompressive surgery for DCM by protecting neurons from inflammation, without compromising the composition of circulating immune cells. We propose that MP, which is commonly used for neurological disorders including spinal cord injury, be considered as a perioperative adjunct to decompressive surgery to attenuate neurological complications.

Comparative Outcomes of Perioperative Epidural Steroids After Percutaneous Endoscopic Lumbar Discectomy for Lumbar Disc Herniation: A Randomized Placebo-Controlled Trial

OBJECTIVE

To assess postoperative outcomes and complications after percutaneous endoscopic lumbar discectomy (PELD) with or without epidural steroids (ES) administration in lumbar disc herniation.

METHODS

In a double-blind randomized, placebo-controlled trial at Ramathibodi Hospital, Mahidol University, from May 2014 to May 2015, 30 patients were randomly allocated to receive ES or placebo (saline) after PELD. The primary outcome was 24-hour morphine consumption. Secondary outcomes were visual analog scale (VAS) scores for leg and back pain, Oswestry Disability Index score, Roland-Morris Disability Questionnaire score, and complications at 6-month follow-up.

RESULTS

Mean patient age was 60.0 years, and 0.57% of patients were male. Mean VAS back pain, VAS leg pain, Oswestry Disability Index, and Roland-Morris Disability Questionnaire scores at baseline were 4.7, 6.1, 24.9, 17.5 in the ES group and 5.1, 5.5, 24.7, 16.7 in the placebo group, respectively. Mean morphine requirements measured at 8, 16, and 24 hours were 3.47, 2.67, and <0.001 in the ES group and 3.13, 1.67, and 0.40 in the placebo group. The mean VAS scores measured at 4, 8, 12, 16, 20, and 24 hours were 2.99, 2.70, 2.56, 3.30, 3.05, and 2.05 the ES group and 3.13, 1.13, 1.26, 1.65, 1.22, and 1.08 in placebo group. The difference was not statistically significant (P > 0.05 for all).

CONCLUSIONS

Administration of ES with PELD for lumbar disc herniation does not improve postoperative pain, morphine requirements, or disability scores in the short-term and midterm periods.

Epidural versus intravenous steroids application following percutaneous endoscopic lumbar discectomy

Retrospectively study.The purpose of this study was to compare the effects of intraoperative epidural steroids and single dose intravenous steroids following a percutaneous endoscopic lumbar discectomy (PELD).Inflammatory irritation of dorsal root ganglia or sensory nerve roots may cause postoperative pain. Epidural steroids have been applied after a lumbar discectomy for more than 20 years. Epidural steroid application after a PELD is easier to perform and safer because the operations are under observation of the scope.We retrospectively reviewed the medical records of patients with lumbar intervertebral disc herniation who had undergone transforaminal PELD at our department. There are 60 patients in epidural steroid group, intravenous steroid group, and control group, respectively. Visual analog scores (VAS) and the Oswestry Disability Index (ODI) were collected. Successful pain control is defined as 50% or more reduction in back and leg pain (VAS scores).VAS scores (back and leg) and ODI showed a significant decrease in all groups when comparing pre- and postoperatively. Epidural steroid group had a significant improvement in successful pain control compared with the control group at 2 weeks of follow-up. VAS scores (leg) in the epidural steroid group showed a significant decrease compared with the intravenous steroids group at 1, 3, and 7 days after the surgery, but this difference had no statistical significance at 1, 6, and 12 months of follow-up. All groups did not show a significant difference in ODI at 1, 6, and 12 months follow-up.Epidural application of steroid has a better effect on controlling the postoperative pain of PELD in the short term. The epidural application of steroid did not show a tendency to cause infection.

Endogenous Opiates and Behavior: 2016

This paper is the thirty-ninth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2016 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.

Efficacy of intraoperative epidural triamcinolone application in lumbar microdiscectomy: a matched-control study

OBJECTIVE

The purpose of this study was to investigate whether the intraoperative application of an epidural steroid (ES) on the decompressed nerve root improves short- and midterm subjective and objective clinical outcomes after lumbar microdiscectomy.

METHODS

This study was a retrospective analysis of a 2-center database including consecutive cases in which patients underwent lumbar microdiscectomy. All patients who received ES application (40 mg triamcinolone, ES group) were matched by age and sex to patients who had not received ES application (control group). Objective functional impairment (OFI) was determined using age- and sex-adjusted T-scores of the Timed Up and Go (TUG) test. Back and leg pain (visual analog scale), functional impairment (Oswestry Disability Index [ODI], Roland-Morris Disability Index [RMDI], and health-related quality of life (hrQoL; 12-Item Short Form Health Survey [SF-12] physical component summary [PSC] score and EuroQol [EQ-5D index]) were measured at baseline, on postoperative day 3, and at postoperative week 6.

RESULTS

Fifty-three patients who received ES application were matched with 101 controls. There were no baseline demographic or disease-specific differences between the study groups, and preoperative pain, functional impairment, and hrQoL were similar. On postoperative day 3, the ES group had less disability on the RMDI (mean 7.4 vs 10.3, p = 0.003) and higher hrQoL as determined by the SF-12 PCS (36.5 vs 32.7, p = 0.004). At week 6, the ES group had less disability on the RMDI (3.6 vs 5.7, p = 0.050) and on the ODI by trend (17.0 vs 24.4, p = 0.056); better hrQoL, determined by the SF-12 PCS (44.3 vs 39.9, p = 0.018); and lower OFI (TUG test T-score 100.5 vs 110.2, p = 0.005). The week 6 responder status based on the minimum clinically important difference (MCID) was similar in the ES and control groups for each metric. The rates and severity of complications were similar, with a 3.8% and 4.0% reoperation rate in the ES group and control group, respectively (p = 0.272). There was a tendency for shorter hospitalization in the ES group (5.0 vs 5.8 days, p = 0.066).

CONCLUSIONS

Intraoperative ES application on the decompressed nerve root is an effective adjunct treatment that may lower subjective and objective functional impairment and increase hrQoL in the short and intermediate term after lumbar microdiscectomy. However, group differences were lower than the commonly accepted MCIDs for each metric, indicating that the effect size of the benefit is limited.

■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: retrospective cohort trial; evidence: Class II.

Epidural Steroids at Closure After Microdiscectomy/Laminectomy for Reduction of Postoperative Analgesia: Systematic Review and Meta-Analysis

BACKGROUND

This review assessed the efficacy of epidural steroid administration on the reduction of pain, hospital stay time, and use of opioid analgesics postoperatively.

METHODS

We searched Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews for studies using epidural steroids through any route after lumbar surgery. The primary study outcomes included preoperative and postoperative pain as assessed with a visual analogue scale (VAS), length of hospital stay (LOS), and postoperative use of opioid analgesics. The data were extracted and stratified according to the steroid administered. Data were then assessed for heterogeneity, subgroup differences, and ultimately tabulated in a Forest plot.

RESULTS

A total of 17 randomized controlled trials were included in this review, with 16 undergoing quantitative analysis. Steroids were shown to be superior in terms of VAS outcome at 24 hours, with triamcinolone and dexamethasone performing similarly. Methylprednisolone paradoxically performed worse at the 24-hour mark. At 1 month, all steroids illustrated superiority in terms of VAS outcome. Steroids also proved superior in reducing LOS and postoperative use of opioid analgesia.

CONCLUSIONS

Intraoperative or perioperative epidural administration of steroids offers significant benefits in terms of pain control, reduction in LOS, and use of postoperative opioid analgesia. Before steroids are routinely used by spinal surgeons, however, significantly more research is required. A particular emphasis should be placed on quality study protocols and data recording, to allow for more thorough analyses in the future.

Perioperative steroids for lumbar disc surgery: A meta-analysis of randomized controlled trials

BACKGROUND

Our review question was "Does perioperative steroids administration, in comparison with other treatments or placebo, improve either postoperative pain control, length of hospital stay, or return to work in patients undergoing lumbar disc surgery?"

METHODS

We searched PubMed, CINAHL PLUS, and Cochrane databases for randomized control trials (RCTs) studying the role of steroids for lumbar disc surgery. Studies that compared perioperative steroids with other treatments or placebo were included. Study outcomes included postoperative back pain, leg pain, length of hospital stay, and return to work. Data was extracted through a proforma. Means and mean differences were calculated for continuous data, whereas odds ratios were calculated for dichotomous data. Data were analyzed with the help of Rev Man 5.

RESULTS

Twenty RCTs were included in the review. Quantitative analysis could be performed on 19 RCTs. Intraoperative steroids improve control of back pain at 24-48 hours. Although there was some benefit of steroid administration in controlling postoperative leg pain, it disappeared at 1 year and in the overall pooled analysis. The length of hospital stay was much shorter in the steroid group. The frequency of adverse events and complications also favored steroid administration.

CONCLUSION

Intraoperative epidural steroid administration offers some benefit in pain control with a significant reduction in the length of hospital stay. However, there is insufficient evidence to support the routine use of oral and intravenous steroids in the perioperative period.

Intraregional differences of perioperative management strategy for lumbar disc herniation: is the Devil really in the details?

BACKGROUND

This study intends to evaluate whether regional common habits or differences in case-volume between surgeons are significative variables in the perioperative management of patients undergoing surgery for lumbar disc herniation.

METHODS

An e-mail survey was sent to all neurosurgeons working in Lombardy, Italy's most populated region. The survey consisted of 17 questions about the perioperative management of lumbar disc herniation.

RESULTS

Forty-seven percent (47%) out of 206 Lombard neurosurgeons answered the survey. Although in some respects there is clear evidence in current literature on which is the best practice to adopt for an optimal management strategy, we noticed substantial differences between respondents, not only between hospitals but also between surgeons from the same hospital. Still, no differences were evident in a high vs low case-volume comparison.

CONCLUSION

We identified no regional clusterization as for practical principles in the perioperative management of lumbar disc herniation and neither was case-volume a significative variable. Other causes may be relevant in the variability between the perioperative management and the outcomes achieved by different specialists.

Percutaneous Lumbar Disc Decompression Using the Dekompressor: A Prospective Long-Term Outcome Study

BACKGROUND DATA

Few studies have investigated the long-term efficacy of percutaneous lumbar disc decompression (PLDD) with Dekompressor (Stryker, Kalamazoo, MI) for discogenic radicular pain that has failed conservative management.

OBJECTIVE

Determine long-term outcomes of Dekompressor PLDD for discogenic radicular pain.

METHODS

Prospective cohort study at a tertiary academic spine center of consecutive patients (12/2004-11/2005) with discogenic lumbosacral radicular pain who underwent PLDD with Dekompressor. Numerical Rating Scale (NRS) leg pain score and Oswestry Disability Index (ODI) score data were collected at 6 months and 1 year. These two measures, 5-point Likert scale patient satisfaction, and surgical rate data were collected at 8 years.

RESULTS

Seventy patients underwent PLDD. Forty and 25 patients were successfully contacted at 1-year and 8-year follow-up, respectively. Using intention to treat analysis, at 1 year and 8 years, NRS leg pain scores were reduced >50% in 47% (95% confidence interval [CI] 35%, 59%) and 29% (95% confidence interval [CI] 18%, 40%) of patients, respectively; ODI score improved >30% in 43% (CI 32%, 55%) and 26% (CI 19%, 41%) of patients, respectively. Of the patients who followed up at 8 years, 36% (CI 17%, 55%) had undergone surgery and the median satisfaction was "4" (interquartile range 2,5).

CONCLUSIONS

While limited by loss-to-follow-up, this study suggests that treatment of discogenic lumbosacral radicular pain with Dekompressor results in decreased leg pain and disability and favorable satisfaction at long-term follow-up. Further study with adequate follow-up retention is needed to confirm that Dekompressor spares open spinal surgery.