Epidural steroids, postoperative morbidity, and recovery in patients undergoing microsurgical lumbar discectomy

Methylprednisolone Following Minimally Invasive Lumbar Decompression: A Large Prospective Single-Institution Study

STUDY DESIGN

Prospective randomized.

OBJECTIVE

Intraoperative methylprednisolone is a common adjunct following microscopic laminectomy/microdiscectomy. The goal of epidural instillation is a rapid symptomatic reduction in irritation of neural elements. There is inconsistent data supporting its use intraoperatively. To understand whether this maneuver results in any clinical effect, we performed a multiyear prospective study.

SUMMARY OF BACKGROUND DATA

Previous work has demonstrated equivocal effects on pain with a suggestion of an increased risk of complication. These studies tend to suffer from small sample sizes and short follow-ups.

MATERIALS AND METHODS

Study obtained IRB approval. During the study period from 2013 to 2019, nearly equivalent numbers of patients who had received steroids during MIS decompressions were followed. Primary outcomes included pain (visual analog scale) and disability [Oswestry Disability Index (ODI)] at 2 weeks and 4 months. Secondary outcomes included complications, readmissions, and reoperation rates during the study period.

RESULTS

Four hundred eighty-six patients were followed for a mean follow-up of 5.17 years. The index case was more likely to be a revision surgery in the steroid group. Across all patients, there was no difference in pain at 2 weeks or 4 months. Disability was reduced at 2 weeks in the steroid group (ODI: 16.71 vs . 21.02, P = 0.04) but not at 4 months. By subgroup analysis, this is largely explained by ODI reduction in patients with high preoperative ODI (13.00 vs . 43.43, P = 0.03). Patients in the steroid cohort were more likely to undergo subsequent spinal surgery during the study period.

CONCLUSION

Methylprednisolone instillation is associated with a large, transient reduction in ODI for patients with high preoperative ODI; there is no measurable effect on pain. There is equivocal effect on risk of subsequent reoperation. This issue was clarified in peer review but changes did not make it to the abstract. Therefore, the technique is likely best reserved for patients with significant preoperative disability.

Effects of local intraoperative epidural use of triamcinolone acetonide-soaked Gelfoam on postoperative outcomes in patients undergoing posterolateral lumbar spinal fusion surgery: a randomized, placebo-controlled, double-blind trial

OBJECTIVE

Prior evidence has supported the use of local intraoperative epidural steroids in lumbar discectomy for improvements in postoperative pain and outcomes. However, currently there is a paucity of data regarding the efficacy of local epidural steroids in spinal fusion procedures. The present investigation aimed to evaluate the impact of local epidural administration of triamcinolone acetonide-soaked Gelfoam on postoperative pain and patient-reported outcomes in patients undergoing instrumented posterolateral lumbar spinal fusion.

METHODS

In this randomized, double-blind, placebo-controlled trial, patients were randomly divided into two groups (treatment and control). Patients in the treatment group received a Gelfoam carrier soaked in 1 ml of triamcinolone acetonide (40 mg), which was placed over the nerve roots in the epidural space before the closure. Patients in the control group received a Gelfoam carrier soaked in normal saline in a similar fashion to the treatment group. Patients were followed up during their hospital stay and at 4 and 12 weeks postoperatively. The primary outcome measure was early postoperative visual analog scale (VAS) scores for pain both at rest and with movement.

RESULTS

A total of 100 patients were recruited in this study and were randomly allocated to the treatment or control group. No significant difference was found in baseline demographic, clinical, and surgical characteristics between the two groups. Postoperative VAS scores for pain both at rest and with movement were comparable between the treatment and control groups. Cumulative morphine consumption, length of hospital stay, and incidence of postoperative complications such as surgical site infection were also similar between the two groups. There was no significant difference in patient-reported outcomes including VAS scores for back and leg pain as well as the Oswestry Disability Index at 4 and 12 weeks postoperatively. The proportion of patients who achieved a minimum clinically important difference for patient-reported outcomes were also similar between the two groups.

CONCLUSIONS

In contrast to the existing literature on the beneficial use of local intraoperative epidural steroids in conventional lumbar discectomy, the present study did not demonstrate such significant efficacy for the use of local epidural steroids in instrumented posterolateral lumbar spinal fusion. However, there is still a lack of evidence in this regard and further high-quality clinical trials are required to evaluate the efficacy of local epidural steroids in this group of patients.

Computer-navigated versus conventional total knee arthroplasty: A randomized controlled trial protocol in China

BACKGROUND

The literature lacks studies that confirm whether the improved radiographic alignment that can be achieved with computer-navigated total knee arthroplasty (TKA) improves patients' activities of daily living or the durability of total knee prostheses. Thus, in this protocol, we designed a randomized controlled trial to compare implant alignment, functional scores, and survival of the implant using computer-assisted surgery versus a conventional surgical technique.

METHODS

This prospective, blinded randomized controlled trial was conducted at our single hospital. This study was approved by the ethics committee of Jiaxing Second Hospital. The patient inclusion criteria were age 20 to 80 years' old, a body mass index of ≤35 kg/m, and consented for primary knee arthroplasty performed through a medial parapatellar approach by the senior author. We randomized consented study participants on a 1:1 ratio to 1 of 2 study groups using a computer-generated list of random numbers in varying block sizes. The primary outcome in this study was the Knee Injury and Osteoarthritis Outcome Score. Secondary outcomes were the Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis Index, complications, and range of motion together with alignment and rotational positioning of the implant. Statistical significance was defined as a P value of ≤0.05.

CONCLUSIONS

Authors hypothesized that computer-assisted surgery in primary TKA improves implant alignment, functional scores, and survival of the implant compared to the conventional technique.

Efficacy and safety of epidural steroid injection following discectomy for patients with lumbar disc herniation: A protocol

BACKGROUND

Concerns exist regarding the analgesia effect and safety of epidural steroid injection (ESI) after discectomy. There is an urgent need of studies that efficiently control for confounding, conduct comprehensive and consecutive observation of potential risks of ESI, and investigate its clinical applicability. We thus further designed a randomized controlled study to assess the efficacy of ESI on postoperative pain and complications in patients undergoing unilateral lumbar microdiscectomy.

METHODS

This prospective, blinded randomized controlled trial was conducted at our single hospital. This study was approved by the Committee at the No.2 People's Hospital of Yibin. All procedures were performed by a single surgeon and informed consent was obtained from each patient. Ninty eligible patients diagnosed at our institution with herniated lumbar disc during a period from June 2020 to July 2021 will be assessed. Group 1 was a mixture of 1 mL of 0.5% bupivacaine and 10 mg of triamcinolone acetonide in 1 mL. Group 2 was a mixture of 1 mL of 0.5% bupivacaine and 1 mL of normal saline. The primary outcome measure was the amount of morphine consumption from a patient-controlled analgesia pump at 12, 24, and 48 hours after surgery. The following secondary outcomes were also assessed: postoperative pain score, back pain score, functional disability, and adverse effect.

CONCLUSIONS

We hypothesized that the ESI was associated with lower pain score, morphine consumption, and hospital stay, with no significant difference in complications for ESI application after lumbar discectomy in lumbar disc herniation when compared with placebo.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5683).

Intraoperative epidural application of steroid and local anaesthetic agent following lumbar discectomy: A prospective double blinded randomized controlled trial

BACKGROUND

Postoperative pain management following lumbar discectomy is a key part of the procedure and various postoperative pain protocols including a wide range of agents are being used in daily practice worldwide. The aim of this study is to investigate the effect of intraoperative epidural infiltration of local anaesthetic and steroid compared with placebo (normal saline) following microscopic lumbar discectomy.

METHODS

Sixty patients undergoing lumbar discectomy were randomized to intraoperative infiltration of 3 mg betamethoasone acetate and 18 mg ropivacaine (Group A) or normal saline (Group B). Infiltration was performed after discectomy and decompression and immediately prior to incision closure. Postoperatively a standard protocol of intravenous acetaminophen administration and physiotherapy was followed. Additional analgesia with tramadol was given only in patients who required further pain management. Postoperative pain was evaluated using VAS score. Opioid consumption was recorded. Primary outcome measures included immediate postoperative back pain VAS score, opioid consumption and infection rate. Patients were reviewed in clinic at 6 weeks, 6 months and 1 year postoperatively.

RESULTS

None of the patients in Group A required further analgesia while 12 Group B patients required further treatment with tramadol (p = 0.01). At 3 h postoperatively the VAS score was significantly lower in Group A compared to Group B (p < 0.05). Fifty-seven patients completed the 1 year follow up (95%) and 2 patients (1 from each group) suffered a complication of postoperative radiculopathy.

CONCLUSION

Intraoperative application of steroid and local anaesthetic agent is effective on pain reduction for only a short period after surgery, while there is no effect on infection rate or any other long-term outcome compared with placebo. Hence although it is a safe technique, its benefits are limited from the duration of action.

Effect of Steroid-Soaked Gelatin Sponge on Soft Tissue Swelling Following Anterior Cervical Discectomy and Fusion: A Radiographic Analysis

Study Design

Retrospective radiological review and analysis of 79 patients who underwent primary anterior cervical discectomy and fusion (ACDF) of 2 or 3 levels between 2011 and 2013.

Purpose

This study aimed to determine the effect of the local placement of a steroid-soaked gelatin sponge after ACDF on prevertebral soft tissue swelling.

Overview of Literature

Although ACDF has become a popular choice for cervical fusion, the surgical involvement of the delicate anatomy of the neck frequently results in tissue irritation and edema. Swelling of the prevertebral soft tissue may consequently lead to mild-to-severe complications, ranging from dysphonia to dyspnea.

Methods

Out of the 79 patients who underwent primary ACDF, 52 received a gelatin sponge soaked with 40 mg of Depo-Medrol placed adjacent to the operated cervical levels. Prevertebral soft tissue swelling was detected using postoperative lateral X-ray. The radiographic values were compared to those of 27 patients who did not receive the treatment.

Results

Soft tissue swelling was markedly decreased in patients who received the placement of the steroid-soaked gelatin sponge next to their fused levels after surgery compared with that in patients who did not receive it. No complications were documented with the use of steroids.

Conclusions

The placement of a steroid-soaked gelatin sponge markedly reduces postoperative soft tissue swelling following 2- or 3-level primary ACDF.

Do Preoperative Corticosteroid Injections Increase the Risk for Infections or Wound Healing Problems After Spine Surgery?: A Swiss Prospective Multicenter Cohort Study

STUDY DESIGN

A prospective multicenter cohort study.

OBJECTIVES

This study evaluates the risk for surgical site infections (SSIs) or wound healing problems (WHPs) in patients who underwent corticosteroid injection before lumbar decompression surgery.

SUMMARY OF BACKGROUND DATA

Corticosteroid injections are often used for the treatment of the degenerated spine. However, their well-known immunosuppressive effects could increase the risk for local infections, particularly if a surgical intervention follows the injection rapidly.

METHODS

The Swiss Lumbar Stenosis Outcome Study (LSOS), which is a prospective multicenter cohort study of patients with symptomatic lumbar spinal stenosis, was used as database. Of 743 patients, 422 patients underwent surgery and were eligible for the study. Ten patients (2.4%) were revised for either SSIs (n = 6) or WHPs (n = 4). A control group (n = 19) was constructed matched according to age, sex, diabetes, and body mass index (BMI). Odds ratios (ORs) were calculated by using a conditional logistic regression model to quantify the risk of SSI or WHP after preoperative corticosteroid injection. Subgroup analysis was performed for patients with injection within 0 to 3 months before surgery, 0 to 6 months before surgery, or any injection at all before surgery.

RESULTS

Within this cohort, no significant association could be found between preoperative corticosteroid injection and postoperative SSI or WHP in patients with corticosteroid injections within 0 to 3 months before surgery [OR = 0.36, 95% confidence interval (95% CI) 0.04-3.22], 0 to 6 months before surgery (OR = 0.69 95% CI 0.14-3.49), or any time before surgery (OR = 0.43, 95% CI 0.04-3.22).

CONCLUSION

Within the here investigated cohort, the risk of SSIs or WHPs following lumbar spinal decompression surgery seems not highly associated with preoperative corticosteroid injections. However, the safe time interval between corticosteroid infiltrations and surgery remains unknown, should not be decreased incautiously, and is the subject of further research.

LEVEL OF EVIDENCE

2.

Efficacy of intraoperative epidural triamcinolone application in lumbar microdiscectomy: a matched-control study

OBJECTIVE

The purpose of this study was to investigate whether the intraoperative application of an epidural steroid (ES) on the decompressed nerve root improves short- and midterm subjective and objective clinical outcomes after lumbar microdiscectomy.

METHODS

This study was a retrospective analysis of a 2-center database including consecutive cases in which patients underwent lumbar microdiscectomy. All patients who received ES application (40 mg triamcinolone, ES group) were matched by age and sex to patients who had not received ES application (control group). Objective functional impairment (OFI) was determined using age- and sex-adjusted T-scores of the Timed Up and Go (TUG) test. Back and leg pain (visual analog scale), functional impairment (Oswestry Disability Index [ODI], Roland-Morris Disability Index [RMDI], and health-related quality of life (hrQoL; 12-Item Short Form Health Survey [SF-12] physical component summary [PSC] score and EuroQol [EQ-5D index]) were measured at baseline, on postoperative day 3, and at postoperative week 6.

RESULTS

Fifty-three patients who received ES application were matched with 101 controls. There were no baseline demographic or disease-specific differences between the study groups, and preoperative pain, functional impairment, and hrQoL were similar. On postoperative day 3, the ES group had less disability on the RMDI (mean 7.4 vs 10.3, p = 0.003) and higher hrQoL as determined by the SF-12 PCS (36.5 vs 32.7, p = 0.004). At week 6, the ES group had less disability on the RMDI (3.6 vs 5.7, p = 0.050) and on the ODI by trend (17.0 vs 24.4, p = 0.056); better hrQoL, determined by the SF-12 PCS (44.3 vs 39.9, p = 0.018); and lower OFI (TUG test T-score 100.5 vs 110.2, p = 0.005). The week 6 responder status based on the minimum clinically important difference (MCID) was similar in the ES and control groups for each metric. The rates and severity of complications were similar, with a 3.8% and 4.0% reoperation rate in the ES group and control group, respectively (p = 0.272). There was a tendency for shorter hospitalization in the ES group (5.0 vs 5.8 days, p = 0.066).

CONCLUSIONS

Intraoperative ES application on the decompressed nerve root is an effective adjunct treatment that may lower subjective and objective functional impairment and increase hrQoL in the short and intermediate term after lumbar microdiscectomy. However, group differences were lower than the commonly accepted MCIDs for each metric, indicating that the effect size of the benefit is limited.

■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: retrospective cohort trial; evidence: Class II.

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.

Epidural Steroids After a Percutaneous Endoscopic Lumbar Discectomy

STUDY DESIGN

Randomized controlled study from a single surgeon.

OBJECTIVE

The objective of the present study is to assess the effectiveness of the administration of epidural steroids in patients who undergo a percutaneous endoscopic lumbar discectomy (PELD) because of a herniated lumbar disc.

SUMMARY OF BACKGROUND DATA

Steroids are drugs that show strong anti-inflammatory effects; in specific, the effects of epidural steroid application after an open lumbar discectomy have been studied extensively. However, no study has been conducted on the effects of perioperative epidural steroids after PELD.

METHODS

One hundred patients who had undergone a PELD because of a herniated lumbar disc were randomized into 2 groups. Patients in group 1 were subjected to an epidural steroid application after a PELD, whereas patients in group 2 were treated with saline after a PELD.

RESULTS

There was a significant decrease in visual analogue scale (VAS) scores (back, leg) and Oswestry Disability Index at all examinations (P < 0.01). When comparing the 2 groups, group 1 showed lower levels of VAS scores (back) in all examinations than group 2 but was not statistically significant (P = 0.257). In VAS score (leg), group 1 showed a significant decrease compared with the group 2 at 1 and 4 weeks of follow-up examination (P = 0.020, P = 0.032). In Oswestry Disability Index, group 1 showed a significant decrease compared with the group 2 at 1-week follow-up examination (P < 0.01).The mean hospital stay was statistically significantly shorter in group 1 (P < 0.01). The mean periods before returning to work for those who returned to work in group 1 and group 2 were 4.45 ± 3.59 weeks and 6.48 ± 4.88 weeks, respectively, when measured at follow-up at 6 months; the period in group 1 was statistically significantly shorter (P = 0.024).

CONCLUSION

Epidural steroids after a PELD reduce back pain and leg pain while improving functional outcomes in the short-term postsurgery period.

LEVEL OF EVIDENCE

2.

Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses

BACKGROUND

There are numerous treatment approaches for sciatica. Previous systematic reviews have not compared all these strategies together.

PURPOSE

To compare the clinical effectiveness of different treatment strategies for sciatica simultaneously.

STUDY DESIGN

Systematic review and network meta-analysis.

METHODS

We searched 28 electronic databases and online trial registries, along with bibliographies of previous reviews for comparative studies evaluating any intervention to treat sciatica in adults, with outcome data on global effect or pain intensity. Network meta-analysis methods were used to simultaneously compare all treatment strategies and allow indirect comparisons of treatments between studies. The study was funded by the UK National Institute for Health Research Health Technology Assessment program; there are no potential conflict of interests.

RESULTS

We identified 122 relevant studies; 90 were randomized controlled trials (RCTs) or quasi-RCTs. Interventions were grouped into 21 treatment strategies. Internal and external validity of included studies was very low. For overall recovery as the outcome, compared with inactive control or conventional care, there was a statistically significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy, and exercise therapy were significantly inferior to epidural injections or surgery. For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant. Biological agents were significantly better for pain reduction than bed rest, nonopioids, and opioids. Opioids, education/advice alone, bed rest, and percutaneous discectomy were inferior to most other treatment strategies; although these findings represented large effects, they were statistically equivocal.

CONCLUSIONS

For the first time, many different treatment strategies for sciatica have been compared in the same systematic review and meta-analysis. This approach has provided new data to assist shared decision-making. The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction. The issue of how best to estimate the effectiveness of treatment approaches according to their order within a sequential treatment pathway remains an important challenge.

Dexamethasone for Morbidity After Subdural Electrode Insertion – A Randomized Controlled Trial

Background:

Invasive monitoring with subdural electrodes (SDE) for investigation of medically intractable epilepsy may be associated with undesirable immediate postoperative morbidity such as headache, nausea, vomiting, fever, and meningism. We undertook to evaluate the potential beneficial role of perioperative dexamethasone in reducing these symptoms.

Methods:

In a double-blind placebo controlled clinical trial 30 patients undergoing SDE insertion were randomized to receive either placebo or a course of dexamethasone beginning one hour prior to surgery and tapering to discontinue over 72 hours postoperatively. Pain, pain relief, nausea, nausea relief, temperature, and meningism were assessed regularly in the postoperative period, and analgesic, antipyretic, and antiemetic drug requirements were tabulated.

Results:

One patient was withdrawn from the dexamethasone group due to lack of data. With regards to postoperative pain, the direction of benefit favoured dexamethasone but a significant treatment by time interaction prevented further analysis of treatment effect. The dexamethasone group did have significantly lower temperatures and higher nausea relief scores. There was no statistically significant difference between the groups with regards to pain relief, nausea, and meningism scores. The beneficial effects of dexamethasone were delayed in onset, of limited duration, and not uniform over the observation period.

Conclusion:

Dexamethasone appears to have a role in reducing immediate morbidity following SDE insertion but its effect is not uniform in the postoperative period; it appears to be delayed in onset, and of limited duration. Further study is necessary to determine the ideal dosing schedule.

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.

Rehabilitation after lumbar disc surgery

BACKGROUND

Several rehabilitation programmes are available for individuals after lumbar disc surgery.

OBJECTIVES

To determine whether active rehabilitation after lumbar disc surgery is more effective than no treatment, and to describe which type of active rehabilitation is most effective. This is the second update of a Cochrane Review first published in 2002.First, we clustered treatments according to the start of treatment.1. Active rehabilitation that starts immediately postsurgery.2. Active rehabilitation that starts four to six weeks postsurgery.3. Active rehabilitation that starts longer than 12 months postsurgery.For every cluster, the following comparisons were investigated.A. Active rehabilitation versus no treatment, placebo or waiting list control.B. Active rehabilitation versus other kinds of active rehabilitation.C. Specific intervention in addition to active rehabilitation versus active rehabilitation alone.

SEARCH METHODS

We searched CENTRAL (2013, Issue 4) and MEDLINE, EMBASE, CINAHL, PEDro and PsycINFO to May 2013.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs).

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently assessed studies for eligibility and risk of bias. Meta-analyses were performed if studies were clinically homogeneous. The GRADE approach was used to determine the overall quality of evidence.

MAIN RESULTS

In this update, we identified eight new studies, thereby including a total of 22 trials (2503 participants), 10 of which had a low risk of bias. Most rehabilitation programmes were assessed in only one study. Both men and women were included, and overall mean age was 41.4 years. All participants had received standard discectomy, microdiscectomy and in one study standard laminectomy and (micro)discectomy. Mean duration of the rehabilitation intervention was 12 weeks; eight studies assessed six to eight-week exercise programmes, and eight studies assessed 12 to 13-week exercise programmes. Programmes were provided in primary and secondary care facilities and were started immediately after surgery (n = 4) or four to six weeks (n = 16) or one year after surgery (n = 2). In general, the overall quality of the evidence is low to very low. Rehabilitation programmes that started immediately after surgery were not more effective than their control interventions, which included exercise. Low- to very low-quality evidence suggests that there were no differences between specific rehabilitation programmes (multidisciplinary care, behavioural graded activity, strength and stretching) that started four to six weeks postsurgery and their comparators, which included some form of exercise. Low-quality evidence shows that physiotherapy from four to six weeks postsurgery onward led to better function than no treatment or education only, and that multidisciplinary rehabilitation co-ordinated by medical advisors led to faster return to work than usual care. Statistical pooling was performed only for three comparisons in which the rehabilitation programmes started four to six weeks postsurgery: exercise programmes versus no treatment, high- versus low-intensity exercise programmes and supervised versus home exercise programmes. Very low-quality evidence (five RCTs, N = 272) shows that exercises are more effective than no treatment for pain at short-term follow-up (standard mean difference (SMD) -0.90; 95% confidence interval (CI) -1.55 to -0.24), and low-quality evidence (four RCTs, N = 252) suggests that exercises are more effective for functional status on short-term follow-up (SMD -0.67; 95% CI -1.22 to -0.12) and that no difference in functional status was noted on long-term follow-up (three RCTs, N = 226; SMD -0.22; 95% CI -0.49 to 0.04). None of these studies reported that exercise increased the reoperation rate. Very low-quality evidence (two RCTs, N = 103) shows that high-intensity exercise programmes are more effective than low-intensity exercise programmes for pain in the short term (weighted mean difference (WMD) -10.67; 95% CI -17.04 to -4.30), and low-quality evidence (two RCTs, N = 103) shows that they are more effective for functional status in the short term (SMD -0.77; 95% CI -1.17 to -0.36). Very low-quality evidence (four RCTs, N = 154) suggests no significant differences between supervised and home exercise programmes for short-term pain relief (SMD -0.76;  95% CI -2.04 to 0.53) or functional status (four RCTs, N = 154; SMD -0.36; 95% CI -0.88 to 0.15).

AUTHORS' CONCLUSIONS

Considerable variation was noted in the content, duration and intensity of the rehabilitation programmes included in this review, and for none of them was high- or moderate-quality evidence identified. Exercise programmes starting four to six weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment, with small to medium effect sizes, and high-intensity exercise programmes seem to lead to a slightly faster decrease in pain and disability than is seen with low-intensity programmes, but the overall quality of the evidence is only low to very low. No significant differences were noted between supervised and home exercise programmes for pain relief, disability or global perceived effect. None of the trials reported an increase in reoperation rate after first-time lumbar surgery. High-quality randomised controlled trials are strongly needed.

Long-term Clinical Outcomes in Patients Undergoing Lumbar Discectomy by Fenestration

Objective:

To investigate the long-term outcome of discectomy and relevant factors associated with clinical outcome.

Methods:

Patients who underwent lumbar discectomy by fenestration were evaluated retrospectively, using the Oswestry disability index (ODI; 0 - 20 minimal, 21 - 40 moderate, > 41 severe disability) and the Stauffer-Coventry criteria (‘excellent’, ‘good’, ‘fair’, ‘poor’) to measure clinical and radiographic outcomes.

Results:

Sixty patients (mean follow-up, 214 months) were included in the analysis. At final follow-up, patients were rated as ‘excellent’ (n = 31), ‘good’ (n = 13), ‘fair’ (n = 5) and ‘poor’ (n = 11) using the Stauffer-Coventry criteria; the latter group included six patients who underwent reoperations. The mean ODI score was 11.2. The height of the operative intervertebral space was significantly inversely correlated with the follow-up ODI value. Heavy manual work, smoking and a long duration of aggressive preoperative symptoms were significantly associated with unsatisfactory outcomes.

Conclusions:

The long-term outcome of lumbar discectomy by fenestration was satisfactory in the majority of patients. Heavy manual work, smoking and the duration of aggressive preoperative symptoms were negative predictors of a good clinical outcome.

Beyond opioid patient-controlled analgesia: a systematic review of analgesia after major spine surgery

Postoperative pain control in patients undergoing spine surgery remains a challenge for the anesthesiologist. In addition to incisional pain, these patients experience pain arising from deeper tissues such as bones, ligaments, muscles, intervertebral disks, facet joints, and damaged nerve roots. The pain from these structures may be more severe and can lead to neural sensitization and release of mediators both peripherally and centrally. The problem is compounded by the fact that many of these patients are either opioid dependent or opioid tolerant, making them less responsive to the most commonly used therapy for postoperative pain (opioid-based intermittent or patient-controlled analgesia). The purpose of this review was to compare all published treatment options available that go beyond intravenous opiates and attempt to find the best possible treatment modality.

Effect of retropharyngeal steroid on prevertebral soft tissue swelling following anterior cervical discectomy and fusion: a prospective, randomized study

STUDY DESIGN

A prospective, randomized study.

OBJECTIVE

To analyze the effect of local retropharyngeal steroid to reduce prevertebral soft tissue swelling (PSTS) after anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

There have been several reports on intravenous corticosteroid to prevent airway complication without a consensus; however, there have been no reports to date that have discussed the use of local steroids to reduce PSTS.

METHODS

Fifty cases that underwent ACDF involving 1 or 2 segments were enrolled. The mean follow-up period was 22 months. Of the 25 cases randomly selected as the steroid group, a mixture of triamcinolone and morcellized collagen sponge was applied to the retropharyngeal space before wound closure. For the control group, the other 25 cases received the operation without steroid. We measured the PSTS ratio to vertebral body from C3 to 7 and PSTS index (PSTSI; mean of PSTS ratio at C3, 4, and 5) on cervical spine. Simple lateral radiographs were taken preoperatively, immediately after operation, and at postoperative 2 days, 4 days, 2 weeks, and the last follow-up. The changes in odynophagia, radiological union, Neck Disability Index were analyzed.

RESULTS

The PSTS ratio of the steroid group was significantly lower on C3 and C4 immediately after operation, on C3, 4, 5 and C6 at postoperative 2 days, on C3, 4, and 5 at 4 days. The differences of PSTSI (the steroid: control group) maintained at 58.2: 74.3% (P = 0.004) immediately after operation, 57.9: 84.1% (P = 0.000) at 2 days, 56.3: 82.9% (P = 0.000) at 4 days, and 44.9: 51.4% (P = 0.037) at 2 weeks. The mean Visual Analogue Scale for odynophagia was significantly lower in the steroid group until postoperative 2 weeks. The last follow-up showed no significant difference in the radiological and clinical outcome.

CONCLUSION

Using the retropharyngeal local steroid, we significantly reduced PSTS and odynophagia following ACDF without additional complication. This method may be considered a simple and effective method to decrease PSTS following anterior cervical spine surgery.

Perioperative epidural steroids for lumbar spine surgery in degenerative spinal disease

Object

This systematic review assesses the efficacy of epidural steroids on adults undergoing lumbar spine surgery for degenerative spinal disease.

Methods

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase databases were searched for relevant articles. Search terms included “laminectomy,” “discectomy,” and “steroid.” Randomized and quasi-randomized controlled trials of adults undergoing lumbar spinal surgery for degenerative spinal disease were included. The main outcomes were pain, quality of life, total analgesic agent consumption, postoperative length of hospital stay, the ability to return to full-time work, and adverse events.

Results

Twelve trials (involving 1053 patients) were included. Epidural steroids reduced back pain at 12–24 hours postoperatively (standardized mean difference [SMD] –1.26, 95% CI –2.35 to –0.0.18, p = 0.02), and radicular pain at 1 week postoperatively (SMD –0.71, 95% CI –1.19 to –0.24, p = 0.003) and 1–2 months postoperatively (SMD –2.14, 95% CI –3.47 to –0.81, p = 0.002). Epidural steroids decreased postoperative consumption of analgesic agents (SMD –0.38, 95% CI –0.62 to –0.14, p = 0.002), length of stay (SMD –0.95, 95% CI –1.62 to –0.27, p = 0.006) and the risk of not returning to full-time work at 1 year (relative risk of 0.27, 95% CI 0.13–0.57, p = 0.0006). There was no significant difference in quality of life or in adverse events.

Conclusions

There is evidence that epidural steroids decrease pain in the short term and shorten length of stay in adults undergoing lumbar spinal surgery for degenerative spinal disease. Most of the evidence comes from studies without validated outcomes and that selectively report positive results. More research is required before establishing perioperative epidural steroids as an effective adjunct to surgery for reducing pain in the long term.

Efficacy of triamcinolone acetonide and bupivacaine for pain after lumbar discectomy

The study is a prospective blinded randomised controlled trial to compare the efficacy of triamcinolone acetonide, bupivacaine or in combination in managing pain after lumbar discectomy. Patients undergoing primary single-level lumbar discectomy were randomised. Triamcinolone acetonide, bupivacaine or in combination was instilled at the nerve root as decompression. Preoperative, day 1 and 6 weeks pain score, 24-h postoperative opiate requirements and duration of inpatient stay were recorded. Data was analysed using Mann-Whitney test for statistical significance. 100 patients were recruited. A significant difference was noted in day one postoperative mean pain score, mean 24-h opiate requirement and mean inpatient stay in the triamcinolone acetonide and bupivacaine group. At 8 weeks postoperatively, no significant differences were seen in the pain score in all groups. Significant postoperative pain reduction and opiate requirements in the first 24 h, and significantly shortened duration of inpatient stay were achieved in the triamcinolone acetonide and bupivacaine group compared with other groups.

Rehabilitation after lumbar disc surgery: an update Cochrane review

STUDY DESIGN

Cochrane systematic review of randomized controlled trials.

OBJECTIVE

To evaluate the effects of active rehabilitation for adults after first-time lumbar disc surgery.

SUMMARY OF BACKGROUND DATA

Several rehabilitation programs are available for individuals after lumbar disc surgery, however, little is known about the efficacy of these treatments.

METHODS

Search strategies were performed on CENTRAL (The Cochrane Library 2007, Issue 2) and MEDLINE, EMBASE, CINAHL, and PsycINFO up to May 2007. All randomized controlled trials without language limitations were included. Pairs of review authors independently assessed studies for eligibility and risk of bias. A meta-analysis was performed with clinically homogeneous studies. The GRADE approach was used to determine the quality of evidence.

RESULTS

Fourteen studies were included, 7 of which had a low risk of bias. Most programs were only assessed in 1 study. Statistical pooling was only completed for 3 comparisons in which exercises started 4 to 6 weeks postsurgery: exercise programs versus no treatment, high versus low intensity exercise programs, and supervised versus home exercises. We found low quality evidence (3 randomized controlled trials [RCTs], N = 122) that exercises are more effective than no treatment for pain at short-term follow-up (weighted mean difference [WMD]:-11.13; 95% CI: -18.44 to -3.82) and moderate evidence (2 RCTs, N = 102) that exercises are more effective for functional status on short-term follow-up (WMD: -6.50; 95% CI: -9.26 to -3.74). None of the studies reported that exercises increased the reoperation rate. We also found low quality evidence (2 RCTs, N = 103) that high intensity exercises are slightly more effective than low intensity exercise programs for pain in the short-term (WMD: -10.67; 95% CI: -17.04 to -4.30) and moderate evidence (2 RCTs, N = 103) that they are more effective for functional status in the short-term (standardized mean difference [SMD] -0.77; 95% CI: -1.17 to -0.36). Finally, we found low quality evidence (3 RCTs, N = 95) that there were no significant differences between supervised and home exercises for short-term pain relief (SMD: -1.12; 95% CI: -2.77-0.53) or functional status (3 RCT, N = 95; SMD -1.17; 95% CI: -2.63-0.28).

CONCLUSION

Exercise programs starting 4 to 6 weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment. High intensity exercise programs seem to lead to a faster decrease in pain and disability than low intensity programs. There were no significant differences between supervised and home exercises for pain relief, disability, or global perceived effect. There is no evidence that active programs increase the reoperation rate after first-time lumbar surgery.

Lumbar discectomy: a national survey of neurosurgeons and literature review

BACKGROUND

To ascertain neurosurgical practices in the surgical management of one-level lumbar discectomies in the Canadian adult population.

METHODS

One page questionnaire faxed to each Neurosurgeon in Canada with questions relating to their practice in the management of this common neurosurgical procedure. All data analyzed using Chi-square statistics.

RESULTS

112 completed surveys were returned hence, giving a 64% response rate with the respondents being predominantly adult neurosurgeons. Of the respondents, 88% perform lumbar discectomy in adults. Only 15% of respondents had a Spine Fellowship. For preoperative imaging, 44% use BOTH CT and MRI whereas 28% use only MRI and 15% use only CT. Prior to initial skin incision, 57% use a localization X-ray image. Preoperative antibiotics are prescribed by 92% of respondents. Majority of respondents (60%) use a pre-incision local anesthetic, whereas only a minority (44%) of respondents employ pre-closure intramuscular injection. With respect to magnification, 70% use microscope, 19% loupes, and 8% neither. Only 12% use minimally invasive tubular retractors. 68% remove "as much disc as possible", while 31% remove "ONLY herniated part". In the case of dural tears, 77% of respondents use fibrin glue (Tisseel). Prior to skin closure, majority of neurosurgeons do NOT use a fat graft (72%), whereas 61% of respondents use epidural steroids. With respect to discharge from the hospital, 58% are discharged on the next day, 18% on the same day, and 23% in two days. Return to work is not recommended until at least six weeks post-op (96%). Most neurosurgeons (93%) would not operate on an individual with a chief complaint of low back pain.

CONCLUSIONS

Our survey has identified variations in practice patterns amongst Canadian Neurosurgeons with respect to performing one-level lumbar discectomies. This survey is expected to form a basis for the design of a randomized controlled trial in the evaluation of the best management approach for this common neurosurgical procedure.

Effect of hyperglycemia on progressive paraparesis in a rat metastatic spinal tumor model

Object

Hyperglycemia has been shown to potentiate ischemic injury of the spinal cord by quenching vasodilators and potentiating tissue acidosis and free radical production. Steroid-induced hyperglycemia is a common event in the surgical management of metastatic epidural spinal cord compression (MESCC). The goal in this study was to determine whether experimentally induced hyperglycemia accelerates neurological decline in an established animal model of MESCC.

Methods

Sixteen Fischer 344 rats underwent a transabdominal approach for implantation of a CRL-1666 breast adenocarcinoma cell line within the vertebral body of L-6. After 72 hours of recovery from tumor implantation, the animals received intraperitoneal injections every 12 hours of either 2 g/kg dextrose in 5 ml 0.09% saline (hyperglycemia, 8 rats) or 5 ml 0.09% saline alone (normoglycemia, 8 rats). Weights were taken daily, and the hindlimb function was tested daily after tumor implantation by using the Basso-Beattie-Bresnahan (BBB) scale (score range 1–21). Animals were killed at time of paralysis (BBB Score < 7), and the volume of epidural tumor growth within the spinal canal was measured. To determine the degree of hyperglycemia induced by this dextrose regimen, a surrogate group of 10 Fischer 344 rats underwent intraperitoneal injections of 2 g/kg dextrose (5 rats) or 0.09% saline (5 rats) every 12 hours, and serum glucose levels were assessed 1, 3, 6, 8, 10, and 12 hours after injections for 24 hours.

Results

Dextrose versus saline injections resulted in elevated mean serum glucose at 3 (259 vs 103 μg/dl), 6 (219 vs 102 μg/dl), 8 (169 vs 102 μg/dl), and 10 hours (118 vs 99 μg/dl) after injection, returning to normal levels by 12 hours (96 vs 103 μg/dl) just prior to subsequent injection. All rats had normal hindlimb function for the first 8 days after tumor implantation. Hyperglycemic versus normoglycemic rats demonstrated a worsened median BBB score by postimplantation Day 9 (Score 20 vs 21, p = 0.023) through Day 16 (Score 8 vs 12, p = 0.047). Epidural tumor volume demonstrated a near-linear growth rate across both groups; however, hyperglycemic rats developed paralysis earlier (median 15.5 vs 17.5 days, p = 0.0035), with significantly less epidural tumor volume (2.75 ± 0.38 cm3 vs 4 ± 0.41 cm3, p < 0.001) at time of paralysis.

Conclusions

In a rat model of metastatic epidural spinal cord compression, rats maintained in a hyperglycemic state experienced accelerated time to paralysis. Also, less epidural tumor volume was required to cause paralysis in hyperglycemic rats. These results suggest that hyperglycemic states may contribute to decreased spinal cord tolerance to compression resulting from MESCC. Clinical studies evaluating the effect of aggressive glucose control in patients with MESCC may be warranted.

Rehabilitation after lumbar disc surgery

BACKGROUND

Several rehabilitation programs are available for individuals after lumbar disc surgery.

OBJECTIVES

To evaluate the effects of active rehabilitation for adults after first-time lumbar disc surgery.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2007, Issue 2) and MEDLINE, EMBASE, CINAHL and PsycINFO to May 2007.

SELECTION CRITERIA

We only included randomised controlled trials (RCTs).

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently assessed studies for eligibility and risk of bias. A meta-analysis was performed with clinically homogeneous studies. The GRADE approach was used to determine the quality of evidence.

MAIN RESULTS

Fourteen studies were included, seven of which had a low risk of bias. Most programs were only assessed in one study. Statistical pooling was only completed for three comparisons in which exercises were started four to six weeks post-surgery: exercise programs versus no treatment, high versus low intensity exercise programs, and supervised versus home exercises.There is low quality evidence (three RCTS, N = 156) that exercises are more effective than no treatment for pain at short-term follow-up (WMD -11.13; 95% CI -18.44 to -3.82) and moderate evidence (two RCTs, N = 136) that they are more effective for functional status on short-term follow-up (WMD -6.50; 95% CI -9.26 to -3.74). None of the studies reported that exercises increased the re-operation rate.There is low quality evidence (two RCTs, N =103) that high intensity are slightly more effective than low intensity exercise programs for pain in the short term (WMD -10.67; 95% CI -17.04 to -4.30) and moderate evidence (two RCTs, N = 103) that they are more effective for functional status in the short term (SMD -0.77; 95% CI -1.17 to -0.36).There is low quality evidence (three RCTS, N = 95) that there were no significant differences between supervised and home exercises for short-term pain relief (SMD -1.12; 95% CI -2.77 to 0.53) or functional status (three RCTs, N = 88; SMD -1.18; 95% CI -2.63 to 0.26).

AUTHORS' CONCLUSIONS

Exercise programs starting four to six weeks post-surgery seem to lead to a faster decrease in pain and disability than no treatment. High intensity exercise programs seem to lead to a faster decrease in pain and disability than low intensity programs. There were no significant differences between supervised and home exercises for pain relief, disability, or global perceived effect. There is no evidence that active programs increase the re-operation rate after first-time lumbar surgery.

[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.

Predictors of ambulatory function after decompressive surgery for metastatic epidural spinal cord compression

OBJECTIVE

Metastatic epidural spinal cord compression (MESCC) is a relatively common and debilitating complication of metastatic disease that often results in neurological deficits. This study was designed to explore associations with maintaining and regaining ambulatory function after decompressive surgery for MESCC.

METHODS

Seventy-eight patients undergoing decompressive surgery for MESCC at an academic tertiary care institution between 1995 and 2005 were retrospectively reviewed. Fisher's exact analysis was used to compare preoperative ambulatory and nonambulatory patients. Multivariate Cox proportional hazards regression was used to identify associations with either maintaining or regaining the ability to walk.

RESULTS

Patients were followed for 7.1 +/- 1.6 (mean +/- standard deviation) months after surgery. Preoperative nonambulatory patients required more extensive surgery (increased operative spinal levels and number of laminectomies) and had more surgical site complications (wound dehiscences and cerebrospinal fluid leaks) compared with preoperative ambulatory patients. From the multivariate analysis, preoperative ability to walk (relative risk [RR], 2.320; 95% confidence interval [CI], 1.301-4.416; P < 0.01) independently increased the likelihood of ambulation at the last follow-up evaluation 2.3-fold. Pathological vertebral compression fracture at presentation (RR, 0.471; 95% CI, 0.235-0.864; P = 0.01) independently decreased the likelihood of ambulation at the time of the last follow-up evaluation 2.1-fold. For patients unable to walk at the time of surgery, preoperative radiation therapy (RR, 0.406; 95% CI, 0.124-0.927; P = 0.03) decreased the likelihood of regaining the ability to walk 2.5-fold. Symptoms present for less than 48 hours (RR, 2.925; 95% CI, 1.133-2.925; P = 0.02) and postoperative radiotherapy (RR, 2.595; 95% CI, 1.039-8.796; P = 0.04) independently increased the likelihood of regaining ambulatory ability 2.9- and 2.6-fold, respectively, by the time of last follow-up evaluation.

CONCLUSION

The identification of these associations with neurological outcome may help guide in the preservation or return of ambulation after surgery for patients with MESCC.

Neurological outcome after resection of intramedullary spinal cord tumors in children

OBJECTIVE

With modern surgical advances, radical resection of pediatric intramedullary spinal cord tumors (IMSCT) can be achieved with preservation of long-term neurological function. Clinical and radiographic risk factors predictive of postoperative neurological outcome may serve as a guide for surgical risk stratification.

MATERIALS AND METHODS

We prospectively reviewed the outcomes of 16 consecutive cases of pediatric IMSCT resection at a single institution. Clinical, radiographic, and operative variables were analyzed as predictors of postoperative neurological function defined by the modified McCormick score (MMS).

RESULTS

Sixteen children 10 +/- 5 years old presented with median (interquartile range) MMS score of 2 (1-2) with IMSCTs (eight cervical, eight thoracic) involving 4 +/- 2 levels. Pathology revealed astrocytoma in 12 cases (three pilocytic, four grade II, three grade III, two GBM), gangliogliomas in two, ependymoma in one, and gliosis in one case. At median follow-up of 7 months, six (38%) patients experienced improved neurological function, eight (50%) remained stable, one (6%) experienced a delayed decrease in neurological function (GBM progression), and one (6%) died (GBM progression). Five (31%) patients developed persistent dysesthetic symptoms. Four (80%) patients with cystic tumors experienced neurological improvement compared to only two (18%) patients with noncystic tumors, p < 0.05. Preoperative steroid use (odds ratio, OR [95% confidence interval, CI] = 18.0 [1.24-260.1], p = 0.03) and cystic tumor (OR [95%CI] = 18.0 [1.24-260.1], p = 0.03) predicted neurological improvement after surgery.

CONCLUSION

Radical resection of pediatric IMSCTs can be achieved with low incidence of neurological injury. Sensory syndromes frequently occur after pediatric IMSCT resection and frequently affect patient's quality of life. Tumors with compressive cysts may identify patients more likely to experience improved neurological function after surgical resection.

Interaoperative use of epidural methylprednisolone or bupivacaine for postsurgical lumbar discectomy pain relief: a randomized, placebo-controlled trial

BACKGROUND

Many patients with lumbar disc surgery experience postoperative back and radicular pain, delaying hospital discharge and resumption of normal activity. Some surgeons have used intraoperative epidural corticosteroids and local anesthetics to decrease pain following surgery for a herniated lumbar disc. Controversies still exist regarding the benefits of these drugs. The present study was meant to compare the effects of the intraoperative administration of epidural methylprednisolone and bupivacaine with that of normal saline (placebo) in lumbar disc surgery for postoperative pain control.

PATIENTS AND METHODS

One hundred fifty patients with single level herniated nucleus pulposus (L4-L5 or L5-S1), which was refractory to 6 weeks of conservative management, were divided randomly in three groups. A standard hemipartial lamimectomy and discectomy was performed on all patients. At the end of the surgery, before the closure of fascia, 40 mg methylprednisolone with 3 mL normal saline for group 1, 2 mL bupivacaine 5% with 2 mL normal saline for group 2 and 4 mL normal saline for group 3 were instilled onto the epidural and exposed nerve root. Postoperative back and radicular pain intensity was assessed by a visual analogue scale (VAS) before and at 24, 48, 72, and 96 hours after surgery.

RESULTS

There was no significant difference in back and radicular pain intensity between the three groups.

CONCLUSION

Intraoperative administration of epidural methylprednisolone or bupivacaine does not relieve postoperative back and radicular pain.

Peridural methylprednisolone and wound infiltration with bupivacaine for postoperative pain control after posterior lumbar spine surgery: a randomized double-blinded placebo-controlled trial

STUDY DESIGN

A randomized, double-blind placebo controlled trial in multimodal analgesia for postoperative pain was conducted.

OBJECTIVE

To examine whether combination of corticosteroid and bupivacaine administered in patients undergoing posterior lumbosacral spine surgery reduces postoperative morphine consumption, back and leg pain relief, and improves functional disability and general health status.

SUMMARY OF BACKGROUND DATA

Patients with lumbar spine surgery had moderate to severe postoperative pain. Administration of corticosteroid or injection of local anesthetic agent has been additive treatment methods for opioid drugs. There is uncertainty as to whether corticosteroid and bupivacaine combination improves outcomes in lumbosacral spine surgery.

METHODS

A total of 103 patients who were scheduled to undergo elective posterior lumbar discectomy, decompressive laminectomy with or without instrumented fusion for degenerative spinal diseases, received either methylprednisolone locally applied to the affected nerve roots (and bupivacaine was infiltrated into the wound) or injected placebo. Morphine consumption and pain scores were recorded at 1, 2, 3, 6, 12, 24, and 48 hours after surgery. Oswestry Index and Short Form SF-36 scores were recorded before surgery and at 1 and 3 months later.

RESULTS

Demographic data between the 2 groups were comparable. The cumulative morphine dose and postoperative pain was significantly lower in the study group than in the placebo group (P = 0.01 and P = 0.001, respectively). When performing subgroup analyses, the beneficial effects were found in all groups of surgery but could not demonstrated statistically significant difference for all subgroup comparisons. There was no significant difference between the 2 groups with regard to pain on cough, Oswestry Index, and SF-36 scores. No complications were associated with the perioperative use of methylprednisolone or bupivacaine.

CONCLUSIONS

Administration of methylprednisolone-bupivacaine provided a favorable effect immediately after posterior lumbosacral spine surgery for discectomy, decompression, and/or spinal fusion without complication.

Effect of high-dose intravenous dexamethasone on postlumbar discectomy pain

STUDY DESIGN

A prospective, randomized triple-blind clinical trial.

OBJECTIVE

To evaluate the effect of 40 and 80 mg intravenous (IV) dexamethasone versus placebo to reduce postlumbar diskectomy pain.

SUMMARY OF BACKGROUND DATA

Lumbar discectomy is a procedure to ablate radicular and low pack pain (LBP) in select patients. Unfortunately, some patients have radicular pain for several days after successful surgery, possibly caused by nerve root inflammation.

METHODS

A total of 61 patients with single-level herniated lumbar disc at L4-L5 or L5-S1 were randomly assigned to 3 groups. After the skin incision, group 1 received 40 mg, group 2 received 80 mg IV dexamethasone, and group 3 received placebo. All patients also received 50 mg ranitidine IV at the same time. Preoperative and postoperative radicular and LBP were evaluated using the visual analog scale. Morphine was administered and recorded as a sole pain-killer during hospital admission if indicated. Collected data were analyzed using the 1-way analysis of variance test.

RESULTS

A total of 61 consecutive patients entered the study. There were 19 patients who received 40 mg dexamethasone IV (group 1), 20 received 80 mg (group 2), and 22 received placebo (group 3). Preoperative data, including age, sex, level of disc herniation, and radicular and LBP, were statistically matched among groups. Postoperative LBP was decreased in all groups equally. Based on the visual analog scale, mean radicular pain was significantly decreased 4.26 points in group 1, 4.15 points in group 2 versus 2.73 points in group 3 (P = 0.006). Mean total morphine used was also significantly lower in group 1 versus group 3 (5.26 vs. 9 mg P = 0.012).

CONCLUSION

Intraoperative IV injection of 40 mg dexamethasone could effectively reduce postoperative radicular leg pain and narcotics usage in patients with single-level herniated lumbar disc.

Magnetic resonance imaging of the lumbar spine after epidural and nerve root injection therapy: evaluation of soft tissue changes

OBJECTIVE

Magnetic resonance imaging (MRI) was performed to evaluate soft tissue changes after nerve root and epidural injections in lumbar spine in patients with radiculopathy.

MATERIALS/METHODS

Patients underwent a multiple-shot injection protocol to nerve root/epidural space. The MRI protocol included T1-weighted, T2-weighted, STIR, and contrast-enhanced, fat-saturated T1-weighted sequences before and after treatment.

RESULTS

In all treated patients, a diffuse wedge-shaped edema in paravertebral tissues with a slight contrast enhancement was seen. Two small hematomas in the paravertebral muscle were noted. No changes in the epidural space, the abscess, or a lipodystrophy in epidural/nerve root space occurred.

CONCLUSION

Normal tissue changes after injection therapy of lumbar radiculopathy include wedge-shaped tissue edema at the injection level. In a minority of patients, small hematomas may occur.

Efficacy and safety of steroid use for postoperative pain relief. Update and review of the medical literature

Despite the availability of various analgesic regimens, patient surveys have indicated that moderate-to-severe postoperative pain is still poorly managed. The use of corticosteroids for postoperative pain relief, although popular, has yet to gain wider acceptance because of concerns over side effects, in particular adrenal suppression, osteonecrosis, impaired wound-healing, and concerns about efficacy. The medical literature provides evidence that should substantially decrease these concerns with regard to low and short-dose applications. The results of randomized trials have shown low, short-dose corticosteroid regimens to be safe and effective for reducing postoperative pain. There is strong, grade-A evidence supporting the use of corticosteroids in multimodal analgesia protocols to contribute to the postoperative recovery of the patient by minimizing opioid doses and therefore side effects. However, the optimal mode, dose, and timing of administration remain unclear.

Role of Analgesic Adjuncts in Postoperative Pain Management

Postoperative pain remains a major problem. A multi-modal analgesic approach is recommended to optimize pain management and reduce opiate-related adverse effects. Several analgesic adjuncts have been investigated, and many have proved to have a useful analgesic effect. This article reviews the literature regarding use of analgesic adjuncts in the perioperative period.

Does Intraoperative Electromyographic Monitoring in Lumbar Microdiscectomy Correlate with Postoperative Pain?

OBJECTIVES

Our objective was to correlate the findings of intraoperative electromyographic (EMG) monitoring with immediate postoperative pain in patients undergoing lumbar microdiscectomy.

METHODS

A total of 112 patients undergoing de novo lumbar microdiscectomy were prospectively randomized into a control group (n = 45) and a study group (n = 67) in which intraoperative EMG monitoring was used. Postoperative pain and postoperative narcotic consumption were recorded for each patient.

RESULTS

The presence or absence of EMG monitoring did not influence the level of reported pain in any anatomic area. In the monitored group, the degree of recorded nerve root irritation did not correlate with reported pain or postoperative narcotic consumption. The level of back pain was found to be significantly higher than the level of hip and calf pain (P < 0.0001).

CONCLUSIONS

In our study no correlation was found between intraoperative EMG findings and immediate postoperative pain.

The effect of perioperative corticosteroids on the outcome of microscopic lumbar disc surgery

Eighty adult patients with lumbar disc herniation verified by magnetic resonance imaging (MRI) and clinical findings corresponding to the radiological level underwent microscopic disc removal to evaluate the outcome of perioperatively given corticosteroids in a prospective randomized double-blind study. In the treatment group the patient received 250 mg Solu-Medrol intravenously and 160 mg Depo-Medrol intramuscularly. Before closure of the wound, a free fat transplant soaked in 80 mg Depo-Medrol was placed on the dural sac. In the control group the same procedure was performed, but sodium chloride was given instead of Depo-Medrol. All patients underwent a clinical examination before surgery and at 2, 6, 12, 26, 52 and 104 weeks postoperatively, rating their pain with the visual analog scale (VAS) and function with the Disability Rating Index (DRI). The postoperative hospital stay was significantly shorter (P=0.01) in the treatment group (1.7 days) compared to the control group (2.3 days). Time taken to return to full-time work was also significantly shorter in the treatment group (P=0.003). VAS-W (Worst Pain during last week) was significantly lower in the treatment group (P=0.02). Postoperative spondylitis occurred in one patient in the control group and no adverse corticosteroids effect was seen. Our study shows that perioperatively given corticosteroids improve the outcome of microscopic disc surgery in terms of length of hospital stay and time taken to return to full-time work. The results also indicate that corticosteroid treatment reduces pain and improves functional outcome.

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

OBJECTIVE

This study was designed to assess the efficacy of perioperative administration of celecoxib (Celebrex; Pharmacia GmbH, Erlangen, Germany) in reducing pain and opioid requirements after single-level lumbar microdiscectomy.

METHODS

We studied 34 patients (mean age, 44.26 yr; standard deviation [SD], 13.09 yr) allocated randomly to receive celecoxib 200 mg twice a day for 72 hours starting on the evening before surgery or placebo capsules in a double-blind study. Fourteen patients received 20 to 80 mg dexamethasone intravenously during surgery (mean, 40 mg; SD, 19.22 mg) because of visible signs of compression of the affected nerve root. After lumbar disc surgery, patients were monitored for visual analog scores for pain at rest and on movement, patient-controlled analgesia (PCA) piritramide requirements, and von Frey thresholds in the wound area.

RESULTS

Pain scores decreased and wound von Frey thresholds increased continuously until discharge, with no intergroup differences. Mean 24-hour PCA piritramide requirements were 22.63 mg (SD, 23.72 mg) and 26.14 mg (SD, 22.57 mg) in the celecoxib and placebo groups, respectively (P = not significant). However, patients with intraoperative dexamethasone (n = 14) required only 10.29 mg (SD, 8.55 mg) 24-hour PCA piritramide, in contrast to the 34.25 mg (SD, 24.69 mg) needed in those who did not receive intraoperative dexamethasone (P = 0.001). In addition, 24 hours after the operation, pain scores on movement were significantly lower in the dexamethasone subgroup (P = 0.003).

CONCLUSION

Celecoxib has no effect on postoperative pain scores and PCA piritramide requirements. The intraoperative use of 20 to 80 mg dexamethasone is able to significantly decrease postoperative piritramide consumption and pain scores on the first day after surgery.

Rehabilitation following first-time lumbar disc surgery: a systematic review within the framework of the cochrane collaboration

STUDY DESIGN

A systematic review of randomized controlled trials.

BACKGROUND

Although several rehabilitation programs, physical fitness programs, or protocols regarding instruction for patients to return to work after lumbar disc surgery have been suggested, little is known about the efficacy of these treatments, and there are still persistent fears of causing reinjury, reherniation, or instability.

OBJECTIVES

The objective of this systematic review was to evaluate the effectiveness of active treatments that are used in the rehabilitation after first-time lumbar disc surgery.

METHODS

The authors searched the MEDLINE, Embase, and Psyclit databases up to April 2000 and the Cochrane Controlled Trials Register 2001, issue 3. Both randomized and nonrandomized controlled trials on any type of active rehabilitation program after first-time disc surgery were included. Two independent reviewers performed the inclusion of studies, and two other reviewers independently performed the methodologic quality assessment. A rating system that consists of four levels of scientific evidence summarizes the results.

RESULTS

Thirteen studies were included, six of which were of high quality. There is no strong evidence for the effectiveness for any treatment starting immediately postsurgery, mainly because of the lack of good quality studies. For treatments that start 4 to 6 weeks postsurgery, there is strong evidence (level 1) that intensive exercise programs are more effective on functional status and faster return to work (short-term follow-up) as compared to mild exercise programs, and there is strong evidence (level 1) that on long-term follow-up there is no difference between intensive exercise programs and mild exercise programs with regard to overall improvement. For all other primary outcome measures for the comparison between intensive and mild exercise programs, there is conflicting evidence (level 3) with regard to long-term follow-up. Furthermore, there is no strong evidence for the effectiveness of supervised training as compared to home exercises. There is also no strong evidence for the effectiveness of multidisciplinary rehabilitation as compared to usual care. There is limited evidence (level 3) that treatments in working populations that aim at return to work are more effective than usual care with regard to return to work. Also, there is limited evidence (level 3) that low-tech and high-tech exercises, started more than 12 months postsurgery, are more effective in improving low-back functional status as compared to physical agents, joint manipulations, or no treatment. Finally, there is no strong evidence for the effectiveness of any specific intervention when added to an exercise program, regardless of whether exercise programs start immediately postsurgery or later. None of the investigated treatments seem harmful with regard to reherniation or reoperation.

CONCLUSIONS

There is no evidence that patients need to have their activities restricted after first-time lumbar disc surgery. There is strong evidence for intensive exercise programs (at least if started about 4-6 weeks postoperative) and no evidence they increase the reoperation rate. It is unclear what the exact content of postsurgery rehabilitation should be. Moreover, there are no studies that investigated whether active rehabilitation programs should start immediately postsurgery or possibly 4 to 6 weeks later.

Complications associated with the prophylactic use of methylprednisolone during surgical stabilization after spinal cord injury

OBJECT

The authors attempted to determine if there is a significant relationship between the incidence of medical complications and the prophylactic use of methylprednisolone (MP) during spine surgery in patients with acute spinal cord injury (SCI) who had already received MP on hospital admission (typically in the setting of an Emergency Room/Trauma Center).

METHODS

The authors studied 73 patients with acute SCI who were admitted to the hospital for at least 7 days postinjury. All patients 1) received a 24-hour regimen of MP in the acute period of hospitalization; and 2) underwent surgery to stabilize the spine and/or decompress the spinal cord. Patients were separated into two groups on the basis of whether they received additional MP therapy during spine surgery. A chart review was conducted retrospectively to determine the incidence of complications up to 6 weeks postinjury. Muscle strength and American Spinal Injury Association grades were determined prospectively throughout the follow-up period. In patients who received two courses of MP following acute SCI (one at initial hospitalization and one during surgery), a significantly increased probability of complications was demonstrated compared with those who received no MP therapy during surgery. This was particularly evident when the incidences of serious complications were compared.

CONCLUSIONS

Prophylactic use of MP as a neuroprotective agent during spine surgery in patients with acute SCI should be avoided in those in whom MP was administered on admission to the hospital.

Rehabilitation after lumbar disc surgery

BACKGROUND

Although several rehabilitation programs, physical fitness programs or protocols regarding instruction for patients to return to work after lumbar disc surgery have been suggested, little is known about the efficacy and effectiveness of these treatments. There are still persistent fears of causing re-injury, re-herniation, or instability.

OBJECTIVES

The objective of this systematic review was to evaluate the effectiveness of active treatments that are used in the rehabilitation after first-time lumbar disc surgery.

SEARCH STRATEGY

We searched the MEDLINE, EMBASE and Psyclit databases up to April 2000 and the Cochrane Controlled Trials Register 2001, Issue 3.

SELECTION CRITERIA

Both randomized and non-randomized controlled trials on any type of active rehabilitation program after first-time disc surgery were included.

DATA COLLECTION AND ANALYSIS

Two independent reviewers performed the inclusion of studies and two other reviewers independently performed the methodological quality assessment. A rating system that consists of four levels of scientific evidence summarizes the results.

MAIN RESULTS

Thirteen studies were included, six of which were of high quality. There is no strong evidence for the effectiveness for any treatment starting immediately post-surgery, mainly because of lack of (good quality) studies. For treatments that start four to six weeks post-surgery there is strong evidence (level 1) that intensive exercise programs are more effective on functional status and faster return to work (short-term follow-up) as compared to mild exercise programs and there is strong evidence (level 1) that on long term follow up there is no difference between intensive exercise programs and mild exercise programs with regard to overall improvement. For all other primary outcome measures for the comparison between intensive and mild exercise programs there is conflicting evidence (level 3) with regard to long-term follow-up. Furthermore, there is no strong evidence for the effectiveness of supervised training as compared to home exercises. There was also no strong evidence for the effectiveness of multidisciplinary rehabilitation as compared to usual care. There is limited evidence (level 3) that treatments in working populations that aim at return to work are more effective than usual care with regard to return to work. Also, there is limited evidence (level 3) that low-tech and high-tech exercises, started more than 12 months post-surgery are more effective in improving low back functional status as compared to physical agents, joint manipulations or no treatment. Finally, there is no strong evidence for the effectiveness of any specific intervention when added to an exercise program, regardless of whether exercise programs start immediately post-surgery or later. None of the investigated treatments seem harmful with regard to re-herniation or re-operation.

REVIEWER'S CONCLUSIONS

There is no evidence that patients need to have their activities restricted after first time lumbar disc surgery. There is strong evidence for intensive exercise programs (at least if started about 4-6 weeks post-operative) on short term for functional status and faster return to work and there is no evidence they increase the re-operation rate. It is unclear what the exact content of post-surgery rehabilitation should be. Moreover, there are no studies that investigated whether active rehabilitation programs should start immediately post-surgery or possibly four to six weeks later.

Microcatheterization of the cervical epidural space via lumbar puncture: technical note

OBJECTIVE

Deposition of opiates, corticosteroids, or local anesthetics into the epidural space is useful for the management of painful maladies of the cervical and thoracic spine. We describe a novel technique for epidural medication delivery via an angiographic microcatheter inserted at or below the conus and advanced cephalad under fluoroscopic guidance. Unlike commercial kits used by anesthesiologists, this method uses a radiopaque catheter that can be precisely targeted to the levels of interest. The hazards of direct puncture, such as "wet tap" or injury to the cervical cord, are minimized.

METHODS

An 18-gauge Tuohy needle is inserted into the lumbar epidural space. A 2.3-French microcatheter and a 0.018-inch steerable guidewire are then introduced through the lumen of the needle. The catheter is fluoroscopically advanced to the cervical epidural space, where Depo-Medrol (Pharmacia & Upjohn, Kalamazoo, MI) is administered. As the catheter is withdrawn, additional corticosteroid can be delivered to the thoracic epidural space, together with long-acting morphine compounds or local anesthetics. Regional pressures within the epidural space and other physiological parameters can be measured, and the local microenvironment can be sampled.

RESULTS

To date, we have performed 16 procedures for 13 patients. All patients reported improvement, of varying extent and duration. There have been no complications.

CONCLUSION

Our system of accessing the epidural space has many advantages, compared with direct puncture and commercially available kits. It provides a safe means of delivering epidural medication to multiple spinal levels and permits measurement of physiological variables that may be useful in the diagnosis and treatment of cervical and thoracic spine disease.

Postoperative narcotic requirement after microscopic lumbar discectomy is not affected by intraoperative ketorolac or bupivacaine

STUDY DESIGN

Prospective, randomized, double-blind study.

OBJECTIVE

To assess the efficacy of ketorolac and bupivacaine in reducing postoperative pain after microsurgical lumbar discectomy.

SUMMARY OF BACKGROUND DATA

Microsurgical lumbar discectomy often is performed as an ambulatory procedure. Pain, nausea, and urinary retention may delay discharge. It was hypothesized that intraoperative ketorolac or bupivacaine would reduce postoperative pain as measured by morphine demand.

METHODS

After Institutional Review Board (IRB) approval and informed consent, 30 patients undergoing single-level microsurgical lumbar discectomy under general anesthesia randomly received either intravenous ketorolac, intramuscular bupivacaine, or placebo before wound closure. After surgery, all patients received intravenous, MSO4, patient-controlled analgesia. MSO4 demand was compared between groups at 30 minutes and at 1, 4, 8, 16, 20, and 24 hours after surgery by one-way ANOVA. Pre- and postoperative pain was assessed by using a standard scale and was correlated to postoperative MSO4 demand by Pearson correlation. Significance was assumed at P < 0.05.

RESULTS

There were no group differences in age, gender, weight, disc level, preoperative pain, or preoperative use of pain medication. Neither ketorolac nor bupivacaine decreased pain or nausea scores, MSO4 demand, or time to void and ambulation. Preoperative pain was significantly correlated to postoperative narcotic demand (r = 0.46, P < 0.01). Preoperative narcotic or NSAID use was not correlated to either preoperative pain scores or postoperative MSO4 requirement.

CONCLUSIONS

Neither ketorolac nor bupivacaine decreased the postoperative narcotic requirement in patients undergoing microsurgical lumbar discectomy. Postoperative narcotic requirements are increased in patients who are in severe pain before surgery, regardless of preoperative narcotic use.