Acute Pain Following Musculoskeletal Injuries and Orthopaedic Surgery: Mechanisms and Management

Association of iPACK block and adductor canal block in dogs undergoing the tibial plateau leveling osteotomy technique: Report of 4 cases

Orthopedic procedures are associated with severe postoperative pain. In TPLO, the block commonly used is the sciatic nerve block associated with the femoral nerve block. In orthopedic surgeries in human medicine, the iPACK block associated with the adductor canal block has been used as alternatives that do not affect the strength of the quadriceps femoris muscle. The objective of this study was to evaluate the trans and postoperative analgesic effect of the association of iPACK block and adductor canal block, as well as to evaluate the patient's motor recovery after surgery. Four patients were selected, without distinction of breed and gender, weighing more than 22lb, referred to TPLO. All patients underwent the combination of iPACK block and adductor canal block with 0.5% bupivacaine. The intraoperative evaluation was carried out by measuring mean arterial pressure, heart rate and respiratory rate, and all patients were stable during the procedure. The postoperative evaluation was carried out based on the assessment of pain using the modified Glasgow scale, in which all patients scored less than 05/24, and assessment of ambulation through videos using the adapted Muzzi scale, presenting ambulation between grade 1 and 2. No patient required intraoperative or postoperative analgesic rescue.

Randomized, double-blind, Placebo-Controlled Study to Compare the Efficacy of Combination of Lidocaine with ketorolac or triamcinolone versus Lidocaine Alone for Soft Tissue Injuries

Background

Corticosteroid and Ketorolac tromethamine is a pain reducing.

Objective

The primary objective was pain intensity scores (VAS) in 10, 30, 60 min, 2, 6 h, 1, and 7 days.

Method

120 patients were randomized. The placebo group (normal saline) and experimental groups (ketorolac 30 mg, 60 mg, triamcinolone 10 mg, 20 mg, and 40 mg, respectively) were compared.

Result

VAS at 60 min, 2, 6 h, 1 and 7 days was significantly different (P < 0.05). Ketorolac 30 mg, 60 mg, and triamcinolone 10 mg shown non inferiority to triamcinolone 40 mg.

Conclusions

ketorolac was considered equal to triamcinolone.

Perioperative Pain Management in the Critically Ill Patient

PURPOSE OF REVIEW

The assessment and management of perioperative pain in an intensive care setting is complex and challenging, requiring several patient-specific considerations. Administering analgesia is difficult due to interacting effects of pre-existing conditions, interventions, and deviation from standard levels of expressiveness of pain. A significant part of this complexity also arises from the reduced capacity of critically ill patients to fully communicate the severity and nature of their pain. We provide an overview of pharmacological approaches and regional techniques, which can be employed alongside the management of anxiety and sleep, to alleviate pain in the critically ill patients in the perioperative period. These interventions require additional assessments unique to critical care, yet achieving pain relief for improving clinical outcomes and patient satisfaction remains a constant.

RECENT FINDINGS

The latest research has found that the development of standardized mechanisms and protocols to optimize the diagnosis, assessment, and management of pain in the critically ill can provide the best outcomes. The numerical rating scale, critical care pain observation criteria, and behavior pain scale has shown higher reliability to accurately assess pain in the critically ill. Most importantly, preemptive analgesia and the emphasis on early pain control-in the perioperative setting, ICU, and post-discharge-are crucial in minimizing chronic post-discharge pain. Finally, the multimodal approach is still found to be the most effective. This includes pharmacological treatments, regional nerve block, and epidural techniques, as well as alternative methods that are cheap, safe, and easily available. All these together have shown to help control pain, provide psychological support, and prevent long-term co-morbidities in the critically ill. Largely, pain in the critically ill patient is still a very complex issue that requires appropriate diagnosis, assessment, and management of the pain itself and treating all the underlying co-morbidities as well. Many different factors makes it challenging, especially the difficulty in communicating with an ICU patient. However, by looking at the patient as a whole, treating pain early with the multimodal approach, there seems to be some promising results in improving outcomes. It has shown that the improved outcomes in critically ill patients in the perioperative period seen with optimized pain management and ICU can shorten hospital stays, decreased inpatient costs, and limit the use of limited resources.

Injectable Nonsteroidal Anti-Inflammatory Drugs in Sport

OBJECTIVE

The primary objective of this article is to review the basic science of nonsteroidal anti-inflammatory drugs (NSAIDs), their clinical effects, indications, potential complications, and ethical issues associated with the use of injectable NSAIDs in the treatment of athletes. These objectives are presented taking into consideration the contemporaneous issues associated with the treatment of amateur and professional athletes.

DATA SOURCES

A nonformal review of the published medical literature and lay media focusing on the use of injectable NSAIDs in athletes was used for this article.

MAIN RESULTS

All NSAIDs work through the inhibition of the cyclooxygenase (COX) pathway (either one or both subtypes) to reduce inflammation and inhibit pain by reducing prostaglandin and thromboxane synthesis. Complications related to NSAID use involve primarily the gastrointestinal, renal, and cardiovascular systems through this COX pathway inhibition. Ketorolac is the only NSAID currently available in an injectable form. Despite its analgesic efficacy comparable with opioid medication, injectable ketorolac has the potential to cause bleeding in collision athletes resulting from impaired hemostasis.

CONCLUSIONS

Nonsteroidal anti-inflammatory drug medications are currently used at every level of competition. Injectable ketorolac is an effective analgesic and anti-inflammatory drug. However, its potential effectiveness must be weighed against the risk of potential complications in all athletes, especially those who participate in contact/collision sports. The team physician must balance the goal of treating pain and inflammation with the ethical implications and medical considerations inherent in the administration of injectable medications solely to prevent pain and/or return the athlete to competition.

Expectancy Reduces Symptoms but not Functional Impairment Following Exercise-induced Musculoskeletal Injury

OBJECTIVES

To quantify the extent to which the participant-provider interaction influences the response to sham treatment following exercised-induced acute musculoskeletal pain.

MATERIALS AND METHODS

In total, 40 participants between the ages of 18 and 35 volunteered for the study. Participants came to the laboratory for 3 test sessions 48-hour apart (day 1, 3, and 5). During the initial session, baseline measures were assessed and participants underwent a fatigue protocol for the biceps brachii. Participants were then assigned to a positive expectation or a no-expectation condition before receiving a sham laser therapy treatment. The positive expectation group received symptom improvement priming before their sham treatment. Participants allocated to the no-expectation condition received no feedback before the sham treatment. Maximum voluntary isometric contraction; relaxed elbow angle; visual analog scale; and the QuickDash questionnaire were used as outcome measures.

RESULTS

The positive expectation group had a significant reduction in perceived pain compared with the no-expectation group at day 3 follow-up, with the mean scores being 34.65 mm (SE=4.44) compared with 49.4 mm (SE=5.79), respectively. There were no between-group differences with respect to maximum voluntary isometric contraction, QuickDash, or relaxed elbow angle outcomes. In addition, there were no significant between-group differences observed with expected pain on follow-up visits, the effect sizes were d=0.26 on day 1 for day 3 and d=0.51 on day for day 5.

DISCUSSION

Positive expectations before a sham treatment enhanced reduction in pain intensity but did not improve functional impairments following exercise-induced acute musculoskeletal injury.

Evaluation of a Behavioral Assessment Tool for the Individual Unable to Self-report Pain

Assessment of pain intensity using a standard self-reported pain score is standard practice in most institutions. These instruments require the cognitive ability to process the pain intensity into a numeric or descriptive value. Many institutions are considering adopting an assessment tool for cognitive impairment. The purpose of this study is to evaluate a clinician-administered assessment tool, PAINAD, in patients with cognitive impairment. Opioid consumption and frequency of documented unknown pain were collected in 2 cognitive impaired groups. In the control group, a self-reporting pain intensity tool was used, and in a second group, the PAINAD was used. Opioid use was significantly higher ( P = .003) and the rates of reported unknown pain were significantly lower ( P < .01) in the group using the PAINAD instrument compared to the control group of patients with cognitive impairment. There were no noted differences in opioid-induced adverse reactions in either group.

Mechanisms-based classifications of musculoskeletal pain: part 3 of 3: symptoms and signs of nociceptive pain in patients with low back (± leg) pain

As a mechanisms-based classification of pain 'nociceptive pain' (NP) refers to pain attributable to the activation of the peripheral receptive terminals of primary afferent neurones in response to noxious chemical, mechanical or thermal stimuli. The symptoms and signs associated with clinical classifications of NP have not been extensively studied. The purpose of this study was to identify symptoms and signs associated with a clinical classification of NP in patients with low back (± leg) pain. Using a cross-sectional, between-subjects design; four hundred and sixty-four patients with low back (± leg) pain were assessed using a standardised assessment protocol after which their pain was assigned a mechanisms-based classification based on experienced clinical judgement. Clinicians then completed a clinical criteria checklist indicating the presence/absence of various symptoms and signs. A regression analysis identified a cluster of seven clinical criteria predictive of NP, including: 'Pain localised to the area of injury/dysfunction', 'Clear, proportionate mechanical/anatomical nature to aggravating and easing factors', 'Usually intermittent and sharp with movement/mechanical provocation; may be a more constant dull ache or throb at rest', and the absence of 'Pain in association with other dysesthesias', 'Night pain/disturbed sleep', 'Antalgic postures/movement patterns' and 'Pain variously described as burning, shooting, sharp or electric-shock-like'. This cluster was found to have high levels of classification accuracy (sensitivity 90.9%, 95% CI: 86.6-94.1; specificity 91.0%, 95% CI: 86.1-94.6). Pattern recognition of this empirically-derived cluster of symptoms and signs may help clinicians identify an assumed dominance of NP mechanisms in patients with low back pain disorders.

Evaluation of analgesic efficacy of intra-articular bupivacaine, bupivacaine plus fentanyl, and bupivacaine plus tramadol after arthroscopic knee surgery

PURPOSE

To compare the efficacy of intra-articular (IA) bupivacaine, bupivacaine-fentanyl, and bupivacaine-tramadol for relief of postoperative pain after arthroscopic knee surgery.

METHODS

In a randomized double-blind design, 60 adult American Society of Anesthesiologists class I or class II patients undergoing elective arthroscopic knee surgery under general anesthesia were randomized to 3 groups: all received 30 mL of 0.25% bupivacaine, plus either 1 mL of normal saline solution (group I), 1 mL (50 μg) of fentanyl (group II), or 1 mL (50 mg) of tramadol (group III). Pain was assessed by use of a 100-mm visual analog scale (VAS) at 0, 1, 2, 4, 6, and 8 hours postoperatively. Intramuscular diclofenac sodium was used as rescue analgesic. Postoperative adverse effects were noted.

RESULTS

The mean VAS pain scores were the lowest for group II, intermediate for group III, and highest for group I. There was a significant main effect for group differences on pain scores (F = 41.138, P < .001). The main effect for the time factor was also significant (F = 6.097, P < .001). However, both group II and group III were comparable and both were superior to group I with regard to supplementary analgesia in terms of (1) number of patients receiving it, (2) total consumption during the study period, and (3) time to first supplementary analgesic requirement. The incidence of adverse event was comparable among the 3 groups.

CONCLUSIONS

On the primary outcome measure (VAS pain score), both bupivacaine with fentanyl and bupivacaine with tramadol were better than IA bupivacaine, and bupivacaine with fentanyl was better than that with tramadol. However, both the combinations were comparable to each other with regard to the secondary outcome measure (supplementary analgesic requirement). Thus IA bupivacaine-fentanyl appears to be the best combination for relief of postoperative pain in patients undergoing arthroscopic knee surgery, followed by IA bupivacaine-tramadol.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

[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.

Peri-operative pain management

Surgery is a circumstance in which we know that we will cause pain. Although most of our perioperative pain management interventions are symptomatic, several strategies can reduce and even prevent pain in the perioperative setting. Because the physiologic mechanisms of postoperative pain are understood, it is possible to interrupt these mechanisms before the patient actually becomes symptomatic. This article reviews the literature and presents these strategies with the hope of implementation of the readers.