The effect of preoperative administration of morphine in alleviating intraoperative pain of percutaneous transforaminal endoscopic discectomy under local anesthesia: A STROBE compliant study

Morphine aggravates inflammatory, behavioral, and hippocampal structural deficits in septic rats

Although pain and sepsis are comorbidities of intensive care units, reported data on whether pain control by opioid analgesics could alter inflammatory and end-organ damage caused by sepsis remain inconclusive. Here, we tested the hypothesis that morphine, the gold standard narcotic analgesic, modifies behavioral and hippocampal structural defects induced by sepsis in male rats. Sepsis was induced with cecal ligation and puncture (CLP) and behavioral studies were undertaken 24 h later in septic and/or morphine-treated animals. The induction of sepsis or exposure to morphine (7 mg/kg) elicited similar: (i) falls in systolic blood pressure, (ii) alterations in spatial memory and learning tested by the Morris water maze, and (iii) depression of exploratory behavior measured by the new object recognition test. These hemodynamic and cognitive defects were significantly exaggerated in septic rats treated with morphine compared with individual interventions. Similar patterns of amplified inflammatory (IL-1β) and histopathological signs of hippocampal damage were noted in morphine-treated septic rats. Additionally, the presence of intact opioid receptors is mandatory for the induction of behavioral and hemodynamic effects of morphine because no such effects were observed when the receptors were blocked by naloxone. That said, our findings suggest that morphine provokes sepsis manifestations of inflammation and interrelated hemodynamic, behavioral, and hippocampal deficits.

Spinal anesthesia for L5-S1 interlaminar endoscopic lumbar discectomy: a retrospective study

OBJECTIVE

This study aimed to report our experience with spinal anesthesia (SA) in patients undergoing L5-S1 interlaminar endoscopic lumbar discectomy (IELD) and clarify its advantages and disadvantages.

METHODS

One hundred twelve patients who underwent IELD for an L5-S1 disc herniation under SA were retrospectively analyzed. SA with 0.5% ropivacaine was administered using a 27-gauge fine needle. Intraoperatively, the volume and level of SA, surgical time, blood loss, and cardiopulmonary complications were documented. Postoperative data was collected included the number of patients who ambulated on the day of surgery, incidence of complications and were then statistically analyzed.

RESULTS

Analgesia was complete throughout the entire operation in all patients and no other adjuvant intraoperative analgesic drugs were needed. Mean visual analog scale scores for intraoperative and early postoperative (24 h) pain were 0 and 2.43 ± 1.66. SA was administered at the L3-4 interspace in 34 patients (30.4%) and the L2-3 interspace in 78 (69.6%). Administration was successful with the first attempt in all patients. Mean operation time was 70.12 ± 6.52 min. Mean intraoperative blood loss volume was 20.71 ± 5.26 ml. Ninety-eight patients ambulated on the same day as surgery. Mean length of hospital stay was 24.36 ± 3.64 h. Dural injury without damaging the nerve root occurred in one patient. One patient experienced recurrent disc herniation. Intraoperative hypotension and respiratory distress occurred in five (4.5%) and three (2.7%) patients, respectively. Three patients (2.7%) received postoperative analgesia therapy and two (1.8%) experienced nausea. Two patients (1.8%) developed urinary retention. Spinal headache, cauda equina syndrome, and neurotoxicity did not occur.

CONCLUSION

SA can achieve satisfactory pain control for patients undergoing IELD with a low incidence of adverse events. SA may be a useful alternative to local and general anesthesia for IELD surgery. Future randomized controlled trials are warranted to investigate.

Anesthesia methods for full-endoscopic lumbar discectomy: a review

Full-endoscopic lumbar discectomy under local anesthesia is major trends for the treatment of lumbar disc herniation in spine minimally invasive surgery. However, sometimes local anesthesia is not enough for analgesic in surgery especially in interlaminar approach. This study summarizes the current study of anesthesia methods in full-endoscopic lumbar discectomy. Local anesthesia is still the most common anesthesia method in full-endoscopic lumbar discectomy and the comparison group for other anesthesia methods due to high safety. Compared to local anesthesia, Epidural anesthesia is less applied in full-endoscopic lumbar discectomy but reports better intraoperative pain control and equivalent safety due to the motor preservation and pain block characteristic of ropivacaine. General anesthesia can achieve totally pain block during surgery but nerve injury can not be ignored, and intraoperative neuromonitoring can assist. Regional anesthesia application is rare but also reports better anesthesia effects during surgery and equivalent safety. Anesthesia methods for full-endoscopic lumbar discectomy should be based on patient factors, surgical factors, and anesthesiologist factors to achieve satisfactory anesthesia experience and successful surgery.

Angulation error assessment for the trajectory in the anteroposterior and lateral fluoroscopic views during percutaneous endoscopic transforaminal lumbar discectomy

BACKGROUND

Anteroposterior (AP) and lateral fluoroscopies are often used to evaluate the intraoperative location and angulation of the trajectory in percutaneous endoscopic transforaminal lumbar discectomy (PETLD). Although the location of the trajectory shown in fluoroscopy is absolutely accurate, the angulation is not always reliable. This study aimed to evaluate the accuracy of the angle shown in the AP and lateral fluoroscopic views.

METHODS

A technical study was performed to assess the angulation errors of PETLD trajectories shown in AP and lateral fluoroscopic views. After reconstructing a lumbar CT image, a virtual trajectory was placed into the intervertebral foramen with gradient-changing coronal angulations of the cephalad angle plane (CACAP). For each angulation, virtual AP and lateral fluoroscopies were taken, and the cephalad angles (CA) of the trajectory shown in the AP and lateral fluoroscopic views, which indicated the coronal CA and the sagittal CA, respectively, were measured. The angular relationships among the real CA, CACAP, coronal CA, and sagittal CA were further demonstrated with formulae.

RESULTS

In PETLD, the coronal CA is approximately equal to the real CA, with a small angle difference and percentage error, whereas the sagittal CA shows a rather large angle difference and percentage error.

CONCLUSION

The AP view is more reliable than the lateral view in determining the CA of the PETLD trajectory.

Adequacy of Anaesthesia for Nociception Detection during Vitreoretinal Surgery

Vitreoretinal surgery (VRS) is one of the most widely performed precise procedures in ophthalmic surgery; the majority of cases are carried out under regional anaesthesia (RA) only. However, in specific situations (such as when the patient fails to cooperate with the operator for various reasons), general anaesthesia (GA), alone or in combination with GA (combined general-regional anaesthesia, CGR), is the only safe way to perform VRS. While monitoring the efficacy of an intraoperative rescue opioid analgesia (IROA) during surgery (assessing the adequacy of anaesthesia (AoA)) may be challenging, the surgical pleth index (SPI) is a useful tool for detecting the reaction to noxious stimuli and allows for the rational titration of opioid analgesics (AO) during surgery. The current study investigated the influence of the SPI-based titration of fentanyl (FNT) in combination with various pre-emptive analgesia (PA) techniques on intraoperative pain perception during various stages of VRS performed under AoA. A total of 176 patients undergoing VRS under GA were enrolled in the study. They were randomly assigned to one of the five following study arms: Group GA (control group)-patients who received general anaesthesia alone; Group PBB-GA with preprocedural peribulbar block (with 0.5% bupivacaine and 2% lidocaine); Group T-GA with preventive, topical 2% proparacaine; Group M-GA with a preprocedural intravenous infusion of 1.0 g of metamizole; and Group P-GA with a preprocedural intravenous infusion of 1.0 g of paracetamol. The whole procedure was divided in four stages: Stage 1 and 2-preoperative assessment, PA administration, and the induction of GA; Stage 3-intraoperative observation; Stage 4-postoperative observation. the SPI values were monitored during all stages. The occurrence of nociception (expressed as ∆SPI >15) during various manipulations in the surgical field was observed, as were cumulative doses of rescue analgesia, depending on the PA administered. During the course of VRS, rescue FNT doses varied depending on the stage of surgery and the group investigated. The majority of patients, regardless of their group allocation, needed complementary analgesia during trocar insertion, with Group GA patients requiring the highest doses. Likewise, the highest cumulative doses of IROA were noted during endophotocoagulation in Group GA. Preventive PBB and topical anaesthesia were proven to be most efficient in blunting the response to speculum installation, while topical anaesthesia and paracetamol infusion were shown to be more efficient analgesics during endophotocoagulation than other types used PA. In the performed study, none of the PA techniques used were superior to GA with FNT dosing under the SPI with respect to providing efficient analgesia throughout the whole surgery; there was a necessity to administer a rescue OA dose in both the control and investigated groups.

Analgesic effect of epidural anesthesia via the intervertebral foramen approach in percutaneous transforaminal endoscopic discectomy: a retrospective study

BACKGROUND

Satisfactory intraoperative analgesia is critical for percutaneous transforaminal endoscopic discectomy (PTED). Local anesthesia (LA) and epidural anesthesia (EA) are recommended for PTED. LA alone does not achieve satisfactory pain management during PTED and other analgesics or sedatives are usually needed. Traditional EA, which involves implanting an epidural catheter through the midline or paramedian, has disadvantages such as difficulty in catheterization and increased preoperative preparation time. Rather than performing conventional EA, we injected local anesthetics through the intervertebral foramen during the puncture process, which we termed lumbar transforaminal EA (LTEA), and observed its feasibility and safety. This study aimed to conduct a comprehensive comparison of differences in analgesia between LA and LTEA in patients with PTED.

METHODS

We performed a retrospective analysis of patients who underwent PTED between January 2018 and January 2021. Patients were divided into LA and LTEA groups. Data obtained from the electronic medical records included primary outcomes (visual analog scale [VAS] scores and anesthesia satisfaction rate) and secondary outcomes, including vital signs such as heart rate (HR), mean arterial pressure (MAP), total dosage of fentanyl, operation time, X-ray exposure time, Oswestry Disability Index (ODI) scores, and complications.

RESULTS

In total, 160 patients (80 in each group) were analyzed in this study. The VAS scores for lumbar and leg pain were significantly lower in the LTEA group than in the LA group (P < 0.0001). The anesthesia satisfaction rate was 90.0% in the LTEA group and 72.5% in the LA group (P < 0.005). MAP and HR values in the LTEA group were significantly lower than those in the LA group (P < 0.05). The total dose of fentanyl in the LTEA group was significantly lower than that in the LA group (P < 0.05). As for ODI values, the average operation time, X-ray exposure time, and incidence of complications were not significantly different between the two groups (P > 0.05).

CONCLUSIONS

LTEA simplifies the process of EA and can achieve a good analgesic effect intraoperatively without increasing the preoperative preparation time; thus, it may be adopted as an alternative mode of anesthesia during PTED surgery.

Determining the Minimum Effective Concentration of Ropivacaine in Epidural Anesthesia for Tolerable Pain in Transforaminal Percutaneous Endoscopic Lumbar Discectomy to Avoid Nerve Injury: A Double-Blind Study Using a Biased-Coin Design

Purpose

Epidural anesthesia (EA) is the main anesthesia method for transforaminal percutaneous endoscopic lumbar discectomy (PELD). Reducing the concentration of ropivacaine can help preserve tactile sensation, allowing patients to provide timely feedback to the surgeons when a nerve root is contacted to avoid nerve injury. Therefore, a 90% effective concentration (EC₉₀) that allows for mild pain [visual analog scale (VAS) score ≤3] while maximizing tactile sensation must be identified.

Methods

The concentration of ropivacaine for EA was varied for consecutive patients in this study using a two-stage biased-coin design (BCD) according to the response of the previous patient; the concentration used for the first patient was 0.2%. When the previous patient had a negative response (VAS score >3), the concentration used for the next one was increased by 0.015%. When the previous patient had a positive response (VAS score ≤3), the concentration used for the next one had an 89% probability of remaining the same and an 11% probability of being reduced by 0.015%. The EC₉₀ of ropivacaine was estimated using isotonic regression, and the 95% confidence interval (CI) was estimated using the bootstrapping method in R.

Results

A total of 58 patients were included in the study. The calculated EC₉₀ was 0.294% [95% CI (0.271%, 0.303%)]. Among 13 patients who reported unintended nerve root contact during the operation, none were found to have irreversible nerve injury after the operation.

Conclusion

To preserve maximum tactile sensation, the EC₉₀ of ropivacaine was 0.294% for patients with allowed mild pain. This concentration could allow for timely feedback when the nerve root is contacted, to avoid nerve injury.

Effect Analysis of Epidural Anesthesia with 0.4% Ropivacaine in Transforaminal Endoscopic Surgery

Background

Epidural anesthesia used in percutaneous endoscopic lumber discectomy (PELD) has the risk of complete neurotactile block. Patients cannot timely respond to the operator when the nerve is touched by mistake, so the potential risk of nerve injury cannot be avoided. According to pharmacodynamics, with the decrease of local anesthetic concentration, the nerve tactile gradually recovered; however, the analgesic effect also gradually weakened. Therefore, it is necessary to explore an appropriate concentration of local anesthetics that can keep the patients' nerve touch without pain. By comparing the advantages and disadvantages of 0.4% ropivacaine epidural anesthesia, local anesthesia and intravenous anesthesia on intraoperative circulation fluctuation, the incidence of salvage analgesia and the incidence of nerve non-touch, the feasibility of using low concentration epidural anesthesia in PELD to obtain enough analgesia and avoid the risk of nerve injury was confirmed.

Methods

153 cases of intervertebral foramen surgery from October 2017 to January 2020 were selected and divided into local anesthesia group (LA group), 0.4% ropivacaine epidural anesthesia group (EA group), and intravenous anesthesia group (IVA group) according to different anesthesia methods. The changes of blood pressure and heart rate, the incidence of rescue analgesia and nerve root non-touch were compared among the three groups.

Results

The difference of map peak value among the three groups was statistically significant (P < 0.001); pairwise comparison showed that the map peak value of the LA group was higher than that of the EA group (P < 0.001) and IVA group (P < 0.001), but there was no statistical significance between the EA group and IVA group. The difference of HR peak value among the three groups was statistically significant; pairwise comparison showed that the HR peak value of the LA group was higher than that of the EA group (P < 0.001) and IVA group (P < 0.001), but there was no statistical significance between the EA group and IVA group. There was significant difference in the incidence of intraoperative hypertension among the three groups (P < 0.05); pairwise comparison showed that the incidence of intraoperative hypertension in the EA group was lower than that in the LA group (P < 0.05), while there was no significant difference between the IVA group, EA group, and LA group. There was significant difference in the incidence of rescue analgesia among the three groups (P < 0.01); pairwise comparison showed that the incidence of rescue analgesia in the EA group was lower than that in the LA group (P < 0.05) and IVA group (P < 0.05), but there was no significant difference between the LA group and IVA group. Due to the different analgesic mechanisms of the three anesthesia methods, local anesthesia and intravenous anesthesia do not cause the loss of nerve tactile, while the incidence of nerve tactile in 0.4% ropivacaine epidural anesthesia is only 2.4%, which is still satisfactory.

Conclusion

Epidural anesthesia with 0.4% ropivacaine is a better anesthesia method for PELD. It not only has a low incidence of non-tactile nerve, but also has perfect analgesia and more stable intraoperative circulation.

Comparison of effectiveness and safety between epidural anesthesia vs local anesthesia for percutaneous transforaminal endoscopic discectomy: A systematic review and meta-analysis

OBJECTIVES

To compare the effectiveness and safety of epidural anesthesia (EA) with those of local anesthesia (LA) for percutaneous transforaminal endoscopic discectomy (PTED) and provide reference data for clinical decision-making.

METHODS

We searched PubMed, Embase, the Cochrane library, Web of Science, Medline, ScienceDirect, and the China National Knowledge Infrastructure from inception to June 2019 in order to identify randomized and nonrandomized controlled trials comparing EA and LA for PTED. Studies assessing at least 2 of the following indicators were eligible: surgical duration, X-ray exposure time, satisfaction rate, visual analog scale (VAS) scores for pain, Oswestry Disability Index (ODI), and complications. Two assessors evaluated the quality of the literature using the Cochrane Handbook or Newcastle-Ottawa Scale. Meta-analysis was conducted using Review Manager 5.3.3 software.

RESULTS

Four randomized controlled trials and 4 retrospective cohort studies involving a total of 1000 patients were included. The LA and EA groups included 473 and 527 patients, respectively. Meta-analysis revealed significant intergroup differences in the intraoperative (P < .00001) and postoperative (P < .00001) lumbar VAS scores, intraoperative (P < .00001) and postoperative (P = .001) leg VAS scores, and anesthesia satisfaction rate (P < .00001), with EA being superior to LA in all aspects. There were no significant intergroup differences in the surgical duration, X-ray exposure time, postoperative ODI, and complication rate.

CONCLUSION

EA is as safe as LA and produces better anesthetic effects than does LA in patients undergoing PTED. Therefore, it should be promoted as a reliable anesthetic technique for PTED.