Cyclooxygenase-2 inhibition does not impair block bone grafts healing in rabbit model

The effect of NSAIDs on spinal fusion: a cross-disciplinary review of biochemical, animal, and human studies

PURPOSE

Non-steroidal anti-inflammatory drugs (NSAIDs) play an important role in postoperative pain management. However, their use in the setting of spine fusion surgery setting has long been a topic of controversy. In this review we examined relevant research, including in vivo, animal, and clinical human studies, with the aim of understanding the effect of NSAIDs on spinal fusion.

STUDY DESIGN/SETTING

Systematic review of study designs of all types from randomized controlled trials and meta-analyses to single-institution retrospective reviews.

METHODS

A search of PubMed and Embase was conducted using the keywords: "spine," "spinal fracture," NSAIDs, anti-inflammatory non-steroidal agents, bone, bone healing, fracture, fracture healing, yielding a total of 110 studies. Other 28 studies were identified by cross-referencing, resulting in total 138 studies.

RESULTS

There is no level I evidence from human studies regarding the use of NSAIDs on spinal fusion rates. The overall tone of the spine literature in the early 2000s was that NSAIDs increased the rate of non-union; however, nearly all human studies published after 2005 suggest that short-term (<2 weeks) postoperative use have no such effect. The dose dependency that is seen with a 2-week postoperative course is not present when NSAIDs are only used for 48 h after surgery.

CONCLUSIONS

NSAID appear to have dose-dependent and duration-dependent effects on fusion rates. The short-term use of low-dose NSAIDs around the time of spinal fusion surgery is reasonable. Spine surgeons can consider the incorporation of NSAIDs into pain control regimens for spinal fusion patients with the goal of improving pain control and reducing the costs and complications associated with opioids.

Meloxicam temporally inhibits the expression of vascular endothelial growth factor receptor (VEGFR)-1 and VEGFR-2 during alveolar bone repair in rats

BACKGROUND

Vascular endothelial growth factor (VEGF) plays an important role during angiogenesis and bone repair. This study investigated whether the use of meloxicam alters bone repair via downregulation of VEGF and receptor expression.

METHODS

One hundred twenty male Wistar rats had their maxillary right incisor extracted. Animals were divided into a control group (CG; n = 60) and a meloxicam-treated group (TG; n = 60) that received either a single daily intraperitoneal injection of 0.9% NaCl or meloxicam 3 mg/kg, respectively, for 7 consecutive days. Alveolar bone repair was evaluated histomorphometrically, whereas VEGF and its receptors were analyzed by immunohistochemistry and quantitative polymerase chain reaction (qPCR). Data were submitted to two-way analysis of variance and Tukey post hoc test with P < 0.05.

RESULTS

Bone volume density increased significantly (P = 0.001) in both groups with a strong correlation between treatment and periods (P = 0.003). In the TG, a small amount of bone formation occurred compared with the CG between 3 and 21 days. No significant differences in the number of VEGF-positive cells per square millimeter (P = 0.07) and VEGF messenger RNA (mRNA) expression (P = 0.49) were found between groups. Immunostained cells per square millimeter and mRNA expression for VEGF receptor (VEGFR)-1 (P = 0.04 and P < 0.001) and VEGFR-2 (P < 0.001 for both analysis) showed a strong interaction between treatment groups and periods. In the TG, immunostained cells per square millimeter and mRNA expression for VEGFR-1 were, respectively, 89% and 37% lower from 3 to 10 days compared with the CG, whereas for VEGFR-2, these values were 252% and 60%, respectively, from 3 to 7 days.

CONCLUSION

In rat alveolar bone repair, meloxicam did not affect VEGF expression but downregulated VEGFR expression, which may cause a delay in the bone repair/remodeling process.

Acetaminophen, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2 selective inhibitors: an update

SUMMARY

Plastic and cosmetic surgery is often performed as an ambulatory procedure, and pain is often mild to moderate. Good pain relief is central to patient comfort and satisfaction. Analgesics used should ensure rapid onset and adequate pain relief lasting a sufficiently long duration with minimal or no side effects. Acetaminophen is well tolerated by patients, efficacious, and associated with only minor side effects, when used in the minimal effective doses. Nonsteroidal anti-inflammatory drugs (NSAIDs) are more efficacious, having lower numbers needed to treat compared with acetaminophen, but have several side effects and contraindications. However, when used in the correct doses in healthy patients, NSAIDs are excellent for pain management with one caveat that there is an increased risk for oozing or bleeding. In contrast, cyclooxygenase inhibitors (Coxibs) are equally efficacious as NSAIDs but have the added advantage that they have minimal or no effect on platelet function, and therefore, the risk for bleeding complications is minimal. However, there has been some concern about the risk of vascular events in patients with ischemic heart disease, specifically when using Coxibs, but even some NSAIDs, for example, diclofenac. In conclusion, acetaminophen should be given postoperatively to all patients undergoing plastic surgical procedures. For patients undergoing moderately invasive surgery, the addition of Coxibs to acetaminophen would be an advantage except in the patient with ischemic heart disease where NSAIDs could have a place in management of pain. Side effects and contraindications of NSAIDs, however, restrict their use to the healthy patient with mild comorbidities.

Sintered anorganic bone graft increases autocrine expression of VEGF, MMP-2 and MMP-9 during repair of critical-size bone defects

This study aimed to evaluate morphometrically the bone formation and immunohistochemically the expression of vascular endothelial growth factor (VEGF) and metalloproteinase (MMP)-2 and -9 during the healing of critical-size defects treated with sintered anorganic bone (sAB). The 8-mm diameter full-thickness trephine defects created in the parietal bones of rats were filled with sAB (test group) or blood clot (CSD-control group). At 7, 14, 21, 30, 90 and 180 days postoperatively (n = 6/period) the volume of newly formed bone and total number of immunolabeled cells (Ntm) for each protein were determined. Bone formation was smaller and faster in the CSD-control group, stabilizing at 21 days (6.74 mm(3)). The peaks of VEGF, MMP-2 and MMP-9 occurred at 7 and 14 days in fibroblasts and osteoblasts, with mean reduction of 0.80 time at 21 days, keeping constant until 180 days. In the test group, sAB provided continuous bone formation between particles throughout all periods. The peak of MMP-2 was observed at 7-14 days in connective tissue cells and for VEGF and MMP-9 at 30 days in osteoblasts and osteocytes. Ntm for VEGF, MMP-2 and MMP-9 were in average, respectively, 3.70, 2.03 and 5.98 times higher than in the control group. At 180 days, newly formed bone (22.9 mm(3)) was 3.74 times greater in relation to control. The physical and chemical properties of sAB allow increased autocrine expression of VEGF, MMP-2 and MMP-9, favoring bone formation/remodeling with very good healing of cranial defects when compared to natural repair in the CSD-control.