Nonsteroidal anti-inflammatory drugs and bone metabolism in spinal fusion surgery: a pharmacological quandary

Comparison of the effects of opioid-free anesthesia (OFA) and opioid-based anesthesia (OBA) on postoperative analgesia and intraoperative hemodynamics in patients undergoing spine surgery: A prospective randomized double-blind controlled trial

Background

Opioids form the basis of perioperative pain management but are associated with multiple side effects. In opioid-free anesthesia (OFA), several non-opioid drugs or neuraxial/regional blocks are used as substitutes for opioids. Ketamine, a N-methyl-d-aspartate antagonist, provides intense analgesia. However, there is a shortage of literature on the effects of ketamine-based OFA on hemodynamics (HD) and postoperative analgesia in patients undergoing thoracolumbar spine surgery.

Materials and Methods

This prospective randomized controlled trial included 60 adult patients. The patients in Group OFA (n = 30) received OFA with ketamine and ketofol (1:5) infusion, and those in Group OBA (n = 30) received opioid-based anesthesia (OBA) with fentanyl and propofol infusion. The postoperative pain-free period, pain scores, rescue analgesia, intraoperative HDs, and postoperative complications were assessed.

Results

The mean pain-free period in Group OFA (9.86 ± 1.43 hr) was significantly higher than that in Group OBA (6.93 ± 1.93 hr) (P = 0.002). During the postoperative 48 hours, the total requirement of fentanyl was considerably lower in Group OFA (P < 0.05). There was a significantly higher incidence of hypertension in Group OFA (46%) and hypotension (43%) in Group OBA (43%), respectively. Postoperative nausea vomiting (PONV) was more common in Group OBA at the 2nd and 6th hr (P = 0.046 and P = 0.038).

Conclusion

OFA with ketamine and ketofol provided adequate postoperative analgesia with a lower incidence of PONV after spine surgery. However, hypertension in the ketamine group and hypotension in the propofol group required fine titration of the infusion rate of drugs during the intraoperative period.

The Effect of Nonsteroidal Anti-inflammatory Drugs on Union Rates Following Joint Arthrodesis: A Meta-Analysis

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most widely used and prescribed medications because of their important role in reducing inflammation and pain, in addition to their non-addictive properties and safety profiles. However, some studies have documented an association between NSAIDs and delayed union or nonunion of joint arthrodesis procedures due to a potential inhibition of the bone's inflammatory healing response. As a result, some orthopedic surgeons hesitate to prescribe NSAIDs after an arthrodesis procedure. The purpose of this meta-analysis is to review all relevant literature regarding the effect of NSAIDs on union rates after arthrodesis and determine if NSAID therapy increases the risk of non-union in the setting of arthrodesis procedures. The study hypothesis was that NSAIDs would not have a significant effect on the risk of nonunion after arthrodesis. A thorough systematic review of Medline, Embase, the Cochrane Database of Systematic Reviews, and the Web of Science identified 3,050 articles to be screened. The variables of interest encompassed demographic factors, procedural details, type and administration of NSAIDs, the number of patients exposed to NSAIDs with and without successful union (case group), as well as the number of patients who did not receive NSAIDs with and without successful union (control group). All the data were analyzed using a maximum likelihood random-effects model. The number of non-union events versus routine healing from each study was used to calculate the odds ratio (OR) of successful healing after arthrodesis procedures with versus without NSAID therapy. Thirteen articles met the inclusion criteria for the meta-analysis. NSAID exposure showed an increased risk of nonunion, delayed union, or both following arthrodesis procedures; however, this did not meet statistical significance (OR, 1.48; confidence interval [CI], 0.96 to 2.30). A sub-analysis of pediatric and adult studies showed a significant increase in non-union risk in adults (OR, 1.717; CI, 1.012 to 2.914) when removing the pediatric cohort (p = 0.045). This meta-analysis provides evidence that NSAIDs can increase the risk of nonunion, delayed union, or both following arthrodesis procedures in adults. However, the study did not identify a risk of nonunion, delayed union, or both following arthrodesis procedures in the pediatric population.

The effect of ketorolac on posterior minimally invasive transforaminal lumbar interbody fusion: an interim analysis from a randomized, double-blinded, placebo-controlled trial

BACKGROUND CONTEXT

Postoperative pain control following posterior lumbar fusion continues to be challenging and often requires high doses of opioids for pain relief. The use of ketorolac in spinal fusion is limited due to the risk of pseudarthrosis. However, recent literature suggests it may not affect fusion rates with short-term use and low doses.

PURPOSE

We sought to demonstrate noninferiority regarding fusion rates in patients who received ketorolac after undergoing minimally invasive (MIS) posterior lumbar interbody fusion. Additionally, we sought to demonstrate ketorolac's opioid-sparing effect on analgesia in the immediate postoperative period.

STUDY DESIGN/SETTING

This is a prospective, randomized, double-blinded, placebo-controlled trial. We are reporting our interim analysis.

PATIENT SAMPLE

Adults with degenerative spinal conditions eligible to undergo a one to three-level MIS transforaminal lumbar interbody fusion (TLIF).

OUTCOME MEASURES

Six-month and 1-year radiographic fusion as determined by Suk criteria, postoperative opioid consumption as measured by intravenous milligram morphine equivalent, length of stay, and drug-related complications. Self-reported and functional measures include validated visual analog scale, short-form 12, and Oswestry Disability Index.

METHODS

A double-blinded, randomized placebo-controlled, noninferiority trial of patients undergoing 1- to 3-level MIS TLIF was performed with bone morphogenetic protein (BMP). Patients were randomized to receive a 48-hour scheduled treatment of either intravenous ketorolac (15 mg every 6 hours) or saline in addition to a standardized pain regimen. The primary outcome was fusion. Secondary outcomes included 48-hour and total postoperative opioid use demonstrated as milligram morphine equivalence, pain scores, length of stay (LOS), and quality-of-life outcomes. Univariate analyses were performed. The present study provides results from a planned interim analysis.

RESULTS

Two hundred and forty-six patients were analyzed per protocol. Patient characteristics were comparable between the groups. There was no significant difference in 1-year fusion rates between the two treatments (p=.53). The difference in proportion of solid fusion between the ketorolac and placebo groups did not reach inferiority (p=.072, 95% confidence interval, -.07 to .21). There was a significant reduction in total/48-hour mean opioid consumption (p<.001) and LOS (p=.001) for the ketorolac group while demonstrating equivalent mean pain scores in 48 hours postoperative (p=.20). There was no significant difference in rates of perioperative complications.

CONCLUSIONS

Short-term use of low-dose ketorolac in patients who have undergone MIS TLIF with BMP demonstrated noninferior fusion rates. Ketorolac safely demonstrated a significant reduction in postoperative opioid use and LOS while maintaining equivalent postoperative pain control.

Effect of Zingiber officinale Roscoe rhizome (ginger) capsule on postpartum pain: Double-blind randomized clinical trial

BACKGROUND

Postpartum pain contributes to increased irritability and excessive stress in the mother and consequently may inhibit successful breastfeeding, reduce a mother's ability to take care of her baby, and cause an imperfect mother-baby interaction. Evidence suggests the positive effect of ginger on reduction in uterus-associated pain. The objective of this study is to investigate the effect of ginger capsules on postpartum pain.

MATERIALS AND METHODS

The present double-blinded, randomized, placebo-controlled trial was conducted in Mahdiyeh Educational Hospital, Tehran. One hundred and twenty-eight mothers having moderate-to-severe pain following vaginal delivery were included. The participants were divided into two groups (A and B). Interventions were performed every 8 h in 24 h. In the first intervention (2 h after the delivery), Group A received 500 mg of placebo capsules (containing chickpea flour) and Group B received 500 mg of Zintoma (ginger rhizome) capsules. In the second and third interventions, Group A received 250 mg placebo capsules and Group B received 250 mg Zintoma capsules. All participants received 250 mg capsules of mefenamic acid in each intervention in addition to ginger or placebo capsules. The pain severity was measured before and half an hour, an hour, and 2 h after each intervention. Statistical analysis was performed using the SPSS software version. 22. The Chi-square, Fisher's, and t tests and the GEE model were applied to assess the pain severity.

RESULTS

The average pain severity was not statistically significant between the groups in the beginning of the intervention (P = 0.623). The mean score of pain significantly decreased within the duration of intervention in both groups (P < 0.001); however, the pain severity was significantly lower in the intervention group as compared to the control group at any point after the intervention (P = 0.006).

CONCLUSION

Ginger can be used as an effective remedy for postpartum pain relief.

Cytokine "fine tuning" of enthesis tissue homeostasis as a pointer to spondyloarthritis pathogenesis with a focus on relevant TNF and IL-17 targeted therapies

A curious feature of axial disease in ankylosing spondylitis (AS) and related non-radiographic axial spondyloarthropathy (nrAxSpA) is that spinal inflammation may ultimately be associated with excessive entheseal tissue repair with new bone formation. Other SpA associated target tissues including the gut and the skin have well established paradigms on how local tissue immune responses and proven disease relevant cytokines including TNF and the IL-23/17 axis contribute to tissue repair. Normal skeletal homeostasis including the highly mechanically stressed entheseal sites is subject to tissue microdamage, micro-inflammation and ultimately repair. Like the skin and gut, healthy enthesis has resident immune cells including ILCs, γδ T cells, conventional CD4+ and CD8+ T cells and myeloid lineage cells capable of cytokine induction involving prostaglandins, growth factors and cytokines including TNF and IL-17 that regulate these responses. We discuss how human genetic studies, animal models and translational human immunology around TNF and IL-17 suggest a largely redundant role for these pathways in physiological tissue repair and homeostasis. However, disease associated immune system overactivity of these cytokines with loss of tissue repair “fine tuning” is eventually associated with exuberant tissue repair responses in AS. Conversely, excessive biomechanical stress at spinal enthesis or peripheral enthesis with mechanically related or degenerative conditions is associated with a normal immune system attempts at cytokine fine tuning, but in this setting, it is commensurate to sustained abnormal biomechanical stressing. Unlike SpA, where restoration of aberrant and excessive cytokine “fine tuning” is efficacious, antagonism of these pathways in biomechanically related disease may be of limited or even no value.

Megestrol acetate induced proliferation and differentiation of osteoblastic MC3T3-E1 cells: A drug repurposing approach

AIMS

Drug repurposing or repositioning i.e.; identifying new indications for existing drugs have recently accelerated the process of drug discovery and development. Megestrol acetate (1) is a well-known progestin. It is commonly used as an appetite stimulant, and also in the treatment of breast, and endometrial cancers. The aim of this study is to investigate the effect of megestrol acetate (1) in osteoblast differentiation, and to determine the possible mechanism involved in megestrol acetate (1) induced osteoblast differentiation.

MAIN METHODS

Cytotoxicity of different steroidal drugs was evaluated using MTT assay. Alkaline phosphatase (ALP) activity was also determined, and alizarin red S (ARS) staining was performed to measure extracellular mineralization. Osteogenic protein levels were determined using Western blot analysis.

KEY FINDINGS

Results of the current study indicated that the megestrol acetate (1) enhanced the proliferation and differentiation of osteoblast cells at 1, 0.2, and 0.04 µM. This stimulatory effect of the megestrol acetate (1) was more prominent at 0.2 µM for cell proliferation, while the maximum cell differentiation (ALPase activity, and calcification) was observed at 0.04 μM. Western blot analysis also showed that megestrol acetate (1) altered the expression of bone morphogenic protein-2 (BMP2), p38, and pJNK proteins. Hence, only moderate doses of MGA (1) can enhance osteoblast proliferation and differentiation.

SIGNIFICANCE

Our results identified that megestrol acetate (1) could be a potential lead for further research towards bone fragility related disorders.

The effect of ketorolac on posterior thoracolumbar spinal fusions: a prospective double-blinded randomised placebo-controlled trial protocol

INTRODUCTION

Ketorolac has been shown to provide quality postoperative pain control and decrease opioid requirement with minimal side effects following spinal surgery. However, the literature addressing its use in spinal fusions is highly variable in both its effectiveness and complications, such as pseudarthrosis. Recent literature postulates that ketorolac may not affect fusion rates and large randomised controlled trials are needed to demonstrate ketorolac as a safe and effective adjuvant treatment to opioids for postoperative pain control.

METHODS AND ANALYSIS

This is a multihospital, prospective, double-blinded, randomised placebo-controlled trial. Data concerning fusion rates, postoperative opioid use, pain scores, length of stay will be recorded with the aim of demonstrating that the use of ketorolac does not decrease thoracolumbar spinal fusion rates while identifying possible adverse events related to short-term minimal effective dose compared with placebo. Additionally, this investigation aims to demonstrate a decrease in postoperative opioid use demonstrated by a decrease in morphine equivalence while showing equivalent postoperative pain control and decrease the average length of stay.

ETHICS AND DISSEMINATION

Ethical approval was obtained at all participating hospitals by the institutional review board. The results of this study will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03278691.

Alcoholism as a predictor for pseudarthrosis in primary spine fusion: An analysis of risk factors and 30-day outcomes for 52,402 patients from 2005 to 2013

Introduction

This study assessed the incidence and risk factors for pseudarthrosis among primary spine fusion patients.

Methods

Retrospective review of ACS-NSQIP (2005-2013). Differences in comorbidities between spine fusion patients with and without pseudarthrosis (Pseud, N-Pseud) were assessed using chi-squared tests and Independent Samples t-tests. Binary logistic regression assessed patient-related and procedure-related predictors for pseudarthrosis.

Results

52,402 patients (57yrs, 53%F, 0.4% w/pseudarthrosis). Alcohol consumption (OR:2.6[1.2-5.7]) and prior history of surgical revision (OR:1.6[1.4-1.8]) were risk factors for pseudarthrosis operation. Pseud patients at higher risk for deep incisional SSI (at 30-days:OR:6.6[2.0-21.8]). Pseud patients had more perioperative complications (avg:0.24 ± 0.43v0.18 ± 0.39,p=0.026).

Conclusions

Alcoholism and surgical revision are major risk factors for pseudarthrosis in patients undergoing spine fusion.

The Biological Enhancement of Spinal Fusion for Spinal Degenerative Disease

In this era of aging societies, the number of elderly individuals who undergo spinal arthrodesis for various degenerative diseases is increasing. Poor bone quality and osteogenic ability in older patients, due to osteoporosis, often interfere with achieving bone fusion after spinal arthrodesis. Enhancement of bone fusion requires shifting bone homeostasis toward increased bone formation and reduced resorption. Several biological enhancement strategies of bone formation have been conducted in animal models of spinal arthrodesis and human clinical trials. Pharmacological agents for osteoporosis have also been shown to be effective in enhancing bone fusion. Cytokines, which activate bone formation, such as bone morphogenetic proteins, have already been clinically used to enhance bone fusion for spinal arthrodesis. Recently, stem cells have attracted considerable attention as a cell source of osteoblasts, promising effects in enhancing bone fusion. Drug delivery systems will also need to be further developed to assure the safe delivery of bone-enhancing agents to the site of spinal arthrodesis. Our aim in this review is to appraise the current state of knowledge and evidence regarding bone enhancement strategies for spinal fusion for degenerative spinal disorders, and to identify future directions for biological bone enhancement strategies, including pharmacological, cell and gene therapy approaches.

The effect of nonsteroidal anti-inflammatory drugs on bone healing in humans: A qualitative, systematic review

STUDY OBJECTIVE

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in postoperative pain management. While an increasing number of in vitro and animal studies point toward an inhibitory effect of NSAIDs on bone healing process, the few existing retro- and prospective clinical studies present conflicting data.

DESIGN

The aim of this qualitative, systematic review was to investigate the impact of perioperative use of NSAIDs in humans on postoperative fracture/spinal fusion healing compared to other used analgesics measured as fracture nonunion with radiological control.

PATIENTS/INTERVENTIONS

We performed a systematic literature search of the last 38 years using PubMed Embase and the Cochrane Controlled Trials Register including retro- and prospective clinical, human trials assessing the effect of NSAIDs on postoperative fracture/spinal fusion healing when used for perioperative pain management with a radiological follow up to assess eventual nonunion. Due to different study designs, drugs, dosages/exposition times and different methods to assess fracture nonunion, these studies were not pooled for a meta-analysis. A descriptive summary of all studies, level of evidence, study quality and study bias assessment using different scores were used.

MAIN RESULTS

Three prospective randomized controlled studies and thirteen retrospective cohort human studies were identified for a total of 12'895 patients. The overall study quality was low according to Jadad and Oxford Levels of Evidence scores.

CONCLUSIONS

Published results of human trials did not show strong evidence that NDAIDs for pain therapy after fracture osteosynthesis or spinal fusion lead to an increased nonunion rate. Reviewed studies present such conflicting data, that no clinical recommendation can be made regarding the appropriate use of NSAIDs in this context. Considering laboratory data of animal, human tissue research and recommendation of clinical reviews, a short perioperative exposition to NSAIDs is most likely not deleterious. However, randomized, controlled studies are warranted to support or refute this hypothesis.

Nonsteroidal Anti-Inflammatory Drugs and Bone-Healing: A Systematic Review of Research Quality

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are often avoided by orthopaedic surgeons because of their possible influence on bone-healing. This belief stems from multiple studies, in particular animal studies, that show delayed bone-healing or nonunions associated with NSAID exposure. The purpose of this review was to critically analyze the quality of published literature that evaluates the impact of NSAIDs on clinical bone-healing.

METHODS

A MEDLINE and Embase search was conducted to identify all articles relating to bone and fracture-healing and the utilization of NSAIDs. All human studies, including review articles, were identified for further analysis. Non-English-language manuscripts and in vitro and animal studies were excluded. A total of twelve clinical articles and twenty-four literature reviews were selected for analysis. The quality of the clinical studies was assessed with a modified Coleman Methodology Score with emphasis on the NSAID utilization. Review articles were analyzed with regard to variability in the cited literature and final conclusions.

RESULTS

The mean modified Coleman Methodology Score (and standard deviation) was significantly lower (p = 0.032) in clinical studies that demonstrated a negative effect of NSAIDs on bone-healing (40.0 ± 14.3 points) compared with those that concluded that NSAIDs were safe (58.8 ± 10.3 points). Review articles also demonstrated substantial variability in the number of cited clinical studies and overall conclusions. There were only two meta-analyses and twenty-two narrative reviews. The mean number (and standard deviation) of clinical studies cited was significantly greater (p = 0.008) for reviews that concluded that NSAIDs were safe (8.0 ± 4.8) compared with those that recommended avoiding them (2.1 ± 2.1). Unanimously, all reviews admitted to the need for prospective randomized controlled trials to help clarify the effects of NSAIDs on bone-healing.

CONCLUSIONS

This systematic literature review highlights the great variability in the interpretation of the literature addressing the impact of NSAIDs on bone-healing. Unfortunately, there is no consensus regarding the safety of NSAIDs following orthopaedic procedures, and future studies should aim for appropriate methodological designs to help to clarify existing discrepancies to improve the quality of care for orthopaedic patients.

CLINICAL RELEVANCE

This systematic review highlights the limitations in the current understanding of the effects of NSAIDs on bone healing. Thus, withholding these medications does not have any proven scientific benefit to patients and may even cause harm by increasing narcotic requirements in cases in which they could be beneficial for pain management. This review should encourage further basic-science and clinical studies to clarify the risks and benefits of anti-inflammatory medications in the postoperative period, with the aim of improving patient outcomes.

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.

Impact of surgical site infection and surgical debridement on lumbar arthrodesis: A single-institution analysis of incidence and risk factors

This study identifies the rate of pseudarthrosis following surgical debridement for deep lumbar spine surgical site infection and identify associated risk factors. Patients who underwent index lumbar fusion surgery from 2013 to 2014 were included if they met the following criteria: 1) age >18years, 2) had debridement of deep lumbar SSI, and had 3) lumbar spine AP, lateral and flexion/extension X-rays and computed tomography (CT) at 12months or greater postoperatively. Criteria for fusion included 1) solid posterolateral, facet, or disk space bridging bone, 2) no translational or angular motion on flexion/extension X-rays, and 3) intact posterior hardware without evidence of screw lucency or breakage. Twenty-five patients (age 63.2±12.6years, 10 male) involving 58 spinal levels met inclusion criteria. They underwent fusion at a mean of 2.32 [range 1-4] spinal levels. Sixteen (64.0%) patients received interbody grafts at a total of 34 (58.6%) spinal levels. All underwent surgical debridement with removal of all non-incorporated posterior bone graft and devascularized tissue. At one-year postoperatively, (56%) patients and 30 (52%) spinal levels demonstrated radiographic evidence of successful fusion. Interbody cage during initial fusion was significantly associated with successful arthrodesis at follow-up (p=0.017). There is a high rate of pseudoarthrosis in 44% of patients (48% of levels) undergoing lumbar fusion surgery complicated by SSI requiring debridement. Use of interbody cage during initial fusion was significantly associated with higher rate of arthrodesis.

Pain management following spinal surgeries: An appraisal of the available options

Spinal procedures are generally associated with intense pain in the postoperative period, especially for the initial few days. Adequate pain management in this period has been seen to correlate well with improved functional outcome, early ambulation, early discharge, and preventing the development of chronic pain. A diverse array of pharmacological options exists for the effective amelioration of post spinal surgery pain. Each of these drugs possesses inherent advantages and disadvantages which restricts their universal applicability. Therefore, combination therapy or multimodal analgesia for proper control of pain appears as the best approach in this regard. The current manuscript discussed the pathophysiology of postsurgical pain including its nature, the various tools for assessment, and the various pharmacological agents (both conventional and upcoming) available at our disposal to respond to post spinal surgery pain.

NSAIDs and fracture healing

PURPOSE OF REVIEW

Published data raise concerns about the use of nonselective NSAIDs and selective cyclo-oxygenase (COX)-2 inhibitors as anti-inflammatory or analgesic drugs in patients after a recent fracture or who are undergoing (uncemented) arthroplasty or osteotomy. However, clinical reports on the effect of COX-2 inhibition on fracture healing in humans have been variable and inconclusive. This review gives an overview of the published data and an advice when to avoid NSAIDs.

RECENT FINDINGS

Prostaglandins play an important role as mediators of inflammation and COX are required for their production. Inflammation is an essential step in the fracture healing process in which prostaglandin production by COX-2 is involved. Data from animal studies suggest that NSAIDs, which inhibit COX-2, can impair fracture healing due to the inhibition of the endochondral ossification pathway. Animal data suggest that the effects of COX-2 inhibitors are dependent on the timing, duration, and dose, and that these effects are reversible.

SUMMARY

These animal data, together with the view of limited scientifically robust clinical evidence in humans, indicate that physicians consider only short-term administration of COX-2 inhibitors or other drugs in the pain management of patients who are in the phase of fracture or other bone defect healing. COX-2-inhibitors should be considered a potential risk factor for fracture healing, and therefore to be avoided in patients at risk for delayed fracture healing.

Parecoxib: a shift in pain management?

Parecoxib (Dynastat) is a parenteral cyclooxygenase-2 inhibitor available in Europe. Clinical trials have reported a benefit in reducing pain following oral, orthopedic, gynecologic and cardiac surgeries. The overall efficacy was dose-related and similar to ketorolac (Toradol). Several trials reported an opioid-sparing effect with parecoxib. No trials have reported significantly fewer opioid-related gastrointestinal side effects (e.g., nausea, vomiting, constipation and intestinal ileus) when opioids were administered with parecoxib versus placebo. Gastroduodenal ulcers, gastric ulcers and duodenal ulcers or erosions were less common with parecoxib than ketorolac. Parecoxib does not affect platelet aggregation, interfere with the antiplatelet affect of aspirin, affect prothrombin and partial thromboplastin time or platelet counts when administered with heparin.

High-dose ketorolac affects adult spinal fusion: a meta-analysis of the effect of perioperative nonsteroidal anti-inflammatory drugs on spinal fusion

STUDY DESIGN

Meta-analysis of literature.

OBJECTIVE

To evaluate the effect of perioperative nonsteroidal anti-inflammatory drugs (NSAIDs) on the success rate of adult spinal fusion.

SUMMARY OF BACKGROUND DATA

NSAIDs are commonly used to treat postsurgical orthopedic pain. Studies on animal models have shown a significant inhibiting effect of NSAIDs on osteogenesis process, on which spinal fusion also depends. Recently, great interest has been shown in the effect of NSAIDs on the success rate of adult spinal fusion. Clinical trials have tested the effect of perioperative NSAIDs in spinal fusion procedures. A cumulative result of these studies would give more credit to the final conclusions.

METHODS

A systematic search of electronic databases and references from eligible articles was conducted. Comparative studies reporting on the results of primary spinal fusion including treatment group of NSAIDs perioperatively were regarded eligible. A pooled estimate of effect size was produced using both random and fixed effect model.

RESULTS

Five retrospective comparative studies (n = 1403 participants) were included in the present study. The mean age of these patients was more than 40 years and none of them had NSAIDs for longer than 14 days following spinal fusion surgery. High-dose ketorolac showed a statistically significant adverse effect on spinal fusion (P = 0.001, RR = 2.87, 95% CI = 1.53 = - 5.38) with no statistical heterogeneity (I = 3%, P = 0.38), whereas normal-dose NSAIDs (ketorolac, diclofenac sodium, celecoxib, or rofecoxib) did not appear to produce inferior results than the no-NSAIDs group (P = 0.30, RR = 1.39, 95% CI = 0.74 - 2.61) with no statistical heterogeneity (I² = 0%, P = 0.50).

CONCLUSION

Although randomized controlled trials would be optimal for meta-analyses, the data of this review revealed that short-time (<14 days) exposure to normal-dose NSAIDs (ketorolac, diclofenac sodium, celecoxib, or rofecoxib) were safe after spinal fusion, whereas short-time (<14 days) exposure to high-dose ketorolac increased the risk of nonunion, which meant that the effect of perioperative NSAIDs on spinal fusion might be dose-dependent. Further studies would be needed to find out whether long-time exposure to normal-dose NSAIDs could also increase the risk of nonunion and which type of NSAIDs would like to have a worse effect on spinal fusion.

NSAID exposure and risk of nonunion: a meta-analysis of case-control and cohort studies

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used for postoperative pain control. However, concerns regarding the potential deleterious effects of NSAIDs on bone healing have compelled many physicians to avoid NSAIDs in patients with healing fractures, osteotomies, and fusions. We systematically reviewed and analyzed the best clinical evidence regarding the effects of NSAID exposure on bone healing. Medline, Embase, and Cochrane electronic databases were searched for prospective and retrospective clinical studies of fracture, osteotomy, and fusion studies of patients with NSAID exposure and nonunion as an outcome. Study quality was assessed using the Newcastle-Ottawa Scale. Data on study design, patient characteristics, and risk estimates were extracted. Pooled effect estimates were calculated. Subanalyses were performed by bone type and by NSAID dose, duration, and route of administration. In the initial analysis of 11 cohort and case-control studies, the pooled odds ratio for nonunion with NSAID exposure was 3.0 (95% confidence interval 1.6-5.6). A significant association between lower-quality studies and higher reported odds ratios for nonunion was observed. When only higher-quality studies were considered, seven spine fusion studies were analyzed, and no statistically significant association between NSAID exposure and nonunion was identified (odds ratio = 2.2, 95% confidence interval 0.8-6.3). There was no increased risk of nonunion with NSAID exposure when only the highest-quality studies were assessed. Randomized controlled trials assessing NSAID exposure in fracture, fusion, and osteotomy populations are warranted to confirm or refute the findings of this meta-analysis of observational studies.

Non-steroidal anti-inflammatory drugs in orthopaedic and perioperative practice

Non-steroidal anti-inflammatory drugs are powerful and effective anti-inflammatory, analgesic and anti-pyretic drugs. They are routinely used in orthopaedic conditions and in the perioperative setting. They are however associated with potentially life-threatening side-effects and it is important to appreciate these before these medicines are administered. There is evidence suggesting that these drugs adversely affect bone formation, and this has implications for their use in patients with fractures and other pathologies that involve bone remodelling.

The use of NSAIDs in pediatric scoliosis surgery - a survey of physicians' prescribing practice

BACKGROUND

Pediatric scoliosis surgery is associated with considerable postoperative pain requiring opioids for analgesia. Nonsteroidal antiinflammatory drugs (NSAIDs) can be used as adjuvants for analgesia; however, the potential of these agents to affect bone healing raises concerns. No large-scale prospective studies have been performed to evaluate the benefit-to-risk ratio of NSAID use after pediatric scoliosis surgery. Given the lack of evidence in the literature, a survey of practice patterns of anesthesiologists from around the world was conducted with respect to the use of NSAIDs after pediatric spinal fusion surgery for scoliosis.

METHODS

One hundred and fourteen anesthesiologists from international academic pediatric hospitals were asked to complete an online survey. After 1 month, nonresponders were sent a second e-mail asking for their participation. All questions were developed specifically for this study.

RESULTS

Out of 80 anesthesiologists who responded 61 were included in the final analysis. Fifty-nine percent routinely use NSAIDs, the most common agents being intravenous ketorolac and oral ibuprofen. The majority of respondents begin to administer NSAIDs within the first three postoperative days for a duration of four or more days. The primary reason for not routinely prescribing NSAIDs was the risk of bone nonunion.

CONCLUSIONS

This survey demonstrates that the practice patterns of pediatric anesthesiologists from around the world with respect to the administration of NSAIDs for the management of postoperative pain after pediatric spinal fusion reflects the conflicting evidence in the literature and the lack of high-quality studies in humans.

Update on the role of nonsteroidal anti-inflammatory drugs and coxibs in the management of acute pain

PURPOSE OF REVIEW

Although NSAIDs have been shown to reduce postoperative analgesics, their ability to reduce opioid-related adverse effects and improve functional outcomes is questioned. Further, perioperative NSAID use may contribute to cardiovascular toxicity and impaired bone healing. This review highlights recent advances in our understanding of the role perioperative NSAIDs have on modulating nociception, their benefits when utilized as components of a multimodal analgesic regimen, and potential deleterious cardiovascular and osteogenic effects.

RECENT FINDINGS

Recent research indicates that, in addition to peripheral blockade of prostaglandin synthesis, central inhibition of cyclooxygenase-2 may play an important role in modulating nociception. Although nonspecific NSAIDs provide analgesic efficacy similar to coxibs, their use has been limited in the perioperative setting because of platelet dysfunction and gastrointestinal toxicity. Coxibs may be a safer alternative in that setting. Both coxibs and traditional NSAIDs may contribute to a dose-dependent increase in cardiovascular toxicity and impaired osteogenesis. When used short term at the lowest effective dose, however, NSAIDs may provide for analgesic benefit without significant toxicity.

SUMMARY

When utilized as a component of a multimodal analgesic regimen for acute pain, short-term NSAID administration reduces opioid-related side effects and may contribute to improved functional outcomes without significant adverse effects.

Selective and nonselective cyclooxygenase-2 inhibitors and experimental fracture-healing. Reversibility of effects after short-term treatment

BACKGROUND

Cyclooxygenase-2-specific anti-inflammatory drugs (coxibs) and nonspecific nonsteroidal anti-inflammatory drugs have been shown to inhibit experimental fracture-healing. The present study tested the hypothesis that these effects are reversible after short-term treatment.

METHODS

With use of a standard model of fracture-healing, identical ED50 dosages of either a nonsteroidal anti-inflammatory drug (ketorolac), a coxib (valdecoxib), or vehicle (control) were orally administered to rats for either seven or twenty-one days and fracture-healing was assessed with biomechanical, histological, and biochemical analyses.

RESULTS

When healing was assessed at twenty-one days, the seven-day treatment produced only a trend for a higher rate of nonunion in valdecoxib and ketorolac-treated animals as compared with controls. No differences were observed at thirty-five days. The twenty-one-day treatment produced significantly more nonunions in valdecoxib-treated animals as compared with either ketorolac-treated or control animals (p < 0.05), but these differences disappeared by thirty-five days. The dose-specific inhibition of these drugs on prostaglandin E2 levels and the reversibility of the effects after drug withdrawal were assessed in fracture calluses and showed that ketorolac treatment led to twofold to threefold lower levels of prostaglandin E2 than did valdecoxib. Withdrawal of either drug after six days led to a twofold rebound in these levels by fourteen days. Histological analysis showed delayed remodeling of calcified cartilage and reduced bone formation in association with valdecoxib treatment.

CONCLUSIONS

Cyclooxygenase-2-specific drugs inhibit fracture-healing more than nonspecific nonsteroidal anti-inflammatory drugs, and the magnitude of the effect is related to the duration of treatment. However, after the discontinuation of treatment, prostaglandin E2 levels are gradually restored and the regain of strength returns to levels similar to control.

Remifentanil versus fentanyl for short-term analgesia-based sedation in mechanically ventilated postoperative children

BACKGROUND

Analgesia-based sedation techniques are becoming more established in the intensive care unit (ICU) setting. The aim of this study was to compare remifentanil and fentanyl infusions for postoperative analgesia in pediatric ICU patients.

METHODS

After receiving ethical committee approval, a prospective randomized, double-blind study was performed. Twenty-two postoperative orthopedic surgery patients received either remifentanil 0.1 microg.kg(-1).min(-1) or fentanyl 0.025 microg.kg(-1).min(-1) infusions diluted to the same volume. Analgesic infusion was titrated to predefined levels of analgesia [behavioral pain scale (BPS) score of 3]. Propofol was added if sedation was unsatisfactory after BPS score 3 had been achieved.

RESULTS

There were no differences in groups regarding demographics, tracheal extubation times, and pain scores of the patients. After cessation of the opioid infusion, the sedation scores and the heart rates were always higher in the remifentanil group compared with the fentanyl group. The incidences of nausea, vomiting, apnea, desaturation, reintubation within 24 h and constipation were also similar between the two groups.

CONCLUSIONS

We conclude that a remifentanil infusion provides clinically comparable analgesia with a fentanyl infusion in mechanically ventilated postoperative pediatric patients. These two drugs are suitable for short-term analgesia-based sedation in pediatric postoperative ICU patients.

High dose nonsteroidal anti-inflammatory drugs compromise spinal fusion

PURPOSE

Although nonsteroidal anti-inflammatory drugs (NSAIDs) provide benefit to patients following spinal fusion surgery, their routine administration has remained controversial due to concerns about possible deleterious effects on bone healing. The goal of this retrospective study was to assess the incidence of non-union following the perioperative administration of ketorolac, celecoxib, or rofecoxib.

METHODS

We retrospectively analyzed the data of 434 patients receiving perioperative ketorolac (20-240 mg.day(-1)), celecoxib (200-600 mg.day(-1)), rofecoxib (50 mg.day(-1)), or no NSAIDs in the five days following spinal fusion surgery.

RESULTS

There were no significant differences in the incidence of non-union among the groups that received no NSAIDs (11/130; 8.5%), celecoxib 5/60; 8.3%), or rofecoxib (9/124; 7.3%). In contrast, 23/120 of patients (19.2%) that received ketorolac had a higher incidence (P < 0.001) of non-union compared to non-NSAID users. However, only 3/50 patients (6%) receiving low-dose ketorolac (< or = 110 mg.day(-1)) resulted in non-union which was not significantly different from non-NSAID users. Patients administered higher doses of ketorolac (120-240 mg.day(-1)) resulted in a higher incidence (P < 0.0001) of non-union (20/70; 29%) compared to non-NSAID users. For those patients developing non-union, there was a higher incidence comparing smokers vs non-smokers (P < 0.0001) and one level fusion vs two level fusions (P < 0.001).

CONCLUSIONS

This study revealed that the short-term perioperative administration of celecoxib, rofecoxib, or low-dose ketorolac (< or = 110 mg.day(-1)) had no significant deleterious effect on non-union. In contrast, higher doses of ketorolac (120-240 mg.day(-1)), history of smoking, and two level vertebral fusions resulted in a significant increase in the incidence of non-union following spinal fusion surgery.

The effect of cyclooxygenase-2 inhibition on analgesia and spinal fusion

BACKGROUND

Cyclooxygenase (COX)-2-specific inhibitors demonstrate analgesic efficacy comparable with that of conventional nonsteroidal anti-inflammatory drugs but are associated with reduced gastrointestinal side effects and an absence of antiplatelet activity. Thus, they can be administered to patients undergoing spinal fusion surgery without an added risk of bleeding. However, concerns regarding a possible deleterious effect on bone-healing have limited their routine use. Celecoxib, a COX-2 inhibitor, recently was approved for the treatment of acute pain. The goals of the present study were to examine the analgesic efficacy of celecoxib and to determine the incidence of nonunion at one year following spinal fusion surgery.

METHODS

Eighty patients who were scheduled to undergo spinal fusion received either celecoxib or placebo one hour before the induction of anesthesia and every twelve hours after surgery for the first five postoperative days. Pain scores and morphine use were recorded one hour after arrival in the post-anesthesia care unit and at four, eight, twelve, sixteen, twenty, and twenty-four hours later. Intraoperative blood loss was recorded. The status of the fusion was determined radiographically at the time of the one-year follow-up.

RESULTS

There were no differences in demographic data or blood loss between the two groups. Pain scores were lower in the celecoxib group at one, four, eight, sixteen, and twenty hours postoperatively. There were no differences between the two groups with regard to the pain scores at twelve and twenty-four hours postoperatively. Morphine use was lower in the celecoxib group at all postoperative time-intervals. There was no difference between the celecoxib group and the placebo group with regard to the incidence of nonunion at the time of the one-year follow-up (7.5% [three of forty] compared with 10% [four of forty]).

CONCLUSIONS

The perioperative administration of celecoxib resulted in a significant reduction in postoperative pain and opioid use following spinal fusion surgery. In addition, the short-term administration of this COX-2-specific non-steroidal anti-inflammatory drug had no apparent effect on the rate of nonunion at the time of the one-year follow-up.

Differential inhibition of fracture healing by non-selective and cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) specifically inhibit cyclooxygenase (COX) activity and are widely used as anti-arthritics, post-surgical analgesics, and for the relief of acute musculoskeletal pain. Recent studies suggest that non-specific NSAIDs, which inhibit both COX-1 and COX-2 isoforms, delay bone healing. The objectives of this study were 2-fold; first, to measure the relative changes in the normal expression of COX-1 and COX-2 mRNAs over a 42 day period of fracture healing and second, to compare the effects of a commonly used non-specific NSAID, ketorolac, with a COX-2 specific NSAID, Parecoxib (a pro-drug of valdecoxib), on this process. Simple, closed, transverse fractures were generated in femora of male Sprague-Dawley rats weighing approximately 450 g each. Total RNA was prepared from the calluses obtained prior to fracture and at 1, 3, 5, 7, 10, 14, 21, 35 and 42 days post-fracture and levels of COX-1 and COX-2 mRNA were measured using real time PCR. While the relative levels of COX-1 mRNA remained constant over a 21-day period, COX-2 mRNA levels showed peak expression during the first 14 days of healing and returned to basal levels by day 21. Mechanical properties of the calluses were then assessed at 21 and 35 days post-fracture in untreated animals and animals treated with either ketorolac or high or low dose parecoxib. At both 21 and 35 days after fracture, calluses in the group treated with the ketorolac showed a significant reduction in mechanical strength and stiffness when compared with controls (p<0.05). At the 21-day time point, calluses of the parecoxib treated animals showed a lower mean mechanical strength than controls, but the inhibition was not statistically significant. Based on physical analysis of the bones, 3 of 12 (25%) of the ketorolac-treated and 1 of 12 (8%) of the high dose parecoxib-treated animals showed failure to unite their fractures by 21 days, while all fractures in both groups showed union by 35 days. Histological analysis at 21 days showed that the calluses in the ketorolac-treated group contained substantial amounts of residual cartilage while neither the control nor the parecoxib-treated animals showed comparable amounts of cartilage at this stage. These results demonstrate that ketorolac and parecoxib delay fracture healing in this model, but in this study daily administration of ketorolac, a non-selective COX inhibitor had a greater affect on this process. They further demonstrate that a COX-2 selective NSAID, such as parecoxib (valdecoxib), has only a small effect on delaying fracture healing even at doses that are known to fully inhibit prostaglandin production.

Cyclooxygenase-2 inhibitors and nonsteroidal anti-inflammatory drugs in the management of arthritis

The management of arthritis pain should be individualized to the needs and characteristics of the patient. The decision to use nonsteroidal anti-inflammatory drugs (NSAIDs), and in particular the cyclooxygenase-2 (COX-2) inhibitors, is multidimensional. The challenge is to achieve optimal pain relief at the minimum dose to minimize adverse effects. Whenever possible, NSAIDs should be given as monotherapies or in combinations at the lowest effective doses. The COX-2 inhibitors are a safe choice for most patients who are at low risk for a cardiovascular event. Individuals who are at risk for thromboses should not receive unopposed COX-2 inhibitors; COX-2 should be given in combination with low-dose aspirin which is expected to be cardioprotective in high-risk patients.