Postoperative pain relief using intermittent intrapleural analgesia following thoracoscopic anterior correction for progressive adolescent idiopathic scoliosis

Analgesic options for anterior approach to scoliosis repair: a scoping review

PURPOSE

The ideal analgesic regimen for the anterior approach to scoliosis repair is not clearly defined. The purpose of the study was to summarize and identify gaps in the current literature specific to the anterior approach to scoliosis repair.

METHODS

A scoping review was conducted in July 2022 utilizing PubMed, Cochrane, and Scopus databases guided by the PRISMA-ScR framework.

RESULTS

The database search generated 641 possible articles, 13 of which met all inclusion criteria. All articles focused on the effectiveness and safety of regional anesthetic techniques, while a minority also provided both opioid and non-opioid medication frameworks.

CONCLUSION

Continuous Epidural Analgesia (CEA) is the most well-studied intervention for pain control in anterior scoliosis repair, but other, more novel regional anesthetic techniques offer safe and effective potential alternatives. More research is indicated to compare the effectiveness of different regional techniques and perioperative medication regimens specific to anterior scoliosis repair.

Opioid sparing effects of the bupivacaine pleural catheter in surgical decompression of the thoracic outlet

OBJECTIVE

Rib resection in thoracic outlet decompression can result in significant postoperative pain requiring high levels of opioid medications. We evaluated the impact of a bupivacaine infusing pleural catheter on postoperative pain and opioid usage in patients undergoing rib resection for thoracic outlet syndrome. We hypothesized that delivery of local anesthetic via the pleural catheter would improve postoperative pain control compared to standard multimodal analgesia, and that the use of the catheter would decrease opioid use during the index hospitalization and prescriptions for opioid pain medications at discharge.

METHODS

We conducted a single-center retrospective cohort study of 26 patients who underwent rib resection for thoracic outlet decompression. Primary outcome was opioid consumption during the index hospitalization, measured in morphine milligram equivalents (MME). Secondary outcomes were MME prescribed at discharge and pain scores during the index hospitalization before and after the pleural drain and pleural catheter were removed.

RESULTS

Patients in the bupivacaine infusion pleural catheter group (n=11) had significantly lower milligram morphine equivalent (MME) usage during the index hospitalization (22.5 [1.9, 65.6] vs. 119.8 [76.5, 167.4]), and significantly lower MME prescribed at discharge (0 [0, 37.5] vs. 225 [183, 315]), compared to standard multimodal analgesia in controls (n=15). Only 3 patients in the bupivacaine pleural catheter group were discharged with any opioid prescriptions (27%), compared to 14 patients in the control group (93%). There was no difference in postoperative pain scores between groups before or after removal of the pleural drain, which was placed in all cases (p=0.31 and p=0.76, respectively).

CONCLUSIONS

Intraoperative placement of a bupivacaine infusion pleural catheter significantly reduced opioid use during the index hospitalization and opioid prescribing at discharge. Anesthetic infusion pleural catheters should be the treatment modality of choice for postoperative pain management in patients undergoing thoracic outlet decompression.

The Association between Low Body Weight and Scoliosis among Korean Elementary School Students

Background: The prevalence of scoliosis in Korean elementary school students is increasing, leading to various physical and psychological problems. This study aimed to investigate the association between low body weight and scoliosis among Korean elementary school students. Methods: This was a cross-sectional analysis. Participants were 1062 elementary school students in the metropolitan areas of Korea. Participants were evaluated for scoliosis based on body composition, including weight and height, and with spine structure analysis equipment. Scoliosis diagnosis was defined as having a Cobb's angle greater than 10°. Results: Participants were divided into Normal Weight (NW), Underweight (UW), and Severely Underweight (SUW) groups. Results show that the UW and SUW groups had significantly higher risks of developing scoliosis (odds ratio (OR): 1.43, 95% CI (confidence interval): 1.07⁻1.90; OR: 1.45, 95% CI: 1.02⁻2.05) compared to the NW group; after controlling for age and gender, the OR were 1.44 (95% CI: 1.08⁻1.92) and 1.46 (95% CI: 1.01⁻2.09), respectively. Conclusions: Low weight and the risk of developing scoliosis are very closely associated. Maintenance of appropriate and normal weight in Korean elementary school students appears to be a very effective method for preventing and reducing the risk of scoliosis.

Is vertebral rotation correction maintained after thoracoscopic anterior scoliosis surgery? A low-dose computed tomography study

Background

Axial vertebral rotation is a key characteristic of adolescent idiopathic scoliosis (AIS), and its reduction is one of the goals of corrective surgery. Recurrence of deformity after surgical correction may relate to rotation changes that occur in the anterior vertebral column after surgery, but whether any change occurs within the fused segment or in adjacent unfused levels following thoracoscopic anterior spinal fusion (TASF) is unknown. An analysis of measurements from an existing postoperative CT dataset was performed to investigate the occurrence of inter- and intra-vertebral rotation changes after TASF within and adjacent to the fused spinal segment and look for any relationships with the Cobb angle and rib hump in the two years after surgery.

Methods

39 Lenke Type 1 main thoracic patients underwent TASF for progressive AIS and low dose computed tomography scanning of the instrumented levels of the spine at 6 and 24 months after surgery. Vertebral rotation was measured at the superior and inferior endplates on true axial images for all vertebral levels in the fused segment plus one adjacent level cranially and caudally. Intra-observer variability for rotation measurements was assessed using 95% limits of agreement to detect significant changes in inter/intra-vertebral rotation.

Results

Significant local changes in inter- and intra-vertebral rotation were found to have occurred between 6 and 24 months after anterior surgical fusion within the fused spinal segment, albeit with no consistent pattern of location or direction within the instrumented fusion construct. No significant en-bloc movement of the entire fused spinal segment relative to the adjacent un-instrumented cranial and caudal intervertebral levels was found. No clear correlation was found between any vertebral rotation changes and Cobb angle or rib hump measures.

Conclusions

Localised inter- and intra-vertebral rotation occurs between 6 and 24 months after TASF, both within the instrumented spinal segments and in the adjacent un-instrumented levels of the adolescent spine. The lack of measurable en-bloc movement of the fused segment relative to the adjacent un-instrumented levels suggests that overall stability of the instrumented construct is achieved, however the vertebrae within the fusion mass continue to adapt and remodel, resulting in ongoing local anatomical and biomechanical changes in the adolescent spine.

Change in Lung Volume Following Thoracoscopic Anterior Spinal Fusion Surgery: A 3-Dimensional Computed Tomography Investigation

STUDY DESIGN

Lung volumes and thoracic anatomy were measured from low-dose computed tomography (CT) scans preoperatively and 2 years following thoracoscopic anterior spinal fusion (TASF) for adolescent idiopathic scoliosis (AIS).

OBJECTIVE

The aim of this study was to assess changes in lung volume after TASF surgical correction.

SUMMARY OF BACKGROUND DATA

AIS patients are known to have decreased pulmonary function as a consequence of their spinal and ribcage deformity. Several studies have evaluated changes in pulmonary function clinically after scoliosis correction surgery showing varied results. To date, there have been no published studies using CT to evaluate lung volume changes following TASF.

METHODS

Twenty-three female AIS patients with both pre- and 2 years postoperative low-dose CT scans were selected from an ethically approved, historical databank. Three-dimensional lung volumes were reconstructed to determine anatomical lung volumes. Right and left lung volumes, total lung volume, and right-to-left lung volume ratio were obtained as well as hemithoracic symmetry, to indicate the extent of thorax deformity. Cobb angle, rib hump, levels fused in surgery, and patient height were used for correlation analysis with the lung volume results.

RESULTS

Left lung volume, total lung volume, and hemithoracic ratio all increased significantly 2 years after surgery. There was no significant change in right-to-left lung volume ratio (P = 0.36). Statistical regression found significant positive correlation between lung volume changes, reduction in Cobb angle, increase in height, and improvement in hemithoracic symmetry ratio.

CONCLUSION

TASF resulted in a statistically significant increase in lung volume following surgery, as well as improvement in the symmetry of the thoracic architecture; however, the postoperative lung volumes remained in the lower 50th percentile relative to females without thoracic deformity. Furthermore, change in lung volume was significantly correlated with changes in Cobb angle, hemithoracic asymmetry, and increased patient height, which are important consequences of thoracic deformity correction surgery.

LEVEL OF EVIDENCE

3.

Postthoracotomy Ipsilateral Shoulder Pain: A Literature Review on Characteristics and Treatment

Context. Postthoracotomy Ipsilateral Shoulder Pain (IPS) is a common and sometimes intractable pain syndrome. IPS is different from chest wall pain in type, origin, and treatments. Various treatments are suggested or applied for it but none of them is regarded as popular accepted effective one. Objectives. To review data and collect all present experiences about postthoracotomy IPS and its management and suggest future research directions. Methods. Search in PubMed database and additional search for specific topics and review them to retrieve relevant articles as data source in a narrative review article. Results. Even in the presence of effective epidural analgesia, ISP is a common cause of severe postthoracotomy pain. The phrenic nerve has an important role in the physiopathology of postthoracotomy ISP. Different treatments have been applied or suggested. Controlling the afferent nociceptive signals conveyed by the phrenic nerve at various levels—from peripheral branches on the diaphragm to its entrance in the cervical spine—could be of therapeutic value. Despite potential concerns about safety, intrapleural or phrenic nerve blocks are tolerated well, at least in a selected group of patient. Conclusion. Further researches could be directed on selective sensory block and motor function preservation of the phrenic nerve. However, the safety and efficacy of temporary loss of phrenic nerve function and intrapleural local anesthetics should be assessed.

Partial Intervertebral Fusion Secures Successful Outcomes After Thoracoscopic Anterior Scoliosis Correction: A Low-Dose Computed Tomography Study

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVES

To analyze intervertebral (IV) fusion after thoracoscopic anterior spinal fusion (TASF) and explore the relationship between fusion scores and key clinical variables.

SUMMARY OF BACKGROUND INFORMATION

TASF provides comparable correction with some advantages over posterior approaches but reported mechanical complications, and their relationship to non-union and graft material is unclear. Similarly, the optimal combination of graft type and implant stiffness for effecting successful radiologic union remains undetermined.

METHODS

A subset of patients from a large single-center series who had TASF for progressive scoliosis underwent low-dose computed tomographic scans 2 years after surgery. The IV fusion mass in the disc space was assessed using the 4-point Sucato scale, where 1 indicates <50% and 4 indicates 100% bony fusion of the disc space. The effects of rod diameter, rod material, graft type, fusion level, and mechanical complications on fusion scores were assessed.

RESULTS

Forty-three patients with right thoracic major curves (mean age 14.9 years) participated in the study. Mean fusion scores for patient subgroups ranged from 1.0 (IV levels with rod fractures) to 2.2 (4.5-mm rod with allograft), with scores tending to decrease with increasing rod size and stiffness. Graft type (autograft vs. allograft) did not affect fusion scores. Fusion scores were highest in the middle levels of the rod construct (mean 2.52), dropping off by 20% to 30% toward the upper and lower extremities of the rod. IV levels where a rod fractured had lower overall mean fusion scores compared to levels without a fracture. Mean total Scoliosis Research Society (SRS) questionnaire scores were 98.9 from a possible total of 120, indicating a good level of patient satisfaction.

CONCLUSIONS

Results suggest that 100% radiologic fusion of the entire disc space is not necessary for successful clinical outcomes following thoracoscopic anterior selective thoracic fusion.

Regional anaesthesia and postoperative analgesia techniques for spine surgery - a review

The use of regional anaesthesia techniques for intra-operative anaesthesia and postoperative analgesia remains very controversial for patients scheduled to undergo spinal interventions. Spine surgeries, especially the most extensive types, are mostly performed under general anaesthesia. This has to be explained by the position required during surgery, the preference of the surgeon and/or anaesthesiologist and lack of sufficient literature supporting locoregional anaesthesia. In addition, there is an increasing trend to prefer general anaesthesia for spinal surgery. Nevertheless, with respect to spine surgeries more than 80% of the actual literature on neuraxial blocks is dated less than 12 years. The present overview was focused in the first place on the feasibility of (loco) regional techniques to be used intra-operatively. These techniques are also of interest for postoperative analgesia, either with a single bolus injection of local anaesthetics, opioids and adjuvants, alone or in combination, in continuous or intermittent administration and requiring the presence of foreign material in the neighborhood of the surgical field. As all techniques described offered variable success rates, future research is mandatory to determine their superiority over general intra-operative anaesthesia and conventional pain therapy with paracetamol, NSAIDs, opioids used alone or in combination.