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Renard Y, El-Boghdadly K, Rossel JB, Nguyen A, Jaques C, Albrecht E. Non-pulmonary complications of intrathecal morphine administration: a systematic review and meta-analysis with meta-regression. Br J Anaesth 2024:S0007-0912(24)00416-1. [PMID: 39098521 DOI: 10.1016/j.bja.2024.05.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/31/2024] [Accepted: 05/31/2024] [Indexed: 08/06/2024] Open
Abstract
BACKGROUND Intrathecal morphine provides effective analgesia for a range of operations. However, widespread implementation into clinical practice is hampered by concerns for potential side-effects. We undertook a systematic review, meta-analysis, and meta-regression with the primary objective of determining whether a threshold dose for non-pulmonary complications could be defined and whether an association could be established between dose and complication rates when intrathecal morphine is administered for perioperative or obstetric analgesia. METHODS We systematically searched the literature for randomised controlled trials comparing intrathecal morphine vs control in patients undergoing any type of surgery under general or spinal anaesthesia, or women in labour. Primary outcomes were rates of postoperative nausea and vomiting, pruritus, and urinary retention within the first 24 postoperative hours, analysed according to doses (1-100 μg; 101-200 μg; 201-500 μg; >500 μg), type of surgery, and anaesthetic strategy. Trials were excluded if doses were not specified. RESULTS Our analysis included 168 trials with 9917 patients. The rates of postoperative nausea and vomiting, pruritus, and urinary retention were significantly increased in the intrathecal morphine group, with an odds ratio (95% confidence interval) of 1.52 (1.29-1.79), P<0.0001; 6.11 (5.25-7.10), P<0.0001; and 1.73 (1.17-2.56), P=0.005, respectively. Meta-regression could not establish an association between dose and rates of non-pulmonary complications. There was no subgroup difference according to surgery for any outcome. The quality of evidence was low (Grading of Recommendations Assessment, Development, and Evaluation [GRADE] system). CONCLUSIONS Intrathecal morphine significantly increased postoperative nausea and vomiting, pruritus, and urinary retention after surgery or labour in a dose-independent manner. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42023387838).
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Affiliation(s)
- Yves Renard
- Department of Anaesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Kariem El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK; King's College London, London, UK
| | - Jean-Benoît Rossel
- Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Alexandre Nguyen
- Department of Anaesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Cécile Jaques
- Medical Library, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eric Albrecht
- Department of Anaesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland.
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Prabhakar P, Mariappan R, Moorthy RK, Nair BR, Karuppusami R, Lionel KR. Adding Ketamine to Epidural Morphine Does Not Prolong Postoperative Analgesia After Lumbar Laminectomy or Discectomy. J Neurosurg Anesthesiol 2024; 36:244-251. [PMID: 37000813 DOI: 10.1097/ana.0000000000000914] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/23/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Epidural opioids provide effective postoperative analgesia after lumbar spine surgery. Ketamine has been shown to reduce opioid-induced central sensitization and hyperalgesia. We hypothesized that adding ketamine to epidural opioids would prolong the duration of analgesia and enhance analgesic efficacy after lumbar spine surgery. METHODS American Society of Anesthesiologists physical status class I to II patients aged between 18 and 70 years with normal renal function undergoing lumbar laminectomy were recruited into this single-center randomized trial. Patients were randomized to receive either single-dose epidural morphine (group A) or epidural morphine and ketamine (group B) for postoperative analgesia. The primary objective was to compare the duration of analgesia as measured by time to the first postoperative analgesic request. Secondary objectives were the comparison of pain scores at rest and movement, systemic hemodynamics, and the incidence of side effects during the first 24 hours after surgery. RESULTS Fifty patients were recruited (25 in each group), of which data from 48 were available for analysis. The mean±SD duration of analgesia was 20±6 and 23±3 hours in group A and group B, respectively ( P =0.07). There were 12/24 (50%) patients in group A and 17/24 (71%) patients in group B who did not receive rescue analgesia during the first 24-hour postoperative period ( P =0.07). Pain scores at rest and movement, systemic hemodynamics, and postoperative complications were comparable between the groups. CONCLUSIONS The addition of ketamine to epidural morphine did not prolong the duration of analgesia after lumbar laminectomy.
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Affiliation(s)
| | | | | | | | - Reka Karuppusami
- Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
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Yue L, Zhang F, Mu G, Shang M, Lin Z, Sun H. Effectiveness and safety of intrathecal morphine for percutaneous endoscopic lumbar discectomy under low-dose ropivacaine: a prospective, randomized, double-blind clinical trial. Spine J 2023; 23:954-961. [PMID: 36931566 DOI: 10.1016/j.spinee.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/06/2023] [Accepted: 03/02/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND CONTEXT Percutaneous endoscopic lumbar discectomy (PELD) is a surgical setting that requires minimal motor impairment. Low-dose spinal ropivacaine induces little motor blockade and could be ideal for maintaining safety of PELD, but its analgesic efficacy is questionable. An adjunct analgesic approach is needed to maximize the benefits of low-dose spinal ropivacaine for PELD. PURPOSE This study aimed to explore the effectiveness and safety of 100 µg intrathecal morphine (ITM) as an adjuvant analgesic method for PELD under low-dose spinal ropivacaine. STUDY DESIGN A double-blind, randomized, placebo-controlled trial. TRIAL REGISTRATION ChiCTR2000039842 (www.chictr.org.cn). SAMPLE Ninety patients scheduled for elective single-level PELD under low-dose spinal ropivacaine. OUTCOME MEASURES The primary outcome was the overall intraoperative visual analogue scale (VAS) score for pain. Secondary outcomes were intraoperative VAS scores assessed at multiple timepoints; intraoperative rescue analgesic requirement; postoperative VAS scores; disability scale; patients' satisfaction with anesthesia; adverse events; and radiographic outcomes. METHODS Patients were randomized to receive low-dose ropivacaine spinal anesthesia with (ITM group, n=45) or without (control group, n=45) 100 µg ITM. RESULTS The overall intraoperative VAS score in the ITM group was significantly lower than that in the control group (0 [0, 1] vs 2 [1, 3], p<.001). During operation, the VAS scores at cannula insertion, 30 minutes after insertion, 60 minutes after insertion, and 120 minutes after insertion were all significantly lower in the ITM group (all p<.05). Less patients in the ITM group required rescue analgesia during operation compared with those in the control group (14% vs 42%, p= .003). The VAS score for back pain in the ITM group was lower than that in the control group at 1 hour, 12 hours, and 24 hours postoperatively. Besides, the satisfaction score in the ITM group was significantly higher than that in the control group (p=.017). For adverse events, 8/43 of ITM and 1/44 of control participants experienced pruritus (p=.014), with a relative risk (95% confidence interval) of 8.37 (1.09-64.16). The incidence of other adverse events was similar between the two groups. Of note, respiratory depression occurred in one ITM-treated patient. CONCLUSION The addition of 100 µg ITM to low-dose ropivacaine appears to be effective in analgesia without compromised motor function for PELD; however, ITM increased the risk of pruritus and clinicians should be vigilant about its potential risk of respiratory depression.
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Affiliation(s)
- Lei Yue
- Department of Orthopedics, Peking University First Hospital, 8th Xishuku Ave, Xicheng District, Beijing, 100034, China
| | - Feng Zhang
- Department of Anesthesiology, Peking University First Hospital, 8th Xishuku Ave, Xicheng District, Beijing, 100034, China
| | - Guanzhang Mu
- Department of Orthopedics, Peking University First Hospital, 8th Xishuku Ave, Xicheng District, Beijing, 100034, China
| | - Meixia Shang
- Department of Medical Statistics, Peking University First Hospital, 8th Xishuku Ave, Xicheng District, Beijing,100034, China
| | - Zengmao Lin
- Department of Anesthesiology, Peking University First Hospital, 8th Xishuku Ave, Xicheng District, Beijing, 100034, China.
| | - Haolin Sun
- Department of Orthopedics, Peking University First Hospital, 8th Xishuku Ave, Xicheng District, Beijing, 100034, China.
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Hong B, Baek S, Kang H, Oh C, Jo Y, Lee S, Park S. Regional analgesia techniques for lumbar spine surgery: a frequentist network meta-analysis. Int J Surg 2023; 109:1728-1741. [PMID: 36912781 PMCID: PMC10389589 DOI: 10.1097/js9.0000000000000270] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 02/06/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Various regional analgesia techniques are used to reduce postoperative pain in patients undergoing lumbar spine surgery. Traditionally, wound infiltration (WI) with local anesthetics has been widely used by surgeons. Recently, other regional analgesia techniques, such as the erector spinae plane block (ESPB) and thoracolumbar interfascial plane (TLIP) block, are being used for multimodal analgesia. The authors aimed to determine the relative efficacy of these using a network meta-analysis. MATERIALS AND METHODS The authors searched PubMed, EMBASE, the Cochrane Controlled Library, and Google Scholar databases to identify all randomized controlled trials that compared the analgesic efficacy of the following interventions: ESPB, TLIP block, WI technique, and controls. The primary endpoint was postoperative opioid consumption during the first 24 hours after surgery, while the pain score, estimated postoperatively at three different time periods, was the secondary objective. RESULTS The authors included 34 randomized controlled trials with data from 2365 patients. TLIP showed the greatest reduction in opioid consumption compared to controls [mean difference (MD) =-15.0 mg; 95% CI: -18.8 to -11.2]. In pain scores, TLIP had the greatest effect during all time periods compared to controls (MD=-1.9 in early, -1.4 in middle, -0.9 in late). The injection level of ESPB was different in each study. When only surgical site injection of ESPB was included in the network meta-analysis, there was no difference compared with TLIP (MD=1.0 mg; 95% CI: -3.6 to 5.6). CONCLUSIONS TLIP showed the greatest analgesic efficacy after lumbar spine surgery, in terms of postoperative opioid consumption and pain scores, while ESPB and WI are also alternative analgesic options for these surgeries. However, further studies are needed to determine the optimal method of providing regional analgesia after lumbar spine surgery.
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Affiliation(s)
- Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital
- Departments of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University
- Biomedical Research Institute, Chungnam National University Hospital, Daejeon, Korea
| | - Sujin Baek
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital
- Departments of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University
| | - Hyemin Kang
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital
- Departments of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University
| | - Chahyun Oh
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital
- Departments of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University
| | - Yumin Jo
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital
- Departments of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University
| | - Soomin Lee
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital
- Departments of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University
| | - Seyeon Park
- Department of Nursing, College of Nursing, Chungnam National University
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The effect of intraoperative intrathecal opioid administration on the length of stay and postoperative pain control for patients undergoing lumbar interbody fusion. Acta Neurochir (Wien) 2022; 164:3061-3069. [PMID: 36114913 DOI: 10.1007/s00701-022-05359-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 08/25/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE In an effort to control postoperative pain more effectively in spinal fusion patients, intraoperative intrathecal morphine (ITM) administration is gaining popularity and acceptance with clinicians. This study seeks to determine the impact of intraoperative intrathecal opioid (ITO) administration following lumbar fusion surgery on postoperative pain and length of hospitalization as primary outcomes. Secondary outcomes will investigate postoperative opioid intake and side effects. METHODS The retrospective analysis of collected data was performed. The study compared patients undergoing one- or two-level transforaminal interbody fusions between 2019 and 2021 who intraoperatively received two different ITO doses (n = 89) vs. the reference group (n = 48) that did not receive ITO. The patients in the ITO group received either 0.2 mg (n = 44) of duramorph or 0.2 mg duramorph + 50 mcg fentanyl (n = 45). The effect of ITO was evaluated for the first four postoperative days (POD) on pain scores (visual analog scale), length of stay (LOS, hours) and opioid requirement (MED, morphine equivalent dose). RESULTS In the ITO group, a significant reduction of postoperative pain scores (t(99) = 4.3, p < 0.001) and opioid intake (t(70) = 2.49, p = 0.015) was noted on POD1. Cohen's d effect sizes were 0.76 and 0.50, meaning that postoperative pain and MED intake were reduced by about ¾ to ½ standard deviations (SD) in the ITO group. Further, multivariate regression models revealed that ITO administration predicted lower postoperative pain scores for the two PODs (β = - 0.83, p < 0.001; β = - 0.63, p = 0.022) and MED intake for the first two PODs (β = - 20.8, p = 0.047; β = - 16.4, p = 0.030). Mean LOS was 15.4 h less in the ITO group (mean ± SD, 63.4 ± 37.1 vs. 78.8 ± 39.6, p = 0.10). CONCLUSIONS In conclusion, our study provides results in a large sample of patients undergoing transforaminal lumbar fusions. The results demonstrated that ITO administration is effective in reducing POD1 pain scores and POD1-2 opioid requirement while not increasing the risk of any opioid-related side effects.
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Johnson JPJ, Arumugam R, Karuppusami R, Mariappan R. Intraoperative administration of systemic/epidural/intrathecal morphine on the quality of recovery following substitutional urethroplasty with buccal mucosal graft: A randomized control trial. J Anaesthesiol Clin Pharmacol 2022; 38:537-543. [PMID: 36778804 PMCID: PMC9912865 DOI: 10.4103/joacp.joacp_589_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 04/14/2021] [Accepted: 04/17/2021] [Indexed: 12/30/2022] Open
Abstract
Background and Aims Substitutional urethroplasty with buccal mucosal grafting for urethral stricture is associated with significant pain, and thus inappropriate perioperative pain management could delay postoperative recovery. The objective of our research was to determine the effects of analgesia with systemic or epidural or intrathecal morphine on quality of recovery (QoR) in patients undergoing substitutional urethroplasty with buccal mucosal grafting. Material and Methods This prospective, double-blinded, randomized control trial was conducted over 2 years in ASA I and II patients who underwent substitutional urethroplasty with buccal mucosal graft. Patients were randomized into three groups, and Group A received systemic morphine (0.1 mg/kg), Group B received epidural morphine (3 mg), and Group C received intrathecal morphine (150 μg). The QoR between the groups were compared postoperatively using the 40-item QoR questionnaire, and the hemodynamic variations, time taken for ambulation, resumption of oral intake, and incidence of complications were also compared. Results Out of the recruited 93 patients, 88 patients were analyzed. The QoR score for each domain was comparable between the three groups. The total QoR score for systemic, epidural, and intrathecal morphine groups were 189 (185-191), 189 (187-191), and 185 (183-189), respectively. Additionally, the hemodynamic variations, time taken for ambulation, and resumption of oral intake were comparable between all three groups except the incidence of postoperative nausea and vomiting (PONV) and pruritis, which were higher in the intrathecal group. Conclusion All three modalities, namely systemic morphine (0.1 mg/kg), epidural morphine (3 mg), and intrathecal morphine (150 μg), offer similar QoR after substitutional urethroplasty. However, the incidence of PONV and pruritis was higher with the administration of intrathecal morphine.
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Affiliation(s)
| | - Rajasekar Arumugam
- Senior Fellow in Cardiothoracic Transplant Anaesthesia, Critical Care and ECMO, North-West Heart Centre, Manchester University, NHS Foundation Trust, Manchester, United Kingdom
| | - Reka Karuppusami
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ramamani Mariappan
- Department of Anaesthesia, Christian Medical College, Vellore, Tamil Nadu, India
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Use of a Multifunctional Cocktail for Postoperative Bleeding and Pain Control in Spinal Fusion: A Randomized, Double-blind, Controlled Trial. Spine (Phila Pa 1976) 2022; 47:1328-1335. [PMID: 34610611 DOI: 10.1097/brs.0000000000004249] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/31/2021] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective, randomized, double-blind controlled trial. OBJECTIVE To explore the effect of multifunctional cocktail for bleeding and pain control after spinal fusion. SUMMARY OF BACKGROUND DATA Managing postoperative bleeding and pain after spinal fusion remains a challenge. Topical application of tranexamic acid or anesthetic agents for bleeding or pain management just started recently, and the multifunctional cocktail for bleeding and pain control simultaneously after spinal fusion have never been published. METHODS Ninety patients who underwent posterior spinal fusion were enrolled in this study. The multifunctional cocktail was injected into the incision before wound closure in the cocktail group. In the control group, an equal volume of normal saline was injected and a patient-controlled analgesic pump was used. Visual analogue scale score; opioid consumption; intraoperative, postoperative, hidden and total blood loss; volume of drainage, hematocrit levels of drainage; hemoglobin levels; and complications were compared between the two groups. RESULTS There were no differences in the visual analogue scale within 48 hours after surgery between the two groups. However, the opioid dosages in the control group were higher than those in the cocktail group. The postoperative blood loss, total blood loss, and hidden blood loss were lower in the cocktail group than in the control group. The drainage volume showed no differences between the two groups; however, the hematocrit level of drainage at 24 hours after surgery was lower in the cocktail group than in the control group. The hemoglobin level was higher in the cocktail group than in the control group at postoperative day 3. Thirteen patients with unbearable nausea and vomiting in the control group, whereas no complications in the cocktail group. CONCLUSION Topical application of a multifunctional cocktail that we designed provides an effective and safe method for reducing pain and bleeding after spinal fusion.
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Shlobin NA, Rosenow JM. Nonopioid Postoperative Pain Management in Neurosurgery. Neurosurg Clin N Am 2022; 33:261-273. [DOI: 10.1016/j.nec.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Trivedi R, John J, Ghodke A, Trivedi J, Munigangaiah S, Dheerendra S, Balain B, Ockendon M, Kuiper J. Intrathecal morphine in combination with bupivacaine as pre-emptive analgesia in posterior lumbar fusion surgery: a retrospective cohort study. J Orthop Surg Res 2022; 17:241. [PMID: 35436917 PMCID: PMC9017052 DOI: 10.1186/s13018-022-03124-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/31/2022] [Indexed: 11/17/2022] Open
Abstract
Background The purpose of this study was to evaluate the efficacy of intrathecal morphine (ITM) in combination with bupivacaine as pre-emptive analgesia in patients undergoing posterior lumbar fusion surgery. This is in comparison with traditional opioid analgesics such as intravenous (IV) morphine. Methods Two groups were identified retrospectively. The first (ITM group) included patients who had general anaesthesia (GA) with low-dose spinal anaesthesia prior to induction using 1–4 mls of 0.25% bupivacaine and 0.2 mg ITM. 1 ml of 0.25% bupivacaine was administered per hour of predicted surgery time, up to a maximum of 4 ml. The insertion level for the spinal anaesthetic corresponded to the spinal level of the iliac crest line and the level at which the spinal cord terminated. The control group had GA without any spinal anaesthesia. Patients were instead administered opioid analgesia in the form of IV morphine or diamorphine. The primary outcome was the consumption of opioids administered intraoperatively and in recovery, and over the first 48 h following discharge from the post-anaesthesia care unit (PACU). Total opioid dose was measured, and a morphine equivalent dose was calculated. Secondary outcomes included visual analogue scale (VAS) pain scores in recovery and at day two postoperatively, and the length of stay in hospital. Results For the ITM group, the median total amount of IV morphine equivalent administered intraoperatively and in recovery, was 0 mg versus 17 mg. The median total amount morphine equivalent, administered over the first 48 h following discharge from PACU was 20 mg versus 80 mg. Both are in comparison with the control group. The median length of stay was over 1 day less and the median VAS for pain in recovery was 6 points lower. No evidence was found for a difference in the worst VAS for pain at day two postoperatively. Conclusion ITM in combination with bupivacaine results in a significantly decreased use of perioperative opioids. In addition, length of hospital stay is reduced and so too is patient perceived pain intensity. Trial registration The study was approved by the ethics committee at The Robert Jones and Agnes Hunt Orthopaedic Hospital as a service improvement project (Approval no. 1617_004).
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Affiliation(s)
- R Trivedi
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK.
| | - J John
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - A Ghodke
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - J Trivedi
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - S Munigangaiah
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - S Dheerendra
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - B Balain
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - M Ockendon
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - J Kuiper
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
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Beltrame SA, Fasano F, Jalón P. Bilateral Radioscopically-Guided Erector Spinae Plane Block for Postoperative Analgesia in Spine Surgery: A Randomized Clinical Trial. J Neurol Surg A Cent Eur Neurosurg 2022; 84:360-369. [PMID: 35144297 DOI: 10.1055/a-1768-3797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
STUDY DESIGN Randomized clinical trial. OBJECTIVES To compare two perioperative pain management procedures: a radioscopically-guided erector spinae plane (ESP) block versus the standard wound infiltration technique with local anaesthetics, in patients undergoing lumbosacral spine surgery. METHODS A randomized, double-blind clinical trial was performed, in which adults at our hospital undergoing lumbosacral surgery without fixation were randomly assigned to receive either the standard wound infiltration technique, employing long-term anaesthetics, or a radioscopically-guided ESP block. Postoperative pain severity, morphine consumption, number of patients immobilised due to wound pain, length of hospitalisation, and complications were recorded. RESULTS Over the first seven postoperative hours, pain relief was superior in the ESP block group among patients who underwent discectomies or one-level decompression (p<0.0001). Using an ESP block also was statistically superior at decreasing all postoperative variables recorded in patients scheduled for multi-level decompression: VAS pain severity over the first seven hours after the procedure (p=0,0004); number of patients with wound pain 1 (p=0.049), 7 (p<0.0001) and 24 hours (p=0.007) after surgery; length of hospitalisation (p=0.0007), number of patients immobilised for wound pain (p=0.0004) and rescue morphine consumption (p<0.0001). CONCLUSION The ESP block is a safe procedure which seems to outperform the infiltration wound technique for postoperative pain management in patients undergoing open spinal surgery. Future studies are needed to verify its effectiveness for arthrodesis/fixation and minimally-invasive procedures, and for chronic spine pain relief.
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Affiliation(s)
| | - Francisco Fasano
- Neurosurgery, Hospital de Clinicas Jose de San Martin, Buenos Aires, Argentina
| | - Pablo Jalón
- Neurosurgery, Hospital de Clínicas, Buenos Aires, Argentina
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Mazy A, Serry M, Kassem M. High-volume, multilevel local anesthetics-Epinephrine infiltration in kyphoscoliosis surgery: Intra and postoperative analgesia. J Anaesthesiol Clin Pharmacol 2021; 37:73-78. [PMID: 34103827 PMCID: PMC8174417 DOI: 10.4103/joacp.joacp_338_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 07/14/2019] [Accepted: 10/28/2019] [Indexed: 11/29/2022] Open
Abstract
Background and Aims: Local anesthetic (LA) infiltration is one of the analgesic techniques employed during scoliosis correction surgery. However, its efficacy is controversial. In the present study for optimizing analgesia using the infiltration technique, we proposed two modifications; first is the preemptive use of high volume infiltration, second is applying three anatomical multilevel infiltrations involving the sensory, motor, and sympathetic innervations consecutively. Material and Methods: This prospective study involved 48 patients randomized into two groups. After general anesthesia (GA), the infiltration group (I) received bupivacaine 0.5% 2 mg/kg, lidocaine 5 mg/kg, and epinephrine 5 mcg/mL of the total volume (100 mL per 10 cm of the wound length) as a preemptive infiltration at three levels; subcutaneous, intramuscular, and the deep neural paravertebral levels, timed before skin incision, muscular dissection, and instrumentation consecutively. The control group (C) received normal saline in the same manner. Data were compared by Mann-Whitney, Chi-square, and t-test as suitable. Results: Intraoperatively, the LA infiltration reduced fentanyl, atracurium, isoflurane, nitroglycerine, and propofol consumption. Postoperatively, there was a 41% reduction in morphine consumption, longer time to the first analgesic request, lower VAS, early ambulation, and hospital discharge with high-patient satisfaction. Conclusion: The preemptive, high-volume, multilevel infiltration provided a significant intra and postoperative analgesia in scoliosis surgery.
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Affiliation(s)
- Alaa Mazy
- Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Egypt
| | - Mohamed Serry
- Orthopedic Surgery, Faculty of Medicine, Mansoura University, Egypt
| | - Mohamed Kassem
- Neurosurgery, Faculty of Medicine, Mansoura University, Egypt
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Aljoghaiman M, Martyniuk A, Farrokhyar F, Cenic A, Kachur E. Survey of lumbar discectomy practices: 10 years in the making. JOURNAL OF SPINE SURGERY 2020; 6:572-580. [PMID: 33102894 DOI: 10.21037/jss-20-519] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Lumbar discectomy is a common spinal procedure. The purpose of this survey is to ascertain neurosurgeons' practices in the surgical management of one-level lumbar discectomies in the Canadian adult population and to determine changes over a 10-year period. Methods One-page questionnaire distributed electronically to neurosurgeons in Canada and results were compared with similarly completed survey from 2007. Results A total of 109 completed surveys were returned representing 43.8% response rate. This is compared to 112 completed surveys in 2007 reaching 64.4% response rate. Statistically significant differences between the two points in time were noted. There was an increase in spine fellowship training [26 (33.3%) 2017 vs. 15 (15.3%) 2007 (P=0.007)], use of pre-operative magnetic resonance imaging (MRI) [65 (83.3%) 2017 vs. 27 (27.6%) 2007] (P<0.001), use of intramuscular injection [58 (74.4%) 2017 vs. 43 (43.9%) 2007 (P<0.001)], use of both microscope and loupes [20 (25.6%) 2017 vs. 3 (3.1%) 2007 (P<0.001)], use of tubular retraction [26 (33.3%) 2017 vs. 12 (12.2%) 2007 (P=0.001)], use of fibrin glue for a durotomy [72 (92.3%) 2017 vs. 75 (76.5%) 2007 (P=0.007)]. There was an increased rate of same-day discharge in 2017 [46 (59.0%) vs. 18 (18.4%) 2007 (P<0.001)], and quicker return to work [62.8% in 6 weeks or less vs. 39.7% (P=0.003)]. No statistical differences were noted with pre-incision localization, pre-op antibiotics, pre-incision local anesthetic use, use of fat graft or epidural steroids. In either survey the majority would not perform lumbar discectomy on a patient whose primary complaint is back pain. Conclusions Our survey identified changes in practice patterns amongst Canadian neurosurgeons with respect to performing one-level lumbar discectomy over the past 10 years. These changes include increased preference for minimally invasive surgical technique, same-day discharge and sooner return to work. Randomized trials would be helpful to provide evidence regarding which practices are associated with better outcomes.
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Affiliation(s)
- Majid Aljoghaiman
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, King Faisal University, Alahsa, Saudi Arabia
| | - Amanda Martyniuk
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Forough Farrokhyar
- Department of Epidemiology and Biostatistics, Office of Surgical Research Services, Surgical Research Methodology, McMaster University, Hamilton, Ontario, Canada
| | - Aleksa Cenic
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Edward Kachur
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Shrestha N, Wu L, Wang X, Jia W, Luo F. Preemptive Infiltration with Betamethasone and Ropivacaine for Postoperative Pain in Laminoplasty or Laminectomy (PRE-EASE): study protocol for a randomized controlled trial. Trials 2020; 21:381. [PMID: 32370780 PMCID: PMC7201781 DOI: 10.1186/s13063-020-04308-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 04/02/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Laminoplasty and laminectomy have been used for decades for the treatment of intraspinal space-occupying lesions, spinal stenosis, disc herniation, injuries, etc. After these procedures, patients often experience severe postoperative pain at the surgical site. Intense immediate postoperative pain after many spinal procedures makes its control of utmost importance. Preemptive injection of local anesthetics can significantly reduce postoperative pain during rest and movement; however, the analgesic effect is only maintained for a relatively short period of time. Whether betamethasone combined with local anesthetic for laminoplasty or laminectomy has better short-term and long-term effects than the local anesthetic alone has not been reported yet. METHODS The PRE-EASE trial is a prospective, randomized, open-label, blinded endpoint, single-center clinical study including 116 participants scheduled for elective laminoplasty or laminectomy, with a 6 months' follow-up process. Preemptive local infiltration with betamethasone and ropivacaine (treatment group) or ropivacaine alone (control group) throughout the entire thickness of the planned incision site will be performed by the surgeon prior to making the incision. The primary outcome will be the cumulative butorphanol consumption within the first 48-h postoperative period. DISCUSSION This study will add significant new knowledge to the effect and feasibility of preemptive local infiltration of betamethasone for postoperative pain management in laminoplasty and laminectomy. TRIAL REGISTRATION ClinicalTrials.gov: NCT04153396. Registered on 6 November 2019.
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Affiliation(s)
- Niti Shrestha
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Liang Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaodi Wang
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Wenqing Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fang Luo
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.
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Dhaliwal P, Yavin D, Whittaker T, Hawboldt GS, Jewett GAE, Casha S, du Plessis S. Intrathecal Morphine Following Lumbar Fusion: A Randomized, Placebo-Controlled Trial. Neurosurgery 2018; 85:189-198. [DOI: 10.1093/neuros/nyy384] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 07/23/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Despite the potential for faster postoperative recovery and the ease of direct intraoperative injection, intrathecal morphine is rarely provided in lumbar spine surgery.
OBJECTIVE
To evaluate the safety and efficacy of intrathecal morphine following lumbar fusion.
METHODS
We randomly assigned 150 patients undergoing elective instrumented lumbar fusion to receive a single intrathecal injection of morphine (0.2 mg) or placebo (normal saline) immediately prior to wound closure. The primary outcome was pain on the visual-analogue scale during the first 24 h after surgery. Secondary outcomes included respiratory depression, treatment-related side effects, postoperative opioid requirements, and length of hospital stay. An intention-to-treat, repeated-measures analysis was used to estimate outcomes according to treatment in the primary analysis.
RESULTS
The baseline characteristics of the 2 groups were similar. Intrathecal morphine reduced pain both at rest (32% area under the curves [AUCs] difference, P < .01) and with movement (22% AUCs difference, P < .02) during the initial 24 h after surgery. The risk of respiratory depression was not increased by intrathecal morphine (hazard ratio, 0.86; 95% confidence interval, 0.44 to 1.68; P = .66). Although postoperative opioid requirements were reduced with intrathecal morphine (P < .03), lengths of hospital stay were similar (P = .32). Other than a trend towards increased intermittent catheterization among patients assigned to intrathecal morphine (P = .09), treatment-related side effects did not significantly differ. The early benefits of intrathecal morphine on postoperative pain were no longer apparent after 48 h.
CONCLUSION
A single intrathecal injection of 0.2 mg of morphine safely reduces postoperative pain following lumbar fusion.
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Affiliation(s)
- Perry Dhaliwal
- Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Daniel Yavin
- Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Tara Whittaker
- Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Geoffrey S Hawboldt
- Department of Anesthesia, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Gordon A E Jewett
- Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Steven Casha
- Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- The Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Stephan du Plessis
- Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Pendi A, Lee YP, Farhan SADB, Acosta FL, Bederman SS, Sahyouni R, Gerrick ER, Bhatia NN. Complications associated with intrathecal morphine in spine surgery: a retrospective study. JOURNAL OF SPINE SURGERY 2018; 4:287-294. [PMID: 30069520 DOI: 10.21037/jss.2018.05.13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Supplemental intrathecal morphine (ITM) represents an option to manage postoperative pain after spine surgery due to ease of administration and ability to confer effective short-term analgesia at low dosages. However, whether ITM increases risk of surgical site infections (SSI), cerebrospinal fluid (CSF) leak, and incidental dural tears (IDT) has not been investigated. Therefore, this study was performed to determine the rates of SSI, CSF leak, and IDT in patients that received ITM. Methods Patients that underwent posterior instrumented fusion from January 2010 to 2016 that received ITM were compared to controls with respect to demographic, medical, surgical, and outcome data. Fisher's exact test was used to compare rates of SSI, CSF leak, and IDT between groups. Poisson regression was used to analyze complication rates after adjusting for the influence of covariates and potential confounders. Results A total of 512 records were analyzed. ITM was administered to 78 patients prior to wound closure. The remaining 434 patients compromised the control group. IDT was significantly more common among patients receiving ITM (P=0.009). Differences in rates of CSF leak and SSI were not statistically significant (P=0.373 and P=0.564, respectively). After compensating for additional variables, Poisson regression revealed a significant increase in rates of IDT (P=0.007) according to ITM injection and advanced age (P=0.014). There was no significant difference in rates of CSF leak or SSI after accounting for the additional variables (P>0.05). Conclusions ITM for pain control in posterior instrumented spinal fusion surgery was linked to increased likelihood of IDT but not CSF leaks or SSI. Age was also noted to be a significant predictor of IDT. Spine surgeons should weigh potential risks against benefits when deciding whether to administer ITM for postoperative pain management following spine surgery.
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Affiliation(s)
- Arif Pendi
- School of Medicine, Wayne State University, Detroit, MI, USA
| | - Yu-Po Lee
- Department of Orthopaedic Surgery, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Saif Al-Deen B Farhan
- Department of Orthopaedic Surgery, School of Medicine, University of California Irvine, Orange, CA, USA
| | - Frank L Acosta
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Ronald Sahyouni
- School of Medicine, University of California Irvine, CA, USA
| | - Elias R Gerrick
- TH Chan School of Public Health, Harvard University, Harvard, Cambridge, MA, USA
| | - Nitin N Bhatia
- Department of Orthopaedic Surgery, School of Medicine, University of California Irvine, Orange, CA, USA
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Intramuscular Local Anesthetic Infiltration at Closure for Postoperative Analgesia in Lumbar Spine Surgery: A Systematic Review and Meta-Analysis. Spine (Phila Pa 1976) 2017; 42:1088-1095. [PMID: 28426530 DOI: 10.1097/brs.0000000000001443] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic Review and Meta-Analysis OBJECTIVE.: To identify whether intramuscular local anesthetic infiltration prior to wound closure was effective in reducing postoperative pain and facilitating early discharge following lumbar spine surgery. SUMMARY OF BACKGROUND DATA Local anesthetic infiltration prior to wound closure may form part of the multimodal strategy for postoperative analgesia, facilitating early mobilization and discharge. Although there are a number of small studies investigating its utility, a quantitative meta-analysis of the data has never been performed. METHODS This review was conducted according the PRISMA statement and was registered with the PROSPERO database. Only randomized controlled trials were eligible for inclusion. Key outcomes of interest included time to first analgesic demand, total postoperative opiate usage in the first 24 hours, visual analogue score (VAS) at 1, 12 and 24 hours and postoperative length of stay. RESULTS Eleven publications fulfilled the inclusion criteria. A total of 438 patients were include; 212 in the control group and 226 in the intervention group. Local anesthetic infiltration resulted in a prolonged time to first analgesic demand (mean difference (MD) 65.88 minutes, 95% confidence interval (95% CI) 23.70 to 108.06, P.0.002) as well as a significantly reduced postoperative opiate demand (M.D. -9.71 mg, 95% CI -15.07, -4.34, p = 0.0004). There was a small but statistically significant reduction in postoperative visual analogue score (VAS) at 1 hour (M.D. -0.87 95%CI -1.55, -0.20, p = 0.01), but no significant reduction at 12 or 24 hours (p = 0.93 and 0.85 respectively). CONCLUSION This systematic review and meta-analysis provides evidence that postoperative intramuscular local anaesthetic infiltration reduces postoperative analgesic requirements and the time to first analgesic demands for patients undergoing lumbar spine surgery. Key research priorities include optimization of the choice and strength of local anaesthetic agent and health-economic analyses to strengthen the case for routine use of postoperative local anesthetics in lumbar spine surgery. LEVEL OF EVIDENCE 1.
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Abstract
STUDY DESIGN Meta-analysis of randomized controlled trials (RCTs). OBJECTIVE The aim of this study was to evaluate the effectiveness of intrathecal morphine (ITM) in reducing postoperative pain and opioid analgesic consumption following spine surgery. SUMMARY OF BACKGROUND DATA The use of ITM following adult spine surgery is of particular interest because of the ease of access to the thecal sac and the potential to provide adequate analgesia at low doses. However, previous studies of ITM have been limited by small sample sizes and conflicting results. METHODS A comprehensive search of PubMed, Web of Science, Clinicaltrials.gov, and the Cochrane Central Register of Controlled Trials for prospective RCTs was performed by two independent reviewers. Postoperative opioid consumption, pain scores, and complications were documented from the identified studies. Standard mean differences (SMDs) were applied to continuous outcomes and odds ratios were determined for dichotomous outcomes. RESULTS Eight RCTs involving 393 subjects met inclusion criteria and were included in this meta-analysis. Patients receiving ITM (ITM group) as an adjunct to postoperative opioid analgesic were compared to patients receiving postoperative opioids only (control group). Postoperative morphine equivalent consumption was significantly lower during the first 24 hours postoperative in the ITM group (P < 0.001). Pain scores were similarly lower in the first 24 hours following spine surgery in those who received ITM (P < 0.001). In patients administered ITM, a greater percentage experienced pruritus (P < 0.001). Respiratory depression was solely encountered in the ITM group (P = 0.25). There were no significant differences between the ITM and control groups in terms of sedation (P = 0.18), nausea (P = 0.67), vomiting (P = 0.62), or length of stay (P = 0.13). CONCLUSION In patients undergoing spine surgery, use of ITM significantly reduced opioid analgesic consumption and Visual Analogue Schores pain scores compared to controls within the first 24 hours postoperatively. High-quality, follow-up RCTs with large sample sizes are recommended to determine the potential of supplementary ITM in spine surgery and complete the side effects profile. LEVEL OF EVIDENCE 1.
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Abstract
OBJECTIVES Intrathecal morphine (ITM) is an efficacious method of providing postoperative analgesia and reducing pain associated complications. Despite adoption in many surgical fields, ITM has yet to become a standard of care in lumbar spine surgery. Spine surgeons' reticence to make use of the technique may in part be attributed to concerns of precipitating a cerebrospinal fluid (CSF) leak. METHODS Herein we describe a method for oblique intrathecal injection during lumbar spine surgery to minimize risk of CSF leak. The dural sac is penetrated obliquely at a 30° angle to offset dural and arachnoid puncture sites. Oblique injection in instances of limited dural exposure is made possible by introducing a 60° bend to a standard 30-gauge needle. RESULTS The technique was applied for injection of ITM or placebo in 104 cases of lumbar surgery in the setting of a randomized controlled trial. Injection was not performed in two cases (2/104, 1.9%) following preinjection dural tear. In the remaining 102 cases no instances of postoperative CSF leakage attributable to oblique intrathecal injection occurred. Three cases (3/102, 2.9%) of transient CSF leakage were observed immediately following intrathecal injection with no associated sequelae or requirement for postsurgical intervention. In two cases, the observed leak was repaired by sealing with fibrin glue, whereas in a single case the leak was self-limited requiring no intervention. CONCLUSIONS Oblique dural puncture was not associated with increased incidence of postoperative CSF leakage. This safe and reliable method of delivery of ITM should therefore be routinely considered in lumbar spine surgery.
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Local infiltration analgesia with ropivacaine in acute fracture of thoracolumbar junction surgery. Orthop Traumatol Surg Res 2017; 103:291-294. [PMID: 28038991 DOI: 10.1016/j.otsr.2016.11.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 09/11/2016] [Accepted: 11/28/2016] [Indexed: 02/02/2023]
Abstract
STUDY DESIGN Retrospective study. INTRODUCTION Local infiltration analgesia is effective in many surgeries as knee arthroplasty, but the analgesic efficacy of local infiltration analgesia with ropivacaine in trauma spine surgery in T10 to L2 has not been clarified. We conducted a trial to assess the analgesic efficacy of intraoperative local infiltration analgesia (LIA) with ropivacaine. OBJECTIVE The aim of the present study was to clarify the effect of intraoperative local infiltration analgesia with ropivacaine on postoperative pain for patients undergoing thoracolumbar junction fracture surgery. METHODS In a retrospective study, in 76 patients undergoing spine surgery for thoracolumbar junction fracture, 20ml of ropivacaine 7.5% (n R group=38) was infiltrated using a systematic technique, or no infiltration was realized (n M group=38). We assessed postoperative pain with Visual Analogue Scale (VAS) and morphine consumption in the 24 first hours. RESULTS VAS pain score upon awakening and at 2hours postoperatively were significantly lower in the ropivacaine group (P=0.01 and P=0.002). Rescue opioid requirement during the 24 first hours were about 50% lower in the ropivacaine group (P=0.01). No local or systemic side effects were observed. CONCLUSION Intraoperative LIA with ropivacaine in thoracolumbar junction fracture surgery may have an analgesic effect in postoperative pain control (24hours) with a reduction of VAS and morphine consumption.
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Intrathecal Versus Intravenous Morphine in Minimally Invasive Posterior Lumbar Fusion: A Blinded Randomized Comparative Prospective Study. Spine (Phila Pa 1976) 2017; 42:281-284. [PMID: 27306255 DOI: 10.1097/brs.0000000000001733] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A blinded, randomized, comparative prospective study. OBJECTIVE The aim of this study was to compare the use of intrathecal morphine to endovenous morphine on postoperative pain after posterior lumbar surgery. SUMMARY OF BACKGROUND DATA Intrathecal morphine can provide significant safe analgesia for at least 12 hours and up to 24 hours in patients undergoing major surgery. Its dosages have been decreasing in the last 30 years, but currently, the optimal dose remains unknown. As of today, there are no studies comparing the efficacy and the side effects of this technique with intravenous morphine administration after minimally invasive lumbar fusion surgery. METHODS We randomized and compared two groups of 25 patients, who were given either 100 μg intrathecal (ITM group) or 5 ± 2 mg intravenous morphine delivered intravenously for 24 hours at 2 mL/h (IVM group) after minimally invasive posterior lumbar fusion. VAS score at 0, 6, 12, 24 hours, mobilization out of bed at 6 hours, hospitalization duration and complications as lower limbs paresthesia, urinary retention at 6 and 12 hours, nausea, vomit, itch, and constipation were evaluated. RESULTS Data showed a lower VAS score, a reduction of constipation, lower limbs paresthesia, or urinary retention at 12 hours in ITM rather than in the IVM group. None suffered of vomit, itch, or nausea in both groups. Urinary retention was observed more frequently in ITM group at 6 hours. Patients of ITM group were mobilized out bed earlier than those from IVM group. CONCLUSION A low dosage of intrathecal morphine is safe and effective after minimally invasive lumbar fusion surgery. The reduction of pain in the study group permitted a shorter hospitalization and earlier mobilization out of bed, augmenting patients' comfort. LEVEL OF EVIDENCE 2.
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Hida T, Yukawa Y, Ito K, Machino M, Imagama S, Ishiguro N, Kato F. Intrathecal morphine for postoperative pain control after laminoplasty in patients with cervical spondylotic myelopathy. J Orthop Sci 2016; 21:425-430. [PMID: 27083315 DOI: 10.1016/j.jos.2016.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Revised: 03/10/2016] [Accepted: 03/12/2016] [Indexed: 02/09/2023]
Abstract
OBJECTIVES To examine the clinical efficacy of intrathecal morphine as postoperative analgesia for cervical laminoplasty. SUMMARY OF BACKGROUND DATA Patients who undergo posterior cervical spinal surgery frequently experience significant postoperative pain. Postoperative pain contributes to patient morbidity because of decreasing early voluntary mobilization and delayed rehabilitation. Intrathecal morphine is known to be a simple and effective analgesia. However, the effectiveness of intrathecal morphine for cervical spinal surgery has not yet been reported. METHODS Seventy-eight patients with cervical spondylotic myelopathy were divided into two groups prospectively, a diclofenac suppository (DS) group who received 50 mg diclofenac suppository at the end of the surgery, and an intrathecal morphine (ITM) group who were preoperatively administered 0.3 mg of morphine chloride, intrathecally, via a lumbar puncture. All patients underwent double-door laminoplasty of C3-6 or C3-7 level. Visual analog scale (VAS) of cervical pain, self-rating pain impression, supplemental analgesic usage, and complication rate were evaluated until the seventh postoperative day. RESULTS Thirty-one patients in the DS group and 32 patients in the ITM group were finally assessed. No baseline variable differences between the two groups were observed. The VAS was significantly lower in the ITM group at 4 h and 24 h until the seventh postoperative day. Self-rating pain impression was significantly better in the ITM group. No significant difference was observed in complication rate. CONCLUSIONS Intrathecal morphine was an effective and safe analgesic method for cervical laminoplasty in patients with cervical spondylotic myelopathy.
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Affiliation(s)
- Tetsuro Hida
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan; Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Japan.
| | | | - Keigo Ito
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan
| | - Masaaki Machino
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Japan
| | - Naoki Ishiguro
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Japan
| | - Fumihiko Kato
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Japan
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Jamjoom BA, Jamjoom AB. Efficacy of intraoperative epidural steroids in lumbar discectomy: a systematic review. BMC Musculoskelet Disord 2014; 15:146. [PMID: 24885519 PMCID: PMC4014751 DOI: 10.1186/1471-2474-15-146] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 04/30/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study is a descriptive review of the literature aimed at examining the efficacy of the use of intraoperative epidural steroids in lumbar disc surgery, a matter that remains controversial. METHODS The relevant clinical trials were selected from databases and reviewed. The methodological quality of each included study was assessed and graded for perceived risk of bias. All the documented significant and non-significant findings were collected. Our outcome targets were reduction in postoperative pain scores, consumption of analgesia, duration of hospital stay and no increase in complication rates. The variation in the timing of postoperative pain assessments necessitated grouping the outcome into three postoperative stages; early: 0 to 2 weeks, intermediate: more than 2 weeks to 2 months and late: more than 2 months to 1 year. RESULTS Sixteen trials that were published from 1990 to 2012 were eligible. At least one significant reduction in pain score was reported in nine of the eleven trials that examined pain in the early stage, in four of the seven trials that examined pain in the intermediate stage and in two of the eight trials that examined pain in the late stage. Seven of the nine trials that looked at consumption of postoperative analgesia reported significant reduction while six of the ten trails that examined the duration of hospital stay reported significant reduction. None of the trials reported a significant increase of steroid-related complications. CONCLUSIONS There is relatively strong evidence that intraoperative epidural steroids are effective in reducing pain in the early stage and reducing consumption of analgesia. There is also relatively strong evidence that they are ineffective in reducing pain in the late stage and in reducing duration of hospital stay. The evidence for their effectiveness in reducing pain in the intermediate stage is considered relatively weak. The heterogeneity between the trials makes it difficult to make undisputed conclusions and it indicates the need for a large multicenter trial with validated outcome measures that are recorded at fixed time intervals.
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Affiliation(s)
| | - Abdulhakim B Jamjoom
- Department of Surgery, Section of Neurosurgery, King Khalid National Guards Hospital, P O Box 9515, Jeddah 21423, Saudi Arabia.
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Postoperative Analgesic Effects of Wound Infiltration With Tramadol and Levobupivacaine in Lumbar Disk Surgeries. J Neurosurg Anesthesiol 2012; 24:331-5. [DOI: 10.1097/ana.0b013e3182611a1d] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Beyond opioid patient-controlled analgesia: a systematic review of analgesia after major spine surgery. Reg Anesth Pain Med 2012; 37:79-98. [PMID: 22030723 DOI: 10.1097/aap.0b013e3182340869] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Postoperative pain control in patients undergoing spine surgery remains a challenge for the anesthesiologist. In addition to incisional pain, these patients experience pain arising from deeper tissues such as bones, ligaments, muscles, intervertebral disks, facet joints, and damaged nerve roots. The pain from these structures may be more severe and can lead to neural sensitization and release of mediators both peripherally and centrally. The problem is compounded by the fact that many of these patients are either opioid dependent or opioid tolerant, making them less responsive to the most commonly used therapy for postoperative pain (opioid-based intermittent or patient-controlled analgesia). The purpose of this review was to compare all published treatment options available that go beyond intravenous opiates and attempt to find the best possible treatment modality.
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KJAERGAARD M, MØINICHE S, OLSEN KS. Wound infiltration with local anesthetics for post-operative pain relief in lumbar spine surgery: a systematic review. Acta Anaesthesiol Scand 2012; 56:282-90. [PMID: 22260370 DOI: 10.1111/j.1399-6576.2011.02629.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND In this systematic review, we evaluated double-blind, randomized and controlled trials on the effect of wound infiltration with local anesthetics compared with the effect of placebo on post-operative pain after lumbar spine surgery. METHODS Medline, the Cochrane Library and Google Scholar were searched for appropriate trials. Qualitative analysis of post-operative effectiveness was evaluated by assessment of significant difference (P < 0.05) between study groups regarding pain relief using pain scores, supplemental analgesic consumption and time to first analgesic request as outcome measures. Data on adverse effects were extracted and evaluated. RESULTS Nine trials including 12 comparisons and 529 patients met the inclusion criteria. Ten comparisons presented data on pain scores. In only three of these 10 comparisons (30%), a reduction in pain score using local anesthetic infiltration was observed averaging between 8 and 40 mm on a 100 mm visual analog scale. In six out of 12 comparisons, the local anesthetic infiltration significantly reduced the supplemental opioid consumption after surgery. Observed reductions in analgesic consumption over the first 24 h averaged between 2.5 mg and approximately 15 mg of morphine. Data on opioid-related adverse effects were incomplete and difficult to interpret. CONCLUSION Interpretation of the results was difficult because of diversity of the studies. However, clinical significance was in general questionable, with only a few trials showing a small or a modest reduction in pain intensity, which was observed mainly immediately after the operation. Similarly, although more frequently observed, only a minor and probably not clinically relevant reduction in opioid consumption was shown.
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Affiliation(s)
- M. KJAERGAARD
- Department of Anesthesia and Intensive Care; Glostrup University Hospital; Glostrup; Denmark
| | - S. MØINICHE
- Department of Anesthesia and Intensive Care; Glostrup University Hospital; Glostrup; Denmark
| | - K. S. OLSEN
- Department of Anesthesia and Intensive Care; Glostrup University Hospital; Glostrup; Denmark
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Meylan N, Elia N, Lysakowski C, Tramèr MR. Benefit and risk of intrathecal morphine without local anaesthetic in patients undergoing major surgery: meta-analysis of randomized trials. Br J Anaesth 2009; 102:156-67. [PMID: 19151046 DOI: 10.1093/bja/aen368] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Intrathecal morphine without local anaesthetic is often added to a general anaesthetic to prevent pain after major surgery. Quantification of benefit and harm and assessment of dose-response are needed. We performed a meta-analysis of randomized trials testing intrathecal morphine alone (without local anaesthetic) in adults undergoing major surgery under general anaesthesia. Twenty-seven studies (15 cardiac-thoracic, nine abdominal, and three spine surgery) were included; 645 patients received intrathecal morphine (dose-range, 100-4000 microg). Pain intensity at rest was decreased by 2 cm on the 10 cm visual analogue scale up to 4 h after operation and by about 1 cm at 12 and 24 h. Pain intensity on movement was decreased by 2 cm at 12 and 24 h. Opioid requirement was decreased intraoperatively, and up to 48 h after operation. Morphine-sparing at 24 h was significantly greater after abdominal surgery {weighted mean difference, -24.2 mg [95% confidence interval (CI) -29.5 to -19.0]}, compared with cardiac-thoracic surgery [-9.7 mg (95% CI -17.6 to -1.80)]. The incidence of respiratory depression was increased with intrathecal morphine [odds ratio (OR) 7.86 (95% CI 1.54-40.3)], as was the incidence of pruritus [OR 3.85 (95% CI 2.40-6.15)]. There was no evidence of linear dose-responsiveness for any of the beneficial or harmful outcomes. In conclusion, intrathecal morphine decreases pain intensity at rest and on movement up to 24 h after major surgery. Morphine-sparing is more pronounced after abdominal than after cardiac-thoracic surgery. Respiratory depression remains a major safety concern.
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Affiliation(s)
- N Meylan
- Division of Anaesthesiology, University Hospitals of Geneva, 24, rue Micheli-du-Crest, CH-1211 Geneva 14, Switzerland
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Affiliation(s)
- Jeffrey J Pasternak
- Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
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