Percutaneous balloon kyphoplasty with the patient under intravenous analgesia and sedation: a feasibility study

Intraoperative pain prediction of percutaneous kyphoplasty under local anesthesia by preoperative experimental pain assessment

BACKGROUND

Percutaneous kyphoplasty (PKP) is the preferred treatment for osteoporotic vertebral compression fractures (OVCF) Currently, the preoperative anesthesia methods for PKP are mainly local anesthesia and tracheal intubation general anesthesia.

OBJECTIVE

To assess whether patient sensitivity to pain measured preoperatively could predict the patients' pain response during PKP treatment under local anesthesia, to facilitate the development of an optimal preoperative anesthesia plan for patients.

METHODS

Fifty-five female patients diagnosed with osteoporotic single vertebral fracture who were treated with PKP under local anesthesia were selected. The patients' pain sensitivities, including pain threshold and pain tolerance threshold, were evaluated with a pain test device on the day before the operation in the ward. Heart rate (HR), mean arterial pressure (MAP), and blood oxygen saturation (SpO2) were recorded before anesthesia, post-anesthesia, after needle puncture, and after balloon dilatation. At the same time, blood was drawn at the above time points to determine the level of norepinephrine (NA) as an indicator of intraoperative pain stress response. The numerical rating scale (NRS) during surgery was recorded at the end of the surgery.

RESULTS

The preoperative pain tolerance threshold of 55 surgical patients was correlated with the intraoperative NRS score (r=-0.768, P< 0.001), as well as with the preoperative and intraoperative changes in HR (r=-0.791, P< 0.001), MAP (r=-0.819, P< 0.001), and NA (r=-0.553, P< 0.001). Thus, the lower the preoperative pain tolerance threshold, the more severe the patient's response to pain during PKP treatment under local anesthesia, and the greater the hemodynamic changes. Consequently, the intraoperative experience becomes worse. However, there was no correlation between preoperative pain threshold and NRS scores (r=-0.069, P= 0.616) nor between the preoperative and intraoperative changes in HR (r= 0.103, P= 0.453), MAP (r= 0.086, P= 0.535), and NA (r=-0.058, P= 0.674).

CONCLUSION

The results indicated that preoperative pain assessment could predict the level of pain response in OVCF patients during PKP surgery under local anesthesia.

Effectiveness and safety of ultrasound-guided thoracic paravertebral block versus local anesthesia for percutaneous kyphoplasty in patients with osteoporotic compression fracture

BACKGROUND

Kyphoplasty for osteoporotic vertebral compression fractures (OVCF) is a short but painful intervention. Different anesthetic techniques have been proposed to control pain during kyphoplasty; however, all have limitations.

OBJECTIVE

To compare the effectiveness and safety of ultrasound-guided thoracic paravertebral block with local anesthesia for percutaneous kyphoplasty (PKP).

METHODS

In this prospective study, non-randomized patients with OVCF undergoing PKP received either ultrasound-guided thoracic paravertebral block (group P) or local anesthesia (group L). Perioperative pain, satisfaction with anesthesia, and complications were compared between the groups.

RESULTS

Mean intraoperative (T1-T4) perioperative visual analog scale (VAS) scores were significantly lower in group P than in group L (2 [1-3] vs. 3 [2-4], 2 [2-3] vs. 4 [2-4], 2 [2-3] vs. 5 [3-5], and 3 [2-3] vs. 5 [3-5], respectively; P< 0.05). Investigators' satisfaction scores, patients' anesthesia satisfaction scores, and anesthesia re-administration intention rate were significantly higher in group P than in group L (4 [3-5] vs. 3 [2-4], 2 [2-3] vs. 2 [1-3], 90.63% vs. 69.70%; P< 0.05). There was no significant intergroup difference in complications.

CONCLUSIONS

Ultrasound-guided thoracic paravertebral block has similar safety to and better effectiveness than local anesthesia in PKP.

[Vertebroplasty and kyphoplasty : A critical statement]

BACKGROUND

Despite optimal drug-conservative therapy, a relevant percentage of patients with vertebral compression fractures (WKF) do not experience any relevant improvement in their pain symptoms. Vertebroplasty (VP) and kyphoplasty (KP) are described in the literature as percutaneous interventional procedures for the treatment of WKF.

OBJECTIVE

Assessment of the effectiveness of the VP and KP in the treatment of WKF and discussion of the procedures in the context of the current literature.

MATERIAL AND METHODS

Presentation of the fundamentals of VP and KP and their further developments. Description of indications and contraindications. Discussion of the current literature and recommendations of the individual professional associations.

RESULTS

In patients with vertebral compression fractures, VP or KP of the affected vertebral body leads to a pain reduction in more than 90% of cases. Clinically relevant complications occur in less than 1% of interventions.

CONCLUSION

VP and KP are a safe and effective method for treating painful WKF. Optimal patient selection improves the clinical outcome.

Do the dynamic stress mobility radiographs predict the postoperative vertebral height restoration, kyphosis correction, and cement volume injected after vertebroplasty for osteoporotic thoracolumbar vertebral fractures with intravertebral cleft?

BACKGROUND

This prospective clinical-radiological study was conducted to determine whether the dynamic mobility stress radiographs can predict the postoperative vertebral height restoration, kyphosis correction, and cement volume injected after vertebroplasty.

METHODS

Patients included had the diagnosis of significant back pain caused by osteoporotic vertebral compression fracture secondary to trivial injury. All the patients underwent routine preoperative sitting lateral spine radiograph, supine stress lateral spine radiograph, and supine anteroposterior spine radiograph. The radiological parameters recorded were anterior vertebral height (AVH), middle vertebral height (MVH), posterior vertebral height (PVH), MVH level below, wedge endplate angle (WEPA), and regional kyphotic angle (RKA). The supine stress versus sitting difference (SSD) for all the above parameters were calculated.

RESULTS

A total of 28 patients (4 males; 24 females) with the mean age of 75.6 ± 7.7 years were recruited into this study. The mean cement volume injected was 5.5 ± 1.8 ml. There was no difference between supine stress and postoperative radiographs for AVH ( p = 0.507), PVH ( p = 0.913) and WEPA ( p = 0.379). The MVH ( p = 0.026) and RKA ( p = 0.005) were significantly less in the supine stress radiographs compared to postoperative radiographs. There was significant correlation ( p < 0.05) between supine stress and postoperative AVH, MVH, PVH, WEPA, and RKA. The SSD for AVH, PVH, WEPA, and RKA did not have significant correlation with the cement volume ( p > 0.05). Only the SSD-MVH had significant correlation with cement volume, but the correlation was weak ( r = 0.39, p = 0.04).

CONCLUSIONS

Dynamic mobility stress radiographs can predict the postoperative vertebral height restoration and kyphosis correction after vertebroplasty for thoracolumbar osteoporotic fracture with intravertebral clefts. However, it did not reliably predict the amount of cement volume injected as it was affected by other factors.

Epidural analgesia for percutaneous kyphoplasty in a patient with multiple medical comorbidities

Kyphoplasty is a minimally invasive procedure intended to stabilize the fractured bone and restore bone height. It involves percutaneous introduction of an inflatable bone tamp into a fractured vertebral body, followed by injection of bone cement into the ballooned pocket. Anesthetic options typically considered for this procedure include intravenous sedation or general anesthesia. These patients are often elderly, frail, in significant pain, and may poorly tolerate sedation or general anesthesia in the prone position. Spinal anesthesia has been suggested as an alternative method. However, it has major limitations. We would like to report a case of a 79-year-old patient with multiple comorbidities, who presented for kyphoplasty, where epidural anesthesia was conducted and successfully provided adequate analgesia as well as optimal surgical conditions.

Preoperative prone position exercises: a simple and novel method to improve tolerance to kyphoplasty for treatment of single level osteoporotic vertebral compression fractures

Background

The proper choice of anesthesia for kyphoplasty remains controversy. There are only a few clinical studies specially focusing on and giving detailed information about this treatment under local anesthesia with or without conscious sedation. To evaluate the effect of preoperative prone position exercises on patient tolerance to percutaneous kyphoplasty under local anesthesia.

Methods

Eighty-three patients with single level osteoporotic vertebral compression fractures were nonrandomly assigned to undergo percutaneous kyphoplasty under local anesthesia with preoperative prone position exercises or without. The number of procedure with or without a pause, need for intravenous sedation, and patient satisfactory were recorded and analyzed. Clinical outcomes were assessed using the visual analog scale and the Oswestry Disability Index. The follow-up time was 6 months.

Results

The baseline characteristics of both groups were comparable. The number of procedure without a pause in the exercises group was more than the control group (30/42 patients and 10/41 patients, respectively, P < 0.001), and fewer patients required intravenous sedation in the exercises group (7/42 and 28/41, respectively, P < 0.001). Patients in the exercises group were more satisfied compared to the control group (41/42 and 32/41, respectively, P < 0.01). There were no significant differences between the two groups with regard to improvement in pain and functional scores at all postoperative intervals.

Conclusions

Prone position exercises may improve patient tolerance and satisfaction and reduce the need for intravenous sedation for those with single level vertebral compression fracture undergoing kyphoplasty under local anesthesia. We expect large sample size and multi-center randomized controlled trial studies to be conducted.

Percutaneous thoracolumbar decompression combined with percutaneous pedicle screw fixation and fusion: a method for treating spinal degenerative pain in a biplane angiography suite with the avoidance of general anesthesia

BACKGROUND

Spondylytic degeneration of the axial lumbar spine is a major cause of pain and disability. Recent advances in spinal surgical instrumentation, including percutaneous access and fusion techniques, have made possible the performance of instrumented fusion through small incisions. By blending strategies of interventional pain management, neuroradiology, and conventional spine surgery, it is now feasible to treat spinal axial pain using permanent fixation techniques and local anesthesia in the setting of a fluoroscopy suite using mild sedation and local anesthesia.

METHODS

The author presents a series of percutaneous thoracolumbar fusion procedures performed in a biplane neuroangiographic suite and without general anesthesia for the treatment of spondylytic pain. All procedures utilized pedicle screw fixation, harvesting of local bone autograft, and application of bone fusion material.

RESULTS

In this series of 13 patients, a statistically significant reduction of pain was seen at both the 2-week post-operative timepoint, as well as at the time of longest follow-up (mean 40 weeks).

DISCUSSION

The advanced and rapid imaging capabilities afforded by a neuroangiographic suite can be safely combined with percutaneous fusion techniques so as to allow for fusion therapies to be applied to patients where the avoidance of general anesthesia is desirable.

Comparison of remifentanil with dexmedetomidine for monitored anaesthesia care in elderly patients during vertebroplasty and kyphoplasty

OBJECTIVES

This clinical trial is registered at ClinicalTrials.gov. (NCT02476981)This randomized, prospective double-blind study compared remifentanil with dexmedetomidine for monitored anaesthesia care during minimally invasive corrections of vertebral compression fractures (vertebroplasty or kyphoplasty).

METHODS

Patients > 65 years of age with American Society of Anesthesiologists (ASA) classification I-III, scheduled for vertebroplasty or kyphoplasty under monitored anaesthesia care, received remifentanil (i.v. infusion 1-5 µg/kg/h) or dexmedetomidine (loading dose 0.3-0.4 µg/kg followed by i.v. infusion 0.2-1 µg/kg/h) to maintain observer's assessment of alertness/sedation (OAA/S) scale <4 during the procedure.

RESULTS

There were no statistically significant differences in demographic data between the remifentanil (n = 37) and dexmedetomidine groups (n = 38). Patients on dexmedetomidine experienced lower mean arterial pressure (MAP) and heart rate (HR), and higher SpO2 values, than patients on remifentanil. Compared with dexmedetomidine, remifentanil produced more respiratory depression, oxygen desaturation, and reduced the need for additional intraoperative opioids. There were no significant between-group differences in terms of recovery time, investigators' satisfaction scores, or patients' overall pain experiences.

CONCLUSIONS

During monitored anaesthesia care, dexmedetomidine provides less respiratory depression, lower MAP and HR, but also less analgesic effect than remifentanil in elderly patients undergoing vertebroplasty or kyphoplasty.

Vertebral Augmentation for Osteoporotic Compression Fractures

Vertebral augmentation procedures such as vertebroplasty and kyphoplasty were developed to reduce pain and improve quality of life for patients with osteoporotic vertebral compression fractures. However, the use of vertebral augmentation has been debated and questioned since its inception. This article addresses some of these issues.