Bilateral erector spinae plane block for postoperative pain relief in lumbar spine surgery: A PRISMA-compliant updated systematic review & meta-analysis

Study design

Systematic review.

Objective

Erector spinae plane block (ESPB) is growing in popularity over the recent past as an adjuvant modality in multimodal analgesic management following lumbar spine surgery (LSS). The current updated meta-analysis was performed to analyze the efficacy of ESPB for postoperative analgesia in patients undergoing LSS.

Methods

We conducted independent and duplicate electronic database searches including PubMed, Embase and Cochrane Library till June 2023 for randomized controlled trials (RCTs) analyzing the efficacy of bilateral ESPB for postoperative pain relief in lumbar spine surgeries. Post-operative pain scores, total analgesic consumption, first analgesic requirement time, length of stay and complications were the outcomes evaluated. Statistical analysis was performed using STATA 17 software.

Results

32 RCTs including 1464 patients (ESPB/Control = 1077/1069) were included in the analysis. There was a significant pain relief in ESPB group, as compared to placebo across all timelines such as during immediate post-operative period (p < 0.001), 4 h (p < 0.001), 8 h (p < 0.001), 12 h (p < 0.001), 24 h (p = 0.001) post-surgery. Similarly, ESPB group showed a significant reduction in analgesic requirement at 8 h (p < 0.001), 12 h (p = 0.001), and 24 h (p < 0.001). However, no difference was noted in the first analgesic requirement time, time to ambulate or total length of stay in the hospital. ESPB demonstrated significantly improved overall satisfaction score for the analgesic management (p < 0.001), reduced intensive care stay (p < 0.05) with significantly reduced post-operative nausea and vomiting (p < 0.001) compared to controls.

Conclusion

ESPB offers prolonged post-operative pain relief compared to controls, thereby reducing the need for opioid consumption and its related complications.

Academic Footprint of Journal of Orthopedic Case Reports in the Past 5 Years - A Scientometric Analysis

Patient outcomes have been enhanced every day due to significant research, advances in clinical methods, and insights presented in case reports, which numerous contemporary journals now publish.[1] The significance of accessing these case reports in our evolving and dynamic world remains acknowledged.[2] While case reports might sometimes be overshadowed by more comprehensive, evidence-backed publications, their impact has been profound.[3] Sharing such reliable information has catalyzed breakthroughs and the development of treatments for new diseases.[4] This practice of sharing experiential insights has evolved into a respected academic publication mode, efficiently disseminating knowledge to the broader medical community. Journal of Orthopaedic Case Reports (JOCR) is an international, online, scientific, peer-reviewed, monthly journal that started out publishing high-quality articles in 2011.[5] The journal is the official publication of the Indian Orthopaedic Research Group. The journal is indexed in various journal indexing databases including the Directory of Open Access Journals, Index Copernicus, PubMed Central, and so. The articles published are under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License.[6] In this article, the academic impact of the journal in the past 5 years has been analyzed. The scientometric analysis was performed using the metadata of the articles published in the journal and indexed in PubMed Central over the past 5 years (2018-2022). Visualization of the data is made using VOSviewer (version 1.6.19) software.[7]

Lateral clavicle fracture-plating options and considerations

Clavicle fractures are among the most prevalent types of fractures with numerous treatment strategies that have evolved over time. In the realm of lateral-third clavicle fracture management, several surgical methods are available, with plate and screw constructs being one of the most frequently employed options. Within this construct, numerous choices exist for fixing the fracture. This editorial provides an overview of the common plate options utilized in the management of distal third clavicle fractures underscoring the critical considerations and approaches that guide clinicians in selecting the most appropriate fixation techniques, considering the complex landscape of clavicle fractures and their challenging management.

Tenosynovitis of hand: Causes and complications

Tenosynovitis represents a common clinical condition characterized by inflammation of the synovium that encases the tendon sheath. Although tenosynovities may be noted in any tendon in the body, extremities such as hand, and foot remain the sites of high predilection to acquire this condition. The predominant cause of this predilection rests in the intricate tendon arrangements in these extremities that permit fine motor actions. This editorial explores the common causes and the complications associated with this condition to improve the understanding of the readers of this common condition encountered in our everyday clinical practice.

Delay in Time to Diagnosis of Idiopathic Transient Osteoporosis of the Hip with Radiographs: Diagnostic Insights from a Series of 10 Cases

Introduction

Transient osteoporosis of the hip (TOH) is a poorly recognized self-limiting clinical entity. Due to a lack of awareness among the clinicians, the condition is often misdiagnosed leading to inappropriate treatment, thereby lengthening the time to diagnosis (TTD). In this study, we analyze the delay in TTD of TOH using plain radiographs and present the optimal management strategy.

Case Report

We retrospectively collected the data of patients who were diagnosed with TOH from March 2017 to March 2022. A total of 10 patients with a mean age of 43.7 years (range 33-56 years) were included in the study. The mean time to presentation from the onset of symptoms was 4 weeks (range 2-8 weeks) Radiologic evaluation with radiographs was sensitive in only 8 patients with osteopenia, whereas magnetic resonance imaging (MRI) was sensitive in all the patients and aided in early diagnosis of TOH. Radiographic evaluation alone leads to a mean delay in TTD of 1.6 weeks (range 0-8 weeks) in our study. All the patients were treated conservatively without any major complications.

Conclusion

Plain radiographs were not sensitive in the early detection of TOH and increased the TTD by 1.6 weeks, however, MRI imaging was found to be highly sensitive and specific in diagnosing TOH.

Cross-beam Non-vascular Fibular Graft Reconstruction in the Management of Long Bone Giant Aneurysmal Bone Cyst - A Case Series

Introduction

Aneurysmal bone cyst (ABC) is a benign expansile osteolytic lesion, characterized by a blood-filled cavity in the bone. Giant ABC (GABC) is an uncommon condition due to the delayed presentation of an ABC that is difficult to handle when it occurs in long weight-bearing bones due to its aggressive nature. The common treatment relies on total resection of tumor with reconstruction of the resultant defect.

Case Report

We present the results of 5 cases of GABCs of long bones managed with non-vascularized fibular graft in a cross-beam fashion along with internal fixation. All patients achieved complete consolidation of the lesion by 12 months along with full incorporation of the graft with good-excellent musculoskeletal tumor society scores. None of the patients had recurrence/pathological fracture till 2 years of follow-up.

Conclusion

We suggest the method of using a non-vascularized fibula graft in a cross-beam fashion to reconstruct the void from the resection of long-bone GABC as a safe, reliable technique with excellent functional and radiological results.

Novel Multimodal Treatment Regimen for the Management of Primary Sacrococcygeal Cystic Echinococcosis

INTRODUCTION

Osseous hydatidosis is a rare condition most commonly involving the spine. Among spinal segments, sacrococcygeal involvement is even rarer. Moreover, the lesion is more prone to recurrence owing to the infiltrative nature of microvesicular lesions involving the spine. In this case report, we describe an effective multimodal management approach toward the management of primary sacrococcygeal cystic echinococcosis.

CASE REPORT

A 56-year-old female presented with complaints of severe back pain and urinary incontinence for 3 months. She presented with a slow-onset cauda equina syndrome with radiating pain to both lower limbs. Radiographic evaluation showed an expansile lytic lesion affecting the right iliac wing with near-complete cortical bone destruction of the sacrum. Magnetic resonance imaging revealed neural involvement with sacral destruction by a multiloculated cystic mass, extending to the spinal canal. No coexisting lesions were noted anywhere. Echinococcosis was diagnosed with serum enzyme-linked immunosorbent assay. She underwent neoadjuvant therapy with albendazole and praziquantel, followed by ultrasound-guided percutaneous aspiration injection and reaspiration (PAIR) with hypertonic saline followed by sclerosant (95% ethyl alcohol) into the residual cyst cavity. Later, she open excision of the residual multiloculated cystic mass was performed. Adjuvant medical therapy was continued for 3 months post-surgery. The patient regained her neurological functions by 6 months without any residual sequelae or symptomatic recurrence until 4 years of follow-up.

CONCLUSION

Multimodal treatment regimen comprising of oral medical therapy by albendazole and praziquantel along with PAIR and surgical in toto excision of the cyst followed by post-operative oral medical therapy for 3 months has given excellent results in sacrococcygeal cystic echinococcosis.

1411 Amoebic Colitis: Inaccurate Diagnosis; Inappropriate Surgery

Global prevalence of symptomatic Amoebiasis (pathogen Entamoeba histolytica) is approximately 50 million cases per year, with an annual mortality of up to 100,000. Despite this, a diagnosis of amoebiasis is rarely considered in the UK. Transmission is via the faeco-oral route, person-to-person contact or oral-anal sexual contact. The majority of cases diagnosed in the UK are in international travellers or immigrants.

Symptoms of amoebiasis can closely mirror those of Inflammatory Bowel Disease (IBD) resulting in diagnostic uncertainty. A misdiagnosis could result in treatment with corticosteroids, immunosuppressant or biological agents when standard treatment for amoebiasis is actually Metronidazole. In exceptional circumstances, a misdiagnosis of IBD may lead to a patient requiring colectomy and formation of end ileostomy due to an apparent failure of medical management. Emergency colonic surgery is associated with a risk of complications such as wound infections and collections, together with the psychological consequences of major illness and surgery.

We report on two patients who have undergone emergency subtotal colectomy and end ileostomy in whom a diagnosis of amoebic colitis was made on histology. Both British Asian patients were under 55 years of age, had a travel history to India and presented with diarrhoea.

The diagnosis of amoebiasis must be considered in the differential diagnosis for all returning travellers and immigrants who present with GI symptoms, consistent with IBD. A correct diagnosis allows appropriate, simple, curative treatment and avoids unnecessary surgery with its attendant morbidity. Polymerase chain reaction is the gold standard diagnostic test and is currently significantly under-utilised.

Recurrence-free management of type 2 variant of giant cell tumour of extensor tendon sheath of thumb

A 30-year-old woman presented with swelling in her right thumb of 3-month duration which was slow-growing in nature without a history of trauma. On examination, firm non-tender swelling with ill-defined border over the dorsomedial aspect of the first metacarpal was noted. The swelling was mobile only in the vertical plane with restricted adduction and abduction. Plain X-ray revealed mild erosion of the first metacarpal head. Diagnostic ultrasound confirmed the lesion to arise from the extensor tendon sheath of diffuse type without any bony involvement. A wide local excision biopsy of the swelling was planned. Intraoperatively, a 3×2 cm greyish-white mass, bony hard in consistency with lobulated surface was found arising from the tendon sheath of the extensor tendon of the thumb; it was completely excised with a wide margin. Histopathological examination revealed polyhedral cells admixed with osteoclastic type giant cells. Biopsy from the first metatarsal was normal. The patient is on follow-up for the last 5 years with no evidence of recurrence.

A comparative evaluation between cheiloscopic patterns and the permanent molar relationships to predict the future malocclusions

Background

To assess the correlation between different cheiloscopic patterns with the permanent molar relationships.

Material and Methods

300 children who are 14-16 years old with completely erupted 2nd permanent molars upto occlusal table were recruited and the pattern of molar terminal plane was recorded in the proforma. Lip prints of these subjects were recorded with lipstick-cellophane method and middle 10mm of lower lip was analysed for the lip print pattern as suggested by Sivapathasundharam et al. The pattern were classified based on Tsuchihashi and Suzuki classification.

Results

Type II (branched) pattern was the most predominant cheiloscopic pattern. The predominant patterns which related to the Angle’s classification were; type I (complete vertical) pattern for class I, type IV (reticular) pattern for class II and presence of type IV (reticular) pattern and absence of type I’ (incomplete vertical) pattern for class III. In class III molar relationship, males showed an increased type II (branched) pattern and females showed an increased type IV (reticluar) pattern.

Conclusions

Lip prints can provide an alternative to dermatoglyphics to predict malocclusions in permanent dentition. Further studies with larger sample size are required to provide an insight into its significant correlations.

Key words:Cheiloscopy, Angle’s classification, malocclusion.

A comparative evaluation between dermatoglyphic patterns and different terminal planes in primary dentition

Background

Material and Methods

Results

Conclusions

A dose response study of inhaled nitric oxide in hypoxic respiratory failure in preterm infants

BACKGROUND

Inhaled nitric oxide (iNO) is used widely in newborn infants with hypoxic respiratory failure, despite the known and theoretical toxicity of iNO, and a relative lack of information about appropriate doses.

AIM

To determine whether a dose-response relationship existed for iNO in preterm infants.

DESIGN

A four-period, four-dose, cross-over design was used with iNO given for 15 min in a randomised sequence in concentrations of 5, 10, 20 and 40 parts per million (ppm), with a minimum 5 min wash-out period. Data on ventilatory, blood gas and other physiological measurements were recorded before and at the end of each period. The relationship of clinical response with iNO dose and period was analysed using multivariate regression.

SUBJECTS

Infants with gestational age < 34 weeks and < 28 days postnatal age with hypoxic respiratory failure were recruited.

OUTCOME MEASURE

A clinically significant dose-response was defined as a rise in the post-ductal arterial oxygen tension (PaO(2)) of at least 3 kPa.

RESULTS

Thirteen infants were recruited. At trial entry, ten were < 3 days of age; 11 were being treated with high frequency oscillatory ventilation; median (inter-quartile range) gestational age 27 (25-29) weeks; birthweight 983 (765-1120) g; oxygenation index 27.1 (21.8-28.8). Six infants (46%) showed a clinically significant response. After adjusting for period and patient effect, no evidence for an overall dose effect was identified (likelihood ratio test, p=0.34).

CONCLUSION

No evidence of a dose-response relationship with iNO was found in this study of very preterm infants with respiratory failure.

Factors affecting the incidence of chronic lung disease of prematurity in 1987, 1992, and 1997

OBJECTIVE

To determine changes in the incidence of chronic lung disease of prematurity between 1987, 1992, and 1997.

METHODS

Observational study based on data derived from a geographically defined population: Trent Health Region, United Kingdom. Three time periods were compared: 1 February 1987 to 31 January 1988 (referred to as 1987); 1 April 1992 to 31 March 1993 (referred to as 1992); 1997. All infants of < or = 32 completed weeks gestation born to Trent resident mothers within the study periods and admitted to a neonatal unit were included. Rates of chronic lung disease were determined using two definitions: (a) infants who remained dependent on active respiratory support or increased oxygen at 28 days of age; (b) infants who remained dependent on active respiratory support or increased oxygen at a corrected age of 36 weeks gestation.

RESULTS

Between 1987 and 1992 there was a fall in the birth rate, but a significant increase was noted in the number of babies of < or = 32 weeks gestation admitted to a neonatal unit. There was no significant change in survival when the two groups of infants were directly compared. However, mean gestation and birth weight fell. Adjusting for this change showed a significant improvement in survival (28 day survival: odds ratio (OR) = 1.69; 95% confidence interval (95% CI) = 1.23 to 2.33. Survival to 36 week corrected gestation: OR = 1.45; 95% CI = 1.06 to 1.98). These changes were accompanied by a large increase in the incidence of chronic lung disease even after allowing for the change in population characteristics (28 day definition: OR = 2.20; 95% CI = 1.47 to 3.30. 36 week definition: OR = 3.04; 95% CI = 1.91 to 4.83). Between 1992 and 1997 a different pattern emerged. There was a further increase in the number of babies admitted for neonatal care at </= 32 weeks gestation despite a continuing fall in overall birth rate. Survival, using both raw data and data corrected for changes in gestation and birth weight, improved significantly in 1997 (adjusted data: 28 day survival: OR = 1.72 (95% CI = 1.22 to 2.38); survival to 36 week corrected gestation: OR = 1.90 (95% CI = 1.36 to 2.64)). Rates of chronic lung disease showed no significant change between 1992 and 1997 despite improved survival (adjusted data: 28 day definition: OR = 0.72 (95% CI = 0.50 to 1.03); 36 week definition: OR = 0.88 (95% CI = 0.61 to 1.26).

CONCLUSIONS

Current high rates of chronic lung disease are the result of policies to offer neonatal intensive care more widely to the most immature infants. Recent improvements in survival have been achieved without further increases in the risk of infants developing chronic lung disease.