Effect of celecoxib and dexamethasone on postoperative pain after lumbar disc surgery

Methylprednisolone taper is an effective addition to multimodal pain regimens after total shoulder arthroplasty: results of a randomized controlled trial: 2022 Neer Award winner

BACKGROUND

Perioperative corticosteroids have shown potential as nonopioid analgesic adjuncts for various orthopedic pathologies, but there is a lack of research on their use in the postoperative setting after total shoulder arthroplasty (TSA). The purpose of this study was to assess the effect of a methylprednisolone taper on a multimodal pain regimen after TSA.

METHODS

This study was a randomized controlled trial (clinicaltrials.gov NCT03661645) of opioid-naive patients undergoing TSA. Patients were randomly assigned to receive intraoperative dexamethasone only (control group) or intraoperative dexamethasone followed by a 6-day oral methylprednisolone (Medrol) taper course (treatment group). All patients received the same standardized perioperative pain management protocol. Standardized pain journal entries were used to record visual analog pain scores (VAS-pain), VAS-nausea scores, and quantity of opioid tablet consumption during the first 7 postoperative days (POD). Patients were followed for at least one year postoperatively for clinical evaluation, collection of patient-reported outcomes, and observation of complications.

RESULTS

A total of 67 patients were enrolled in the study; 32 in the control group and 35 in the treatment group. The groups had similar demographics and comorbidities. The treatment group demonstrated a reduction in mean VAS pain scores over the first 7 POD. Between POD 1 and POD 7, patients in the control group consumed an average of 17.6 oxycodone tablets while those in the treatment group consumed an average of 5.5 tablets. This equated to oral morphine equivalents of 132.1 and 41.1 for the control and treatment groups, respectively. There were fewer opioid-related side effects during the first postoperative week in the treatment group. The treatment group reported improved VAS pain scores at 2-week, 6-week, and 12-week postoperatively. There were no differences in Europe Quality of Life, shoulder subjective value (SSV), at any time point between groups, although American Shoulder and Elbow Surgeons questionnaire scores showed a slight improvement at 6-weeks in the treatment group. At mean follow-up, (control group: 23.4 months; treatment group:19.4 months), there was 1 infection in the control group and 1 postoperative cubital tunnel syndrome in the treatment group. No other complications were reported.

CONCLUSIONS

A methylprednisolone taper course shows promise in reducing acute pain and opioid consumption as part of a multimodal regimen following TSA. As a result of this study, we have included this 6-day methylprednisolone taper course in our multimodal regimen for all primary shoulder arthroplasties. We hope this trial serves as a foundation for future studies on the use of low-dose oral corticosteroids and other nonnarcotic modalities to control pain after shoulder surgeries.

The impact of perioperative nonsteroidal anti-inflammatory drugs on the postoperative outcomes of spinal surgery: a meta-analysis of 23 randomized controlled trials

In recent years, nonsteroidal anti-inflammatory drug (NSAIDs), which are considered to affect the prognosis of spinal surgery, have been widely used in perioperative analgesia in spinal surgery, but the relationship between these two factors remains unclear. The purpose of this study was to explore the effect of perioperative use of NSAIDs on the prognosis of patients treated with spinal surgery. We systematically searched PubMed, Embase, and Cochrane Library for relevant articles published on or before July 14, 2023. We used a random-effect model for the meta-analysis to calculate the standardized mean difference (SMD) with a 95% confidence interval (CI). Sensitivity analyses were conducted to analyze stability. A total of 23 randomized clinical trials including 1457 participants met the inclusion criteria. Meta-analysis showed that NSAIDs were significantly associated with postoperative morphine use (mg) (SMD = -0.90, 95% CI -1.12 to -0.68) and postoperative pain (SMD = -0.71, 95% CI -0.85 to -0.58). These results were further confirmed by the trim-and-fill procedure and leave-one-out sensitivity analyses. The current study shows that perioperative use of NSAIDs appears to be an important factor in reducing postoperative pain and morphine use in patients undergoing spinal surgery. However, well-designed, high-quality randomized controlled trials (RCTs) are still required.

Perioperative Intravenous Dexamethasone Significantly Reduces Postoperative Opioid Requirement and Nausea After Unilateral Elective Hip Arthroscopy: A Randomized Double-blinded Placebo-controlled Trial

BACKGROUND

Previous studies have shown that dexamethasone has a positive effect on postoperative pain control, opioid consumption, nausea, and vomiting and length of hospital stay after arthroplasty surgery.

PURPOSE/HYPOTHESIS

The purpose of this study was to assess whether adding perioperative dexamethasone to our current pain regimen after hip arthroscopy is more effective than a placebo. It was hypothesized that dexamethasone would reduce postoperative pain, reduce opioid consumption, improve subjective pain and nausea scores, and reduce the number of vomiting events.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 50 patients requiring unilateral elective hip arthroscopy were randomized to receive intravenous dexamethasone immediately before induction of anesthesia and at 8 am on the first postoperative day (2 ×12 mg) or a placebo (sodium chloride 0.9%). The patient, the surgeons, the treating anesthesiologist, and the involved nursing and physical therapy personnel were blinded to group assignment. The primary outcome was postoperative pain, and secondary outcomes were opioid consumption and nausea scores-assessed using a translated revised version of the American Pain Society Patient Outcome Questionnaire 6 hours postoperatively and on days 1 and 2-and vomiting events. A clinical follow-up was performed 12 weeks postoperatively to assess adverse events.

RESULTS

The mean age at inclusion was 29 years in both groups. Postoperative pain levels did not differ significantly in most instances. Opioid requirements during the hospitalization in the dexamethasone group were significantly lower than those in the placebo group (31.96 ± 20.56 mg vs 51.43 ± 38 mg; P = .014). Significantly fewer vomiting events were noted in the dexamethasone group (0.15 ± 0.59 vs 0.65 ± 0.91; P = .034). Descriptive data and surgical parameters did not differ significantly.

CONCLUSION

Perioperative intravenous dexamethasone significantly reduced postoperative opioid consumption by 40% without compromising pain level and safety, as no corticosteroid-related side effects were observed. Dexamethasone may be a valuable adjuvant to a multimodal systemic pain regimen after hip arthroscopy.

REGISTRATION

NCT04610398 (ClinicalTrials.gov identifier).

Efficacy and safety of perioperative use of non-steroidal anti-inflammatory drugs for preemptive analgesia in lumbar spine surgery: a systematic review and meta-analysis

OBJECTIVE

Lumbar spine disorders have become an increasingly common health problem in recent years. Modern clinical studies have shown that perioperative analgesia at certain doses can reduce postoperative pain by inhibiting the process of peripheral sensitization and central sensitization, which is also known as "preemptive analgesia," Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of drugs that achieve antipyretic and analgesic effects by inhibiting cyclooxygenase (COX) and affecting the production of prostaglandins. Our meta-analysis aimed to assess the efficacy and safety of perioperative preemptive analgesia with non-steroidal anti-inflammatory drugs in patients with lumbar spine surgery.

METHODS

We searched PubMed, ScienceDirect, the Cochrane Library, and the Web of Science for randomized controlled trials (RCTs) that met the inclusion criteria. A total of 12 clinical studies were included to assess the efficacy and safety of perioperative NSAIDs preemptive analgesia for lumbar spine surgery.

RESULT

Twelve studies, including 845 patients, met the inclusion criteria. The results showed that perioperative receipt of NSAIDs for preemptive analgesia was effective and safe. Patient's postoperative morphine consumption (P < 0.05), visual analog scale (P < 0.05), and numerical rating scale (P < 0.05) were not statistically associated with postoperative complications (P > 0.05).

CONCLUSION

Our findings suggest that NSAIDs are effective and safe for preemptive analgesia in the perioperative period of lumbar spine surgery and that more and better quality RCTs and more in-depth studies of pain mechanics are still needed.

Oxycodone-acetaminophen versus celecoxib for postoperative pain in knee osteoarthritis patients after total knee arthroplasty: a randomized, controlled study

PURPOSE

Oxycodone-acetaminophen is a synergic combination of semisynthetic opioid agonis and analgesic/antipyretic agent, which improves analgesic efficacy. This randomized, controlled study intended to evaluate the analgesic efficacy and tolerance of oxycodone-acetaminophen compared to celecoxib alone in post-total knee arthroplasty (TKA) knee osteoarthritis patients.

METHODS

One hundred and six knee osteoarthritis patients were randomized into oxycodone-acetaminophen group (N = 54) and celecoxib group (N = 52) at a 1:1 ratio. Each patient orally received oxycodone-acetaminophen (5 mg/325 mg, four times per day) or celecoxib (200 mg, twice per day) from 2 h to day (D) 3 after TKA; meanwhile, each patient received 2-day patient-controlled analgesia (PCA). The primary outcome was pain visual analog scale (VAS) score at rest; other assessments were the secondary outcomes.

RESULTS

Pain VAS scores at rest at D1, D2, D3, and pain VAS scores at flexion at D0.5, D1, D2, D3 were lower in oxycodone-acetaminophen group compared to celecoxib group (all P < 0.050). Besides, extra (P < 0.001) and total (P < 0.001) PCA consumption were declined in oxycodone-acetaminophen group compared with celecoxib group. Furthermore, patients' satisfaction score at D3 (P = 0.012) and D7 (P = 0.043) was higher in oxycodone-acetaminophen group versus celecoxib group. Hospital for special surgery knee score (HSS) at preoperation, M1, and M3 did not differ between the two groups (all P > 0.050). The incidences of all adverse events were not varied between oxycodone-acetaminophen and celecoxib groups (all P > 0.050).

CONCLUSION

Oxycodone-acetaminophen exerts superior analgesic efficacy, patients' satisfaction, and similar tolerance compared to celecoxib in post-TKA knee osteoarthritis patients.

Effect of Perioperative Corticosteroid Administration on Early Postoperative Range of Motion and Functional Outcomes Following Dupuytren's Fasciectomy

BACKGROUND

The purpose of the study was to evaluate whether perioperative corticosteroid (CS) administration improves early postoperative range of motion (ROM) and function in patients undergoing Dupuytren's fasciectomy.

METHODS

We retrospectively identified 58 patients who underwent Dupuytren's fasciectomy by a single fellowship-trained orthopedic hand surgeon from 2016 to 2020. During this time period, 51 digits in 34 patients received a single intraoperative dose of 10 mg of intravenous dexamethasone followed by a 6-day oral methylprednisolone taper course (CS group), and 37 digits in 24 patients did not (control group). Postoperatively, all patients started hand therapy within 1 week of surgery. At 2 and 6 weeks, patients had ROM data and Disabilities of the Arm, Shoulder, and Hand (DASH) scores collected by a blinded hand therapist. Paired t tests were used to compare the change in ROM and DASH scores at weeks 2 and 6.

RESULTS

The 2 cohorts had similar preoperative ROM. At 2 weeks postoperatively, the CS group had greater metacarpophalangeal (MP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) flexion. There was no difference in MP, PIP, or DIP extension. At 6 weeks postoperatively, the CS group had greater PIP flexion. There was no difference between the groups in MP extension, MP flexion, PIP extension, DIP extension, or DIP flexion. Mean DASH scores were significantly lower in the CS group at weeks 2 and 6. There were no postoperative deep infections or complications requiring surgery in either group.

CONCLUSION

Perioperative CS administration appears to be safe and to improve early ROM and DASH scores following Dupuytren's fasciectomy.

Comparison of the effects of preoperative celecoxib and gabapentin on pain, functional recovery, and quality of life after total knee arthroplasty: A randomized controlled clinical trial

Background

Acute pain is one of the main complaints of patients after total knee arthroplasty (TKA), which causes delayed mobility, increased morphine consumption, and subsequently increased costs. Therefore, the present study was performed to evaluate the preventive effect of preoperative celecoxib and gabapentin on reducing patient pain as a primary outcome after TKA surgery.

Materials and Methods

This randomized, double-blind controlled clinical trial was performed on 270 patients with osteoarthritis that were candidates for TKA surgery allocated into three groups. In the first group, 900 mg of gabapentin was administered orally on a daily basis for 3 days before surgery. In the second group, 200 mg of oral celecoxib was administered twice daily for 3 days before surgery. In the third group, oral placebo was administered twice daily for 3 days before the surgery. The patients' pain score and knee and its functional score were recoded.

Results

The mean of reduction pain in gabapentin and celecoxib groups was significantly lower than that of the control group at 12, 24, and 48 h after surgery (P < 0.001); however, two groups were not significantly different from each other (P > 0.05). Furthermore, the two medication groups were not significantly different in this regard (P > 0.05). In addition, the knee score in the gabapentin group with the means of 85.40 ± 5.47 and the celecoxib group with the means of 87.03 ± 3.97 were significantly higher than those of the control group with the means of 78.90 ± 4.39 in the 1^st month after the surgery (P < 0.001).

Conclusion

According to the results of the present study, the preventive administration of gabapentin and celecoxib showed a significant and similar effectiveness on reducing patient pain after TKA surgery and on improving the KSS and quality of life scores.

A Prospective Randomized Controlled Trial of Methylprednisolone for Postoperative Pain Management of Surgically Treated Distal Radius Fractures

PURPOSE

Perioperative glucocorticoids have been effectively used as a pain management regimen for reducing pain after hand surgery. We hypothesize that a methylprednisolone taper (MPT) course following surgery will reduce pain and opioid consumption in the early postoperative period.

METHODS

This study was a randomized controlled trial of patients undergoing surgical fixation for distal radius fracture. Before surgery, patients were randomly assigned to receive preoperative dexamethasone only or preoperative dexamethasone followed by a 6-day oral MPT. Patient pain and opioid consumption data were collected for 7 days after surgery using a patient-reported pain journal.

RESULTS

Our study consisted of 56 patients enrolled from November 2018 to March 2020. Twenty-eight patients each were assigned to the control and treatment groups. Demographic characteristics such as age, body mass index, the dominant side affected, smoking status, diabetes status, and current narcotic use were similar between the control and treatment groups. With a noticeable, significant reduction starting on postoperative day 2, patients who received an MPT course consumed substantially less opioids during the first 7 days (7.8 ± 7.2 pills compared with 15.5 ± 11.5 pills, a 50% reduction). These patients also consumed significantly fewer oral morphine equivalents than the control group (81.2 vs 41.2). A significant difference in the pain visual analog scale scores between the 2 groups was noted starting on postoperative day 2, with 48% of the treatment group reporting no pain by postoperative day 6. No adverse events, including infection or complications of wound or bone healing, were seen in either group.

CONCLUSIONS

There was an early improvement in pain and reduction in early opioid consumption with a 6-day MPT following surgical fixation for distal radius fracture. With no increased risk of adverse events in our sample, MPT may be a safe and effective way to reduce postoperative pain.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

[Role of Dexamethasone for Pain Management in Intervertebral Disc Surgery]

Intervertebral disc operations are already among the most common and their frequency is increasing. The pain associated with these operations is one of the most common postoperative discomforts, has a significant impact on psychosocial aspects, and should therefore be treated effectively. Therefore, we present the importance of dexamethasone for multimodal pain management after intervertebral disc surgery.

Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.

PURPOSE

This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program.

STUDY DESIGN

This is a review article.

METHODS

Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature.

RESULTS

Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented.

CONCLUSION

Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.

Adding corticosteroids to periarticular infiltration analgesia improves the short-term analgesic effects after total knee arthroplasty: a prospective, double-blind, randomized controlled trial

PURPOSE

Periarticular infiltration analgesia (PIA) is widely used to control postoperative pain in patients who underwent total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of adding corticosteroids to the PIA cocktail for pain management in patients who underwent TKA.

METHODS

The patients were randomized to the corticosteroid or control group (double-blind). The patients in the corticosteroid group received a periarticular infiltration of an analgesic cocktail of ropivacaine, epinephrine, and dexamethasone. Dexamethasone was omitted from the cocktail in the control group. The primary outcomes were postoperative pain [assessed using a visual analog scale (VAS)], time until the administration of first rescue analgesia, morphine consumption, and postoperative inflammatory biomarkers [C-reactive protein (CRP) and interleukin-6 (IL-6)]. The secondary outcomes were functional recovery, assessed by the range of knee motion, quadriceps strength, and daily ambulation distance. The tertiary outcomes included postoperative adverse effects.

RESULTS

The patients in the corticosteroid group had significantly lower resting VAS scores at 6 and 12 h after surgery, lower VAS scores during motion up to 24 h after surgery, and lower levels of inflammatory biomarkers. All the differences in the VAS scores between the two groups did not reach the point to be considered clinically significant. The additional use of corticosteroid significantly prolonged analgesic effects and led to lower rescue morphine consumption. The patients in the corticosteroid group had significantly better functional recovery on the first day after surgery. The two groups had a similar occurrence of adverse effects.

CONCLUSIONS

Adding corticosteroids to an analgesic cocktail for PIA could lightly improve early pain relief and accelerate recovery in the first 24 h after TKA.

LEVEL OF EVIDENCE

Randomized controlled trial, Level I.

A Single Preoperative Administration of Dexamethasone, Low-dose Pregabalin, or a Combination of the 2, in Spinal Surgery, Does Not Provide a Better Analgesia Than a Multimodal Analgesic Protocol Alone

OBJECTIVES

A single perioperative dose of glucocorticoid or gabapentinoid, or a combination of the 2, may improve postoperative analgesia, but data are still insufficient to be conclusive. In this single-center, randomized, double-blind, and double-dummy trial, we aimed to test whether the analgesic effect of adding preoperative pregabalin, at a dose unlikely to induce side effects, to preoperative dexamethasone improves early mobilization after spinal surgery.

MATERIALS AND METHODS

A total of 160 patients undergoing scheduled lumbar disk surgery (145 analyzed) comprised the study cohort. The patients received either 0.2 mg/kg intravenous dexamethasone before incision, or 150 mg oral pregabalin 1 hour before surgery, or a combination of the 2, or none of the above (control). Analgesia was supplemented by acetaminophen and ketoprofen, plus oxycodone ad libitum. The primary outcome was pain intensity during the first attempt to sit up, assessed the morning of the first postoperative day on an 11-point Numerical Rating Scale. Pain at rest and when standing up, opioid consumption, and tolerance were also assessed.

RESULTS

None of the treatments tested differed from the control group in terms of efficacy or tolerance, even 6 months after surgery. The overall quality of analgesia was good, with only 10% and 30% of pain scores exceeding 3/10 for pain at rest and during movement, respectively.

DISCUSSION

In this surgical model with the given anesthetic and analgesic environment, there was no advantage gained by adding low-dose pregabalin or dexamethasone. The multimodal analgesic protocol applied to all patients may have reduced the size of the effect.

Multiple versus single doses of dexamethasone in total hip arthroplasty: A protocol of randomized controlled trial

BACKGROUND

Reduction of post-operative pain, nausea, and vomiting in patients undergoing total hip arthroplasty (THA) may facilitate earlier discharge from hospital and reduce healthcare costs. The recommended dose regimen of dexamethasone in THA has not been determined. The purpose of this study was performed to compare the efficiency of multiple versus single doses of dexamethasone for early postoperative pain treatment after THA.

METHODS

This study was a randomized controlled trial which conducted in our hospital. Informed consent for participation in this trial was obtained from each patient before surgery. Two hundred patients undergoing THA received 1 dose of intravenous dexamethasone and 1 dose of normal saline (Group A), or 2 doses of intravenous dexamethasone (Group B). The primary outcome was visual analog scale pain scores in the immediate postoperative period. Secondary outcomes included postoperative opioid use, length of hospital stay, activity level during physical therapy, and hip range of motion.

RESULTS

This clinical trial might provide some insights to estimate the safety of dexamethasone.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5460).

Implementation of a Standardized Multimodal Postoperative Analgesia Protocol Improves Pain Control, Reduces Opioid Consumption, and Shortens Length of Hospital Stay After Posterior Lumbar Spinal Fusion

BACKGROUND

Multimodal analgesia regimens have been suggested to improve pain control and reduce opioid consumption after surgery.

OBJECTIVE

To institutionally implement an evidence-based quality improvement initiative to standardize and optimize pain treatment following neurosurgical procedures. Our goal was to objectively evaluate efficacy of this multimodal protocol.

METHODS

A retrospective cohort analysis of pain-related outcomes after posterior lumbar fusion procedures was performed. We compared patients treated in the 6 mo preceding (PRE) and 6 mo following (POST) protocol execution.

RESULTS

A total of 102 PRE and 118 POST patients were included. The cohorts were well-matched regarding sex, age, surgical duration, number of segments fused, preoperative opioid consumption, and baseline physical status (all P &gt; .05). Average patient-reported numerical rating scale pain scores significantly improved in the first 24 hr postoperatively (5.6 vs 4.5, P &lt; .001) and 24 to 72 hr postoperatively (4.7 vs 3.4, P &lt; .001), PRE vs POST, respectively. Maximum pain scores and time to achieving appropriate pain control also significantly improved during these same intervals (all P &lt; .05). A concomitant decrease in opioid consumption during the first 72 hr was seen (110 vs 71 morphine milligram equivalents, P = .02). There was an observed reduction in opioid-related adverse events per patient (1.31 vs 0.83, P &lt; .001) and hospital length of stay (4.6 vs 3.9 days, P = .03) after implementation of the protocol.

CONCLUSION

Implementation of an evidence-based, multimodal analgesia protocol improved postoperative outcomes, including pain scores, opioid consumption, and length of hospital stay, after posterior lumbar spinal fusion.

Preemptive analgesia after lumbar spine surgery by pregabalin and celecoxib: a prospective study

Objective

To evaluate the preemptive analgesic effect of combination pregabalin with celecoxib for lumbar spine surgery.

Methods

A prospective, randomized study was conducted among 60 lumbar spine surgery patients and divided into two groups. Postoperative pain relief was achieved with intravenous patient-controlled analgesia with morphine. The preemptive analgesia group received oral pregabalin (150 mg) and celecoxib (200 mg) 2 hrs before surgery, and the control group received a placebo. Pain was assessed by visual analogue scale (VAS). Side effects and morphine consumption were monitored until 48 hrs after surgery.

Results

VAS score at rest and during movement was statistically significantly lower in the preemptive analgesia group at most time points (p<0.05). Morphine consumption was significantly lower in the preemptive analgesia group compared with control group in the 24 first hours (29.03±4.38 mg vs 24.43±4.94) and 48 hrs (52.23±9.57 mg vs 44.20±10.21 mg), p<0.05. Hemodynamics, respiratory rate, and SpO₂ were similar for both groups. The sedation score was only statistically significant at H8 time point. The incidence of nausea/vomiting in the preemptive group did not statistically differ from the control group.

Conclusion

Preoperative administration of pregabalin combined with celecoxib had a good preemptive analgesia effect and reduced intravenous morphine consumption after lumbar spine surgery. Side effects were mild and transient.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

PURPOSE

We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.

METHODS

A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018.

RESULTS

We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy.

CONCLUSIONS

Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

Effects of anaesthesia and analgesia on long-term outcome after total knee replacement: A prospective, observational, multicentre study

BACKGROUND

Perioperative regional anaesthesia may protect from persistent postsurgical pain (PPSP) and improve outcome after total knee arthroplasty (TKA).

OBJECTIVES

Aim of this study was to evaluate the impact of regional anaesthesia on PPSP and long-term functional outcome after TKA.

DESIGN

A web-based prospective observational registry.

SETTING

Five Italian Private and University Hospitals from 2012 to 2015.

PATIENTS

Undergoing primary unilateral TKA, aged more than 18 years, informed consent, American Society of Anesthesiologists (ASA) physical status classes 1 to 3, no previous knee surgery.

INTERVENTION(S)

Personal data (age, sex, BMI and ASA class), preoperative pain assessed by numerical rating scale (NRS) score, and risk factors for PPSP were registered preoperatively. Data on anaesthetic and analgesic techniques were collected. Postoperative pain (NRS), analgesic consumption, major complications and patient satisfaction were registered up to the time of discharge. PPSP was assessed by a blinded investigator during a phone call after 1, 3 and 6 months, together with patient satisfaction, quality of life (QOL) and walking ability.

MAIN OUTCOME MEASURES

Experience of PPSP according to the type of peri-operative analgesia.

RESULTS

Five hundred sixty-three patients completed the follow-up. At 6 months, 21.6% of patients experienced PPSP, whereas autonomy was improved only in 56.3%; QOL was worsened or unchanged in 30.7% of patients and improved in 69.3%. Patients receiving continuous regional anaesthesia (epidural or peripheral nerve block) showed a lower NRS through the whole peri-operative period up to 1 month compared with both single shot peripheral nerve block and those who did not receive any type of regional anaesthesia. No difference was found between these latter two groups. Differences in PPSP at 3 or 6 months were not significantly affected by the type of anaesthesia or postoperative analgesia. A higher NRS score at 1 month, younger age, history of anxiety or depression, pro-inflammatory status, higher BMI and a lower ASA physical status were associated with a higher incidence of PPSP and worsened QOL at 6 months.

CONCLUSION

Continuous regional anaesthesia provides analgesic benefit for up to 1 month after surgery, but did not influence PPSP at 6 months. Better pain control at 1 month was associated with reduced PPSP. Patients with higher expectations from surgery, enhanced basal inflammation and a pessimistic outlook are more prone to develop PPSP.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02147730.

Epidural versus intravenous steroids application following percutaneous endoscopic lumbar discectomy

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

Impact of duloxetine and dexamethasone for improving postoperative pain after laparoscopic gynecological surgeries: A randomized clinical trial

Background

Patients' surgical experiences are influenced by their perception of pain management. Duloxetine (Dulox) and dexamethasone (Dex) are used in multimodal analgesia to reduce opioid use and side effects. Dulox is a selective serotonin and norepinephrine reuptake inhibitor and has efficacy in chronic pain conditions. Dex enhances postoperative (PO) analgesia and reduces PO nausea and vomiting (PONV).

Methods

Seventy-five female patients were randomly allocated into one of three equal groups. GI received Dulox 60 mg orally and 100 ml 0.9% sodium chloride (normal saline [NS]) intravenous infusion (IVI) over 15 min, GII: received as GI except Dex 0.1 mg/kg was mixed with NS and GIII received identical placebo for Dulox capsule and Dex IVI, 2 h preoperatively. Patients' vitals, visual analog scale (VAS), and sedation score were assessed at 30 min, 1 h, 2 h, 6 h, and 12 h postoperatively. Total pethidine requirements, plasma cortisol, PONV, and patients satisfaction were recorded.

Results

PO time for 1^st rescue analgesic was significantly high in GI and GII compared to GIII and in GII compared to GI. There was a significant less VAS score, heart rate, mean arterial pressure, and a high sedation score in GI and GII compared to GIII at 30 min, 1, 2, and 6 h postoperatively. Total pethidine requirements were significantly less in GI and GII compared to GIII 12 h postoperatively. There was a significant reduction in the 2 h PO serum cortisol (μg/dl) and a significant increase in the PO patients satisfaction score in GI and GII compared to GIII. PONV was decreased significantly in GII compared to GI and GIII.

Conclusion

The use of oral Dulox 60 mg combined with Dex 0.1 mg/kg IVI is more effective than oral Dulox 60 mg alone, 2 h preoperatively, for improving PO pain by reducing the requirements for rescue analgesia and PONV.

Comparison of Postoperative Quality of Recovery and Pain Relief with Preoperative Single-Dose Dexamethasone and Lignocaine after Laparoscopic Cholecystectomy

Aim

To compare the role of single intravenous (IV) bolus of lignocaine and dexamethasone on pain score and quality of recovery score (QoR40) after laparoscopic cholecystectomy.

Setting and Design

The study was conducted at the postoperative recovery area, This was a double-blind randomized controlled study.

Materials and Methods

Seventy patients 18-60 years of age, American Society of Anesthesiologists physical status Class I and II, who underwent elective laparoscopic cholecystectomy, were enrolled in this study after approval from the Institutional Ethics Committee. Patients were randomly allocated to two groups. Group 1 received: 2 mg/kg lignocaine diluted to 10 ml with normal saline, and Group 2 received 0.1 mg/kg IV dexamethasone diluted to 10 ml with normal saline. Global QoR-40 is a 40-item questionnaire that provides a global score and subscores across five dimensions: psychological support, comfort, independence, pain, and emotions. It was assessed on a preoperative day as baseline to assess patient's basic quality of life and at 24 h postoperative. Visual analog scale (VAS) static and dynamic, total analgesic consumption in a day, nausea and vomiting, and antiemetic per day were assessed.

Statistical Analysis Used

Student's t-test, Chi-square test, Fisher's exact, Levene's test were used for statistical analysis.

Results

Dexamethasone group had higher Global QoR-40 than lignocaine group 187.94 versus 182.85. Among dimensions of QoR-40, dexamethasone had statistically better physical comfort, physical independence, and pain relief as compared to lignocaine. Dexamethasone group had lower VAS compared to lignocaine group. Similarly, there was less fentanyl consumption in dexamethasone group (364.08 ± 127.31) in the postoperative period when compared to the lignocaine group (412.31 ± 147.8).

Conclusions

Preoperative administration of a single dose of dexamethasone enhanced QoR after laparoscopic cholecystectomy as compared to lignocaine bolus dose.

Nonsteroidal anti-inflammatory drugs for postoperative pain control after lumbar spine surgery: A meta-analysis of randomized controlled trials

STUDY OBJECTIVE

Nonsteroidal anti-inflammatory drugs (NSAIDs) play a role in pain relief, especially in postoperative pain caused by inflammation. They have demonstrated significant opioid dose-sparing effects, which help in reducing postoperative effects and opioid side effects. The objective of this meta-analysis was to explore the role of NSAIDs in reducing postoperative pain at different time intervals and provide reference for medication after lumbar spine surgery by a meta-analysis of randomized controlled trials (RCT).

DESIGN

A meta-analysis study of randomized controlled trials.

SETTING

Postoperative recovery area.

PATIENTS

Adult patients who have undergone lumbar spine surgery.

INTERVENTION

Patients received NSAIDs for pain control after lumbar spine surgery.

MEASUREMENTS

Standardized mean difference (SMD) and 95%CI were used to evaluate the visual analog scale of postoperative pain.

MAIN RESULTS

Four hundred and eight participants from eight studies were included in this study. The difference between the NSAIDs group and placebo is significant in 0-6, 12, and 24h groups (overall: SMD=-0.72, 95%CI -0.98 to -0.45; 0-6h: SMD=0.50, 95%CI -0.81 to -0.19; 12h: SMD=-1.07, 95%CI -1.45 to -0.70; 24h: SMD=-1.16, 95%CI -1.87 to -0.45). Heterogeneity and publication bias were observed in the 0-6 and 24h groups.

CONCLUSION

NSAIDs are effective in postoperative analgesia after lumbar spine surgery. The study type, NSAID dose, different surgery types, and analgesic type might influence the efficacy of NSAIDs.

Effect of intermediate dose dexamethasone on post-operative pain in lumbar spine surgery: A randomized, triple-blind, placebo-controlled trial

OBJECTIVES

Dexamethasone has demonstrated analgesic properties and is used as an adjunctive pain agent for many procedures. We evaluated the efficacy of a single, intermediate dose of dexamethasone on post-operative analgesic consumption, and pain scores for lumbar spine surgery.

METHODS

Eighty patients aged between 18 and 70 scheduled for lumbar decompressive laminectomy were randomly allocated into two groups to receive either intravenous 0.2 mg/kg dexamethasone (group D = 40) or normal saline (group P = 40) before anesthetic induction. Post-operative total morphine consumption and the respective pain score at the PACU, 4, 6, 12, 24 and 48 h were evaluated. In addition, any adverse events were recorded.

RESULTS

Total post-operative morphine consumption within 48 h was significantly lower in group D (34.5 vs. 42.5 mg, p = 0.031); however, the respective morphine consumption at each assessment was similar between groups. The respective NRS pain score at rest and upon movement in both groups was not significantly different for any time comparison. The average NRS pain score at rest and upon movement within 48 h was similar in both groups (i.e., NRS at rest Group D 3.6 vs. Group P 3.8, p = 0.936, and NRS for movement Group D 6.2 vs. Group P 6.3, p = 0.791). The adverse events within 48 h were also similar and serious complications (i.e., respiratory depression or surgical infection) were not found in either group.

CONCLUSION

A single, intermediate dose of dexamethasone before anesthetic induction could minimally decrease post-operative morphine consumption within 48 h after lumbar decompressive laminectomy without any effect on the pain score.

Complications of intraoperative epidural steroid use in lumbar discectomy: a systematic review and meta-analysis

OBJECT The authors' aim in this paper was to review the intraoperative use of epidural steroids in lumbar discectomy surgery with a focus on surgical complications. METHODS A comprehensive literature search was done using PubMed, MEDLINE, and the Cochrane Central Registry of Controlled Trials. Relevant papers were retrieved and analyzed. The authors performed a meta-analysis of all available data. Search terms included epidural, steroids, discectomy, lumbar disc surgery, herniated lumbar disc, methylprednisolone, and perioperative.The primary outcome was surgical complications such as wound infection or need for reoperation. Secondary outcomes were pain and postoperative narcotic usage. RESULTS Sixteen trials and 1 retrospective study (a total of 1933 patients) were eligible for inclusion in this study. In all studies, steroids were added epidurally over the nerve root before closure in cases, and control patients underwent discectomy alone. The mean age (42.7 years vs 42.4 years; RR 0.30 [95% CI -0.30 to 0.90], p = 0.32), overall complication rates (2.69% vs 1.18%; RR 1.94 [95% CI 0.72-5.26], p = 0.19), and infectious complication rates (0.94% vs 0.08%; RR 4.58 [95% CI 0.75-27.95], p = 0.10) were similar between the steroid group and control group, respectively. CONCLUSIONS There is good evidence that epidural steroids can decrease pain in the short term and decrease the usage of postoperative narcotics after lumbar spinal surgery for degenerative spinal disease. The authors' results demonstrate a trend toward increased infection with epidural steroid use, but there was not a statistically significant difference. More studies are needed to validate the long-term risk/benefit ratio of epidural steroids in lumbar discectomy.

The Effect of Perioperative Corticosteroids in Total Hip Arthroplasty: A Prospective Double-Blind Placebo Controlled Pilot Study

BACKGROUND

Surgery produces a rapid rise in interleukin 6 (IL-6) which may increase the risk of deep vein thrombosis and medical complications. Perioperative corticosteroids suppress IL-6 release in patients undergoing total knee arthroplasty. This study evaluates the effects of a perioperative corticosteroid regimen on IL-6 formation, thrombogenesis, fibrinolysis, and clinical outcomes in patients undergoing unilateral, uncemented, total hip arthroplasty.

METHODS

Twenty-seven patients (14 placebo and 13 study) were enrolled in this randomized, double-blind, placebo-controlled trial. The study group received 20 mg of prednisone orally followed by 2 doses of intravenous hydrocortisone, each 8 hours apart. Blood was drawn at several time points for IL-6, prothrombin fragment 1.2, and plasmin-alpha-2-antiplasmin complex, a marker of fibrinolysis. In-hospital visual analog pain (visual analog scale) scores, patient-controlled analgesia use, and ability to climb stairs were recorded.

RESULTS

Mean serum IL-6 levels at 6 and 24 hours postoperatively were significantly lower for the study group, whereas serum prothrombin fragment 1.2 and plasmin-alpha-2-antiplasmin were not statistically different at any study time point. Average pain scores were similar (P > .05), but study group experience less severe pain (P < .01) and less patient-controlled analgesia (P = .02). At 3 months, 4 patients in the placebo and 1 patient in the study group had difficulty going up and down staircases (P = .08).

CONCLUSION

The use of corticosteroids was associated with a statistically significant decrease in IL-6 at 6 and 24 hours postoperatively but did not affect thrombogenic markers. The study group had improved postoperative analgesia and a trend toward improved functional outcome at 3 months postoperatively.

Loxoprofen sodium and celecoxib for postoperative pain in patients after spinal surgery: a randomized comparative study

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used to treat inflammation, pain, and fever, but no criterion standard exists for the management of postoperative pain following spinal surgery. In the present study, we compared the analgesic efficacy of loxoprofen sodium (loxoprofen) and celecoxib for the management of postoperative pain following spinal surgery.

METHODS

One-hundred forty-one patients (mean age 62.2 years) were randomly assigned to two groups before spinal surgery: a loxoprofen group (n = 73, 180 mg/day) and a celecoxib group (n = 68, 200 mg/day). The drugs were administered from 1 day until 7 days after surgery. A numeric rating scale (NRS) was used to evaluate pain at nine predefined times every day and the findings were compared between the two groups. Laboratory data and adverse events were also recorded.

RESULTS

There was no significant difference in the maximum and mean NRS scores on each day between loxoprofen and celecoxib, suggesting a comparable analgesic effect for these two NSAIDs. Greater improvement in the NRS score between preadministration (baseline) and 30 min or 2 h after administration was obtained for loxoprofen. This tendency was shown for both slight (NRS score <5 at baseline) and severe pain (NRS score ≥ 5 at baseline). Loxoprofen was discontinued in one patient on day 4 because of renal dysfunction. Celecoxib was discontinued in one patient on day 2 at the patient's request.

CONCLUSIONS

Both loxoprofen sodium and celecoxib were well tolerated for the relief of acute postoperative pain after spinal surgery. A single administration of loxoprofen showed superior and rapid effectiveness compared with celecoxib for both slight and severe postoperative pain.

Perioperative nonopioid agents for pain control in spinal surgery

PURPOSE

Commonly used nonopioid analgesic agents that are incorporated into multimodal perioperative pain management protocols in spinal surgery are reviewed.

SUMMARY

Spinal procedures constitute perhaps some of most painful surgical interventions, as they often encompass extensive muscle dissection, tissue retraction, and surgical implants, as well as prolonged operative duration. Perioperative nonopioid analgesics frequently used in multimodal protocols include gabapentin, pregabalin, acetaminophen, dexamethasone, ketamine, and nonsteroidal antiinflammatory drugs (NSAIDs). There is evidence to suggest that gabapentin is safe and effective in reducing opioid consumption and pain scores at optimal doses of 600-900 mg orally administered preoperatively. Pregabalin 150-300 mg orally perioperatively has been shown to reduce both pain and narcotic consumption. Most reports concur that a single 1-g i.v. perioperative dose is safe in adults and that this dose has been shown to reduce pain and attenuate narcotic requirements. Dexamethasone's influence on postoperative pain has primarily been investigated for minor spinal procedures, with limited evidence for spinal fusions. Ketamine added to a patient-controlled analgesia regimen appears to be efficacious for 24 hours postoperatively when implemented for microdiskectomy and laminectomy procedures at doses of 1 mg/mL in a 1:1 mixture with morphine. For patients undergoing laminectomy or diskectomy, NSAIDs appear to be safe and effective in reducing pain scores and decreasing opioid consumption.

CONCLUSION

Preemptive analgesic therapy combining nonopioid agents with opioids may reduce narcotic consumption and improve patient satisfaction after spinal surgery. Such therapy should be considered for patients undergoing various spinal procedures in which postoperative pain control has been historically difficult to achieve.

Efficacy of intraoperative epidural steroids in lumbar discectomy: a systematic review

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.

A Randomized Controlled Trial on Analgesic Effects of Intravenous Acetaminophen versus Dexamethasone after Pediatric Tonsillectomy

Background

A few studies are available actually comparing the clinical efficacy of intravenous acetaminophen with other medications such as dexamethasone to inhibit postoperative adverse events in children.

Objectives

This randomized blinded controlled trial was designed to compare controlling status of postoperative events in children after tonsillectomy randomized to receive either intravenous acetaminophen or dexamethasone.

Patients and Methods

Eighty four children aged between 4 to 13 undergoing tonsillectomy were randomized using a computer-generated schedule to double-blind treatment with intravenous acetaminophen (15 mg/kg) or intravenous dexamethasone (0.1 mg/kg). Children were post-operatively assessed for swallowing pain, pain while opening mouth, ear pain, and postoperative sore throat in recovery room (within one hour after surgery), at the time of admission to the ward, as well as at 12 and 24 hours after surgery, assessed by the objective pain scoring system (OPS; minimum score: 0 = no pain, maximum score: 10 = extreme pain).

Results

There were no significant differences between the two groups with regard to the severity of postoperative pain due to swallowing or opening mouth measured at the different study time points from postoperative recovery to 24 hours after the surgery. There was no difference in ear pain severity at the time of postoperative recovery, at the admission time to ward and also at 12 hours after surgery; however mean score of ear pain severity was significantly higher in those who administered acetaminophen 24 hours after operation. Also, the mean score severity of sore throat was significantly higher in the acetaminophen compared with the dexamethasone group within 12 hours of surgery. Postoperative vomiting and bleeding were similarly observed between the two study groups. The severity of swallowing pain, pain while opening mouth, ear pain, as well as postoperative sore throat as gradually assuaged within 24 hours of tonsillectomy in both groups, however no between-group differences were observed in the trend of the severity of these events.

Conclusions

The dexamethasone-based regimen may have more advantage over the intravenous acetaminophen regimen for inhibiting pain and PONV following tonsillectomy in children.

Dexamethasone reduces length of hospitalization and improves postoperative pain and nausea after total joint arthroplasty: a prospective, randomized controlled trial

Controlling postoperative pain and nausea after total joint arthroplasty remains an important challenge. We conducted a prospective, randomized controlled trial with 120 patients to determine if the addition of perioperative dexamethasone to a multimodal regimen improves antiemetic and analgesic control, enhances mobility, and shortens hospital length of stay after total hip and knee arthroplasty. Patients administered 10mg of intravenous dexamethasone intraoperatively consumed less daily rescue anti-emetic and analgesic medication, reported superior VAS nausea and pain scores, ambulated further distances, and had a significantly shorter length of stay compared to the control group (P<0.05). A second, 24-hour postoperative dose of 10mg intravenous dexamethasone provided significant additional pain and nausea control and further reduced length of stay (P<0.05). No adverse events were detected with the administration of the intraoperative and/or postoperative dexamethasone.

Does dexamethasone prevent subarachnoid meperidin-induced nausea, vomiting and pruritus after cesarean delivery?

Background:

Opioid-induced side effects such as nausea and vomiting and pruritus are common and may be more debilitating than pain itself. We performed a study to assess the efficacy of dexamethasone in reducing postoperative nausea, vomiting, and pruritus in patients receiving neuraxial anesthesia with meperidine.

Methods:

Fifty-two women undergoing cesarean section were enrolled in the study. The control group and dexamethasone group received intravenously normal saline and dexamethasone, respectively, before spinal anesthesia. The occurrence of postoperative nausea, vomiting, and pruritus was assessed for 24 h in both groups.

Results:

The overall incidence of nausea and vomiting during the 24 h follow-up period was 37% and 22.2% for group saline and 20% and 12% for group dexamethasone, respectively (P=0.175, 0.469). The incidence of pruritus was not significantly different between the two groups. Pruritus severity was significantly less in the dexamethasone group than in the saline group (P=0.019).

Conclusion:

Prophylactic dexamethasone does not reduce the incidence of subarachnoid meperidine-induced nausea, vomiting, and pruritus in women undergoing cesarean delivery.

Perioperative dexamethasone does not affect functional outcome in total hip arthroplasty

Current trends in orthopaedic surgery have explored different forms of adjuvant treatments to minimize postoperative pain and the risk of nausea and vomiting. A small single preoperative dose of dexamethasone, as part of a comprehensive multimodal analgesic regimen in low-risk patients undergoing total hip arthroplasty (THA), provides antiemetic and opioid-sparing effects but the longer-term effects on pain, complications, or function are not known. We therefore asked whether such a routine would affect longer-term pain, complications, or function. Fifty patients undergoing elective primary THA using spinal anesthesia were initially randomized to receive either dexamethasone (40 mg intravenous) or saline placebo. The patients, anesthesiologists, nurses, and research coordinators were blinded to the study arms. The functional outcome was measured using the Harris hip score. Outcomes were assessed 6 weeks and 1 year postoperatively. We observed no difference in resting pain between the two groups at either time period. Both groups had similar functional outcome scores for the total Harris hip score and individual scoring items at each followup interval. There were no wound complications, deep infections, or osteonecrosis in the contralateral hip at 1-year followup. We recommend the addition of a small single preoperative dose of dexamethasone to a comprehensive multimodal analgesic regimen in low-risk patients given its immediate antiemetic and opioid-sparing effects, and absence of subsequent effects.

LEVEL OF EVIDENCE

Level II, therapeutic study (prospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence.

Pregabalin and dexamethasone in combination with paracetamol for postoperative pain control after abdominal hysterectomy. A randomized clinical trial

BACKGROUND

Multimodal analgesia may be important for optimal postoperative pain treatment and facilitation of early mobilization and recovery. We investigated the analgesic effect of pregabalin and dexamethasone in combination with paracetamol after abdominal hysterectomy.

METHODS

One hundred and sixteen patients were randomly assigned to either group A (paracetamol+placebo x 2), group B (paracetamol+pregabalin+placebo) or group C (paracetamol+pregabalin+dexamethasone). According to randomization and preoperatively, patients received paracetamol 1000 mg, pregabalin 300 mg, dexamethasone 8 mg or placebo. General anaesthesia was performed. Postoperative pain treatment was paracetamol 1000 mg x 4 and patient-controlled intravenous morphine, 2.5 mg bolus. Nausea was treated with ondansetron. Morphine consumption, pain score (visual analogue scale) at rest and during mobilization, nausea, sedation, dizziness, number of vomits and consumption of ondansetron were recorded 2, 4 and 24 h after the operation. P<0.05 was considered statistically significant.

RESULTS

The 24-h morphine consumption and pain score, both at rest and during mobilization, were not significantly different between treatment groups. The mean nausea score (P=0.002) was reduced in group C vs. A. The number of vomits was significantly reduced in both group B (P=0.041) and C (P=0.001) vs. A. Consumption of ondansetron was reduced in group C vs. A and B (P<0.001). Other side effects were not different between groups.

CONCLUSION

Combinations of paracetamol and pregabalin, or paracetamol, pregabalin and dexamethasone did not reduce morphine consumption and pain score compared with paracetamol alone for patients undergoing abdominal hysterectomy. Dexamethasone reduced nausea, vomiting and use of ondansetron.

[New substances and applications for postoperative pain therapy]

The onset of postoperative pain is the result of various pathophysiological mechanisms and depends on the type of surgery performed. Therefore, any adequate postoperative pain treatment requires multimodal and procedure-specific analgesia. In addition to reducing perioperative complications and improving patient comfort, optimal postoperative pain management also represents an important quality characteristic which can influence the patient in their choice of hospital. In the past 1-2 years, known groups of substances have been rediscovered for postoperative pain therapy (e.g., Gabapentin and Pregabalin, i.v. Lidocaine, Ketamine or glucocorticoids), while new substances (coxibe, oral oxycodone+naloxone) and applications have been developed. The present overview article discusses the advantages and disadvantages of these substances and analgesic methods, as well as their specific areas of application.

The role of hypothalamo-hypophyseal-adrenocortical system hormones in controlling pain sensitivity

The present review addresses analysis of data demonstrating the role of the hypothalamo-hypophyseal-adrenocortical axis (HHACA) in controlling pain sensitivity. Experiments on rats have demonstrated the analgesic effects of exogenous hormones of all components of the HHACA - corticotropin-releasing hormone (CRH), adrenocorticotropic hormone (ACTH), and glucocorticoids - in the same models, and have also shown that the opioid and non-opioid mechanisms contribute to the development of the analgesia induced by these hormones. Endogenous glucocorticoids are involved in the development of analgesia mediated by non-opioid mechanisms. Along with the non-opioid mechanisms associated with endogenous glucocorticoids, the analgesic effect of ACTH can be mediated by the opioid mechanism. Unlike the situation with ACTH, the analgesic effect of CRH is mediated exclusively by non-opioid mechanisms, one of which is associated with HHACA hormones, while the other, appearing only on systemic administration, is not associated with these hormones. The actions of glucocorticoids on pain are mediated by neurons in the central gray matter of the midbrain.

[Pain therapy after spinal surgery]

A dorsal approach during spinal surgery offers the possibility to distribute drugs directly to the nerve root or epidurally. This can be done via a single intraoperative dose or by placing an epidural catheter. A safe and effective analgesia can thereby be achieved. As placement is done under visual control, no major complications are to be expected. In nerve root compressions, additional local application of steroids and preoperative gabapentin seems sensible. No advantage of preemptive administration of other analgesics can be determined. Another problem, especially of ventral fusions, is the commonly needed autologous pelvic bone grafts. Here the local application of local anesthetics or opioids makes sense. In transthoracic approaches epidural analgesia is recommended by thoracic surgeons, but this is difficult to perform especially in children with deformities. Furthermore it is generally important not to compromise neuralgic controls by analgesic measures.

Epidural steroid following discectomy for herniated lumbar disc reduces neurological impairment and enhances recovery: a randomized study with two-year follow-up

STUDY DESIGN

We randomized 200 patients after lumbar discectomy to receive epidural steroid or none with a 2-year follow-up.

OBJECTIVE

To evaluate the outcome, neurologic impairment and safety of epidural steroid following lumbar discectomy for herniated disc disease.

SUMMARY OF BACKGROUND DATA

Convalescence after discectomy for herniated disc disease is dependent on pain and the inflammatory response. Previous studies in arthroscopic and abdominal surgery demonstrate steroids, which reduce the inflammatory response and enhance recovery. Here we report a 2-year follow-up of a randomized trial of epidural steroid following lumbar discectomy.

METHODS

Through 2001 and 2003 200 patients undergoing discectomy for herniated disc disease were randomly allocated to receive epidural methylprednisolone 40 mg or none. In the control group (62 males and 38 females, median age 41 years, 18-66) 48 L5, 50 L4, and 6 L3 discectomies were performed and in the intervention group (60 males and 40 females, median age 45 years, 15-53) 56 L5, 46 L4, and 3 L3 discectomies. Contemporary with randomization to epidural steroid or none both groups received preoperative prophylactic antibiotics and the same multimodal pain treatment.

RESULTS

Hospital stay was reduced from 8 to 6 days (P = 0.0001) and the number of patients with neurologic signs were reduced more (70% vs. 44%, P = 0.0004) by epidural steroid. Incidence of reoperation at 1 year was 6% in both groups and 8% in the control group and 7% in the intervention group after 2 years. No infections were registered.

CONCLUSION

Epidural methylprednisolone enhances recovery after discectomy for herniated disc disease without apparent side effects.

Nonsteroidal antiinflammatory drugs for postoperative pain management after lumbar spine surgery: a meta-analysis of randomized controlled trials

OBJECT

The authors undertook this meta-analysis to assess the efficacy and safety of nonsteroidal antiinflammatory drugs (NSAIDs) in addition to opioid analgesics on perioperative pain management in lumbar spine surgery.

METHODS

The authors searched MEDLINE, Excerpta Medica (EMBASE), The Cochrane Library, CINAHL, PsycINFO, Allied and Complementary Medicine (AMED), and Science Citation Index Expanded databases. In addition, they manually searched key journals and their references. They included randomized trials comparing the use of NSAIDs in addition to opioid analgesics versus opioid analgesics alone after posterior lumbar discectomy, laminectomy, or spinal fusion. Two independent reviewers performed an assessment of the quality of the methods.

RESULTS

Seventeen studies comprising 400 patients who received NSAIDs in addition to opioid analgesics and 389 patients receiving opioid analgesics alone were included. Patients receiving NSAIDs in addition to opioid analgesics had lower pain scores and consumed fewer opioids than the group receiving opioid analgesics alone. There was no difference in the incidence of adverse effects.

CONCLUSIONS

This meta-analysis provides evidence that the addition of NSAIDs to opioid analgesics in lumbar spine surgery provided better pain control than opioid analgesics alone.

Effect of parecoxib on postoperative pain after lumbar spine surgery: a bicenter, randomized, double-blinded, placebo-controlled trial

STUDY DESIGN

A bicenter randomized, patients, healthcare providers, and data collectors blind placebo-controlled trial in multimodal analgesia for postoperative lumbar spine surgery was conducted.

OBJECTIVE

To assess the efficacy and safety of parecoxib on postoperative pain management after posterior lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Systematic reviews suggest that cyclo-oxygenase-2 inhibitors are an effective treatment for acute postoperative pain. However, previous trials on lumbar spine surgery showed equivocal efficacy of cyclo-oxygenase-2 inhibitors for postoperative pain relief.

METHODS

In this study, 120 patients undergoing posterior lumbar discectomy, spinal decompression, or spinal fusion were stratified based on the surgical procedure to 3 groups (n = 40) and randomly allocated to receive multidoses of parecoxib 40 mg/dose or placebo. Efficacy was assessed by total morphine used from patient-controlled analgesic pump, pain intensity, pain relief, and the patient's subjective rating of the medication.

RESULTS

Parecoxib 40 mg reduced the total amount of morphine required over 48 hours by 39% relative morphine reduction compared with placebo (P = 0.0001). Pain at rest was reduced by 30% (P = 0.0001). Ninety percent of patients given parecoxib experienced at least 50% maximum total pain relief compared with 58% treated with placebo. The number-needed-to-treat for 1 patient to have at least half pain relief was 3.1 (2.0-4.6). Patients' subjective rating of the medication was described as "excellent, good, and fair" by 48%, 43%, and 8% in the parecoxib group, respectively, compared with 21%, 50%, and 28% of placebo patients (P = 0.004). Overall adverse effects of patients receiving parecoxib and morphine were comparable to those receiving morphine alone.

CONCLUSION

The present study demonstrates that the perioperative administration of parecoxib with patient-controlled analgesic morphine after lumber spine surgery resulted in significantly improved postoperative analgesic management as defined by reduction in opioid requirement, lower pain scores, and higher patients' subjective rating of the medication.

The Use of Celecoxib and Dexamethasone for the Prevention and Control of Postoperative Pain After Periodontal Surgery

BACKGROUND

Conventional non-steroidal anti-inflammatory drugs have been widely used in the control of postoperative pain, but sparse information is available on the efficacy of celecoxib, a selective cyclooxygenase-2 inhibitor, or dexamethasone, a steroidal anti-inflammatory drug, after periodontal surgeries. The purpose of the present study was to compare the use of celecoxib and dexamethasone in the management of pain after mucoperiosteal flap surgery.

METHODS

A randomized double-masked cross-over clinical trial was conducted on 20 patients from 27 to 52 years old with generalized moderate to advanced chronic periodontitis. Mucoperiosteal flap surgeries for scaling and root planing were performed under local anesthesia on at least three quadrants, with a 4-week interval between. Each quadrant was randomly assigned to one of the following medication protocols: placebo, 4 mg dexamethasone 1 hour before surgery and 8 hours after the first dose, and 200 mg celecoxib 1 hour before surgery and 12 hours after the first dose. Postoperative pain was accessed during the first 8 hours and on the following 3 days using the visual analog scale (VAS), the 101-point numerical rate scale (NRS-101), and the four-point verbal rating scale (VRS-4).

RESULTS

Pain perception was statistically significantly lower in the celecoxib group than in the placebo group during the first 4 hours using VAS (P = 0.01) and at 1, 2, 3, 4, 6, and 7 hours using NRS-101 (P = 0.03). The level of pain was lower in the dexamethasone group than in the placebo only at the 3-hour period (P = 0.001). Statistically significant differences could be found among the groups at 1 hour (P = 0.015), 3 hours (P = 0.004), 4 hours (P = 0.02), and 7 hours (P = 0.05) using VRS-4. There was no statistically significant difference between the celecoxib and dexamethasone groups.

CONCLUSION

The findings of this study suggest that the preemptive and postoperative use of celecoxib or dexamethasone were effective in the management of postoperative pain following open-flap debridement.