Dexamethasone Perioperative Coanalgesia in Lumbar Spine Fusion: A Controlled Cohort Study of Efficacy and Safety

Association between in situ steroids and spine surgical site infections among instrumented procedures

OBJECTIVE

To estimate the association between in situ steroids and spine surgical-site infections (SSIs), assessing spinal instrumentation as an effect modifier and adjusting for confounders.

DESIGN

Case-control study.

SETTING

Rural academic medical center.

PARTICIPANTS

We identified 1,058 adults undergoing posterior fusion and laminectomy procedures as defined by the National Healthcare Safety Network without a pre-existing SSI between January 2020 and December 2021. We identified 26 SSI as cases and randomly selected 104 controls from the remaining patients without SSI.

METHODS

The primary exposure was the intraoperative administration of methylprednisolone in situ (ie, either in the wound bed or as an epidural injection). The primary outcome was a clinical diagnosis of SSI within 6 months of a patient's first spine surgery at our facility. We quantified the association between the exposure and outcome using logistic regression, using a product term to assess for effect modification by spinal instrumentation and the change-in-estimate approach to select significant confounders.

RESULTS

Adjusting for Charlson comorbidity index and malignancy, in situ steroids were significantly associated with spine SSI relative to no in situ steroids for instrumented procedures (adjusted odds ratio [aOR], 9.93; 95% confidence interval [CI], 1.54-64.0), but they were not associated with spine SSIs among noninstrumented procedures (aOR, 0.86; 95% CI, 0.15-4.93).

CONCLUSIONS

In situ steroids were significantly associated with spine SSI among instrumented procedures. The benefits of in situ steroids for pain management following spine surgery should be weighed against the risk of SSI, especially for instrumented procedures.

Clinical efficacy of single intraoperative 500 mg methylprednisolone management therapy for thoracic myelopathy caused by ossification of the ligamentum flavum

Background

The objective of our study was to compare clinical outcome and postoperative complications between patients with thoracic myelopathy caused by ossification of the ligamentum flavum (OLF) treated with and without intraoperative methylprednisolone (MP).

Methods

This retrospective study enrolled 101 patients who underwent posterior approach surgery for OLF and were followed up at least 1 year. Patients were divided into two groups according to MP use in the operation: MP group (n = 47) and non-MP group (n = 54). Clinical outcomes and complications were evaluated before and after operation and at the last follow-up.

Results

Significant differences were found in modified Japanese Orthopedics Association (mJOA) scores and proportion of Frankel grade (A-C) between the two groups immediately after surgery and at 2-week follow-up. No significant differences were found between the two groups in mJOA score before operation and at the final follow-up. Moreover, no significant differences were observed in recovery rate according to mJOA score at any time points, and there was no significant difference in the proportion of Frankel grade (A-C) between the two groups at final follow-up. There were 13 documented infections: 10 in the MP group and 3 in the non-MP group (P = 0.034).

Conclusion

Management therapy with intraoperative 500 mg MP showed better recovery of nerve function within 2 weeks in patients with thoracic myelopathy caused by OLF compared with those did not receive MP. However, long-term follow-up results showed that there was no significant difference in neurological recovery between patients with intraoperative MP or not. Moreover, intraoperative MP increased the rate of wound infection.

Adjuvant analgesics in spinal surgery

Peri- and postoperative pain control can present a challenge to any doctor, particularly in the setting of spinal surgery. The use of adjuvant pain agents and multimodal analgesia is changing the face of modern anaesthesia and offering clinicians more avenues to control perioperative pain. This article discusses the use of adjuvant medications and some of the evidence surrounding their use in spinal surgery.

Increased acute postoperative wound problems following spinal fusion in overweight patients with adolescent idiopathic scoliosis

This study assessed the rate of adverse wound events in individuals with adolescent idiopathic scoliosis who underwent a posterior spinal fusion and sought to determine if obesity was related to the rate of adverse wound events. A retrospective review of patients with adolescent idiopathic scoliosis that underwent posterior spinal fusion between 2001 and 2013 was performed. Preoperative, perioperative, and postoperative data, including wound adverse events, were obtained through medical record review. Using the Center for Disease Control BMI criteria, participants were grouped into overweight/obese (BMI%≥85 percentile) or healthy/underweight (BMI%<85 percentile) groups. Obesity and prolonged hospital stay were independent risk factors for increased risk of wound problems.

Can Preoperative Intravenous Corticosteroids Administration Reduce Postoperative Pain Scores Following Spinal Fusion?: A Meta-Analysis

Objective: This meta-analysis aimed to assess whether preoperative intravenous corticosteroids reduced postoperative pain in patients undergoing spinal fusion surgery. Methods: We systematically searched PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and Google databases, from inception to March 29, 2018. Randomized controlled trials (RCTs) that compared preoperative intravenous glucocorticoids against a control treatment for the effect on pain following spinal fusion surgery were included. A meta-analysis was performed to generate a pooled risk ratio (RR) and weighted mean difference (WMD) with corresponding 95% confidence interval (CI) for discontinuous outcomes (the occurrence of postoperative nausea and vomiting [PONV] as well as surgical-site infections) and continuous outcomes (visual analog scale [VAS] scores at 12 h, 24 h, 48 h, and 72 h; total morphine consumption and the length of hospital stay), respectively. Results: Ten RCTs that compared intravenous corticosteroids versus placebo were included in our final meta-analysis. Compared with controls, intravenous corticosteroids were associated with a statistically significant reduction in pain VAS scores at 12 h, 24 h, 48 h, and 72 h. Additionally, intravenous corticosteroids decreased total morphine consumption, PONV, and the length of hospital stay. There was no significant difference between intravenous corticosteroids and controls, regarding the occurrence of infection (p > 0.05). Conclusions: In summary, our results indicated that intravenous corticosteroids not only reduce pain but also have anti-emetic effects. More studies should focus on the adverse effects of administering intravenous corticosteroids.

Intravenous glucocorticoid for pain control after spinal fusion: A meta-analysis of randomized controlled trials

OBJECTIVE

Postoperative pain was a common symptom after spinal surgery. This meta-analysis aimed to assess whether intravenous glucocorticoids has a beneficial role in reducing pain in patients following spinal fusion.

METHODS

We systematically searched PubMed, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and Google databases, from inception to March 2, 2018. Randomized controlled trials (RCTs) that comparing intravenous glucocorticoids with control treatment for spinal fusion were included. A meta-analysis was performed to generate pooled risk ratio (RR) and weighted mean difference with corresponding 95% confidence interval (CI) for discontinuous outcomes (the occurrence of nausea and infection) and continuous outcomes (visual analog scale [VAS] at 12, 24, and 48 h; total morphine consumption; and the length of hospital stay), respectively.

RESULTS

Eight clinical trials involving 918 patients (glucocorticoid group = 449, control group = 469) were finally included in this meta-analysis. Compared with control, intravenous glucocorticoids had significantly reduced VAS at 12, 24, and 48 hours with statistically significance (P < .05). Intravenous glucocorticoids can decrease the occurrence of nausea (RR = 0.42, 95% CI 0.29-0.62, P = .000; I = 0.0%) and the length of hospital stay. No difference was noticed in the occurrence of infection between glucocorticoids intravenous and control (P > .05).

CONCLUSION

Existing evidence indicated that intravenous glucocorticoids have a beneficial role in decreasing early pain and the occurrence of nausea after spinal fusion surgery. In consideration of the limitation in current meta-analysis, more high-quality RCTs were needed to identify the optimal dose of glucocorticoids in spinal fusion patients.

Endogenous Opiates and Behavior: 2016

This paper is the thirty-ninth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2016 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.

Description and Results of a Comprehensive Care Protocol for Overnight-Stay Spine Surgery in Adults

STUDY DESIGN

This is a prospective cohort study.

OBJECTIVE

The aim of this study was to define the probability of successful morning-after discharge after adult spine surgery achieved with a standard care protocol as applied to patients with a large variety of common degenerative spine disorders.

SUMMARY OF BACKGROUND DATA

Qualifying criteria for ambulatory or overnight-stay adult spine surgery are not well defined in either the spine or anesthesia literature. Most reports simply go to American Society of Anesthesiology risk classification or surgical technique alternatives and do not present a clearly defined patient care and case management protocol.

METHODS

A standardized protocol of patient preparation, preoperative comorbidities optimization, and perioperative care was applied in a prospective cohort of 126 patients including 83 lumbar and 41 cervical procedures. Office and hospital chart records were reviewed for relevant outcomes.

RESULTS

Fully 122 of 124 appropriately selected cases were able to successfully achieve uneventful same-day discharge without any need for readmission, unscheduled early emergency room or clinic visits, or other major complications. Both failures were for urinary retention in senior males and resolved after a single-day admission to the main hospital.

CONCLUSION

A wide variety of common degenerative spinal pathology in adults can be routinely and safely managed on an overnight-stay basis without requirement for formal hospital inpatient admission in patients appropriately selected and pre-educated to the experience and whose major comorbidities are preoperatively optimized.

LEVEL OF EVIDENCE

N/A.

Comparing the Efficacy of Caudal with Intravenous Dexamethasone in the Management of Pain Following Lumbosacral Spine Surgeries: A Randomized Double Blinded Controlled Study

BACKGROUND

The challenge in providing analgesia for spine surgeries is to provide extended postoperative pain relief and simultaneously allow early neurological assessment and mobilization. Our study aimed to evaluate the analgesic efficacy of intravenous versus caudal dexamethasone in lumbosacral spine surgeries.

MATERIALS AND METHODS

In this prospective double-blind study, a total of 96 patients undergoing lumbosacral spine surgery were randomized into three groups to receive 25 ml of preemptive caudal epidural injection of either injection ropivacaine 0.2% (Group A, n = 32), a 25 ml of injection ropivacaine 0.2%, and intravenous injection dexamethasone 8 mg (Group B, n = 32) or 25 ml mixture of injection ropivacaine 0.2% with injection dexamethasone 8 mg (Group C, n = 32) under general anesthesia. Visual analog scale (VAS), heart rate, blood pressures, blood sugar levels, and time to rescue analgesia were recorded at regular intervals for the first 24 h. Time to discharge was noted. Analysis of variance has been used to find the significance of study parameters between the groups of patients. Statistical software, namely, SAS 9.2 and SPSS 15.0, have been used for the analysis of the data.

RESULTS

The mean VAS was significantly lower in the Group C for up to 24 h following the caudal block. No significant hemodynamic changes were noted in any of the groups. The intravenous dexamethasone group showed higher blood glucose levels at 24 h but was not clinically relevant.

CONCLUSION

These results suggest that injection dexamethasone is a safe adjunct to caudal ropivacaine in lumbosacral spine surgeries.