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The Role of Regional Anesthesia in the Development of Chronic Pain: a Review of Literature. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00536-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Abstract
Purpose of Review
The acute management of pain using regional anesthesia techniques may prevent the development of persistent postsurgical pain (PPP), ultimately improving patient outcomes and enhancing overall quality of life in postsurgical patients. The purpose of this review is to describe the current literature regarding the role of regional anesthesia techniques in the perioperative setting to address and prevent PPP.
Recent Findings
Data was collected and analyzed using results from randomized controlled studies stratified into categories based on different surgical subspecialties. Conclusions were drawn from each surgical category regarding the role of regional anesthesia and/or local analgesia in acute and chronic pain management on the long-term results seen in the studies analyzed.
Summary
Preoperative consultations and optimized perioperative analgesia using regional anesthesia and local analgesia play a fundamental role preventing and treating postoperative pain after many types of surgery by managing pain in the acute setting to mitigate the future development of PPP. Additional studies in different surgical subspecialties are needed to confirm the role regional anesthesia plays in chronic postsurgical pain (CPSP) prevention.
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Muthu S, Ramakrishnan E. Fragility Analysis of Statistically Significant Outcomes of Randomized Control Trials in Spine Surgery: A Systematic Review. Spine (Phila Pa 1976) 2021; 46:198-208. [PMID: 32756285 DOI: 10.1097/brs.0000000000003645] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVES The aim of this study was to assess the robustness of statistically significant outcomes from randomized control trials (RCTs) in spine surgery using Fragility Index (FI) which is a novel metric measuring the number of events upon which statistical significance of the outcome depends. SUMMARY OF BACKGROUND DATA Many trials in Spine surgery were characterized by fewer outcome events along with small sample size. FI helps us identify the robustness of the results from such studies with statistically significant dichotomous outcomes. METHODS We conducted independent and in duplicate, a systematic review of published RCTs in spine surgery from PubMed Central, Embase, and Cochrane Database. RCTs with 1:1 prospective study design and reporting statistically significant dichotomous primary or secondary outcomes were included. FI was calculated for each RCT and its correlation with various factors was analyzed. RESULTS Seventy trials met inclusion criteria with a median sample size of 133 (interquartile range [IQR]: 80-218) and median reported events per trial was 38 (IQR: 13-94). The median FI score was 2 (IQR: 0-5), which means if we switch two patients from nonevent to event, the statistical significance of the outcome is lost. The FI score was less than the number of patients lost to follow-up in 28 of 70 trials. The FI score was found to positively correlated with sample size (r = 0.431, P = 0.001), total number of outcome events (r = 0.305, P = 0.01) while negatively correlated with P value (r = -0.392, P = 0.001). Funding, journal impact-factor, risk of bias domains, and year of publication did not have a significant correlation. CONCLUSION Statistically significant dichotomous outcomes reported in spine surgery RCTs are more often fragile and outcomes of the patients lost to follow-up could have changed the significance of results and hence it needs caution before transcending their results into clinical application. The addition of FI in routine reporting of RCTs would guide readers on the robustness of the statistical significance of outcomes. RCTs with FI ≥5 without any patient lost to follow-up can be considered to have clinically robust results.Level of Evidence: 1.
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Affiliation(s)
- Sathish Muthu
- Government Hospital, Velayuthampalayam, Karur, Tamil Nadu, India
| | - Eswar Ramakrishnan
- Institute of Orthopaedics and Traumatology, Madras Medical College & Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
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Patel RA, Jablonka EM, Rustad KC, Pridgen BC, Sorice-Virk SS, Borrelli MR, Khosla RK, Lorenz HP, Momeni A, Wan DC. Retrospective cohort-based comparison of intraoperative liposomal bupivacaine versus bupivacaine for donor site iliac crest analgesia during alveolar bone grafting. J Plast Reconstr Aesthet Surg 2019; 72:2056-2063. [DOI: 10.1016/j.bjps.2019.09.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 08/26/2019] [Accepted: 09/20/2019] [Indexed: 12/28/2022]
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Levene JL, Weinstein EJ, Cohen MS, Andreae DA, Chao JY, Johnson M, Hall CB, Andreae MH. Local anesthetics and regional anesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children: A Cochrane systematic review and meta-analysis update. J Clin Anesth 2019; 55:116-127. [PMID: 30640059 DOI: 10.1016/j.jclinane.2018.12.043] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 11/23/2018] [Accepted: 12/18/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Regional anesthesia may mitigate the risk of persistent postoperative pain (PPP). This Cochrane review, published originally in 2012, was updated in 2017. METHODS We updated our search of Cochrane CENTRAL, PubMed, EMBASE and CINAHL to December 2017. Only RCTs investigating local anesthetics (by any route) or regional anesthesia versus any combination of systemic (opioid or non-opioid) analgesia in adults or children, reporting any pain outcomes beyond three months were included. Data were extracted independently by at least two authors, who also appraised methodological quality with Cochrane 'Risk of bias' assessment and pooled data in surgical subgroups. We pooled studies across different follow-up intervals. As summary statistic, we reported the odds ratio (OR) with 95% confidence intervals and calculated the number needed to benefit (NNTB). We considered classical, Bayesian alternatives to our evidence synthesis. We explored heterogeneity and methodological bias. RESULTS 40 new and seven ongoing studies, identified in this update, brought the total included RCTs to 63. We were only able to synthesize data from 39 studies enrolling 3027 participants in a balanced design. Evidence synthesis favored regional anesthesia for thoracotomy (OR 0.52 [0.32 to 0.84], moderate-quality evidence), breast cancer surgery (OR 0.43 [0.28 to 0.68], low-quality evidence), and cesarean section (OR 0.46, [0.28 to 0.78], moderate-quality evidence). Evidence synthesis favored continuous infusion of local anesthetic after breast cancer surgery (OR 0.24 [0.08 to 0.69], moderate-quality evidence), but was inconclusive after iliac crest bone graft harvesting (OR 0.20, [0.04 to 1.09], low-quality evidence). CONCLUSIONS Regional anesthesia reduces the risk of PPP. Small study size, performance, null, and attrition bias considerably weakened our conclusions. We cannot extrapolate to other interventions or to children.
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Affiliation(s)
- Jacob L Levene
- Albert Einstein College of Medicine of Yeshiva University, Bronx, NY, United States of America
| | - Erica J Weinstein
- Albert Einstein College of Medicine of Yeshiva University, Bronx, NY, United States of America
| | - Marc S Cohen
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Doerthe A Andreae
- Department of Allergy/Immunology, Milton S Hershey Medical Center, Hershey, PA, United States of America
| | - Jerry Y Chao
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Matthew Johnson
- Human Development, Teachers College, Columbia University, New York, NY, United States of America
| | - Charles B Hall
- Division of Biostatistics, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Michael H Andreae
- Department of Anesthesiology & Perioperative Medicine, Milton S Hershey Medical Center, Hershey, PA, United States of America.
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Heindel KJ, Preston GP, Tharp JS. Chronic Morbidity of a Pilot Hole Burr Technique for Anterior Iliac Crest Autograft in Cervical Fusion. Orthopedics 2019; 42:e68-e73. [PMID: 30484852 DOI: 10.3928/01477447-20181120-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 07/18/2018] [Indexed: 02/03/2023]
Abstract
Anterior cervical decompression and fusion is a commonly performed procedure for cervical pathology. Graft choices include autograft, allograft, xenograft, synthetic, or a combination. Autograft has been shown to increase fusion rate compared with allograft, yet high morbidity at the harvest site has been reported. Few studies have evaluated chronic graft site pain, and to the authors' knowledge, no study has evaluated morbidity of a pilot hole burr technique for anterior iliac crest harvest. The objective of this study was to evaluate chronic morbidity of anterior iliac crest harvest in anterior cervical decompression and fusion using a pilot hole burr technique. A phone survey was used to identify chronic morbidity. Number of levels fused, age, sex, and acute graft site complications were explored to evaluate impact of patient characteristics on chronic graft site pain. A total of 140 patients met inclusion criteria; 106 patients (76%) completed the phone survey. Mean follow-up was 38.9 months. Two patients (1.9%) reported current and constant graft site pain. Nine patients (8.5%) reported intermittent pain. Average numeric pain rating scale score for survey participants was 0.25 of 10. No patients were taking narcotics for graft site pain. Two patients (1.9%) reported functional impairment secondary to the graft site pain. There was no impact of number of levels fused, age, sex, or acute graft site complications on chronic graft site pain. The pilot hole burr technique resulted in low long-term morbidity and may offer an alternative to traditional methods for those wishing to use autologous graft in anterior cervical decompression and fusion. [Orthopedics. 2019; 42(1):e68-e73.].
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Zhang J, Wei Y, Gong Y, Dong Y, Zhang Z. Reconstruction of iliac crest defect after autogenous harvest with bone cement and screws reduces donor site pain. BMC Musculoskelet Disord 2018; 19:237. [PMID: 30025526 PMCID: PMC6053794 DOI: 10.1186/s12891-018-2167-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 07/03/2018] [Indexed: 12/03/2022] Open
Abstract
Background The iliac crest is the most common autogenous bone graft donor site, although associated with postoperative pain, functional disability, cosmesis, morphology and surgical satisfaction. We assessed each aspect above by comparing iliac crest reconstruction with bone cement and screws following harvest with no reconstruction. Methods We evaluated patients who underwent large iliac crest harvesting, including ten patients who underwent iliac crest defect reconstruction with bone cement and cancellous screws (R group) and ten randomly matched patients without reconstruction (NR group) were evaluated prospectively in the same period. Local pain, cosmesis and other complications were assessed postoperatively at 1 week, 6 weeks, 3 months and 6 months. Results Pain, cosmesis and satisfaction of patients significantly differed between the two groups. The R group exhibited less complications and lower pain visual analogue scores at postoperative 1 week (p < 0.001), 6 weeks (p < 0.001) and 3 months (p < 0.01) but not at 6 months, at which time patients reported almost no pain. One patient reported pain for more than 1 year in the NR group. The R group exhibited better cosmesis, morphology and satisfaction than the NR group. In the NR group, one patient suffered pain when sitting up and another when wearing a belt. Conclusion Postoperative pain can be reduced and cosmesis can be improved through reconstructing the iliac crest defects after autogenous harvesting with bone cement and cancellous screws. The technique is simple, safe and easy to implement.
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Affiliation(s)
- Jing Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
| | - Yuxuan Wei
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
| | - Yue Gong
- Department of Breast Surgery, Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, 200032, China
| | - Yang Dong
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China.
| | - Zhichang Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China.
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Weinstein EJ, Levene JL, Cohen MS, Andreae DA, Chao JY, Johnson M, Hall CB, Andreae MH. Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children. Cochrane Database Syst Rev 2018; 6:CD007105. [PMID: 29926477 PMCID: PMC6377212 DOI: 10.1002/14651858.cd007105.pub4] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017. OBJECTIVES To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews. SELECTION CRITERIA We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE. MAIN RESULTS In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 39 studies, enrolling a total of 3027 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution. AUTHORS' CONCLUSIONS We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.
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Affiliation(s)
- Erica J Weinstein
- Albert Einstein College of Medicine of Yeshiva University1300 Morris Park AveBronxNYUSA10461
| | - Jacob L Levene
- Albert Einstein College of Medicine of Yeshiva University1300 Morris Park AveBronxNYUSA10461
| | - Marc S Cohen
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111 E 210 StreetBronxNYUSA#N4‐005
| | - Doerthe A Andreae
- Milton S Hershey Medical CenterDepartment of Allergy/ Immunology500 University DrHersheyPAUSA17033
| | - Jerry Y Chao
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111 E 210 StreetBronxNYUSA#N4‐005
| | - Matthew Johnson
- Teachers College, Columbia UniversityHuman DevelopmentNew YorkNYUSA10027
| | - Charles B Hall
- Albert Einstein College of MedicineDivision of Biostatistics, Department of Epidemiology and Population Health1300 Morris Park AvenueBronxNYUSA10461
| | - Michael H Andreae
- Milton S Hershey Medical CentreDepartment of Anesthesiology & Perioperative Medicine500 University DriveH187HersheyPAUSA17033
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Sheha ED, Meredith DS, Shifflett GD, Bjerke BT, Iyer S, Shue J, Nguyen J, Huang RC. Postoperative pain following posterior iliac crest bone graft harvesting in spine surgery: a prospective, randomized trial. Spine J 2018; 18:986-992. [PMID: 29155001 DOI: 10.1016/j.spinee.2017.10.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 09/19/2017] [Accepted: 10/05/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Postoperative pain at the site of bone graft harvest for posterior spine fusion is reported to occur in 6%-39% of cases. However, the area around the posterior, superior iliac spine is a frequent site of referred pain for many structures. Therefore, many postoperative spine patients may have pain in the vicinity of the posterior iliac crest that may not in fact be caused by bone graft harvesting. The literature may then overestimate the true incidence of postoperative iliac crest pain. PURPOSE We performed a prospective study testing the hypothesis that patients will not report significantly higher visual analog scores over the graft harvest site when compared with the contralateral, non-harvested side. STUDY DESIGN/SETTING This is a prospective, randomized cohort study. PATIENT SAMPLE Patients aged 18-75 years undergoing elective spinal fusion of one to two levels between L4 and S1 for spinal stenosis and spondylolisthesis were randomized to left-sided or right-sided iliac crest bone graft (ICBG) donor sites and blinded to the side of harvest. OUTCOME MEASURES Primary outcome was a 10-point visual analog scale (VAS) for pain over the left and right posterior superior iliac spine. METHODS Bone graft was harvested via spinal access incisions without making a separate skin incision over the crest. Each patient's non-harvested side served as an internal control. Data points were recorded by patients on their study visit sheets preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. RESULTS Forty patients were enrolled in the study (23 females) with an average follow-up of 8.1 months (1.5-12 months). Mean age was 51.7 years (23-77 years). Left- and right-side ICBG harvesting was performed equally between the 40 patients. The average volume of graft harvested from the left was 35.3 mL (15-70 mL) and 36.1 mL (15-60 mL) from the right. There was no statistical difference between preoperative VAS score on the harvested side compared with the non-harvested side (p=.415). Postoperatively, there were consistently higher VAS scores on the operative side; however, these differences were not statistically significant at 6 weeks (p=.111), 3 months (p=.440), 6 months (p=.887), or 12 months (p=.240). Both groups did, however, show statistically significant improvements in VAS scores over time within the operative and nonoperative sides (p<.05). Graft volume had no effect on the VAS scores (p=.382). CONCLUSIONS The current literature does not adequately illuminate the incidence of postoperative pain at the site of harvest and the relative magnitude of this pain in comparison with the patient's residual low back pain. This is the first study to blind the patient to the laterality of bone graft harvesting. Our randomized investigation showed that although pain on the surgical side was slightly higher, it was neither clinically nor statistically different from the nonsurgical side. Our conclusion supports surgeons' use of autologous bone graft, which offers a cost-effective, efficacious spinal fusion supplement.
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Affiliation(s)
- Evan D Sheha
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA.
| | - Dennis S Meredith
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA
| | - Grant D Shifflett
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA
| | - Benjamin T Bjerke
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA
| | - Sravisht Iyer
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA
| | - Jennifer Shue
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA
| | - Joseph Nguyen
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA
| | - Russel C Huang
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA
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Weinstein EJ, Levene JL, Cohen MS, Andreae DA, Chao JY, Johnson M, Hall CB, Andreae MH. Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children. Cochrane Database Syst Rev 2018; 4:CD007105. [PMID: 29694674 PMCID: PMC6080861 DOI: 10.1002/14651858.cd007105.pub3] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017. OBJECTIVES To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews. SELECTION CRITERIA We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE. MAIN RESULTS In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 41 studies, enrolling a total of 3143 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution. AUTHORS' CONCLUSIONS We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.
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Affiliation(s)
- Erica J Weinstein
- Albert Einstein College of Medicine of Yeshiva University1300 Morris Park AveBronxUSA10461
| | - Jacob L Levene
- Albert Einstein College of Medicine of Yeshiva University1300 Morris Park AveBronxUSA10461
| | - Marc S Cohen
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111 E 210 StreetBronxUSA#N4‐005
| | - Doerthe A Andreae
- Milton S Hershey Medical CenterDepartment of Allergy/ Immunology500 University DrHersheyUSA17033
| | - Jerry Y Chao
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111 E 210 StreetBronxUSA#N4‐005
| | - Matthew Johnson
- Teachers College, Columbia UniversityHuman DevelopmentNew YorkUSA10027
| | - Charles B Hall
- Albert Einstein College of MedicineDivision of Biostatistics, Department of Epidemiology and Population Health1300 Morris Park AvenueBronxUSA10461
| | - Michael H Andreae
- Milton S Hershey Medical CentreDepartment of Anesthesiology & Perioperative Medicine500 University DriveH187HersheyUSA17033
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Cansiz E, Sitilci TA, Uzun A, Isler SC. Reconstruction of atrophic maxilla by anterior iliac crest bone grafting via neuroaxial blockade technique: a case report. J Istanb Univ Fac Dent 2017; 51:46-51. [PMID: 28955586 PMCID: PMC5573495 DOI: 10.17096/jiufd.68600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 06/08/2016] [Indexed: 11/21/2022] Open
Abstract
Anterior iliac crest bone grafting is a well-established modality in the treatment of alveolar bone deficiencies. However, this procedure may also have considerable
postoperative morbidity which is mostly related to general anesthesia. Postoperative pain-related complications can be managed by neuroaxial blockade techniques which
provide adequate surgical analgesia and reduce postoperative pain. This clinical report describes the reconstruction of a severely atrophic maxilla with anterior iliac
crest bone grafting using combined spinal epidural anesthesia. Neuroaxial blockade techniques may be a useful alternative to eliminate general anesthesia related
challenges of anterior iliac crest bone grafting procedures.
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Affiliation(s)
- Erol Cansiz
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University Turkey
| | - Tolga A Sitilci
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University Turkey
| | - Aysenur Uzun
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University Turkey
| | - Sabri Cemil Isler
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University Turkey
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The fragility of statistically significant findings from randomized trials in spine surgery: a systematic survey. Spine J 2015; 15:2188-97. [PMID: 26072464 DOI: 10.1016/j.spinee.2015.06.004] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 04/27/2015] [Accepted: 06/01/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Randomized controlled trials (RCTs) are the most trustworthy source for evaluating treatment effects, but RCTs of spine surgery interventions often produce discordant results. The Fragility Index is a novel metric to inform about the robustness of statistically significant results. PURPOSE The aim was to determine the robustness of statistically significant results from RCTs of spine surgery interventions. STUDY DESIGN/SETTING This was a systematic survey. PATIENT SAMPLE The sample included RCTs of spine surgery interventions. OUTCOME MEASURES The Fragility Index is the minimum number of patients in a trial whose status would have to change from a nonevent to an event to change a statistically significant result to a nonsignificant result. Events refer to the occurrence of any dichotomous outcome, such as successful fusion, incident fracture, adjacent segment degeneration, or achievement of a certain functional score. A small Fragility Index indicates that the statistical significance of a result hinges on only a few events, and a large Fragility Index increases one's confidence in the observed treatment effects. METHODS We systematically reviewed a database for evidence-based orthopedics and identified all the RCTs that reported at least one positive outcome (ie, p<.05). Two reviewers independently assessed eligibility and extracted data. We used the Fisher exact test to compute Fragility Index values and multivariable linear regression to evaluate potential associated factors. RESULTS We identified 40 eligible RCTs with a median sample size of 132 patients (interquartile range [IQR] 79-208) and a median total number of outcome events for the chosen outcome of 31 (IQR 13-63). The median Fragility Index was two (IQR 1-3), which means that adding two events to one of the trial's treatment arms eliminated its statistical significance. The Fragility Index was less than or equal to three events in 75% of the trials, and was less than or equal to the number of patients lost to follow-up in 65% of the trials. Fragility Index values correlated positively with total sample size (r=0.35; p<.05). When adjusted for losses to follow-up and risk of bias, increasing Fragility Index values were associated only with increasingly significant reported p values (p<.01). CONCLUSIONS Statistically significant results in spine surgery RCTs are frequently fragile. The addition of only a small number of outcome events can completely eliminate significance. Surgeons, researchers, and other evidence users should exercise caution when interpreting the findings from RCTs with low Fragility Index values and applying these results to patient care.
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Taverna E, D'Ambrosi R, Perfetti C, Garavaglia G. Arthroscopic bone graft procedure for anterior inferior glenohumeral instability. Arthrosc Tech 2014; 3:e653-60. [PMID: 25685669 PMCID: PMC4314560 DOI: 10.1016/j.eats.2014.08.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 08/14/2014] [Indexed: 02/03/2023] Open
Abstract
There are many described surgical techniques for the treatment of recurrent anterior shoulder instability. Numerous authors have performed anterior bone block procedures with good results for the treatment of anterior shoulder instability with glenoid bone loss. The benefits of using arthroscopic procedures for surgical stabilization of the shoulder include smaller incisions with less soft-tissue dissection, better visualization of the joint, better repair accessibility, and the best possible outcome for external rotation. We describe an arthroscopic anteroinferior shoulder stabilization technique with an iliac crest tricortical bone graft and capsulolabral reconstruction. It is an all-arthroscopic technique with the advantage of not using fixation devices, such as screws, but instead using special buttons to fix the bone graft. The steps of the operation are as follows: precise placement of a specific posterior glenoid guide that allows the accurate positioning of the bone graft on the anterior glenoid neck; fixation of the graft flush with the anterior glenoid rim using specific buttons under arthroscopic control; and finally, subsequent capsular, labral, and ligament reconstruction on the glenoid rim using suture anchors and leaving the graft as an extra-articular structure.
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Affiliation(s)
- Ettore Taverna
- Upper Limb Unit, Department of Surgery, OBV, Mendrisio, Switzerland,U.O. Chirurgia della Spalla II, Istituto Ortopedico Galeazzi, Milan, Italy
| | - Riccardo D'Ambrosi
- U.O. Chirurgia della Spalla II, Istituto Ortopedico Galeazzi, Milan, Italy,Address correspondence to Riccardo D'Ambrosi, M.D., U.O. Chirurgia della Spalla II, Istituto Ortopedico Galeazzi, Milan, Italy.
| | - Carlo Perfetti
- U.O. Chirurgia della Spalla II, Istituto Ortopedico Galeazzi, Milan, Italy
| | - Guido Garavaglia
- Upper Limb Unit, Department of Surgery, OBV, Mendrisio, Switzerland
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