Back Pain and Neuraxial Anesthesia

Comparison of the Effect of Landmark-Based Midline and Paramedian Approaches on Spinal Anesthesia-Related Complications in Adult Patients: A Meta-Analysis of Randomized Controlled Trials

Background and Objectives: Spinal anesthesia is widely used in various types of surgery. However, several complications can occur afterward. This study aimed to identify differences in the incidence of anesthesia-related complications according to the approach methods (midline versus paramedian) for landmark-based spinal anesthesia. Materials and Methods: We searched electronic databases, including PubMed, EMBASE, CENTRAL, Scopus, and Web of Science, for eligible randomized controlled trials. The primary outcome was post-dural puncture headache (PDPH) incidence, and secondary outcomes were low back pain (LBP) incidence and success rate in the first trial of spinal anesthesia. We estimated the odds ratio (OR) with 95% confidence intervals (CI) using a random-effects model. Results: In total, 2280 patients from 13 randomized controlled trials were included in the final analysis. The incidence rates of PDPH were 5.9% and 10.4% in the paramedian and midline approach groups, respectively. The pooled effect size revealed that the incidence of PDPH (OR: 0.43, 95% CI [0.22-0.83]; p = 0.01; I2 = 53%) and LBP (OR: 0.27, 95% CI [0.16-0.44]; p < 0.001; I2 = 16%) decreased, and the success rate in the first attempt was higher (OR: 2.30, 95% CI [1.36-3.87]; p = 0.002; I2 = 35%) with the paramedian than with the midline approach. Conclusions: Paramedian spinal anesthesia reduced PDPH and LBP and increased the success rate of the first attempt.

Complications of transvaginal radiofrequency ablation of fibroids: A 5-year experience

Introduction

Transvaginal radiofrequency ablation is a relatively noninvasive approach for the treatment of fibroids in patients who do not wish to undergo conventional surgery. Information on potential complications of this novel technique is very scarce.

Methods

Retrospective, descriptive, epidemiological study of 115 patients who underwent transvaginal radiofrequency ablation of fibroids and for whom complications were recorded.

Results

We performed 115 transvaginal radiofrequency ablation procedures, we recorded a total of 11 complications (9.6%; 95% CI, 3.8-14.8). Of these, 8 (7.0%) were classified as Clavien-Dindo type I, 1 (0.9%,) as type II, and 2 (1.7%) as type IIIb (severe). No other complications were recorded in a year follow-up.

Conclusion

Transvaginal radiofrequency ablation is a treatment option that makes it possible to treat fibroids that are difficult to manage using other techniques. Few associated complications have been described, and most of them are mild.

Incidence and Associated Factors of Postoperative Undesirable Anesthetic Outcomes Among Surgical Patients at Referral Hospitals in Amhara Region, Ethiopia: A Multi-Center Study

Background

Patients undergoing surgery frequently experience unfavorable anesthetic outcomes. They may have an impact on body systems and result in more serious postoperative morbidities. This study was conducted to determine the incidence of postoperative undesirable anesthetic outcomes among surgical patients at referral hospitals in Amhara region, Ethiopia.

Methods

A total of 412 patients, who underwent surgical procedures between August 1 and October 30 of 2022, were included in this study. The Leiden Perioperative Care Patient Satisfaction Questionnaire's (LPPSq) dimension "discomfort and needs" was used to collect data on the first postoperative day. Data entry and analysis were performed using SPSS version 20. To assess how risk factors affected the outcome variable, logistic regression analysis was utilized. In multivariable logistic regression analysis, a variable with a P-value of less than 0.05 was statistically considered as significant.

Results

The proportion of those who had "at least a little bit" of unfavorable outcomes was calculated to estimate their overall prevalence, and the prevalence of those who had "more than moderate" levels of unfavorable outcomes was determined to appreciate how severe these outcomes were. The percentages of postoperative pain, the most common undesired result, for "at least a little bit" and "more than moderate" were 87.7% and 32.3%, respectively. In this study, postoperative cold was the least prevalent (51.4%) undesirable anesthetic outcome. The remaining undesirable postoperative outcomes were reported less frequently.

Conclusion and Recommendation

Undesirable postoperative anesthetic outcomes were still common. The most frequent unfavorable result was postoperative pain. Adequate postoperative patient follow-up and quality service are paramount.

Laryngeal mask general anaesthesia versus spinal anaesthesia for promoting early recovery of cervical conisation: A randomised, controlled clinical study

Background

Although both spinal and general anaesthesia provides good anaesthesia for cervical conization, spinal anaesthesia delays the return of lower limb movements and urinary function, whereas general anaesthesia requires the patient to be unconscious. It is unclear which anaesthetic technique is more conducive to early postoperative recovery in patients undergoing cervical conization.

Patients and methods

140 patients undergoing cervical conization underwent either laryngeal mask general anaesthesia (LMA, n = 70) or spinal anaesthesia (SA, n = 70). In the LMA group, an i-gel mask was used for airway management. In the SA group, spinal anaesthesia was received with 0.75% ropivacaine (15 mg) in the L3-4 interval. The quality of recovery score (QoR-15) was the primary endpoint of the study. Secondary endpoints included incidence of adverse 24-h analgesia (NRS>3); return of lower limb activity; first bed activity and feeding; and the number of catheters removed at 6, 12 and 24 h postoperatively.

Result

The LMA group significantly improved QoR-15 scores (136.62 ± 11.02 vs 119.97 ± 12.75; P < 0.001); and reduced the incidence of poor analgesia (NRS >3) within 24 h postoperatively (20% vs 42.8%, P = 0.006); reduced time in bed (15.62 ± 3.83 h vs 18.27 ± 5.57 vs, P = 0.001); improved patient satisfaction (86% vs 27%; P < 0.001); and catheters removal within 24 h (70/70 vs 42/70, P < 0.001).

Conclusion

LMA general anaesthesia can facilitate early postoperative recovery in patients undergoing cervical conization compared with conventional spinal anaesthesia.

Trial registration

Chinese Clinical Trial Registry (ID: ChiCTR1800019384), http://www.chictr.org.cn/listbycreater.aspx (08/11/2018).

Comparison of postoperative back pain between paramedian and midline approach for thoracic epidural anesthesia

Background: The development of back pain following epidural analgesia is one reason for patient refusal of neuraxial analgesia. The primary endpoint of this study was to compare the incidence and severity of back pain following midline and paramedian epidural technique. The secondary endpoint was to identify the risk factors associated with the occurrence of back pain.Methods: This prospective randomized study included 114 patients receiving thoracic epidural catheterization for pain management following upper abdominal or thoracic surgery. Patients were allocated to either the midline or the paramedian group by computer-generated randomization. An investigator who was blinded to the patient group interviewed patients at 24, and 48 h, and 3–5 days after surgery about the existence of back pain and its severity.Results: The total incidence of back pain following epidural anesthesia was 23.8% in the midline group and 7.8% in the paramedian group. The numerical rating scale of back pain was not different between the two groups at 24 h and 4 days after surgery. The paramdian technique was associated with a lower incidence of back pain than the midline technique (95% confidence interval 0.05–0.74, odds ratio 0.2, P < 0.01). However, the number of attempts, surgical position, body mass index, and duration of surgery were not associated with back pain.Conclusions: This study showed that the midline group of thoracic epidural analgesia demonstrated higher incidence of back pain than the paramedian group. However, the pain was mild in intensity and decreased with time in both groups.

Usefulness of ultrasonography guided femoral and lateral femoral cutaneous nerve blocks in providing analgesia before giving spinal anaesthesia in patients undergoing surgery for intertrochanteric fracture of femur: A randomized clinical trial

Background and Aims

It is challenging to give the patient position for subarachnoid block (SAB) as intertrochanteric (IT) fracture of the femur produces intolerable pain. In this study, we have analyzed the usefulness of combined ultrasonography (USG)-guided femoral nerve block (FNB) and lateral femoral cutaneous nerve block (LFCNB) to reduce the fracture pain before performing SAB.

Material and Methods

A prospective, randomized, comparative study was conducted on 60 American society of anesthesiologists (ASA) grade I and II patients (18-80 years) scheduled for elective IT fracture surgery. Group A (n = 30) patients received USG-guided FNB and LFCNB using 0.75% ropivacaine before SAB. Group B patients (n = 30) received SAB only. All the patients received SAB (3 mL of 0.5% bupivacaine) by an anesthesiologist blinded to the patient groups. The patients were observed for quality of patient positioning for SAB, perioperative visual analog scale (VAS) scores, time to administration of SAB, and duration of analgesia and motor blockade. Statistical analysis was done by Student's t-test and Chi-square test.

Results

Baseline VAS score (T1) was similar in both the groups. Mean T2 (VAS score just before SAB) in group-A (3.2 ± 0.98) was lower compared to group-B (8.23 ± 0.7) with P < 0.0001. The quality of patient positioning in group-A was good to optimal but in group-B, it was satisfactory to not satisfactory. Group-A had longer mean duration of analgesia 804 ± 114.28 minutes with P value < 0.0001 than group-B in which it was 200 ± 28.77 min. Backache was significant in group-B with P value of 0.038 compared to group-A.

Conclusion

USG-guided FNB and LFCNB can be used as an effective supplementation to SAB in patients undergoing surgery for IT fracture of the femur as it reduces fracture site pain, provides good patient positioning during SAB, and prolongs postoperative analgesia.

Prevalence of chronic pain syndrome in patients who have undergone hallux valgus percutaneous surgery: a comparison of sciatic-femoral and ankle regional ultrasound-guided nerve blocks

Background

Chronic pain syndrome (CPS) is a common complication after operative procedures, and only a few studies have focused on the evaluation of CPS in foot-forefoot surgery and specifically on HV percutaneous correction. The objective of this study was to compare postoperative pain levels and incidence of CPS in two groups of patients having undergone femoral-sciatic nerve block or ankle block regional anaesthesia before hallux valgus (HV) percutaneous surgery and the association between postoperative pain levels and risk factors between these patient groups.

Methods

A consecutive patient series was enrolled and evaluated prospectively at 7 days, 1, 3 and 6 months after surgery. The participants were divided into two groups according to the regional anaesthesia received, femoral-sciatic nerve block or ankle block, and their outcomes were compared. The parameters assessed were postoperative pain at rest and during movement by the numerical rating scale (NRS), patient satisfaction using the Visual Analogue Scale (VAS), quality of life and return to daily activities. Statistical analysis was performed.

Results

One hundred fifty-five patients were assessed, 127 females and 28 males. Pain at rest (p < 0.0001) and during movement (p < 0.0001) significantly decreased during the follow-ups; at 6 months, 13 patients suffered from CPS. Over time, satisfaction remained stable (p > 0.05), quality of life significantly increased and patients returned to daily activities and work (p < 0.0001). No significant impact of type of anaesthesia could be detected. ASA 3 (p = 0.043) was associated to higher pain during movement; BMI (p = 0.005) and lumbago (p = 0.004) to lower satisfaction. No operative-anaesthetic complications were recorded. Postoperative pain at rest and during movement improved over time independently of the regional block used, with low incidence of CPS at last follow-up. Among risk factors, only a higher ASA was associated to higher pain during movement, while higher BMI and lumbago to lower satisfaction.

Conclusions

Both ultrasound-guided sciatic-femoral and ankle blocks were safe and effective in reducing postoperative pain with low incidence of CPS at last follow-up.

Trial registration

Clinical Trial NCT02886221. Registered 1 September 2016.

Dry cupping therapy is not superior to sham cupping to improve clinical outcomes in people with non-specific chronic low back pain: a randomised trial

QUESTION

What are the effects of dry cupping on pain intensity, physical function, functional mobility, trunk range of motion, perceived overall effect, quality of life, psychological symptoms and medication use in individuals with chronic non-specific low back pain?

DESIGN

Randomised controlled trial with concealed allocation, intention-to-treat analysis and blinding of participants and assessors.

PARTICIPANTS

Ninety participants with chronic non-specific low back pain.

INTERVENTIONS

The experimental group (n = 45) received dry cupping therapy, with cups bilaterally positioned parallel to the L1 to L5 vertebrae. The control group (n = 45) received sham cupping therapy. The interventions were applied once a week for 8 weeks.

OUTCOME MEASURES

Participants were assessed before and after the first treatment session, and after 4 and 8 weeks of intervention. The primary outcome was pain intensity, measured with the numerical pain scale at rest, during fast walking and during trunk flexion. Secondary outcomes were physical function, functional mobility, trunk range of motion, perceived overall effect, quality of life, psychological symptoms and medication use.

RESULTS

On a 0-to-10 scale, the between-group difference in pain severity at rest was negligible: MD 0.0 (95% CI -0.9 to 1.0) immediately after the first treatment, 0.4 (95% CI -0.5 to 1.5) at 4 weeks and 0.6 (95% CI -0.4 to 1.6) at 8 weeks. Similar negligible effects were observed on pain severity during fast walking or trunk flexion. Negligible effects were also found on physical function, functional mobility and perceived overall effect, where mean estimates and their confidence intervals all excluded worthwhile effects. No worthwhile benefits could be confirmed for any of the remaining secondary outcomes.

CONCLUSION

Dry cupping therapy was not superior to sham cupping for improving pain, physical function, mobility, quality of life, psychological symptoms or medication use in people with non-specific chronic low back pain.

PROTOCOL REGISTRATION NUMBER

NCT03909672.

Prevalence and Factors Associated with Back Pain among Patients Undergoing Spinal Anesthesia at the University of Gondar Comprehensive and Specialized Hospital, North West Ethiopia: An Institutional Based Cross-Sectional Study

BACKGROUND

Back pain is often reported as a common complaint after surgery. Many studies showed that the prevalence of back pain after spinal anesthesia is high and its magnitude is considerable in developing countries. It is highly related to reduced quality of life, loss of work productivity, burden of health care costs, and satisfaction regarding health care service; therefore, measures should be taken to reduce or prevented postspinal back. The aim of this cross-sectional study was to assess the prevalence and factors associated with back pain among patients undergoing spinal anesthesia at the University of Gondar Comprehensive and Specialized Hospital, Northwest Ethiopia. Methodology. An institutional based cross-sectional study was conducted from March to May 2020. A total of 215 participants were enrolled in this study. A convenience sampling technique was used to get the study participants. Both univariable and multivariable logistic regression were used to identify factors associated with postspinal back pain. Variables with a p value less than <0.2 in the bivariable analysis were fitted into the multivariable analysis. In the multivariable analysis, a variable with a p value of <0.05 was considered statistically significant.

RESULTS

The overall prevalence of postspinal back pain was 40.5% (95% CI: 34.0, 47.4). Being overweight (AOR = 3.8; 95% CI: 1.47, 9.96) and obese (AOR = 4.9; 95% CI: 1.19, 20.4), using big spinal needles (AOR = 5.9; 95% CI: 1.04, 33.4), two attempts of lumbar puncture (AOR = 5.5; 95% CI: 1.74, 17.59), more than three attempts of lumbar puncture (AOR = 4.9; 95% CI: 1.63, 15.2), and the number of bone contacts during spinal anesthesia procedure (AOR = 3.1; 95% CI: 1.14, 8.45) were positively associated with postspinal back pain. Conclusion and Recommendation. The overall incidence of back pain is high. Body mass index, size of spinal needle, number of attempts, and number of bone contacts are significantly associated with the incidence of back pain following spinal anesthesia. Thus, it is better to minimize the number of lumbar puncture attempts and bone contacts during spinal anesthesia to reduce postspinal back pain. In addition, using smaller size spinal needle is a good choice.

Incidence of newly developed postoperative low back pain with median versus paramedian approach for spinal anesthesia

Background

The effects of anesthetic techniques on postdural puncture backache (PDPB) have not been specifically evaluated. The purpose of this study was to compare the incidence and severity of PDPB between median and paramedian techniques.

Methods

Patients were randomized to receive spinal anesthesia by either a median (Group M, n = 50) or paramedian (Group P, n = 50) approach.We recorded each patient’s personal number of puncture attempts, surgical position, and operation duration. We investigated the incidence and intensity of back pain 1 day, 1 week, and 1, 2, and 3 months postoperatively.

Results

The overall incidence of PDPB was higher in the Group M (18/50, 36%) than in the Group P (8/50, 16%) (P = 0.023). Twenty-four hours after surgery, 8 patients in Group M and 6 patients in Group P complained of back pain. Seven days after the surgery, 16 patients in the Group M and 5 patients in the Group P complained of pain (P = 0.007). After 1 month, 5 patients in the Group M and 1 patient in the Group P complained of pain. Only one patient in each group complained of pain after 3 months. No significant differences were noted in NRSs between the groups during study period.

Conclusions

The results of this study suggest that spinal anesthesia using the paramedian approach reduces the incidence of PDPB during the early postoperative period.

Dry cupping in the treatment of individuals with non-specific chronic low back pain: a protocol for a placebo-controlled, randomised, double-blind study

BACKGROUND

Low back pain is a very prevalent condition in the population and cupping therapy has been presented as a frequently used non-pharmacological treatment in this population. However, there is a lack of well-designed studies that evaluate the effects of this technique. This protocol describes a placebo-controlled, randomised, double-blind study that aims to evaluate the effect of dry cupping therapy on pain, physical function, trunk range of motion, quality of life and psychological symptoms in individuals with non-specific chronic low back pain.

METHODS AND ANALYSIS

Ninety individuals with chronic non-specific low back pain, aged from 18 to 59 years, will be randomised into two groups: intervention group, which will be submitted to dry cupping therapy application with two suctions; and placebo group which will undergo placebo dry cupping therapy. Both applications will occur bilaterally in parallel to the vertebrae from L1 to L5. The application will be performed once a week for 8 weeks. The volunteers will be evaluated before the treatment (T0), immediately after the first intervention (T1), after 4 weeks of intervention (T4) and after 8 weeks of intervention (T8). The primary outcome will be pain intensity, and secondary outcomes will be physical function, lumbar range of motion, patient expectation, overall perception of effect, quality of life and psychological factors.

ETHICS AND DISSEMINATION

This protocol has been approved by the Ethics Committee of FACISA/UFRN (number: 3639814). The results of the study will be disseminated to participants through social networks and will be submitted to a peer-reviewed journal and scientific meetings.

TRIAL REGISTRATION NUMBER

NCT03909672.

Predictors of difficult epidural placement in pregnant women: A trainees' perspective

BACKGROUND AND AIMS

Epidural analgesia is believed to be the most difficult technique to learn for a trainee. The reason for this is not only inexperience of the provider and the complexity of the technique but also patient factors like obesity, spinal deformity and others which makes the epidural placement difficult. The aim of this study was to evaluate some of the common risk factors for difficult epidural placement as perceived by the anesthesia providers during training, with varying level of experience.

MATERIAL AND METHODS

This prospective observational study includes patients who received epidural placement for labor analgesia. Data recorded on these patients included age, height, weight, body mass index (BMI), ease of palpation of the spinous process, level of epidural placement, number of attempts, time taken for epidural placement and experience of the provider. The association between the variables were assessed using logistic regression for first attempt success and Cox proportional hazard ratio for time to epidural placement.

RESULTS

A total of 373 patients received epidural placement for labor analgesia. The mean BMI at the time of placement was 34. The first attempt success rate for the placement of epidural was 67% (n = 273). Women with well palpable spinous process were 3.3 times more likely to have a successful first attempt placement irrespective of the provider experience or BMI [3.39 (1.77-6.51), P < 0.001]. The time to placement was shorter in patients with good anatomical landmarks [1.58 (1.20-2.07), P < 0.001) and when performed by a trainee who had performed a minimum of 20 epidural procedures [1.57 (1.26-1.94), P < 0.001).

CONCLUSION

Inability to palpate the spinous process contributes to multiple attempts at epidural placement when performed by a trainee.

General or regional? Exploring patients' anaesthetic preferences and perception of regional anaesthesia

INTRODUCTION AND OBJECTIVES

Regional anaesthesia (RA) has gained popularity due to its numerous benefits and increasing safety. Yet, often patients refuse this procedure and prefer general anaesthesia (GA). This study aimed to investigate variables (demographic factors, safety perception of GA and RA, patients' fears, anxiety, and knowledge) related to patients' anaesthetic preference.

MATERIAL AND METHODS

Participants were patients aged 18 years or more proposed to an anaesthesia appointment for preoperative assessment. Patients completed a written questionnaire before meeting the anaesthesiologist. The questionnaire asked about their preferences, fears and perceptions about RA.

RESULTS

One hundred and 2patients agreed to participate. Mean age was 52.6±13.5 years, 57.8% were female and 44.5% had at least 12 years of education. Given the choice, 54.0% would prefer GA and 20.7% said they would refuse RA if proposed by the anaesthesiologist. Among patients who already experienced neuroaxial anaesthesia, 40.0% said they did not wish to repeat it. Patients who preferred GA over RA perceived GA to be safer than RA and expressed more anxiety towards being awake during surgery and more fear of feeling pain during surgery, of having back pain, and of needle puncture. Results also suggested that patients are unaware of RA's real risks and benefits.

CONCLUSIONS

Knowing patients' fears is essential for the anaesthesiologist address their patients' needs. Anaesthesiologists should work on improving general population perspective and knowledge about RA.