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Prabhakar P, Mariappan R, Moorthy RK, Nair BR, Karuppusami R, Lionel KR. Adding Ketamine to Epidural Morphine Does Not Prolong Postoperative Analgesia After Lumbar Laminectomy or Discectomy. J Neurosurg Anesthesiol 2024; 36:244-251. [PMID: 37000813 DOI: 10.1097/ana.0000000000000914] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/23/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Epidural opioids provide effective postoperative analgesia after lumbar spine surgery. Ketamine has been shown to reduce opioid-induced central sensitization and hyperalgesia. We hypothesized that adding ketamine to epidural opioids would prolong the duration of analgesia and enhance analgesic efficacy after lumbar spine surgery. METHODS American Society of Anesthesiologists physical status class I to II patients aged between 18 and 70 years with normal renal function undergoing lumbar laminectomy were recruited into this single-center randomized trial. Patients were randomized to receive either single-dose epidural morphine (group A) or epidural morphine and ketamine (group B) for postoperative analgesia. The primary objective was to compare the duration of analgesia as measured by time to the first postoperative analgesic request. Secondary objectives were the comparison of pain scores at rest and movement, systemic hemodynamics, and the incidence of side effects during the first 24 hours after surgery. RESULTS Fifty patients were recruited (25 in each group), of which data from 48 were available for analysis. The mean±SD duration of analgesia was 20±6 and 23±3 hours in group A and group B, respectively ( P =0.07). There were 12/24 (50%) patients in group A and 17/24 (71%) patients in group B who did not receive rescue analgesia during the first 24-hour postoperative period ( P =0.07). Pain scores at rest and movement, systemic hemodynamics, and postoperative complications were comparable between the groups. CONCLUSIONS The addition of ketamine to epidural morphine did not prolong the duration of analgesia after lumbar laminectomy.
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Affiliation(s)
| | | | | | | | - Reka Karuppusami
- Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
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Zhu X, Jia Z, Zhou Y, Wu J, Cao M, Hu C, Yu L, Chen Z. Current advances in the pain treatment and mechanisms of Traditional Chinese Medicine. Phytother Res 2024. [PMID: 39031847 DOI: 10.1002/ptr.8259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/20/2024] [Accepted: 05/20/2024] [Indexed: 07/22/2024]
Abstract
Traditional Chinese Medicine (TCM), as a unique medical model in China, has been shown to be effective in the treatment of many diseases. It has been proven that TCM can increase the pain threshold, increase the level of endorphins and enkephalins in the body, and reduce the body's response to adverse stimuli. In recent years, TCM scholars have made valuable explorations in the field of pain treatment, using methods such as internal and external application of TCM and acupuncture to carry out research on pain treatment and have achieved more satisfactory results. TCM treats pain in a variety of ways, and with the discovery of a variety of potential bioactive substances for pain treatment. With the new progress in the research of other TCM treatment methods for pain, TCM will have greater potential in the clinical application of pain.
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Affiliation(s)
- Xiaoli Zhu
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zhuolin Jia
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ye Zhou
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jie Wu
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Mayijie Cao
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Changjiang Hu
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Lingying Yu
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zhimin Chen
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
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Fan CY, Wu XX, Ji ZW, Zhang LL, Zhou F, Mao HQ. Application of Enhanced Recovery After Surgery in Patients with Osteoporotic Vertebral Compression Fractures Undergoing Percutaneous Kyphoplasty. World Neurosurg 2024; 181:e339-e345. [PMID: 37839562 DOI: 10.1016/j.wneu.2023.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND The enhanced recovery after surgery (ERAS) program helps patients recover faster and better, postoperatively. The aim of this retrospective study was to assess the clinical effectiveness of the ERAS program after percutaneous kyphoplasty (PKP) for osteoporotic vertebral compression fractures. METHODS We enrolled patients with osteoporotic vertebral compression fracture who had undergone PKP between January 2019 and June 2021 and divided them into the control group (CG; n = 296), without the ERAS program, and the intervention group (IG; n = 306), with the ERAS program. The visual analog scale (VAS), Oswestry Disability Index (ODI), and Barthel Index scores of the 2 groups were compared on admission and 2 days and 1, 6, and 12 months postoperatively. Perioperative evaluation parameters included the mean surgery time, length of stay (LOS), and hospitalization expenses. In addition, postoperative complications were compared. RESULTS Regarding perioperative parameters, LOS and hospitalization expenses were significantly better in IG than in CG (P < 0.001), but the mean surgery time did not differ significantly (P > 0.05). The VAS, Barthel Index, and ODI scores were significantly better in IG than in CG at 2 days and 1 month postoperatively (P < 0.001). None of the clinical effectiveness parameters (VAS, Barthel Index, and ODI scores) differed between IG and CG at 6 or 12 months postoperatively. In addition, 141 patients in CG and 56 patients in IG experienced postoperative complications, including pressure ulcers, deep vein thrombosis, nausea and vomiting, and refracture (P = 0.970, P = 0.036, P < 0.001, P = 0.002 respectively). CONCLUSIONS For patients undergoing PKP, the ERAS program is a reliable and effective perioperative management method that can effectively reduce LOS, postoperative pain, and economic burden and promote recovery of patients.
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Affiliation(s)
- Chun-Yang Fan
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xie-Xing Wu
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zhong-Wei Ji
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China; Department of Pain Management, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Lin-Lin Zhang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Feng Zhou
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Hai-Qing Mao
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.
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Ramírez-Gonzalez M, Torres-Lugo NJ, Deliz-Jimenez D, Echegaray-Casalduc G, Ramírez N, Colón-Rodriguez E, Carro-Rivera J, De La Cruz A, Claudio-Roman Y, Massanet-Volrath J, Escobar-Medina E, Montañez-Huertas J. Efficacy of an Opioid-Sparing Perioperative Multimodal Analgesia Protocol on Posterior Lumbar Fusion in a Hispanic Population: A Randomized Controlled Trial. J Am Acad Orthop Surg 2023; 31:931-937. [PMID: 37192425 DOI: 10.5435/jaaos-d-22-00878] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 04/11/2023] [Indexed: 05/18/2023] Open
Abstract
INTRODUCTION Posterior lumbar fusion surgery has become more common amid an aging population, with degenerative disease as its most common indication. Historically, postoperative pain control for spine surgery has relied on opioids. However, opioid use is associated with adverse effects such as dependence, respiratory depression, and altered cognition. Our study aimed to determine whether an opioid-sparing multimodal analgesia regimen (ketorolac, orphenadrine, and gabapentin) could be a viable alternative to diminish opioid use compared with a standard opioid-based regimen in Hispanic patients undergoing posterior lumbar spinal fusion. METHODS This was a randomized controlled trial of Hispanic patients scheduled to undergo elective posterior spinal fusion. Inclusion criteria included age 30 to 85 years, Hispanic ethnicity, lumbar stenosis between L1 and S1, elective posterior spinal fusion with instrumentation, American Society of Anesthesiologists Score <2, and consent to participate in the study. Patients were randomized into two groups, an experimental multimodal analgesia and control (opioid-based) treatment groups, and outcomes such as morphine milligram equivalents used, visual analog scale score, and length of hospital stay were compared between the groups. RESULTS The MMA experimental group used significantly lower amounts of opioid (measured with morphine milligram equivalent) than the opioid-based group during the 12-hour and 24-hour postoperative periods ( P -value = 0.023 and P -value = 0.033, respectively). No statistically significant difference was observed in opioid use in the 48-hour postoperative period between both groups ( P -value = 0.066). The MMA group had significantly lower VAS scores reported at the 12-hour, 24-hour, and 48-hour postoperative periods compared with the opioid-based group ( P -values = 0.016, 0.020, and 0.020, respectively). No difference was observed in the length of hospital stay between groups ( P -value = 0.169). DISCUSSION Implementing an MMA protocol in Hispanic patients undergoing posterior lumbar fusion resulted in decreased overall opioid use and decreased pain intensity compared with the opioid-based group. MMA is an effective alternative for pain control in patients who want to avoid opioid use. CLINICAL TRIAL REGISTRATION Identifier: NCT05413902.
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Affiliation(s)
- Manuel Ramírez-Gonzalez
- Twin Cities Spine Center, Minneapolis, MN (Ramirez-Gonzalez), University of Puerto Rico School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, PR (Claudio-Roman), Department of Orthopaedic Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, PR (Deliz-Jimenez, Torres-Lugo, and Echegaray-Casalduc, Massanet-Volrath, Carro-Rivera, Escobar-Medina, De La Cruz, and Montañez-Huertas), Department of Pediatric Orthopaedic Surgery, Mayagüez Medical Center, Mayagüez, PR (Ramirez), Department of Anesthesiology, University of Puerto Rico, Medical Sciences Campus, San Juan, PR (Colon-Rodriguez)
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Hamed M, Asoglu H, Lampmann T, Winkelmann LM, Salemdawod A, Müller M, Vatter H, Banat M, Eichhorn L. Pain management with epidural catheter and epidural analgesia after spinal dorsal instrumentation of lumbar spine. Medicine (Baltimore) 2023; 102:e32902. [PMID: 36800634 PMCID: PMC9936043 DOI: 10.1097/md.0000000000032902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
Spinal dorsal instrumentation (SDI) is an established treatment for degenerative spinal diseases. Adequate and immediate postoperative pain control is important for patient recovery and may be compromised by uncertainty about its efficacy and concern about early postoperative surgical complications or adverse events. The aim of the current study was to compare the use of epidural analgesia (EA) with systemic analgesia (SA) as regards pain reduction and early postoperative complications after SDI. Pain management with epidural or systemic analgesia in patients undergoing SDI by posterior approach between January 2019 and July 2020 was evaluated by clinical functional testing, measuring total opioid amounts used, and evaluating numerical rating scale values 24 and 96 hours postoperatively. The following were also monitored: demographic data, number of affected segments, length of hospital stay, inflammatory markers (leukocytes and serum C-reactive protein), early postoperative surgical complication rates, and adverse events. In total 79 patients were included (33 in the EA and 46 in the SA group). The SA group had significantly lower numerical rating scale values at days 1 to 4 after surgery (P ≤ .001) and lower cumulative opioid use than the EA group (P < .001). We found no difference in infection parameters, length of hospital stay or surgery-related complication rates. Our data demonstrate that epidural anesthesia was inferior to an opioid-based SA regime in reducing postoperative pain in patients undergoing spinal surgery. There is no benefit to the use of epidural catheters.
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Affiliation(s)
- Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Harun Asoglu
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Tim Lampmann
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Lena Marie Winkelmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Abdallah Salemdawod
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- Center for Advanced Imaging Research, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Marlene and Stewart Greenebaum, Comprehensive Cancer Center, University of Maryland, Baltimore, MD
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Mohammed Banat
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- * Correspondence: Mohammed Banat, Department of Neurosurgery, University Hospital Bonn, Bonn, Germany (e-mail: )
| | - Lars Eichhorn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
- Clinic for Anesthesiology and Intensive Care Medicine, Helios Klinikum Bonn/Rhein-Sieg, Bonn, Germany
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Muacevic A, Adler JR, M R. Effect of Preemptive Multimodal Analgesia Regimen on Post-operative Epidural Demand Boluses in Lower Limb Orthopaedic Surgeries. Cureus 2023; 15:e33958. [PMID: 36820115 PMCID: PMC9938632 DOI: 10.7759/cureus.33958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2023] [Indexed: 01/21/2023] Open
Abstract
Introduction Excruciating pain is associated with lower limb orthopaedic surgeries involving femoral shaft fractures. Postoperative pain management is still ineffective in low-resource settings where the use of epidural and opioid-free analgesia is impractical. Literature is scarce with respect to the effect of a preemptive multimodal analgesia regimen on the requirement of postoperative epidural demand boluses. Hence, the present study aimed to evaluate the effect of pre-emptive multimodal analgesia in reducing the requirement of epidural demand boluses postoperatively, and to find out the time required to receive the first epidural bolus. Material and methods This double-blinded randomized control study included 48 subjects. Patients aged 18-60 years with lower limb fractures requiring surgery under combined spinal-epidural anesthesia were included. Patients were divided into two groups through random allocation. Group A: Preemptive multimodal group received intravenous paracetamol 1 g, IV diclofenac 75 mg diluted in 100ml NS, IV tramadol 50 mg diluted in 100ml NS and tab pregabalin 75 mg orally, 30 mins before surgery. Group B: Placebo group received 3 pints of 100ml NS IV and tab ranitidine 150 mg, 30 mins before surgery. Intraoperatively, combined spinal-epidural anaesthesia was administered taking all the aseptic precautions. Visual analogue scale (VAS) was recorded immediately on shifting to a postoperative room, and then at 1, 4, 8, 12, and 24 hr for both groups. Epidural boluses (10 ml of 0.125% bupivacaine with 2 μg/ml of fentanyl) were given whenever the patient's visual analogue scale was more than 4. The time at which the first epidural bolus was required by the patient was recorded. The total number of epidural boluses given over 24 hours based on VAS was recorded for both, the preemptive and placebo groups. If the patient still complained of pain, IV diclofenac 75 mg was given if the VAS was more than 4, while IV diclofenac 75 mg along with IV tramadol 50 mg was given if the VAS was more than 6. Patient satisfaction with anesthesia care, in general, was assessed 24 hrs postoperatively. Results A total of 48 subjects were included in the study. During the immediate-postoperative period, and at 8, 12 and 24 hr, the median VAS was significantly low in group A as compared to group B. A significant increase in the demand for epidural bolus immediate-postoperatively was observed in group B (70.83%) compared to group A (4.17%) (p-value of <0.001). At 8 hr, 12hr, and 24hr, patients in group A found a significantly less need for epidural boluses compared to Group B. The mean total number of epidural boluses taken in group A was significantly less compared to group B (1.79 ± 0.41 VS 3.33 ± 0.48, p-Value <0.001). In group A, all patients reported no requirement for diclofenac and tramadol. In group B, 8.33% required diclofenac 75 mg, while the remaining 91.66% had no requirement for diclofenac and tramadol. The difference in patient satisfaction with anaesthesia care in general between the two study groups was found to be significant with a p-value of 0.027. Patients in Group A were very satisfied compared with those in group B. Conclusions The study found that the pre-emptive multimodal analgesia group had better postoperative pain control because they required fewer epidural boluses and no extra analgesics postoperatively. This group was more satisfied with the anaesthesia care in general.
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Methylprednisolone as an Adjunct to Local Infiltration on Laminoplasty or Laminectomy before Wound Closure: A Randomized Controlled Trial. Pain Res Manag 2022; 2022:2274934. [PMID: 35966574 PMCID: PMC9366200 DOI: 10.1155/2022/2274934] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 05/15/2022] [Accepted: 06/07/2022] [Indexed: 11/17/2022]
Abstract
TrialDesign. Patients undergoing laminoplasty and laminectomy often experience severe postoperative pain. Local infiltration analgesia during spine surgery significantly reduces postoperative pain, which only upholds for a short time. Whether methylprednisolone and local anaesthetics are better than local anaesthetics alone in postoperative analgesia is yet to be determined. The primary aim of this research was the postoperative evaluation of efficacy and safety of methylprednisolone when used as an adjunct to local anaesthesia, ropivacaine, before wound closure after surgical procedures, laminoplasty or laminectomy. Methods. 132 patients were divided with a ratio of 1 : 1 into methylprednisolone-ropivacaine and ropivacaine alone groups. Every 30 ml of local infiltration solution consisted of 15 ml of 1% ropivacaine with 14 ml of saline along with 1 ml of 40 mg methylprednisolone and 15 ml of 1% ropivacaine with 15 ml of saline in methylprednisolone-ropivacaine group and ropivacaine group, respectively. The standardization of the study solution depended on the number of levels involved in surgery. Primary outcome was the 48-hour cumulative sufentanil demand. Results. Demographic characters and surgical variables among the groups were identical. The average 48-hour cumulative sufentanil demand was 32.5 ± 20.6 μg in the methylprednisolone-ropivacaine group and 50.9 ± 27.2 μg in the ropivacaine group (
). The estimated median time of demand of the first analgesia via patient-controlled analgesia (PCA) pump was 2.5 hours and 2 hours in the methylprednisolone-ropivacaine group and the ropivacaine group, respectively (hazard ratio (HR) was 0.53, with 95% Cl 0.33 to 0.87 and Log-rank of
). Conclusion. The infiltration of methylprednisolone as adjunct ropivacaine before wound closure is a safe and efficient strategy for pain management following laminoplasty or laminectomy.
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Gasser L, Lener S, Hartmann S, Löscher WN, Thomé C, Hofer A. Does preoperative opioid therapy in patients with a single lumbar disc herniation positively influence the postoperative outcome detected by quantitative sensory testing? Neurosurg Rev 2022; 45:2941-2949. [PMID: 35608709 PMCID: PMC9349102 DOI: 10.1007/s10143-022-01818-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/21/2022] [Accepted: 05/18/2022] [Indexed: 12/02/2022]
Abstract
The importance of the type of pain medication in spinal disease is an ongoing matter of debate. Recent guidelines recommend acetaminophen and NSAIDs as first-line medication for lumbar disc herniation. However, opioid pain medication is commonly used in patients with chronic pain, and therefore also in patients with sciatica. The aim of this study is to evaluate if opioids have an impact on the outcome in patients suffering from lumbar disc herniation. To assess this objectively quantitative sensory testing (QST) was applied. In total, 52 patients with a single lumbar disc herniation confirmed on magnetic resonance imaging (MRI) and treated by lumbar sequesterectomy were included in the trial. Patients were analysed according to their preoperative opioid intake: 35 patients who did not receive opioids (group NO) and 17 patients, who received opioids preoperatively (group O). Further evaluation included detailed medical history, physical examination, various questionnaires, and QST. No pre- and postoperative differences were detected in thermal or mechanical thresholds (p > 0.05). Wind-up ratio (WUR) differed significantly between groups 1 week postoperatively (p = 0.025). The NRS for low back pain was rated significantly higher in the non-opioid group (NO) after 1-week follow-up (p = 0.026). Radicular pain tended to be higher in the NO group after 12 months of follow-up (p = 0.023). Opioids seem to be a positive predictor for the postoperative pain outcome in early follow-up in patients undergoing lumbar sequesterectomy. Furthermore, patients presented with less radicular pain 1 year after surgery.
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Affiliation(s)
- Lea Gasser
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Sara Lener
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria.
| | - Sebastian Hartmann
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Wolfgang N Löscher
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Anja Hofer
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
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Postoperative pain treatment after spinal fusion surgery: a systematic review with meta-analyses and trial sequential analyses. Pain Rep 2022; 7:e1005. [PMID: 35505790 PMCID: PMC9049031 DOI: 10.1097/pr9.0000000000001005] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 12/22/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. Patients undergoing spinal surgery are at high risk of acute and persistent postoperative pain. Therefore, adequate pain relief is crucial. This systematic review aimed to provide answers about best-proven postoperative analgesic treatment for patients undergoing lumbar 1- or 2-level fusions for degenerative spine diseases. We performed a search in PubMed, Embase, and The Cochrane Library for randomized controlled trials. The primary outcome was opioid consumption after 24 hours postoperatively. We performed meta-analyses, trial sequential analyses, and Grading of Recommendations assessment to accommodate systematic errors. Forty-four randomized controlled trials were included with 2983 participants. Five subgroups emerged: nonsteroidal anti-inflammatory drugs (NSAIDs), epidural, ketamine, local infiltration analgesia, and intrathecal morphine. The results showed a significant reduction in opioid consumption for treatment with NSAID (P < 0.0008) and epidural (P < 0.0006) (predefined minimal clinical relevance of 10 mg). Concerning secondary outcomes, significant reductions in pain scores were detected after 6 hours at rest (NSAID [P < 0.0001] and intrathecal morphine [P < 0.0001]), 6 hours during mobilization (intrathecal morphine [P = 0.003]), 24 hours at rest (epidural [P < 0.00001] and ketamine [P < 0.00001]), and 24 hours during mobilization (intrathecal morphine [P = 0.03]). The effect of wound infiltration was nonsignificant. The quality of evidence was low to very low for most trials. The results from this systematic review showed that some analgesic interventions have the capability to reduce opioid consumption compared with control groups. However, because of the high risk of bias and low evidence, it was impossible to recommend a “gold standard” for the analgesic treatment after 1- or 2-level spinal fusion surgery.
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Mayoral Rojals V, Charaja M, De Leon Casasola O, Montero A, Narvaez Tamayo MA, Varrassi G. New Insights Into the Pharmacological Management of Postoperative Pain: A Narrative Review. Cureus 2022; 14:e23037. [PMID: 35419225 PMCID: PMC8994615 DOI: 10.7759/cureus.23037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/10/2022] [Indexed: 11/05/2022] Open
Abstract
Postoperative pain is prevalent and often undertreated. There is a risk that untreated or suboptimally treated postoperative pain may transition into chronic postoperative pain, which can be challenging to treat. Clinical guidelines recommend the use of multimodal analgesia, including non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and, in some cases, opioids. NSAIDs are a broad class of drugs with different attributes such as cyclo-oxygenase (COX)-1 or COX-2 selectivity, onset of action, and analgesic potency. NSAIDs are associated with gastrointestinal and cardiovascular side effects and should be administered at the lowest effective dose for the shortest effective duration but can be effective in postoperative pain. The role of opioids in postoperative analgesia is long-standing but has recently come under scrutiny. Opioids are often used in multimodal analgesic combinations in such a way as to minimize the total consumption of opioids without sacrificing analgesic benefit. Special clinical considerations are required for surgical patients already on opioid regimens or with opioid use disorder. A particularly useful fixed-dose combination product for postoperative analgesia is dexketoprofen-tramadol, which confers safe and effective postoperative pain control and reduces the risk of persistent postoperative pain.
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Ryalino C, Senapathi TA, Sanjaya DGD, Pradhana A, Sutawan IKJ. Comparison of oxycodone with morphine as adjuvant epidural analgesia and its side effects: A systematic review. BALI JOURNAL OF ANESTHESIOLOGY 2022. [DOI: 10.4103/bjoa.bjoa_83_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2021; 34:257-276. [PMID: 34483301 DOI: 10.1097/ana.0000000000000799] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/14/2021] [Indexed: 11/25/2022]
Abstract
Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.
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Ashrafi AN, Yip W, Graham JN, Yu V, Titus M, Widjaja W, Dickerson S, Berger AK, Desai MM, Gill IS, Aron M, Kim MP. Implementation of a multimodal opioid-sparing enhanced recovery pathway for robotic-assisted radical prostatectomy. J Robot Surg 2021; 16:715-721. [PMID: 34431025 DOI: 10.1007/s11701-021-01268-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/13/2021] [Indexed: 12/24/2022]
Abstract
The purpose of the study is to evaluate the impact of a multimodal Enhanced Recovery After Surgery (ERAS) protocol on perioperative opioid consumption and hospital length of stay (LOS) after robotic-assisted radical prostatectomy (RARP). We compared the first 176 patients enrolled in the protocol (ERAS group) with the previous 176 patients (non-ERAS group) at a single quaternary institution from December 2017 to June 2019. The ERAS protocol included a multimodal opioid-sparing regimen utilizing acetaminophen, gabapentin, celecoxib, and liposomal bupivacaine. Demographic data, co-morbidities, post-operative pain scores, post-operative opiate consumption measured by morphine milligram equivalents (MME), operating time, and LOS were collected. The two groups were compared using chi-squared, Fisher exact, or Student t tests as appropriate. Multivariable logistic regression analysis was performed to identify predictors of prolonged LOS (> 1 day). The ERAS and non-ERAS groups were equivalent in terms of baseline characteristics and pathological data. The ERAS group had lower post-operative pain scores, post-operative opiate consumption (MME 15 vs. 46, p < 0.01), and LOS (1.2 vs. 1.7 days, p < 0.01) compared to the non-ERAS group. Only 22% in the ERAS cohort had a prolonged LOS compared to 39% of the non-ERAS group (p < 0.01). The ERAS protocol was a negative predictor of prolonged LOS on multivariable logistic regression analysis (odds ratio 0.39, 95% confidence interval 0.22-0.70, p < 0.01). A limitation of this study is its single-center retrospective design. The implementation of a multimodal opioid-sparing ERAS protocol was associated with improved pain control, reduced perioperative opioid usage, and shorter LOS after RARP.
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Affiliation(s)
- Akbar N Ashrafi
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA. .,Department of Urology, Northern Adelaide Local Health Network, South Australia Health, Adelaide, Australia. .,Adelaide Medical School, The University of Adelaide, Adelaide, Australia. .,College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - Wesley Yip
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - John N Graham
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Valerie Yu
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Micha Titus
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - William Widjaja
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Shane Dickerson
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Andre K Berger
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Mihir M Desai
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Inderbir S Gill
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Monish Aron
- Keck School of Medicine, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Michael P Kim
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Liu X, Wei W, Wu Y, Jiang X, Liu X, Zhang Y, Yeh CH, Zhang Y. Auricular Point Acupressure Combined with Compound Lidocaine Cream to Manage Arteriovenous Fistula Puncture Pain: A Multicenter Randomized Controlled Trial. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2021; 2021:5573567. [PMID: 34367303 PMCID: PMC8337141 DOI: 10.1155/2021/5573567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 07/15/2021] [Indexed: 12/02/2022]
Abstract
BACKGROUND Arteriovenous fistula (AVF) puncture pain is an inevitable problem for maintenance hemodialysis (MHD) patients and may seriously endanger the physical and mental health of patients with MHD. Studies have shown that drug or nondrug measures can reduce AVF puncture pain, but much improvement is needed. When combined with compound lidocaine cream (CLC) in the treatment of AVF puncture pain, auricular point acupressure (APA)-a therapeutic method in which specific points on the auricle of the outer ear are stimulated to treat various disorders of the body-and the therapeutic value and synergistic effects of auriculotherapy merit further investigation. METHODS 120 MHD patients were recruited at blood purification centers in three hospitals between January 2016 and April 2019. After completion of the baseline survey, all patients were randomly divided by the envelope method into a control group, APA group, CLC group, and APA combined with CLC, with 30 subjects per group. The numerical rating scale (NRS) of pain was used to measure the pain before intervention and 1, 4, and 8 weeks after intervention. The State-Trait Anxiety Inventory (STAI), General Comfort Questionnaire (GCQ), blood pressure, and heart rates were obtained before and after the intervention. RESULTS Pain, anxiety, comfort, blood pressure (BP), and heart rates (HR) of the three groups were better than those of the control group; the difference was statistically significant (P < 0.05). In addition, the APA combined with CLC group was better than the APA group and CLC group, respectively, in those outcomes (P < 0.05). CONCLUSION Both APA and CLC can effectively relieve AVF puncture pain, and the combined application has more outstanding effects.
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Affiliation(s)
- Xiaohui Liu
- Department of Nursing, The First Affiliated Hospital of Hunan University of Chinese Medicine, Changsha, Hunan 410007, China
- Department of Traditional Chinese Medicine Nursing, Nursing College of Henan University of Traditional Chinese Medicine, Zhengzhou, Henan 473005, China
| | - Wei Wei
- College of Nursing, Henan University of Traditional Chinese Medicine, Zhengzhou, Henan 473005, China
| | - Yaqi Wu
- College of Nursing, Henan University of Traditional Chinese Medicine, Zhengzhou, Henan 473005, China
| | - Xiao Jiang
- College of Nursing, Henan University of Traditional Chinese Medicine, Zhengzhou, Henan 473005, China
| | - Xueqin Liu
- College of Nursing, Henan University of Traditional Chinese Medicine, Zhengzhou, Henan 473005, China
| | - Ying Zhang
- College of Nursing, Henan University of Traditional Chinese Medicine, Zhengzhou, Henan 473005, China
| | - Chao Hsing Yeh
- Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Room 421, Baltimore, MD 21205, USA
| | - Yuejuan Zhang
- Department of Nursing, The First Affiliated Hospital of Hunan University of Chinese Medicine, Changsha, Hunan 410007, China
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15
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Zhang LK, Li Q, Quan RF, Liu JS. Is preemptive analgesia a good choice for postoperative pain relief in lumbar spine surgeries?: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e25319. [PMID: 33787624 PMCID: PMC8021355 DOI: 10.1097/md.0000000000025319] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 03/02/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Lumbar spine surgery is associated with moderate-to-severe postoperative pain. Adequate pain management during the postoperative period facilitates rehabilitation. Recently, preemptive analgesia has been considered among the important analgesic methods for reducing postoperative pain. However, its efficacy in postoperative pain relief after lumbar spine surgery remains unclear. This study aimed to evaluate the effects of preemptive analgesia on lumbar spine surgery. METHODS We searched for randomized controlled trials in PubMed (1996 to May 2020), Embase (1980 to May 2020), and Cochrane Library (CENTRAL, May 2020). We included seven studies that evaluated the preemptive analgesic efficacy in lumbar spine surgeries. RESULTS Seven studies, including 509 patients, met the inclusion criteria. Pooled data revealed that preemptive analgesia is effective for lumbar spine surgeries with respect to the visual analog scale score (P < .05), total morphine equivalent consumption (P < .05), and length of stay (P < .05), without increasing complications (P = .73). CONCLUSIONS Our findings indicate that preemptive analgesia is safe and effective for lumbar spine surgery.
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Affiliation(s)
- Lu-kai Zhang
- Department of Orthopedics, Xiaoshan Traditional Chinese Medical Hospital
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Qiang Li
- Department of Orthopedics, Xiaoshan Traditional Chinese Medical Hospital
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Ren-Fu Quan
- Department of Orthopedics, Xiaoshan Traditional Chinese Medical Hospital
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Jun-Sheng Liu
- Department of Orthopedics, Xiaoshan Traditional Chinese Medical Hospital
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People's Republic of China
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Venkatraman R, Karthik K, Belinda C, Balaji R. A Randomized Observer-Blinded Controlled Trial to Compare Pre-Emptive with Postoperative Ultrasound-Guided Mandibular Nerve Block for Postoperative Analgesia in Mandibular Fracture Surgeries. Local Reg Anesth 2021; 14:13-20. [PMID: 33603457 PMCID: PMC7882799 DOI: 10.2147/lra.s290462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 01/20/2021] [Indexed: 12/31/2022] Open
Abstract
Background and Aims Ultrasound-guided (UG) mandibular nerve block is effective for providing postoperative analgesia in mandibular fracture surgeries. The pre-emptive nerve blockade prolongs the duration of postoperative analgesia and reduces the consumption of intraoperative opioids. The aim of this prospective, randomized, single-blinded study was to compare the efficacy of pre-emptive and postoperative UG mandibular nerve block for postoperative analgesia in mandibular fracture surgeries. Methods Sixty patients scheduled for unilateral mandibular fracture surgeries were randomly divided into two groups by computer-generated random numbers and sealed envelope method: Group A received UG mandibular nerve block before surgical incision and group B received after surgery with ropivacaine 0.5% 10mL. The second anesthesiologist, who was blinded to the group involved, monitored the patient. The patients as well as the statistician were also blinded. The patients were started on patient-controlled analgesia (PCA) morphine with bolus 1mg and a lockout interval of 10min. The morphine consumption for 24h was recorded. The pain was assessed by the VAS score. The additional intraoperative fentanyl consumption and time for a request for rescue analgesic were recorded. Results The total morphine consumption was reduced in group A (4.566±0.717mg) than group B (5.93±0.876mg) with a p-value of <0.0001. The time for a request for rescue analgesic was also prolonged in group A (794.08±89.561min) than group B (505.333±3.159min). In group A, only four patients required an additional dose of fentanyl as against 11 patients in group B. The heart rate was also lower in group A 30min after the administration of the block and persisted for two hours intraoperatively. Conclusion Pre-emptive ultrasound-guided mandibular nerve block reduces morphine consumption, prolongs the time for a request for rescue analgesic, reduces intraoperative fentanyl consumption, provides better control of intraoperative heart rate, and better pain scores postoperatively when compared to the postoperative mandibular nerve block. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/0ifMIJ8ooiU
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Affiliation(s)
- Rajagopalan Venkatraman
- Department of Anaesthesia, SRM Medical College Hospital and Research Centre, Potheri, Tamilnadu, 603203, India
| | - Kandhan Karthik
- Department of Anaesthesia, SRM Medical College Hospital and Research Centre, Potheri, Tamilnadu, 603203, India
| | - Cherian Belinda
- Department of Anaesthesia, SRM Medical College Hospital and Research Centre, Potheri, Tamilnadu, 603203, India
| | - Ramamurthy Balaji
- Department of Anaesthesia, SRM Medical College Hospital and Research Centre, Potheri, Tamilnadu, 603203, India
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Muthu S, Ramakrishnan E. Fragility Analysis of Statistically Significant Outcomes of Randomized Control Trials in Spine Surgery: A Systematic Review. Spine (Phila Pa 1976) 2021; 46:198-208. [PMID: 32756285 DOI: 10.1097/brs.0000000000003645] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVES The aim of this study was to assess the robustness of statistically significant outcomes from randomized control trials (RCTs) in spine surgery using Fragility Index (FI) which is a novel metric measuring the number of events upon which statistical significance of the outcome depends. SUMMARY OF BACKGROUND DATA Many trials in Spine surgery were characterized by fewer outcome events along with small sample size. FI helps us identify the robustness of the results from such studies with statistically significant dichotomous outcomes. METHODS We conducted independent and in duplicate, a systematic review of published RCTs in spine surgery from PubMed Central, Embase, and Cochrane Database. RCTs with 1:1 prospective study design and reporting statistically significant dichotomous primary or secondary outcomes were included. FI was calculated for each RCT and its correlation with various factors was analyzed. RESULTS Seventy trials met inclusion criteria with a median sample size of 133 (interquartile range [IQR]: 80-218) and median reported events per trial was 38 (IQR: 13-94). The median FI score was 2 (IQR: 0-5), which means if we switch two patients from nonevent to event, the statistical significance of the outcome is lost. The FI score was less than the number of patients lost to follow-up in 28 of 70 trials. The FI score was found to positively correlated with sample size (r = 0.431, P = 0.001), total number of outcome events (r = 0.305, P = 0.01) while negatively correlated with P value (r = -0.392, P = 0.001). Funding, journal impact-factor, risk of bias domains, and year of publication did not have a significant correlation. CONCLUSION Statistically significant dichotomous outcomes reported in spine surgery RCTs are more often fragile and outcomes of the patients lost to follow-up could have changed the significance of results and hence it needs caution before transcending their results into clinical application. The addition of FI in routine reporting of RCTs would guide readers on the robustness of the statistical significance of outcomes. RCTs with FI ≥5 without any patient lost to follow-up can be considered to have clinically robust results.Level of Evidence: 1.
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Affiliation(s)
- Sathish Muthu
- Government Hospital, Velayuthampalayam, Karur, Tamil Nadu, India
| | - Eswar Ramakrishnan
- Institute of Orthopaedics and Traumatology, Madras Medical College & Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
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中国康复技术转化及发展促进会骨科加速康复专业委员会脊柱微创加速康复学组. [Expert consensus on the implementation of enhanced recovery after surgery in percutaneous endoscopic interlaminar lumbar decompression/discectomy (2020)]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1497-1506. [PMID: 33319526 PMCID: PMC8171567 DOI: 10.7507/1002-1892.202011021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 11/20/2020] [Indexed: 12/14/2022]
Abstract
In recent years, enhanced recovery after surgery (ERAS) has been widely used in spine surgery and achieved satisfactory results. In order to standardize the ERAS implementation process and application in percutaneous endoscopic interlaminar lumbar decompression/discectomy (PEID), we reviewed the literatures and cited evidence-based medicine data, and had a national comprehensive discussion among experts of the Group of Minimally Invasive Spinal Surgery and Enhanced Recovery, Professional Committee of Orthopedic Surgery and Enhanced Recovery, Association of China Rehabilitation Technology Transformation and Promotion. Altogether, the up-to-date expert consensus have been achieved. The consensus may provide the reference for clinical treatment in aspect of the standardization of surgical operations, the reduction of surgical trauma and complications, the optimization of perioperative pain and sleep management, the prevention of venous thrombosis, and the guidance of patients' functional training and perioperative education.
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19
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Opioid Alternatives in Spine Surgery: A Narrative Review. J Neurosurg Anesthesiol 2020; 34:3-13. [PMID: 32568816 DOI: 10.1097/ana.0000000000000708] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 05/19/2020] [Indexed: 11/26/2022]
Abstract
Adequate analgesia is known to improve outcomes after spine surgery. Despite recent attention highlighting the negative effects of narcotics and their addiction potential, opioids have been the mainstay of management for providing analgesia following spine surgeries. However, side effects including hyperalgesia, tolerance, and subsequent dependence restrict the generous usage of opioids. Multimodal analgesia regimens acting through different mechanisms offer significant opioid sparing and minimize the side effects of individual drugs. Hence, they are being increasingly incorporated into enhanced recovery protocols. Multimodal analgesia includes drugs such as N-methyl-D-aspartate antagonists, nonsteroidal anti-inflammatory drugs and membrane-stabilizing agents, neuraxial opioids, local anesthetic infiltration, and fascial compartment blocks. Analgesia started before the painful stimulus, termed preemptive analgesia, facilitates subsequent pain management. Both nonsteroidal anti-inflammatory drugs and neuraxial analgesia have been conclusively shown to reduce opioid requirements after spine surgery, and there is a resurgence of interest in the use of low-dose ketamine or methadone. Neuraxial narcotics offer enhanced analgesia for a longer duration with lower dosage and side effect profiles compared with systemic opioid administration. Fascial compartment blocks are increasingly used as they provide effective analgesia with fewer adverse effects. In this narrative review, we will discuss multimodality analgesic regimens incorporating opioid-sparing adjuvants to manage pain after spine surgery.
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20
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Liu Q, Liu Y, Bian J, Li Q, Zhang Y. The preemptive analgesia of pre-electroacupuncture in rats with formalin-induced acute inflammatory pain. Mol Pain 2020; 15:1744806919866529. [PMID: 31322476 PMCID: PMC6685110 DOI: 10.1177/1744806919866529] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Electroacupuncture has been elicited to effectively alleviate the pain sensation. Preemptive analgesic effect of pre-electroacupuncture has also been suggested in recent studies, while the underlying analgesic mechanism of pre-electroacupuncture requires further investigation. This study aimed to explore the preemptive analgesia of pre-electroacupuncture in formalin-induced acute inflammatory pain model. Methods Forty rats were randomly divided into control, model, pre-electroacupuncture, and post-electroacupuncture group. Inflammatory pain model was induced via injecting 50 µl 5% formalin into the plantar surface of right hind paw, while the equal volume of saline injection in the control group. Rats in the pre-electroacupuncture group were treated with electroacupuncture at ipsilateral Zusanli (ST36) and Weizhong (BL40) acupoints (2 Hz, 1 mA) for 30 min before formalin injection, while received the same electroacupuncture treatment immediately after formalin injection in the post-electroacupuncture group. Flinching number and licking time were recorded during 60 min after formalin injection. Immunofluorescence and Western blot were used to detect the expression of ionized calcium binding adapter molecule 1 (Iba1) and c-fos in spinal cord. Moreover, enzyme-linked immunosorbent assay was applied to measure the secretion of IL-6, IFN-γ, IL-4, substance P, and calcitonin gene-related peptide in spinal cord. Results Paw flinching and licking were obviously induced by formalin injection. Iba1, c-fos, proinflammatory cytokines (IL-6 and IFN-γ), and pain neurotransmitters (substance P and calcitonin gene-related peptide) were dramatically increased in the L4-5 spinal cord after formalin injection, while anti-inflammatory cytokine IL-4 was decreased. Pre-electroacupuncture and post-electroacupuncture administration significantly attenuated formalin-induced nociceptive effects, spinal microglia and neurons activation, proinflammatory cytokines and pain neurotransmitters upregulation, and upregulated the anti-inflammatory cytokine. Furthermore, these effects of pre-electroacupuncture were more significant than that of post-electroacupuncture. Conclusions This study illustrates the potential therapeutic effect of pre-electroacupuncture against acute inflammatory pain and reveals the mechanism underlying pre-electroacupuncture mediated analgesia, thus providing a novel preemptive analgesic treatment.
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Affiliation(s)
- Qing Liu
- 1 Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan, China
| | - Yan Liu
- 1 Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan, China
| | - Jiang Bian
- 1 Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan, China
| | - Qun Li
- 1 Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan, China
| | - Ying Zhang
- 1 Department of Anesthesiology, Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan, China
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21
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Brown CH, Jones EL, Lin C, Esmaili M, Gorashi Y, Skelton RA, Kaganov D, Colantuoni EA, Yanek LR, Neufeld KJ, Kamath V, Sieber FE, Dean CL, Edwards CC, Hogue CW. Shaping anesthetic techniques to reduce post-operative delirium (SHARP) study: a protocol for a prospective pragmatic randomized controlled trial to evaluate spinal anesthesia with targeted sedation compared with general anesthesia in older adults undergoing lumbar spine fusion surgery. BMC Anesthesiol 2019; 19:192. [PMID: 31656179 PMCID: PMC6815448 DOI: 10.1186/s12871-019-0867-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 10/07/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Postoperative delirium is common in older adults, especially in those patients undergoing spine surgery, in whom it is estimated to occur in > 30% of patients. Although previously thought to be transient, it is now recognized that delirium is associated with both short- and long-term complications. Optimizing the depth of anesthesia may represent a modifiable strategy for delirium prevention. However, previous studies have generally not focused on reducing the depth of anesthesia beyond levels consistent with general anesthesia. Additionally, the results of prior studies have been conflicting. The primary aim of this study is to determine whether reduced depth of anesthesia using spinal anesthesia reduces the incidence of delirium after lumbar fusion surgery compared with general anesthesia. METHODS This single-center randomized controlled trial is enrolling 218 older adults undergoing lumbar fusion surgery. Patients are randomized to reduced depth of anesthesia in the context of spinal anesthesia with targeted sedation using processed electroencephalogram monitoring versus general anesthesia without processed electroencephalogram monitoring. All patients are evaluated for delirium using the Confusion Assessment Method for 3 days after surgery or until discharge and undergo assessments of cognition, function, health-related quality of life, and pain at 3- and 12-months after surgery. The primary outcome is any occurrence of delirium. The main secondary outcome is change in the Mini-Mental Status Examination (or telephone equivalent) at 3-months after surgery. DISCUSSION Delirium is an important complication after surgery in older adults. The results of this study will examine whether reduced depth of anesthesia using spinal anesthesia with targeted depth of sedation represents a modifiable intervention to reduce the incidence of delirium and other long-term outcomes. The results of this study will be presented at national meetings and published in peer-reviewed journals with the goal of improving perioperative outcomes for older adults. TRIAL REGISTRATION Clinicaltrials.gov , NCT03133845. This study was submitted to Clinicaltrials.gov on October 23, 2015; however, it was not formally registered until April 28, 2017 due to formatting requirements from the registry, so the formal registration is retrospective.
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Affiliation(s)
- Charles H. Brown
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Zayed 6208, 1800 Orleans St, Baltimore, MD 21287 USA
| | - Emily L. Jones
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Zayed 6208, 1800 Orleans St, Baltimore, MD 21287 USA
| | - Charles Lin
- Mercy Anesthesiology Associates, 300 St. Paul Place, Baltimore, MD 21202 USA
| | - Melody Esmaili
- Mercy Anesthesiology Associates, 300 St. Paul Place, Baltimore, MD 21202 USA
| | - Yara Gorashi
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA 02111 USA
| | - Richard A. Skelton
- University of Miami Miller School of Medicine, 1600 NW 10th avenue, Miami, FL 33136 USA
| | - Daniel Kaganov
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Zayed 6208, 1800 Orleans St, Baltimore, MD 21287 USA
| | - Elizabeth A. Colantuoni
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD 21287 USA
| | - Lisa R. Yanek
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 Building; 8024, 600 N. Wolfe St, Baltimore, MD 21287 USA
| | - Karin J. Neufeld
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, A4 Center Suite 457, 4940 Eastern Avenue, Baltimore, MD 21224 USA
| | - Vidyulata Kamath
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, A4 Center Suite 457, 4940 Eastern Avenue, Baltimore, MD 21224 USA
| | - Frederick E. Sieber
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Zayed 6208, 1800 Orleans St, Baltimore, MD 21287 USA
| | - Clayton L. Dean
- The Maryland Spine Center at Mercy, 301 St. Paul Place, Baltimore, MD 21202 USA
| | - Charles C. Edwards
- The Maryland Spine Center at Mercy, 301 St. Paul Place, Baltimore, MD 21202 USA
| | - Charles W. Hogue
- Department of Anesthesiology, Northwestern Feinberg School of Medicine, NMH/Feinberg Room 5-704, 251 E Huron, Northwestern Feinberg School of Medicine, Chicago, IL 60611 USA
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22
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Mordehai E. Letter to the Editor. Confounding factors in predicting postoperative pain and opioid consumption after spine surgery. J Neurosurg Spine 2019; 31:454-455. [PMID: 31299641 DOI: 10.3171/2019.3.spine19324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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