Management of Postoperative Pain in Patients Following Spine Surgery: A Narrative Review

Effect of epidural gelfoam soaked levobupivacaine with or without pethidine on postoperative analgesia after single-level lumbar laminectomy: Randomized controlled study

BACKGROUND

Postoperative pain following spine surgery remains a challenge for patients, surgeons and healthcare facilities. This study aimed to evaluate the postoperative analgesic efficacy of gelfoam soaked in pethidine combined with levobupivacaine, compared to gelfoam soaked in levobupivacaine alone in single-level lumbar laminectomy patients.

METHODS

This was a prospective, randomized, double blinded study. A total of 90 patients of either sex, aged 18 to 60 years with ASA class I or II planned for single-level lumbar laminectomy were randomly assigned into three equal groups: group A (levobupivacaine plus pethidine): epidural gelfoam soaked with 1 ml levobupivacaine 0.25 % plus 1 ml pethidine 50 mg, group B (levobupivacaine alone): epidural gelfoam soaked with 1 ml levobupivacaine 0.25 % plus 1 ml of 0.9 % sodium chloride; and group C (control group): epidural gelfoam soaked with 2 ml of 0.9 % sodium chloride. Total analgesic consumption, time to first rescue analgesic request, time to ambulate, postoperative VAS scores, vital signs and adverse effects were recorded.

RESULTS

Demographic and baseline patients' data were comparable among the 3 groups. Group B had lower total analgesic consumption, prolonged time to first rescue analgesia, earlier ambulation, and lower VAS scores in the first 24 h in compared to control group C. Significant differences were found between groups A and B in total analgesic consumption, time to first rescue analgesia, and VAS score in the first 24 h. However, no significant differences were found between the two groups regarding time of ambulation and average VAS scores 24 to 48 h after surgery. There were no significant differences in the occurrence of adverse effects among the 3 groups.

CONCLUSIONS

This study demonstrated that the addition of pethidine to epidural levobupivacaine in a gelfoam soaked form enhanced the postoperative analgesia in patients undergoing single-level lumbar laminectomy in terms of reduced total analgesic consumption, prolonged time to first rescue analgesia and lower postoperative pain scores.

Optimization of Postoperative Opioids Use Following Spine Surgery

PURPOSE OF REVIEW

The present investigation evaluated the use of opioids for postoperative pain relief in spinal surgery patients.

RECENT FINDINGS

Pain management is a crucial component of postoperative care that greatly impacts patient outcomes. Postoperative pain management has been shown to allow for earlier mobility, discharge, and return to normal life. Opioids are the standard treatment for postoperative pharmacologic pain relief, but they are associated with the same adverse effects that pain management strives to mitigate. Opioids are associated with a large side effect profile, including a higher risk of various postoperative complications. Opioids are potentially highly addictive and postoperative use is associated with dependence, tolerance, and the current opioid epidemic. Some studies indicate that there are similar surgical outcomes amongst patients independent of whether opioids were prescribed opioids for pain relief.

CONCLUSION

Opioids should only be recommended for postoperative pain management under strict guidance and supervision from physicians. All 50 states have acute pain guidelines in place limiting opioid prescribing. One of the strategies of reducing postoperative opioid consumption is the emphasis on opioid alternatives that should be actively considered and explored prior to resorting to opioids. There are pharmacological and non-pharmacological options available for pain relief that can provide similar levels of analgesia as prescription opioid without unwanted effects such as tolerance and dependency. Proper assessment of patient history and risk factors can aid physicians in tailoring a pain management regimen that is appropriate for each individual patient. More research into efficacy and safety of alternative treatments to opioids is warranted.

Surgeon-Guided Fluoroscopic Erector Spinae Plane Block (ESPB) versus Anesthetist-Guided Ultrasonic ESPB for Perioperative Analgesia in Lumbar Fusion Surgery- a Prospective Randomized Control Study

Study designProspective, randomized control study.ObjectiveTo assess the safety and efficacy of fluoroscopy-guided vs ultrasound-guided Erector Spinae Plane Block (ESPB) for perioperative analgesia in lumbar fusion surgery.Materials and Methods66 patients requiring single-level lumbar fusion were randomized into 2 groups. One group had fluoroscopy-guided ESPB by the surgeon (Fluoro-ESPB group) and the other group had Ultrasound-guided ESPB by the anesthetist (USG-ESPB). Demographic details, intraoperative parameters (perioperative total opioid consumption, muscle relaxants used, heart rate, blood pressure), and postoperative parameters (VAS score, alertness, satisfaction score) were recorded and analyzed.ResultsDuring the initial 48 hours following the surgery, both groups provided good perioperative analgesia, and reported very low and comparable postoperative pain scores (VAS scale). The mean VAS score was 2.7 ± 0.5 in the Fluoro-ESPB group and 2.7 ± 0.5 in the USG-ESPB group (P = 0.91). The average time taken to deliver the block in the Fluoro-ESPB group (3.01 ± 0.97 mins) was significantly less than in the USG-ESPB group (4.74 ± 1.49 mins) (P = 0.00). The total perioperative opioid consumption (TOC), total intraoperative muscle relaxant consumption, and intraoperative blood loss were similar in both groups (Fluoro- ESPB, USG ESPB) (P > 0.05). The postoperative MOASS score was consistently high across both groups. The satisfaction scores were high and comparable (P = 0.403).ConclusionThe fluoroscopy-guided ESPB is a safe and effective alternative to the traditional ultrasound-guided technique. It can be performed by the surgeon, reducing overall procedure time, and improving workflow.

Investigation of the relationship between mobility levels of older patients undergoing spinal surgery and fear of pain and fear of falling, and the affecting factors

To determine the relationship between mobility levels (turning from one side to another in bed, sitting on the edge of the bed, standing at the edge of the bed, and walking inside the patient room) of older patients undergoing spinal surgery and their fear of pain and falling, and the factors affecting them. A descriptive correlational study was conducted with 144 older individuals who underwent spinal surgery. Female gender and post-operative pain were predictors of total and all sub-dimensions of mobility level in older patients who underwent spinal surgery. It was determined that the presence of chronic disease was the predictor of the sub-dimensions of turning from one side to the another in bed and standing at the edge of the bed while using aids and fear of falling were the predictors of the sub-dimensions of standing at the edge of the bed and walking inside the patient room.

Liposomal bupivacaine reduces postoperative pain and opioids consumption in spine surgery: a meta-analysis of 1,269 patients

BACKGROUND CONTEXT

Postoperative pain management in spine surgery remains a challenge. Liposomal bupivacaine (LB) has emerged as an alternative or adjunct to opioid-based analgesia. However, existing studies evaluating LB efficacy in spine surgery yield conflicting results and a meta-analysis compiling the literature is lacking.

PURPOSE

The purpose of this meta-analysis was to evaluate pain outcomes, opioid use, and LOS following LB administration after spine surgery.

STUDY DESIGN

Meta-analysis.

METHODS

Following the PRISMA guidelines, PubMed, Cochrane, and Google Scholar (pages 1-20) were accessed and explored up to May 2024. Data on medical complications, postoperative pain, postoperative opioid consumption, and length of stay were extracted. Mean differences (MD) with 95% CI were used for continuous data, and odds ratios (OR) were calculated for dichotomous data.

RESULTS

This meta-analysis comprised eleven studies consisting of 1,269 patients (677 in the LB group, 592 in the control group). No statistically significant difference was observed in complication rates. The LB group exhibited significantly lower pain scores at postoperative day 2 (MD=-0.31; 95% CI: -0.52 to -0.09, p=.006), lower postoperative opioid consumption (MD=-0.42; 95% CI: -0.79 to -0.06, p=.02), and shorter length of stay (MD=-0.57; 95% CI: -0.94 to -0.20, p=.002).

CONCLUSION

In the immediate postoperative period after spine surgery, the utilization of liposomal bupivacaine was associated with improved pain outcomes, decreased opioid consumption, and shortened length of stay. Although further research is warranted, these findings suggest that LB may offer a valuable adjunct to pain management strategies in patients undergoing spine surgery.

Preexisting opioid daily MME and use duration within a national cohort of lumbar spine surgery patients on quality outcomes

OBJECTIVE

Pain management surrounding lumbar spine surgery is a complex topic. Though some authors suggest that preoperative opioid use is a negative prognostic factor, its association with patient-reported outcomes and satisfaction after surgery remains controversial. We aimed to uncover the effect of preoperative opioid use on long-term outcomes using a national sample.

METHODS

Using deidentified data from the lumbar spine surgery Quality Outcomes Database, we compared functional outcomes and satisfaction in 34,934 patients based on presence of preoperative opioid use. Outcomes included Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and satisfaction indices. Regression subanalysis illustrated the effect of preoperative opioid duration and daily MME.

RESULTS

44.1 % used opioids preoperatively. A greater percentage of patients using opioids underwent surgery with instrumentation (p < .005). They exhibited clinically comparable improvement in VAS, ODI, and satisfaction at 3- (p = .069, p < .005, p < .005, respectively) and 12-months (p < .05). Return to work was lower at 3- (74.32 % vs. 80.82 %, p < .005) and 12-months (48.99 % vs. 62.95 %, p < .005). They maintained low postoperative use although greater than opioid naïve patients at 3- (3.1 % vs. 1.2 %, p < .005) and 12-months (3.6 % vs. 0.8 %, p < .005). Preoperative daily MME had no significant effect on outcomes, although increasing duration negatively impacted VAS and ODI scores.

CONCLUSIONS

Preoperative opioid use by itself should not be used in surgical decision making but rather an individual risk assessment according to chronicity of opioid burden. Longer duration of use appears to impair postoperative improvement but not satisfaction with little influence by daily MME; however, larger, granular analyses remain necessary.

Benefits of early recovery after surgery (ERAS) protocols on perioperative outcomes in patients undergoing elective lumbar spinal fusion: a prospective study

BACKGROUND CONTEXT

Enhanced Recovery After Surgery (ERAS) protocols have been shown to accelerate patient recovery across various surgical fields. There are growing reports of the benefits of ERAS for lumbar fusion, but the majority rely on retrospective analysis.

PURPOSE

This study aimed to prospectively assess the impact of an ERAS protocol on perioperative outcomes in patients undergoing lumbar spinal fusion.

STUDY DESIGN/SETTING

Prospective comparative cohort study conducted at a tertiary medical center in Taipei, Taiwan, between November 2020 and May 2023.

PATIENT SAMPLE

The study included 242 patients undergoing lumbar spinal fusion for degenerative spinal conditions divided into ERAS and non-ERAS groups.

OUTCOME MEASURES

Main outcomes measured included operative duration, estimated blood loss (EBL), postoperative nausea and vomiting (PONV), analgesic use, and visual analog scale (VAS) pain score.

METHODS

Propensity score matching (PSM) was used to minimize confounders between the 2 groups. Differences between the 2 groups were assessed using the 2-sample independent t-test or nonparametric Mann-Whitney U test for continuous variables, and the chi-square test or Fisher's exact test for categorical variables.

RESULTS

The ERAS group had significantly shorter operative time (202±68 min vs. 255±85 min) and EBL (480±302 ml vs. 641±387 ml) compared to the non-ERAS group. The ERAS group had significantly less total morphine-sulfate-equivalent (MSE) consumption (27±24 mg vs. 42±42 mg) and used patient-controlled analgesia (PCA) (97% vs. 41%) more frequently compared to the non-ERAS group. Notably, the ERAS group had a shorter time to ambulation and shorter time to removal of Foley catheters.

CONCLUSIONS

These data suggest that the employed ERAS protocol significantly enhances recovery trajectories and the need for analgesics in patients undergoing lumbar spinal fusion.

Exploring strategies to enhance patient safety in spine surgery: a review

Patient safety is the foundation of spine surgery, where the intricate nature of spinal procedures and the unique risks involved call for exceptional diligence and comprehensive protocols. In this high-stakes field, developing and implementing rigorous safety protocols is not only vital for minimizing complications but also for achieving the best possible outcomes and strengthening the confidence patients have in their care team. Each patient entrusts their well-being to their surgical team. This trust underscores the responsibility healthcare providers have to prioritize safety at every stage. In spine surgery, thorough preoperative planning, clear communication during informed consent, and vigilant postoperative care are all crucial for creating a safe environment tailored to each patient's needs. A commitment to patient safety requires more than individual efforts; it calls for a coordinated, multidisciplinary approach where surgeons, nurses, anesthesiologists, and rehabilitation specialists work closely together. This collaboration ensures that each step of the patient's journey is aligned with best practices for safety and care. This review highlights the critical need for ongoing evaluation and refinement of safety protocols in spine surgery. As surgical techniques and technologies advance, and as patients' needs evolve, healthcare teams must remain responsive, cultivating a culture of safety that is both proactive and adaptable. Continuous investment in quality improvement and research is essential to fine-tune these protocols, ensuring they remain both relevant and effective in addressing the unique challenges of spine surgery. Prioritizing comprehensive safety measures goes beyond improving surgical outcomes; it plays a pivotal role in strengthening the trust and confidence patients have in their healthcare providers. By committing to these robust protocols, we reaffirm our dedication to patient-centered care, enhancing not only patient safety and recovery but also fostering a deeper faith in a healthcare system that places patient well-being at the forefront.

Efficacy of Duloxetine for Postspine Surgery Pain: A Systematic Review and Meta-Analysis

BACKGROUND

Duloxetine, a serotonin and norepinephrine reuptake inhibitor (SNRI), is used to treat various health conditions, including major depressive disorder, generalized anxiety disorder, fibromyalgia, and off-label for chemotherapy-induced pain. We conducted this systematic review and meta-analysis aiming to test the current evidence regarding effectiveness and safety of duloxetine for postspine surgeries pain.

METHODS

We searched the Cochrane Central Register of Controlled Trials, PubMed, Scopus and Web of science databases for relevant articles up to March 2024. The following search terms were Used in combination using the Boolean operators ((Duloxetine Hydrochloride) AND ((Pain, Postoperative) OR (Postoperative Period) OR (Postoperative Cognitive Complications) OR (Delayed Emergence from Anesthesia) OR (Postoperative Care) OR (spine surgery)) without time constrain for the search. Meta-analysis was performed using Review Manager (RevMan version 5.4) on the extracted outcome data that present in at least 3 of the included studies. Mean difference (MD) was used as the effect size for continuous outcomes with a 95% confidence interval (CI) or standardized mean difference (SMD) in case of different outcome reporting scales.

RESULTS

Pooled analysis showed that duloxetine significantly reduces pain intensity after 24 h from the operation compared to placebo (SMD = -1.11, 95% CI [-2.16 to -0.07], p = 0.04) with no significant difference in pain after 2 and 48 h. Meta-analysis revealed that duloxetine shows a significant reduction in the amount of analgesic consumption after 24 h postoperative; (MD = -3.33, 95% CI [-5.53 to -1.13], p = 0.003). The analysis did not show any statistically significant difference between duloxetine and placebo in patients experiencing nausea or vomiting (RR = 1.37, 95% CI [0.62 to 3.00] CONCLUSION: The findings of this study suggest that duloxetine may be effective in reducing pain 24 h after spine surgery. Furthermore, there is a promising effect of duloxetine in treating chronic postoperative pain. However, it is important to acknowledge that further research is warranted to thoroughly evaluate the efficacy and safety of duloxetine for relieving chronic postoperative pain.

Opioid Prescribing Trends Following Lumbar Discectomy

BACKGROUND

Lumbar diskectomy is a common procedure, following which a brief course of narcotics is often prescribed. Nonetheless, increasing attention has been given to such prescribing patterns to limit adverse effects and the potential for abuse. This study investigated prescribing patterns of opioid within 90 days following lumbar diskectomy.

METHODS

Patients undergoing single-level lumbar laminotomy/diskectomy from 2011 to 2021 were identified in the PearlDiver Mariner161 database. Exclusion criteria included the following: additional same-day spine procedures, age less than 18 years, same-day diagnosis of neoplasm, trauma, or infection, prior diagnosis of chronic pain, records active for less than 90 days following surgery, and filled opioid prescription between 7 and 30 days before the surgery. Predictors associated with receiving opioid prescriptions and excess prescribed morphine milligram equivalents (MMEs) were assessed with multivariable regression analyses. Prescribing patterns over the years were then analyzed with simple linear regression and compared for 2011 and 2021.

RESULTS

A total of 271,631 patients met the inclusion criteria. Opioids were prescribed for 195,835 (72.1%) and were independently associated with lower age, female sex, higher Elixhauser Comorbidity Index, and geographic region (P < 0.0001 for each). Greater MMEs were independently prescribed to those who were younger, had higher Elixhauser Comorbidity Index, and lived in specific geographic regions (P < 0.0001 for each). The proportion of patients receiving opioid prescriptions slightly increased over time (69.0% in 2011 to 71.0% in 2021), whereas a decrease was observed in median MMEs prescribed (428.9 in 2011 to 225.0 in 2021, P < 0.0001) and mean number of prescriptions filled (3.3 in 2011 and 2.3 in 2021, P < 0.0001).

CONCLUSION

Following lumbar diskectomy, this study found clinical and nonclinical factors to be associated with prescribing opioids and prescribed MME. The decreased MME prescribed over the years was encouraging and the decreased number of prescriptions filled suggests that patients are not needing to return for more prescriptions than prior.

Reducing costs and improving patient recovery through a nurse-driven centralized spinal orthoses program on a post-surgical unit: A quality improvement initiative

Background

An external vendor providing off-the-shelf spinal orthoses to inpatients created significant costs and barriers to quality care for spinal surgery patients. A nursing leadership team initiated a quality improvement project to reduce the cost of providing off-the-shelf spinal orthoses and improve the care provided to spinal patients.

Objective

To develop and evaluate a nursing-led process for providing off-the-shelf orthoses to spinal surgery patients and eliminate high costs.

Design

Quality improvement project evaluated as a retrospective interrupted time-series.

Setting

Post Surgery Inpatient Unit Level II Trauma Center in a United States hospital located in Florida.

Participants

Vendor Program: 134 patients; Centralized Program: 155 patients.

Methods

The nursing leadership team developed a centralized spinal orthoses program where the bedside nurse fitted the patient with a spinal orthosis, eliminating the need for an external orthotist. The study quantifies changes in study metrics by comparing patients identified through chart review who received care in the vendor program to those who received care in the centralized program utilizing nonparametric statistical techniques.

Results

The centralized nursing-led spinal orthosis program allowed the unit to mobilize patients more quickly than patients managed under the vendor program (3.85 hr. [95 % CI: 1.27 to 7.26 hrs] reduction; p = 0.004). The overall length of stay was reduced by 0.78 days ([1.34 - 0.02 days]; p = 0.063) or 18.72 h. While the statistical test did not indicate significance, the 18.72-hour reduction in length of stay represents a potential clinically relevant finding. Evaluating patients that suffered a primary spinal injury and no complications (vendor program: 54 patients; centralized program: 86 patients) showed a similar reduction in time to mobilization (4.5 hr reduction [0.53 to 12.93 hrs]; p = 0.025), but the length of stay reduction increased to 1.02 days [0.12 to 1.97 days], a difference determined to be statistically significant (p = 0.014). Centralizing the process for providing off-the-shelf spinal orthoses reduced the cost of a thoracic-lumbar sacral orthosis by $1,483 and the price of a lumbar-sacral orthosis by $1,327. Throughout the study, the new program reduced the cost of providing spinal orthoses by $175,319.

Conclusions

The results demonstrate that the nursing-led centralized spinal orthosis program positively impacted the quality of care provided to our patients while also reducing the cost of delivering the orthoses.

Tweetable abstract

A nursing-led centralized spinal orthosis program reduces the cost of care while reducing time to mobilization and length of stay.

Reducing Postoperative Neurological Complications in Uniportal Full-Endoscopic Lumbar Interbody Fusion: Efficacy of the GUARD Technique Combined With Delayed Ligamentum Flavectomy

OBJECTIVE

Uniportal full-endoscopic transforaminal lumbar interbody fusion (FE-TLIF) carries a unique risk of nerve traction and abrasion injury during cage insertion. This study aims to evaluate the clinical efficacy of the GUARD technique and delayed ligamentum flavectomy in reducing postoperative radicular pain and neurapraxia in patients undergoing uniportal FE-TLIF.

METHODS

A retrospective analysis was conducted on 45 patients with an average age of 53.9±12.4 years who underwent either FE facet-sparing TLIF (FE fs-TLIF) or FE facet-resecting TLIF (FE fr-TLIF). Patients were divided into 2 groups: the sentinel group (21 patients) using traditional sentinel pin techniques, and the GUARD group (24 patients) using the GUARD technique with delayed ligamentum flavectomy. Patient-reported outcomes included the visual analogue scale (VAS) for leg and back pain, and Oswestry Disability Index. Complication rates, including incidental durotomy, postoperative neurapraxia, and hematoma, were also documented.

RESULTS

Postoperative radicular pain in the legs was significantly reduced at 6 weeks in the GUARD group compared to the sentinel group (VAS: 2.201 vs. 3.267, p=0.021). The incidence of postoperative neurapraxia was markedly lower in the GUARD group (0% vs. 19%, p=0.047). Both groups showed similar improvements in disc height, segmental lordosis, and lumbar lordosis at the 1-year follow-up, with no significant differences in endplate injury or fusion rates.

CONCLUSION

The GUARD technique and delayed ligamentum flavectomy significantly enhance patient safety by reducing postoperative radicular pain and neurapraxia without incurring additional costs. These techniques are easy to learn and integrate into existing surgical workflows, offering a valuable improvement for surgeons performing FE-TLIF procedures.

Intraoperative Methadone in Spine Surgery ERAS Protocols: A Systematic Review of the Literature

STUDY DESIGN

Systematic review.

OBJECTIVE

To systematically review the use of intraoperative methadone in spine surgery and examine its effects on postoperative opioid use, pain, length of stay, and operative time.

SUMMARY OF BACKGROUND DATA

Spine surgery patients commonly have a history of chronic pain and opioid use, and as a result, they are at an increased risk of severe postoperative pain. While pure mu opioids remain the standard for acute surgical pain management, they are associated with significant short-term and long-term adverse events. Methadone presents an alternative to pure mu opioids which may improve postoperative management of pain following intraoperative use.

METHODS

A systematic review of MEDLINE, Embase, and Web of Science databases was conducted to review existing literature detailing operating time, postoperative pain, opioid usage, and hospital length of stay (LOS) following intraoperative methadone administration in spine surgery.

RESULTS

Following screening of 994 articles and application of inclusion criteria, 8 articles were included, 4 of which were retrospective. Conventional spine surgery intraoperative analgesic strategies used as comparators for intraoperative methadone included hydromorphone, ketamine, and sufentanil. Considering patient outcomes, included studies observed that patients treated with intraoperative methadone had statistically similar or significantly reduced pain scores, opioid usage, and LOS compared with comparator analgesics. However, one study observed that intraoperative methadone used in a multimodal analgesia regimen strategy with ketamine resulted in a shortened LOS compared with the use of intraoperative methadone alone. Differences in operating time between cases that used intraoperative methadone and cases that used comparator analgesics were not statistically significant among included studies.

CONCLUSION

Methadone may present an alternative option for both intraoperative and postoperative analgesia in spine surgery recovery protocols and may reduce postoperative pain, opioid use, and LOS while maintaining consistent operating time and reduced side effects of pure mu opioids.

LEVEL OF EVIDENCE

Level II.

Prevalence of pain phenotypes and co-morbidities of chronic pain in Parkinson's Disease

OBJECTIVE

The prevalence of chronic pain in Parkinson's disease (PD) in neurology practices ranges from 24 % to 83 %. To determine whether this prevalence is accurate across patients with PD, we leveraged data from electronic medical records in 80 inpatient and outpatient general practice settings.

METHODS

We explored the prevalence of chronic pain in patients with PD relative to age and sex-matched controls in a large international database with electronic medical records from over 250 million patients (TriNetX Cambridge, MA, USA). We described demographics, co-morbid conditions and medication differences between patients with PD and without PD who have chronic pain.

RESULTS

Extracted data included 4510 patients with PD and 4,214,982 age-matched control patients without Parkinson's Disease. A chronic pain diagnosis was identified in 19.3 % of males and 22.8 % of females with PD. This differed significantly from age-matched patients without PD who had a significantly lower prevalence of chronic pain 3.78 % and 4.76 %. Significantly more PD patients (both male and females) had received tramadol, oxycodone, and neuropathic agents (p<0.001) than patients without PD. Females with PD more often received anti-depressants than males with PD (p<0.05), corresponding with a significantly higher prevalence of depression.

CONCLUSION

Chronic pain in patients with PD is five times as common as in age-matched controls in general practice settings. Patients with PD have a greater prevalence of comorbid conditions that affect development of chronic pain. Whether the pain or the PD is causative to those conditions remains to be elucidated.

Spinal Anesthesia for Awake Spine Surgery: A Paradigm Shift for Enhanced Recovery after Surgery

Awake surgery has been applied for various surgical procedures with positive outcomes; however, in neurosurgery, the technique has traditionally been reserved for cranial surgery. Awake surgery for the spine (ASFS) is an alternative to general anesthesia (GA). As early studies report promising results, ASFS is progressively gaining more interest from spine surgeons. The history defining the range of adverse events facing patients undergoing GA has been well described. Adverse reactions resulting from GA can include postoperative nausea and vomiting, hemodynamic instability and cardiac complications, acute kidney injury or renal insufficiency, atelectasis, pulmonary emboli, postoperative cognitive dysfunction, or malignant hyperthermia and other direct drug reactions. For this reason, many high-risk populations who have typically been poor candidates under classifications for GA could benefit from the many advantages of ASFS. This narrative review will discuss the significant historical components related to ASFS, pertinent mechanisms of action, protocol overview, and the current trajectory of spine surgery with ASFS.

Neurological Complications following Surgical Treatments of the Lower Molars

Aim

The current review aims to explore postoperative neurological complications in third molar extractive surgery.

Materials and Methods

The PRISMA protocols were followed when conducting this review. We found a total of 2,250 articles that matched our topic using the Boolean keywords, mandibular nerve complications AND oral surgery, from PubMed (1,083), Scopus (435), and Web of Science (732), with the filters of English language articles, time range January 1, 2003, to September 30, 2023, and human studies. After 762 duplicates were eliminated, there remained 1,488 articles. Eleven final articles were deemed of the highest relevance to our topic by eliminating articles in animals, non-English language, reviews, meta-analysis, and off-topic. A potential risk in the third molar extraction was temporary loss of sensibility often caused by mild compression or irritation of the mandibular nerve. This typically resolves within weeks or months, but in severe cases, recovery might take longer. Permanent loss of sensation can occur, indicating significant nerve damage and lasting effects on touch, temperature, or pain perception.

Conclusions

Various treatments exist for nerve damage, including low-level laser therapy, pain management medications, or physical therapy. While these therapies may improve neurosensory impairment, patients often report a decline in their quality of life.

Adding Ketamine to Epidural Morphine Does Not Prolong Postoperative Analgesia After Lumbar Laminectomy or Discectomy

BACKGROUND

Epidural opioids provide effective postoperative analgesia after lumbar spine surgery. Ketamine has been shown to reduce opioid-induced central sensitization and hyperalgesia. We hypothesized that adding ketamine to epidural opioids would prolong the duration of analgesia and enhance analgesic efficacy after lumbar spine surgery.

METHODS

American Society of Anesthesiologists physical status class I to II patients aged between 18 and 70 years with normal renal function undergoing lumbar laminectomy were recruited into this single-center randomized trial. Patients were randomized to receive either single-dose epidural morphine (group A) or epidural morphine and ketamine (group B) for postoperative analgesia. The primary objective was to compare the duration of analgesia as measured by time to the first postoperative analgesic request. Secondary objectives were the comparison of pain scores at rest and movement, systemic hemodynamics, and the incidence of side effects during the first 24 hours after surgery.

RESULTS

Fifty patients were recruited (25 in each group), of which data from 48 were available for analysis. The mean±SD duration of analgesia was 20±6 and 23±3 hours in group A and group B, respectively ( P =0.07). There were 12/24 (50%) patients in group A and 17/24 (71%) patients in group B who did not receive rescue analgesia during the first 24-hour postoperative period ( P =0.07). Pain scores at rest and movement, systemic hemodynamics, and postoperative complications were comparable between the groups.

CONCLUSIONS

The addition of ketamine to epidural morphine did not prolong the duration of analgesia after lumbar laminectomy.

Super-elderly, spinal surgery, evaluating the risks and benefits: a retrospective single-centre cohort study

INTRODUCTION

An increasingly ageing population presents emerging healthcare challenges. Adequate clinical evaluation and understanding of outcome-predicting factors are integral to delivering safe spinal surgery to super-elderly patients.

AIM

To evaluate spine surgery outcomes in patients aged 80 or above.

METHODS

We retrospectively evaluated patients 80 years and above who underwent elective or emergency spinal surgery between 2017 and 2022. The Eurospine Surgery Classification (ESC) was used to classify operations into Large, Medium, and Small. We calculated and compared Clinical Frailty Scores (CFS) pre- and post-operatively.

RESULTS

Two hundred forty-five patients met the inclusion criteria. Most were male (n = 145). The age range was 80 to 99 (mean 83.3). Most operations were elective (n = 151, 62%). In our cohort, 211, 22, 10,2 and 1 patients had degenerative, trauma, tumour, infective and vascular pathologies, respectively. According to the Eurospine classification, 201 (82.0%) had Minor spine surgery (63 emergently and 138 electively), 38 had Medium surgery (15.5% - 30 emergently and 8 electively), and 6 had Large surgery (2.4% - 1 emergently and 5 electively). 163 (66.5%) were discharged or under follow-up. There were 11 in-patient mortalities (4.5%). Outpatient mortality was 51 (20.8%), with the median time from surgery to death being 504.5 days, all the outpatient mortalities were neither non-spinal pathology nor spinal surgical related. CFS improved across the cohort, from 5 pre-operatively to 4 post-operatively (p < 0.001).

CONCLUSION

Spine surgery in those over the 80s can be performed safely and improve their quality of life, as demonstrated by improvements in the CFS. Good patient selection and adequate pre-operative workup is essential, although it may not be possible in emergencies.

Erector Spinae Plane Block Placement Utilizing Fluoroscopic Guidance Improves Efficiency in Lumbar Surgery

OBJECTIVE

The erector spinae plane block (ESPB) is a novel regional analgesic technique which improves postoperative outcomes in lumbar surgery patients including length of hospitalization, days to ambulation, and postoperative opioid use. Traditionally, the block is administered by anesthesiologists trained in the ultrasound guidance technique. The use of fluoroscopic guidance may improve the efficiency and accessibility of the ESPB for spine surgeons. We aim to measure the time to administer an ESPB using fluoroscopic guidance and localize the anesthetic using intraoperative three-dimensional (3D) imaging.

METHODS

Two neurosurgeons administered an ESPB to patients undergoing lumbar surgery. Time from insertion of the spinal needle to localize the erector spinae plane using C-arm guidance to time of complete injection and removal of the needle from the skin was recorded. One patient underwent O-arm imaging following injection of an Isovue-Exparel solution at the L3 level to visualize spread of the anesthetic.

RESULTS

A total of 21 patients were enrolled in this study. The average duration to perform an ESPB under fluoroscopic guidance was 1.2 minutes. The Isovue-Exparel solution was injected at the L3 level and was well distributed along the ESP on intraoperative O-arm imaging. The anesthetic dissected the erector spinae muscle from the transverse process at L2, L3, and L4.

CONCLUSIONS

Fluoroscopic guidance allows efficient and appropriate delivery of the anesthetic to the erector spinae plane. Performing an ESPB with fluoroscopic guidance improves efficiency and accessibility of the analgesic technique for spine surgeons, reducing dependence on anesthesiology personnel trained in administering the block.

Immune Responses of Healthy Pregnant Women following an Elective Cesarean Section: Effects of Anesthetic Procedures

A weakened immune system and more inflammatory cytokines being released are possible effects of the surgical stress that a cesarean section induces. This kind of reaction, in addition to the altered reaction to catecholamines, has the potential to significantly affect the immune system of the mother and the patients' general postoperative course. This prospective study compared the plasma levels of catecholamines and cytokines in healthy pregnant patients having cesarean sections under spinal anesthesia versus general anesthesia. A total of 30 pregnant women undergoing elective cesarean sections were divided into two groups: 15 who received general anesthesia (GA) and 15 who received spinal anesthesia (SA). Blood samples were collected from all subjects before anesthesia induction (pre-OP), 6 h postoperatively (6 h post-OP), and 12 h (12 h post-OP), to measure levels of tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), IL-8, IL-4, IL-10, norepinephrine (NE), and epinephrine (EPI). When we compared the two groups, we discovered that only IL-6 and IL-4 had significantly higher levels pre-OP, whereas all studied cytokines exhibited an increase in the GA versus SA group at 6 and 12 h post-OP. In the case of catecholamines, we discovered that serum levels are positively related with pro-inflammatory or anti-inflammatory cytokines, depending on the time of day and type of anesthetic drugs. Compared to SA, GA has a more consistent effect on the inflammatory response and catecholamine levels. The findings of this study confirm that the type of anesthesia can alter postoperative immunomodulation to various degrees via changes in cytokine and catecholamine production. SA could be a preferable choice for cesarean section because it is an anesthetic method that reduces perioperative stress and allows for less opioid administration, impacting cytokine production with proper immunomodulation.

Evolution of Cervical Endoscopic Spine Surgery: Current Progress and Future Directions-A Narrative Review

Cervical endoscopic spine surgery is rapidly evolving and gaining popularity for the treatment of cervical radiculopathy and myelopathy. This approach significantly reduces muscular damage and blood loss by minimizing soft tissue stripping, leading to less postoperative pain and a faster postoperative recovery. As scientific evidence accumulates, the efficacy and safety of cervical endoscopic spine surgery are continually affirmed. Both anterior and posterior endoscopic approaches have surfaced as viable alternative treatments for various cervical spine pathologies. Newer techniques, such as endoscopic-assisted fusion, the anterior transcorporeal approach, and unilateral laminotomy for bilateral decompression, have been developed to enhance clinical outcomes and broaden surgical indications. Despite its advantages, this approach faces challenges, including a steep learning curve, increased radiation exposure for both surgeons and patients, and a relative limitation in addressing multi-level pathologies. However, the future of cervical endoscopic spine surgery is promising, with potential enhancements in clinical outcomes and safety on the horizon. This progress is fueled by integrating advanced imaging and navigation technologies, applying regional anesthesia for improved and facilitated postoperative recovery, and incorporating cutting-edge technologies, such as augmented reality. With these advancements, cervical endoscopic spine surgery is poised to broaden its scope in treating cervical spine pathologies while maintaining the benefits of minimized tissue damage and rapid recovery.

Thoracolumbar Interfascial Plane (TLIP) block verses other paraspinal fascial plane blocks and local infiltration for enhanced pain control after spine surgery: a systematic review

Spinal surgeries are accompanied by excessive pain due to extensive dissection and muscle retraction during the procedure. Thoracolumbar interfascial plane (TLIP) blocks for spinal surgeries are a recent addition to regional anesthesia to improve postoperative pain management. When performing a classical TLIP (cTLIP) block, anesthetics are injected between the muscle (m.) multifidus and m. longissimus. During a modified TLIP (mTLIP) block, anesthetics are injected between the m. longissimus and m. iliocostalis instead. Our systematic review provides a comprehensive evaluation of the effectiveness of TLIP blocks in improving postoperative outcomes in spinal surgery through an analysis of randomized controlled trials (RCTs).We conducted a systematic review based on the PRISMA guidelines using PubMed and Scopus databases. Inclusion criteria required studies to be RCTs in English that used TLIP blocks during spinal surgery and report both outcome measures. Outcome data includes postoperative opioid consumption and pain.A total of 17 RCTs were included. The use of a TLIP block significantly decreases postoperative opioid use and pain compared to using general anesthesia (GA) plus 0.9% saline with no increase in complications. There were mixed outcomes when compared against wound infiltration with local anesthesia. When compared with erector spinae plane blocks (ESPB), TLIP blocks often decreased analgesic use, however, this did not always translate to decreased pain. The cTLIP and mTLP block methods had comparable postoperative outcomes but the mTLIP block had a significantly higher percentage of one-time block success.The accumulation of the current literature demonstrates that TLIP blocks are superior to non-block procedures in terms of analgesia requirements and reported pain throughout the hospitalization in patients who underwent spinal surgery. The various levels of success seen with wound infiltration and ESPB could be due to the nature of the different spinal procedures. For example, studies that saw superiority with TLIP blocks included fusion surgeries which is a more invasive procedure resulting in increased postoperative pain compared to discectomies.The results of our systematic review include moderate-quality evidence that show TLIP blocks provide effective pain control after spinal surgery. Although, the application of mTLIP blocks is more successful, more studies are needed to confirm that superiority of mTLIP over cTLIP blocks. Additionally, further high-quality research is needed to verify the potential benefit of TLIP blocks as a common practice for spinal surgeries.

Prognostic Value in Preoperative Veterans RAND-12 Mental Component Score on Clinical Outcomes for Patients Undergoing Minimally Invasive Lateral Lumbar Interbody Fusion

OBJECTIVE

To evaluate the effect of Veterans RAND 12-item health survey mental composite score (VR-12 MCS) on postoperative patient-reported outcome measures (PROMs) after undergoing lateral lumbar interbody fusion.

METHODS

Retrospective data from a single-surgeon database created 2 cohorts: patients with VR-12 MCS ≥ 50 or VR-12 MCS < 50. Preoperative, 6-week, and final follow-up (FF)- PROMs including VR-12 MCS/physical composite score (PCS), 12-item Short Form health survey (SF-12) MCS/PCS, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), Patient Health Questionnaire-9 (PHQ-9), visual analogue scale (VAS)-back/leg pain (VAS-BP/LP), and Oswestry Disability Index (ODI) were collected. ∆6-week and ∆FF-PROMs were calculated. Minimal clinically important difference (MCID) achievement rates were determined from established cutoffs from the literature. For intercohort comparison, chi-square analysis was used for categorical variables, and Student t-test for continuous variables.

RESULTS

Seventy-nine patients were included; 25 were in VR-12 MCS < 50. Mean postoperative follow-up time was 17.12 ± 8.43 months. The VR-12 MCS < 50 cohort had worse VR-12 PCS, SF-12 MCS, PROMIS-PF, PHQ-9, VAS-BP, and ODI scores preoperatively (p ≤ 0.014, all), worse VR-12 MCS/PCS, SF-12 MCS, PROMIS-PF, PHQ-9, and ODI scores at 6-week postoperatively (p ≤ 0.039, all), and worse VR-12 MCS, SF-12 MCS, PROMIS-PF, PHQ-9, VAS-BP, VAS-LP, and ODI scores at FF (p ≤ 0.046, all). The VR-12 MCS < 50 cohort showed greater improvement in VR-12 MCS and SF-12 MCS scores at 6 weeks and FF (p ≤ 0.005, all). The VR-12 MCS < 50 cohort experienced greater MCID achievement for VR-12 MCS, SF-12 MCS, and PHQ-9 (p ≤ 0.006, all).

CONCLUSION

VR-12 MCS < 50 yielded worse mental health, physical function, pain and disability postoperatively, yet reported greater improvements in magnitude and MCID achievement for mental health.

Postoperative analgesic options after spine surgery: finding the optimal treatment strategies

INTRODUCTION

Spine surgery is one of the most common types of surgeries performed in the United States; however, managing postoperative pain following spine surgery has proven to be challenging. Patients with spine pathologies have higher incidences of chronic pain and resultant opioid use and potential for tolerance. Implementing a multimodal plan for postoperative analgesia after spine surgery can lead to enhanced recovery and outcomes.

AREAS COVERED

This review presents several options for analgesia following spine surgery with an emphasis on multimodal techniques to best aid this specific patient population. In addition to traditional therapeutics, such as acetaminophen, non-steroidal anti-inflammatory medications, and opioids, we discuss intrathecal morphine administration and emerging regional anesthesia techniques.

EXPERT OPINION

Several adjuncts to improve analgesia following spine surgery are efficacious in the postoperative period. Intrathecal morphine provides sustained analgesia and can be instilled intraoperatively by the surgical team under direct visualization. Local anesthetics deposited under ultrasound guidance by an anesthesiologist trained in regional techniques also provide the opportunity for single injections or continuous analgesia via an indwelling catheter.

A study on the 10-year trend of surgeries performed for lumbar disc herniation and comparative analysis of prescribed opioid analgesics and hospitalization duration: 2010-2019 HIRA NPS Data

BACKGROUND

This study, utilizing the claims data from the Health Insurance Review and Assessment Service of Korea, aimed to examine the 10-year (2010-2019) trends in various types of lumbar spine surgeries performed on patients diagnosed with lumbar herniated intervertebral disc (HIVD), and the current status of opioid prescriptions, as well as the duration of postoperative hospital stays based on the type of surgery performed.

METHOD

This retrospective cross-sectional study examined patients with one or more national health insurance claims carrying a primary or secondary diagnosis of HIVD (ICD-10 codes: M511, M518, M519) over a 10-year period (2010-2019). From the patients undergoing lumbar spine surgery, we selected those who did not require reoperation within 30 days following the initial lumbar surgery. Our final study sample comprised patients who underwent only one type of surgery.

RESULTS

Among the patients diagnosed with HIVD and subsequently undergoing lumbar surgery between 2010 and 2019, a slight downward trend was observed in those undergoing open discectomy (OD); however, OD persistently accounted for the highest proportion over the 10 years. Percutaneous endoscopic lumbar discectomy (PELD) demonstrated a consistent upward trend from 2016 to 2018. When inspecting trends, we noted a consistent escalation over the decade in the postoperative opioid prescription rates of strong opioids (50.7% in 2010 to 77.8% in 2019) and tramadol (50.9% in 2010 to 76.8% in 2019). Analyzing these trends by surgery type, spinal fusion exhibited a slightly higher rate of opioid prescriptions than other lumbar surgeries. Regarding the length of postoperative hospital stays, patients undergoing PELD recorded the shortest stay (7.04 ± 6.78 days), while spinal fusion necessitated the longest (20.14 ± 12.18 days).

CONCLUSION

This study analyzed the trends in types of lumbar spine surgeries, opioid analgesic prescriptions, and length of hospital stays over 10 years (2010-2019) among patients with HIVD in Korea. Our data and findings provide valuable evidence that may prove beneficial for clinicians and researchers involved in HIVD-related practices.

Pre-emptive infiltration with betamethasone and ropivacaine for postoperative pain in laminoplasty and laminectomy (PRE-EASE): a prospective randomized controlled trial

BACKGROUND

Postoperative pain after laminoplasty and laminectomy occurs partially from local trauma of the paraspinal tissue. Finding a multimodal analgesic cocktail to enhance the duration and effect of local infiltration analgesia is crucial. Because of the rapid onset and long duration of action of betamethasone, the authors hypothesized that, a pre-emptive multimodal infiltration regimen of betamethasone and ropivacaine reduces pain scores and opioid demand, and improves patient satisfaction following laminoplasty and laminectomy.

MATERIALS AND METHODS

This prospective, randomized, open-label, blinded endpoint study was conducted between 1 September 2021 and 3 June 2022, and included patients between the ages of 18 and 64 scheduled for elective laminoplasty or laminectomy under general anesthesia, with American Society of Anesthesiologists classification I/II. One hundred sixteen patients were randomly assigned to either the BR (Betamethasone-Ropivacaine) group or the R (Ropivacaine) group in a 1:1 ratio. Each group received pre-emptive infiltration of a total of 10 ml study solution into each level. Every 30 ml of study solution composed of 0.5 ml of betamethasone plus 14.5 ml of saline and 15 ml of 1% ropivacaine for the BR group, and 15 ml of 1% ropivacaine added to 15 ml of saline for the R group. Infiltration of epidural space and intrathecal space were avoided and the spinous process, transverse process, facet joints, and lamina were injected, along with paravertebral muscles and subcutaneous tissue. Cumulative 48 h postoperative butorphanol consumption via PCA (Patient-controlled analgesia) was the primary outcome. Intention-to-treat (ITT) principle was used for primary analysis.

RESULTS

Baseline characteristics were identical in both groups ( P >0.05). The cumulative 48 h postoperative butorphanol consumption via PCA was 3.0±1.4 mg in the BR group ( n =58), and 7.1±1.2 mg in the R group ( n =58) ( P <0.001). Overall cumulative opioid demand was lower at different time intervals in the BR group ( P <0.001), along with the estimated median time of first analgesia demand via PCA (3.3 h in the BR group and 1.6 h in the R group). The visual analog scale (VAS) score at movement and rest were also significantly lower until 3 months and 6 weeks, respectively. No side effects or adverse events associated with the intervention were observed in this study.

CONCLUSIONS

Pre-emptive analgesia with betamethasone and ropivacaine provides better postoperative pain management following laminoplasty and laminectomy, compared to ropivacaine alone. This is an effective technique worthy of further evaluation.

Postoperative use and early discontinuation of intravenous lidocaine in spine patients

PURPOSE

Our institution employs a multimodal approach to manage postoperative pain after spine surgery. It involves continuous intravenous (IV) lidocaine until the morning of postoperative day two. This study aimed to determine the rate and reasons for early discontinuation of IV lidocaine in our spine patients.

METHODS

We conducted a retrospective chart review and included pediatric patients who underwent ≥ 3-level spine surgery and received postoperative IV lidocaine from November 2019 to September 2022. For each case, we recorded the side effects of IV lidocaine, adverse events, time to discontinuation, and discontinuation rate. Subsequently, we used the same methodology to generate an adult cohort for comparison.

RESULTS

We included 52 pediatric (18M:34F) and 50 (21M:29F) adult patients. The pediatric cohort's mean age was 14 years (8-18), and BMI 23.9 kg/m2 (13.0-42.8). The adult cohort's mean age was 61 years (29-82), and BMI 28.8 kg/m2 (17.2-44.1). IV lidocaine was discontinued prematurely in 21/52 (40.4%) of the pediatric cases and 26/50 (52.0%) of the adult cases (RR = 0.78, p = 0.2428). The side effects noted in the pediatric cases vary, including numbness, visual disturbance, and obtundation, but no seizures. The most common adverse events were fever and motor dysfunction.

CONCLUSION

The early discontinuation rate of IV lidocaine use after spine surgery for children in our institution does not differ significantly from that of adults. The nature of the side effects and the reasons for discontinuation between the groups were similar. Thus, the safety profile of IV lidocaine for pediatric spine patients is comparable to adults.

Ropivacaine-Epinephrine-Clonidine-Ketorolac Cocktail as a Local Anesthetic for Lumbar Decompression Surgery: A Single Institutional Experience

OBJECTIVE

The goal of this study is to discuss our initial experience with a multimodal opioid-sparing cocktail containing ropivacaine, epinephrine, clonidine, and ketorolac (RECK) in the postoperative management of lumbar decompression surgeries.

METHODS

Patients were either administered no local anesthetic at the incision site or were administered a weight-based amount of RECK into the paraspinal musculature and subdermal space surrounding the operative site once the fascia was closed. We performed a retrospective chart review of all patients 18 years of age or older undergoing lumbar laminectomy and lumbar diskectomy surgeries between December 2019 and April 2021. Outcomes including total opioid use, measured as morphine milligram equivalent, length of stay, and postoperative visual analog scores for pain, were collected. Relationships between variables were analyzed with Student's t-test, chi-square tests, and Fisher exact tests.

RESULTS

A total of 121 patients undergoing 52 lumbar laminectomy and 69 lumbar diskectomy surgeries were identified. For lumbar laminectomy, patients who were administered RECK had decreased opioid use in the postoperative period (11.47 ± 12.32 vs. 78.51 ± 106.10 morphine milligram equivalents, P = 0.019). For patients undergoing lumbar diskectomies, RECK administration led to a shorter length of stay (0.17 ± 0.51 vs. 0.79 ± 1.45 days, P = 0.019) and a lower 2-hour postoperative pain score (3.69 ± 2.56 vs. 5.41 ± 2.28, P = 0.006).

CONCLUSIONS

The RECK cocktail has potential to be an effective therapeutic option for the postoperative management of lumbar decompression surgeries.

Effect of Erector Spinae Plane Block in Terms of Analgesic Efficacy in Elderly Patients Undergoing Posterior Lumbar Spine Surgery: A Retrospective, Propensity-Score Matched Study

INTRODUCTION

For preoperative analgesia during a variety of operations, the erector spinae plane block (ESPB) has grown in popularity. However, its effectiveness in lumbar surgery is still unknown. The purpose of this study was to investigate the potential benefits of ESPB in enhancing analgesic efficacy in elderly individuals following posterior lumbar spine surgery.

METHODS

Patients aged 65 years or older who underwent elective posterior lumbar instrumented fusion (with or without decompression) at our institution between January 2019 and June 2022 were included. Demographic data, comorbidities, and results of preoperative screening were retrospectively collected. Propensity score matching (PSM) was performed in a ratio of 1:1 for control and ESPB groups. The primary outcome was opioid consumption at 24 h after surgery. Secondary outcomes was visual analog scale (VAS) pain scores at rest in the first 24 h. Additional secondary outcomes included number of patients requesting rescue analgesia, incidence of nausea and vomiting, time to the first request for analgesia via patient-controlled analgesia, and length of stay.

RESULTS

A total of 382 patients were included, of whom 119 received ESPB. The mean age of the study patients was 70.6 years old, and 254 (66.5%) were male. After PSM, each group comprised 115 patients. Patients in the ESPB group showed a significantly lower opioid consumption at 24 h after surgery. Compared with the control group, VAS pain scores at rest in the first 24 h, number of patient-controlled intravenous analgesia (PCIA) pump compressions, ratio of patients requesting rescue analgesia, incidence of nausea and vomiting, and length of stay were significantly reduced in the ESPB group. There were no significant differences between the two groups regarding safety outcomes.

CONCLUSIONS

ESPB reduces short-term opioid consumption while providing safe and effective analgesia in elderly patients undergoing posterior lumbar surgery.

Mini-dose esketamine-dexmedetomidine combination to supplement analgesia for patients after scoliosis correction surgery: a double-blind randomised trial

BACKGROUND

Patients often experience severe pain after scoliosis correction surgery. Esketamine and dexmedetomidine each improves analgesia but can produce side-effects. We therefore tested the hypothesis that a mini-dose esketamine-dexmedetomidine combination safely improves analgesia.

METHODS

Two hundred male and female adults having scoliosis correction surgery were randomised to patient-controlled sufentanil analgesia (4 μg kg^-1 in normal saline) with either a combined supplement (esketamine 0.25 mg ml^-1 and dexmedetomidine 1 μg ml^-1) or placebo. The primary outcome was the incidence of moderate-to-severe pain within 72 h, defined as a numeric rating scale (NRS: 0=no pain and 10=worst pain) score ≥4 at any of seven time points. Amongst secondary outcomes, subjective sleep quality was assessed with an NRS score (0=best sleep and 10=worst sleep) for the first five postoperative nights.

RESULTS

There were 199 subjects included in the intention-to-treat analysis. Mean infusion rates were 5.5 μg kg^-1 h^-1 for esketamine and 0.02 μg kg^-1 h^-1 for dexmedetomidine. The primary outcome incidence was lower with the combined supplement (65.7% [65/99]) than with placebo (86.0% [86/100]; relative risk 0.76; 95% confidence interval: 0.65-0.90; P=0.001). Subjects given the combined supplement had lower pain intensity at rest at five time points (median difference -1 point; P≤0.005), lower pain intensity with movement at six time points (median difference -1 point; P≤0.001), and better subjective sleep quality for the first 5 postoperative nights (median difference -2 to -1 points; P<0.001). Adverse events did not differ between groups.

CONCLUSIONS

The mini-dose esketamine-dexmedetomidine combination safely improved analgesia and subjective sleep quality after scoliosis correction surgery.

CLINICAL TRIAL REGISTRATION

NCT04791059.

A Turkish Study to Identify the Discharge Learning Needs of Spinal Surgery Patients

ABSTRACT

PURPOSE: The aim of this study was to identify the learning needs of spinal surgery patients before hospital discharge. METHODS: This cross-sectional study consisted of 117 spinal surgery patients admitted to the neurosurgery department between October 2019 and March 2020. Data were collected using a descriptive information form, visual analog scale, and the Patient Learning Needs Scale. Data were analyzed using descriptive statistics, Mann-Whitney U and Kruskal-Wallis tests, and Spearman correlation analysis. RESULTS: The mean age of the participants was 54 years, 54.7% were male, and 59% underwent surgery because of spinal disc herniation. The mean Patient Learning Needs Scale score was 188.74. The primary learning needs of the patients were related to the dimensions of activities of living, medication, treatment, and complications, whereas the feelings related to condition were the least-demanded dimension of learning needs. Sex and occupation were the primary factors influencing learning needs. CONCLUSION: The level of learning needs in spinal surgery patients was relatively high. Therefore, discharge education may be planned in line with the learning needs and priorities of these patients, and sex and occupation may be considered while planning discharge education.

Team Approach: Use of Opioids in Orthopaedic Practice

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The opioid epidemic represents a serious health burden on patients across the United States.

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This epidemic is particularly pertinent to the field of orthopaedics because it is one of the fields providing the highest volume of opioid prescriptions.

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The use of opioids before orthopaedic surgery has been associated with decreased patient-reported outcomes, increased surgery-related complications, and chronic opioid use.

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Several patient-level factors, such as preoperative opioid consumption and musculoskeletal and mental health conditions, contribute to the prolonged use of opioids after surgery, and various screening tools for identifying high-risk drug use patterns are available.

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The identification of these high-risk patients should be followed by strategies aimed at mitigating opioid misuse, including patient education, opioid use optimization, and a collaborative approach between health care providers.

In-Fracture Pedicular Screw Placement During Ligamentotaxis Following Traumatic Spine Injuries, a Randomized Clinical Trial on Outcomes

Objective

To investigate the efficacy and safety of two different techniques for spinal ligamentotaxis. Spine ligamentotaxis reduces the number of retropulsed bone fragments in the fractured vertebrae. Two different ligamentotaxis techniques require clinical evaluation.

Methods

This was a randomized clinical trial. The case group was defined as one pedicular screw insertion into a fractured vertebra, and the control group as a no-pedicular screw in the index vertebra. Spine biomechanical values were defined as primary outcomes and complications as secondary outcomes.

Results

A total of 105 patients were enrolled; 23 were excluded for multiple reasons, and the remaining were randomly allocated into the case (n=40) and control (n=42) groups. The patients were followed up and analyzed (n=56). The postoperative mid-sagittal diameter of the vertebral canal (MSD), kyphotic deformity correction, and restoration of the anterior height of the fractured vertebrae showed equal results in both groups. Postoperative retropulsion percentage and pain were significantly lower in the case group than in the control group (p=0.003 and p=0.004, respectively). There were no group preferences for early or long-term postoperative complications.

Conclusions

Regarding clinical and imaging properties, inserting one extra pedicular screw in a fractured vertebra during ligamentotaxis results in better retropulsion reduction and lower postoperative pain.