Preoperative Acute Sleep Deprivation Causes Postoperative Pain Hypersensitivity and Abnormal Cerebral Function

Preoperative sleep loss can amplify post-operative mechanical hyperalgesia. However, the underlying mechanisms are still largely unknown. In the current study, rats were randomly allocated to a control group and an acute sleep deprivation (ASD) group which experienced 6 h ASD before surgery. Then the variations in cerebral function and activity were investigated with multi-modal techniques, such as nuclear magnetic resonance, functional magnetic resonance imaging, c-Fos immunofluorescence, and electrophysiology. The results indicated that ASD induced hyperalgesia, and the metabolic kinetics were remarkably decreased in the striatum and midbrain. The functional connectivity (FC) between the nucleus accumbens (NAc, a subregion of the ventral striatum) and the ventrolateral periaqueductal gray (vLPAG) was significantly reduced, and the c-Fos expression in the NAc and the vLPAG was suppressed. Furthermore, the electrophysiological recordings demonstrated that both the neuronal activity in the NAc and the vLPAG, and the coherence of the NAc-vLPAG were suppressed in both resting and task states. This study showed that neuronal activity in the NAc and the vLPAG were weakened and the FC between the NAc and the vLPAG was also suppressed in rats with ASD-induced hyperalgesia. This study highlights the importance of preoperative sleep management for surgical patients.

Clinical Application of Artificial Intelligence: Auto-Discerning the Effectiveness of Lidocaine Concentration Levels in Osteosarcoma Femoral Tumor Segment Resection

Adolescents and children worldwide are threatened by osteosarcoma, a tumor that predominantly affects the long bone epiphysis. Osteosarcoma is the most common and highly malignant bone tumor in youngsters. Early tumor detection is the key to effective treatment of this disease. The discovery of biomarkers and the growing understanding of molecules and their complex interactions have improved the outcome of clinical trials in osteosarcoma. This article describes biomarkers of osteosarcoma with the aim of positively influencing the progress of clinical treatment of osteosarcoma. Femoral bone tumor is a typical condition of osteosarcoma. Due to the wide range of femoral stem types, complexities in the distal femur, and tumors in the rotor part of femur, physicians following the traditional clinical approach face difficulties in removing the lesion and fixing the femur with resection of the tumor segment. In this paper, the effect of small doses of different concentrations of lidocaine anesthesia in patients undergoing lumpectomy for osteosarcoma femoral tumor segments is investigated. A computer-based artificial intelligence method for automated determination of different concentration levels of lidocaine anesthesia and amputation of osteosarcoma femoral tumor segment is proposed. Statistical analysis is carried on the empirical data including intraoperative bleeding, intraoperative and postoperative pain scores, surgical operation time, postoperative complications, patient satisfaction, and local anesthetic dose. The results showed that the patients in the study group had low intraoperative bleeding, short operation time, low postoperative hematoma formation rate, high patient satisfaction, higher dosage of anesthetic solution, and low dosage of lidocaine. Results revealed that mean arterial pressure and heart rate in extubating and intubating were significantly lower in the observation group than in the control group, and a significant difference (P < 0.05) was observed between the two groups. This proves that the proposed algorithm can adequately reduce bleeding, alleviate postoperative pain, shorten operation time, reduce complications, accelerate recovery, and ensure better treatment results.

Utilization and evolving prescribing practice of opioid and non-opioid analgesics in patients undergoing lymphadenectomy for cutaneous malignancy

BACKGROUND AND OBJECTIVES

Opioids are commonly prescribed following surgery and can lead to persistent opioid use. We assessed changes in prescribing practices following an opioid education initiative for patients undergoing lymphadenectomy for cutaneous malignancy.

METHODS

A single-institution retrospective study of all eligible patients (3/2016-3/2020) was performed.

RESULTS

Indications for lymphadenectomy in 328 patients were metastatic melanoma (84%), squamous cell carcinoma (10%), and Merkel cell carcinoma (5%). At discharge, non-opioid analgesics were increasingly utilized over the 4-year study period, with dramatic increases after education initiatives (32%, 42%, 59%, and 79% of pts, respectively each year; p < 0.001). Median oral morphine equivalents (OMEs) prescribed also decreased dramatically starting in year 3 (250, 238, 150, and 100 mg, respectively; p < 0.001). Patients discharged with 200 mg OMEs were less likely to also be discharged with non-opioid analgesics (40% vs. 64%. respectively, p < 0.001).

CONCLUSIONS

Analgesic prescribing practices following lymphadenectomy for cutaneous malignancy improved significantly over a 4-year period, with use of non-opioids more than doubling and a 60% reduction in median OME. Opportunities exist to further increase non-opioid use and decrease opioid dissemination after lymphadenectomy for cutaneous malignancy.

Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: a randomised, observer-masked, controlled trial

The pericapsular nerve group (PENG) block is a novel regional anaesthesia technique that aims to provide hip analgesia with preservation of motor function, although evidence is currently lacking. In this single-centre, observer-masked, randomised controlled trial, patients undergoing total hip arthroplasty received pericapsular nerve group block or no block (control group). Primary outcome measure was maximum pain scores (0-10 numeric rating scale) measured in the first 48 h after surgery. Secondary outcomes included postoperative opioid consumption; patient mobilisation assessments; and length of hospital stay. Sixty patients were randomly allocated equally between groups. The maximum pain score of patients receiving the pericapsular nerve group block was significantly lower than in the control group at all time-points, with a median (IQR [range]) of 2.5 (2.0-3.7 [0-7]) vs. 5.5 (5.0-7.0 [2-8]) at 12 h; 3 (2.0-4.0 [0-7]) vs. 6 (5.0-6.0 [2-8]) at 24 h; and 2.0 (2.0-4.0 [0-5]) vs. 3.0 (2.0-4.7 [0-6]) at 48 h; all p < 0.001. Moreover, the pericapsular nerve group showed a significant reduction in opioid consumption, better range of hip motion and shorter time to ambulation. Although no significant difference in hospital length of stay was detected, our results suggest improved postoperative functional recovery following total hip arthroplasty in patients who received pericapsular nerve group block.

The potential for diversion of prescribed opioids among orthopaedic patients: Results of an anonymous patient survey

INTRODUCTION

Diversion of prescription opioid medication is a contributor to the opioid epidemic. Safe handling practices can reduce the risk of diversion. We aimed to understand: 1) if orthopaedic patients received instructions on how to safely handle opioids, 2) their typical storage/disposal practices, and 3) their willingness to participate in an opioid disposal program (ODP).

METHODS

Cross-sectional study of adult orthopaedic patients who completed an anonymous survey on current or past prescription opioid use, instruction on handling, storage and disposal practices, presence of children in the household, and willingness to participate in an ODP. Frequencies and percentages of responses were computed, both overall and stratified by possession of unused opioids.

RESULTS

569 respondents who reported either current or past prescription opioid use were analyzed. 44% reported receiving storage instructions and 56% reported receiving disposal instructions from a health care provider. Many respondents indicated unsafe handling practices: possessing unused opioids (34%), using unsafe storage methods (90%), and using unsafe disposal methods (34%). Respondents with unused opioids were less likely to report receiving handling instructions or using safe handling methods, and 47% of this group reported having minors or young adults in the household. Respondents who received storage and disposal instructions were more likely to report safe storage and disposal methods. Seventy-four percent of respondents reported that they would participate in an ODP.

CONCLUSION

While many orthopaedic patients report inadequate education on safe opioid handling and using unsafe handling practices, findings suggest targeted education is associated with better behaviours. However, patients are willing to safely dispose of unused medication if provided a convenient option. These findings suggest a need to address patient knowledge and behavior regarding opioid handling to reduce the risk of opioid diversion.

Efficacy of pectoral nerve block type II versus thoracic paravertebral block for analgesia in breast cancer surgery

BACKGROUND

Ultrasound-guided pectoral nerve block type II is a recently proposed technique for postoperative analgesia after breast cancer surgery. The thoracic paravertebral block is widely used for this purpose by decades. The presented study compares the efficacy of these two techniques for postoperative analgesia.

MATERIALS AND METHODS

Sixty adult women were undergoing unilateral radical mastectomy or quadrantectomy with axillary dissection. The patients were randomized to receive either pectoral nerve block with 30ml ropivacaine 0.375% (Pecs group) or thoracic paravertebral block with 20ml ropivacaine 0.5% (TPVB group). The evaluated variables included pain intensity by the numerical rating scale at 0, 2, 4, 6, 12, 18 and the 24 hours, 24-hour postoperative opioid (promedol) and nonopioid (ketoprofen) consumption and the time to first rescue analgesia.

RESULTS

There were no statistically significant differences between both groups in the pain intensity after surgery. Ten (33%) patients from Pecs group and nine (30%) patients from TPVB group did not require any analgesia within the first 24 hours (P = 0.793). The mean postoperative ketoprofen consumption was lower in Pecs group: 63.3 (± 66.87) mg vs. 90.0 (± 84.49) mg (&#1056; = 0.283). The number of patients who required promedol was 6 (20%) vs. 8 (27%) in Pecs and TPVB groups, respectively (&#1056; = 0.542). The time to first analgesic request was longer in Pecs group, 550 (400.0-600.0) min vs. 510 (360.0-600.0) min (&#1056; = 0.506) in TPVB group.

CONCLUSIONS

In breast cancer surgery, the pectoral nerve block type II with ropivacaine 0.375% can provide postoperative analgesia that is comparable to the single-level thoracic paravertebral block.

Ultrasound guided lateral quadratus lumborum block enhanced recovery in patients undergoing laparoscopic colorectal surgery

PURPOSE

This study aimed to evaluate the effects of lateral quadratus lumborum block (QLB) on postoperative pain and recovery in patients undergoing laparoscopic colorectal surgery.

MATERIALS AND METHODS

Patients between 18 and 70 years old, diagnosed with colon or rectal cancer, with American Society of Anesthesiologists (ASA) physical status I or II, and scheduled for laparoscopic colorectal surgery were recruited. Patients were excluded if they were allergic to local anesthetics and unable to complete the procedure of puncture or follow-up evaluation. All included patients were randomly allocated to either QLB or Sham group. The primary outcome was perioperative cumulative sufentanil consumption.

RESULTS

There were no significant differences between the groups in anesthetic time, operation time, dosage of propofol, and remifentanil (P ​> ​0.05). Patients in the QLB group had significantly less sufentanil consumption both intraoperatively and postoperatively, compared with the Sham group (P ​< ​0.05). Postoperative VAS pain scores on coughing in the QLB group at 2 ​h, 6 ​h, 12 ​h, 24 ​h time points and VAS pain score at rest 2 ​h, 6 ​h after surgery were significantly lower than in the Sham group (P ​< ​0.05). Compared with the Sham group, time to first ambulation and anal flatus after surgery in the QLB group were significantly shorter (P ​< ​0.05). Significant differences of postoperative rescue analgesic usage and QoR-15 score at 48 ​h were found between the two groups (P ​< ​0.05).

CONCLUSIONS

Ultrasound-guided lateral QLB significantly reduced perioperative opioid consumption, alleviated postoperative pain, shortened the time to first ambulation and anal flatus, and enhanced postoperative recovery of the patients undergoing laparoscopic colorectal surgery.

NGF-Induced Nav1.7 Upregulation Contributes to Chronic Post-surgical Pain by Activating SGK1-Dependent Nedd4-2 Phosphorylation

At present, chronic post-surgical pain (CPSP) is difficult to prevent and cure clinically because of our lack of understanding of its mechanisms. Surgical injury induces the upregulation of voltage-gated sodium channel Nav1.7 in dorsal root ganglion (DRG) neurons, suggesting that Nav1.7 is involved in the development of CPSP. However, the mechanism leading to persistent dysregulation of Nav1.7 is largely unknown. Given that nerve growth factor (NGF) induces a long-term increase in the neuronal hyperexcitability after injury, we hypothesized that NGF might cause the long-term dysregulation of Nav1.7. In this study, we aimed to investigate whether Nav1.7 regulation by NGF is involved in CPSP and thus contributes to the specific mechanisms involved in the development of CPSP. Using conditional nociceptor-specific Nav1.7 knockout mice, we confirmed the involvement of Nav1.7 in NGF-induced pain and identified its role in the maintenance of pain behavior during long-term observations (up to 14 days). Using western blot analyses and immunostaining, we showed that NGF could trigger the upregulation of Nav1.7 expression and thus support the development of CPSP in rats. Using pharmacological approaches, we showed that the increase of Nav1.7 might be partly regulated by an NGF/TrkA-SGK1-Nedd4-2-mediated pathway. Furthermore, reversing the upregulation of Nav1.7 in DRG could alleviate spinal sensitization. Our results suggest that the maintained upregulation of Nav1.7 triggered by NGF contributes to the development of CPSP. Attenuating the dysregulation of Nav1.7 in peripheral nociceptors may be a strategy to prevent the transition from acute post-surgical pain to CPSP.

Opioid prescribing exceeds consumption following common surgical oncology procedures

BACKGROUND AND OBJECTIVES

Surgical oncology patients are vulnerable to persistent opioid use. As such, we aim to compare opioid prescribing to opioid consumption for common surgical oncology procedures.

METHODS

We prospectively identified patients undergoing common surgical oncology procedures at a single academic institution (August 2017-March 2018). Patients were contacted by telephone within 6 months of surgery and asked to report their opioid consumption and describe their discharge instructions and opioid handling practices.

RESULTS

Of the 439 patients who were approached via telephone, 270 completed at least one survey portion. The median quantity of opioid prescribed was significantly larger than consumed following breast biopsy (5 vs. 2 tablets of 5 mg oxycodone, p < .001), lumpectomy (10 vs. 2 tablets of 5 mg oxycodone, p < .001), and mastectomy or wide local excision (20 tablets vs. 2 tablets of 5 mg oxycodone, p < .001). The majority of patients reported receiving education on taking opioids, but only 27% received instructions on proper disposal; 82% of prescriptions filled resulted in unused opioids, and only 11% of these patients safely disposed of them.

CONCLUSIONS

This study demonstrates that opioid prescribing exceeds consumption following common surgical oncology procedures, indicating the potential for reductions in prescribing.

Effects of morphological changes in the patellar tendon on the development of anterior knee pain after intramedullary nailing for tibial shaft fractures: A retrospective comparative study

OBJECTIVE

This study aimed to investigate the effects of morphological changes of the patellar tendon (length, width, and thickness) on the development of anterior knee pain (AKP) after intramedullary nailing (IMN) of tibial shaft fractures.

METHODS

A total of 39 patients, treated by IMN using the transpatellar approach for tibial shaft fractures, were retrospectively reviewed and included in the study. The patients were then divided into 2 groups based on the presence of AKP: group A, patients who developed AKP (9 men, 9 women; mean age=35.39±9.32 years), and group B, patients without AKP (13 men, 8 women; mean age=41.38±14.78 years). To assess the morphological changes in the patellar tendon, magnetic resonance imaging was performed on the operated and unoperated, contralateral knees of the patients. The patellar tendon index (PTI) was calculated using the length, width, and thickness of the patellar tendon, and a set of variables was established to be a proportion of the measurements of the operated knees to those of the unoperated ones (operated/healthy PTI ratio). PTI ratios were compared between both the groups. Furthermore, the morphological features of the patellar tendon, including the length, width, and thickness, were examined within the groups as independent variables. To assess pain intensity in group A, a 10-cm visual analogue scale (VAS) was used. To evaluate functional status, the Lysholm knee scoring system was used.

RESULTS

The PTI ratio was significantly higher in group A (1.37±0.12) than in group B (1.03±0.08) (p<0.001). In group A, the mean VAS score was 5.35±1.11, and a moderate linear correlation was found between PTI ratios and VAS scores (r=0.494, p=0.044). The mean Lysholm score was significantly lower in group A (80.17±3.05) than in group B (89.76±3.05) (p<0.001). In group A, the width and thickness of the patellar tendon were found to be significantly different between the operated and unoperated knees (p=0.024 and p=0.002, respectively). In group B, there was no difference between the operated and unoperated knees in terms of the 3 measurements (length, width, and thickness) (p=0.762, p=0.753, and p=0.118, respectively).

CONCLUSION

Evidence from this study revealed that morphological changes occurring in the patellar tendon after IMN for tibial shaft fractures using a transpatellar approach may have a significant role in the development of AKP. The increase in the tendon width and thickness may be the cause of pain and insufficient knee function in such patients.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Quadratus Lumborum Block As A Single Anesthetic Method For Laparoscopic Totally Extraperitoneal (Tep) Inguinal Hernia Repair: A Randomized Clinical Trial

Minimally invasive surgery for inguinal hernia repair is advantageous in terms of return to usual activities and lower rates of chronic pain; however, it requires general anesthesia. This study sought to analyze the benefits of ultrasound guided locoregional anesthesia of the quadratus lumborum muscle (QL block) as a single anesthetic technique for endoscopic totally extraperitoneal (TEP) inguinal hernia repair with regard to postoperative pain, length of hospital stay, and hospital cost. A total of 46 patients, aged 18 to 80 years, with unilateral inguinal hernia, one group that received general anesthesia and one that received sedation and QL block for TEP inguinal hernia repair. In the 46 patients the median pain score 6 hours after surgery was significantly lower (2 versus 4) among the QL block group than among the group receiving general anesthesia. Consequently, the former group showed a briefer median hospital stay (6 versus 24 hours, respectively). The anesthesia and hospital costs were also lower for the QL block group, with median reductions of 64.15% and 25%, respectively. QL block is a safe and effective option for patients undergoing TEP inguinal hernia repair, given the observed reduction in early postoperative pain, briefer hospital stay, and decreased anesthesia and hospital costs.

Patient reported postoperative pain with a smartphone application: A proof of concept

Postoperative pain management and pain assessment are still lacking the perspective of the patient. We have developed and studied a prototype smartphone application for patients to self-record postoperative pain. The main objective was to collect patient and stakeholder critique of improvements on the usability in order to develop a definitive version. The secondary objective was to investigate if patient self-recording compared to nurse-led assessment is a suitable method for postoperative pain management. Fifty patients and a stakeholder group consisting of ten healthcare- and ICT professionals and two members of the patient council participated in this study.

Paravertebral catheter versus EPidural analgesia in Minimally invasive Esophageal resectioN: a randomized controlled multicenter trial (PEPMEN trial)

BACKGROUND

Thoracic epidural analgesia is the standard postoperative pain management strategy in esophageal cancer surgery. However, paravertebral block analgesia may achieve comparable pain control while inducing less side effects, which may be beneficial for postoperative recovery. This study primarily aims to compare the postoperative quality of recovery between paravertebral catheter versus thoracic epidural analgesia in patients undergoing minimally invasive esophagectomy.

METHODS

This study represents a randomized controlled superiority trial. A total of 192 patients will be randomized in 4 Dutch high-volume centers for esophageal cancer surgery. Patients are eligible for inclusion if they are at least 18 years old, able to provide written informed consent and complete questionnaires in Dutch, scheduled to undergo minimally invasive esophagectomy with two-field lymphadenectomy and an intrathoracic anastomosis, and have no contra-indications to either epidural or paravertebral analgesia. The primary outcome is the quality of postoperative recovery, as measured by the Quality of Recovery-40 (QoR-40) questionnaire on the morning of postoperative day 3. Secondary outcomes include the QoR-40 questionnaire score Area Under the Curve on postoperative days 1-3, the integrated pain and systemic opioid score and patient satisfaction and pain experience according to the International Pain Outcomes (IPO) questionnaire, and cost-effectiveness. Furthermore, the groups will be compared regarding the need for additional rescue medication on postoperative days 0-3, technical failure of the pain treatment, duration of anesthesia, duration of surgery, total postoperative fluid administration day 0-3, postoperative vasopressor and inotrope use, length of urinary catheter use, length of hospital stay, postoperative complications, chronic pain at six months after surgery, and other adverse effects.

DISCUSSION

In this study, it is hypothesized that paravertebral analgesia achieves comparable pain control while causing less side-effects such as hypotension when compared to epidural analgesia, leading to shorter postoperative length of stay on a monitored ward and superior quality of recovery. If this hypothesis is confirmed, the results of this study can be used to update the relevant guidelines on postoperative pain management for patients undergoing minimally invasive esophagectomy.

TRIAL REGISTRATION

Netherlands Trial Registry, NL8037. Registered 19 September 2019.

Apical periodontitis healing and postoperative pain following endodontic treatment with a reciprocating single-file, single-cone approach: A randomized controlled pragmatic clinical trial

This trial assessed post-operative pain and healing of apical periodontitis following endodontic therapy with a reciprocating system compared to a crown-down technique with hand files and lateral compaction filling. One-hundred and twenty nonvital anterior teeth with apical periodontitis were randomly treated using either a reciprocating single file followed by matching-taper single-cone filling or a hand file and lateral compaction filling. Postoperative pain was assessed during the 7 days after the treatment, using a visual analogue scale and a verbal rating scale. Apical healing was assessed using the periapical index score after a 12-month follow-up. The hypothesis tested was that both protocols were equivalent and present similar effectiveness in healing periapical lesions. Data were analyzed through two one-sided tests, t-tests, as well as Mann-Whitney and Chi-squared tests (α = 0.05). Logistic regression was used to investigate the association of clinical and demographic factors with the success of treatment. Regardless of the assessment time, no difference in incidence (38%-43% at first 24h), intensity of postoperative pain, and incidence of flare-up (≈ 3%) was observed between the two endodontic protocols. Both protocols resulted in a similar healing rate of apical periodontitis. After 12 months, the success rate ranged from 73% to 78% and the difference between the treatments fell within the pre-established equivalence margin (-0.1; -0.41 to 0.2). Endodontic treatment combining a reciprocating single file with matching-taper single cone showed similar clinical effectiveness to the treatment using hand-file instrumentation and the lateral compaction filling.

Persistent post-discharge opioid prescribing after traumatic brain injury requiring intensive care unit admission: A cross-sectional study with longitudinal outcome

Traumatic brain injury (TBI) is associated with increased risk for psychological and substance use disorders. The study aim is to determine incidence and risk factors for persistent opioid prescription after hospitalization for TBI. Electronic medical records of patients age ≥ 18 admitted to a neuroscience intensive care unit between January 2013 and February 2017 for an intracranial injury were retrospectively reviewed. Primary outcome was opioid use through 12 months post-hospital discharge. A total of 298 patients with complete data were included in the analysis. The prevalence of opioid use among preadmission opioid users was 48 (87%), 36 (69%) and 22 (56%) at 1, 6 and 12-months post-discharge, respectively. In the opioid naïve group, 69 (41%), 24 (23%) and 17 (19%) were prescribed opioids at 1, 6 and 12 months, respectively. Preadmission opioid use (OR 324.8, 95% CI 23.1-16907.5, p = 0.0004) and higher opioid requirements during hospitalization (OR 4.5, 95% CI 1.8-16.3, p = 0.006) were independently associated with an increased risk of being prescribed opioids 12 months post-discharge. These factors may be used to identify and target at-risk patients for intervention.

Efficacy of concomitant acromioplasty in the treatment of rotator cuff tears: A systematic review and meta-analysis

Background

Scientific evidence is not clear regarding the routine use of acromioplasty in the treatment of rotator cuff repair. The aim of this study was to compare clinical outcomes between patients undergoing arthroscopic rotator cuff repair with and without concomitant acromioplasty.

Methods

Medline, Cochrane Library, and EMBASE databases were searched to identify eligible studies focused on arthroscopic rotator cuff repair with and without acromioplasty from January 2000 to February 2018. Postoperative functional outcomes, visual analog scale (VAS) for pain and reoperation rate were extracted for systemic analysis.

Results

Six randomized controlled trials (RCTs) and one cohort study (CS), including 651 patients, fulfilled our selection criteria. The results showed a significant difference in American Shoulder and Elbow Surgeons (ASES) score, but not in the Constant score, University of California-Los Angeles (UCLA) score, or Simple Shoulder Test (SST) score, in the treatment of rotator cuff tear with or without concomitant acromioplasty at the final follow-up. In the subgroup analysis, the results showed no significant differences between the two treatments in reoperation rate at the final follow-up or VAS score at 6 months postoperatively and final follow-up, but there was a significant difference in VAS score at 12 months postoperatively in favor of acromioplasty treatment. The evidence quality for each outcome evaluated by the GRADE system was low.

Conclusions

In summary, our present study demonstrated that acromioplasty treatment is significantly superior to nonacromioplasty in shoulder pain relief at 12 months postoperatively and in ASES score improvement at the final follow-up in conjunction with rotator cuff repair. However, these significant differences were not clinically relevant. Thus, there were no differences in shoulder function or pain scores for patients undergoing rotator cuff repair with and without acromioplasty. Further high-quality studies with larger sample sizes and long-term follow-ups are needed to clarify this issue.

Does reduction in sciatica symptoms precede improvement in disability and physical health among those treated surgically for intervertebral disc herniation? Analysis of temporal patterns in data from the Spine Patient Outcomes Research Trial

BACKGROUND CONTEXT

Pain, pain-related disability, and functional limitations are common consequences of intervertebral disc herniation (IDH). We hypothesized that surgical treatment reduces pain, leading to improvement in pain-related disability and, ultimately, better physical health.

PURPOSE

The present study aims to evaluate pathways for improvements in quality of life during the first year after surgery for IDH by studying temporal relationships between sciatica symptoms, pain-related disability, and physical health.

DESIGN

This is a secondary analysis of a randomized controlled trial using an "as treated" dataset.

PATIENT SAMPLE

The sample comprised 803 patients in the Spine Patient Outcomes Research Trial.

OUTCOME MEASURES

We used the Sciatica Bothersome Index, Oswestry Disability Index, and the Medical Outcomes Study Short Form 36 physical component score.

METHODS

We included 803 patients in the Spine Patient Outcomes Research Trial who underwent elective decompressive surgery for IDH between 2000 and 2004. Sciatica, pain-related disability, and physical health were assessed preoperatively and at 3 and 12 months postoperatively using the Sciatica Bothersome Index, Oswestry Disability Index, and Medical Outcomes Study Short Form 36 physical component score, respectively. Temporal associations of improvement in sciatica with pain-related disability and physical health were assessed using cross-lagged path analysis. p<.05 was considered significant. No funding was received in support of the present study. The authors declare no conflicts of interest.

RESULTS

Preoperatively, mean scores were 16.2±5.2 for sciatica, 54.2±20.7 for pain-related disability, and 29.8±8.4 for physical health. After adjustment for patient age and symptom duration, cross-lagged path analysis showed that sciatica reduction at 3 months was correlated with pain-related disability reduction at 3 months (ρ=.76, p<.001), and pain-related disability at 3 months was predictive of physical health at 12 months (β=-.33, p<.001) and sciatica at 12 months (β=.22, p<.001).

CONCLUSION

Three months after surgery, patients reported reduced sciatica and pain-related disability. Improvements in pain and pain-related disability occurred within 3 months. Early reduction in pain-related disability is important because path analysis indicated that disability at 3 months was predictive of sciatica and physical health at 1 year.

An evaluation tool for Myofascial Adhesions in Patients after Breast Cancer (MAP-BC evaluation tool): Concurrent, face and content validity

Purpose

To investigate the concurrent, face and content validity of an evaluation tool for Myofascial Adhesions in Patients after Breast Cancer (MAP-BC evaluation tool).

Methods

1) Concurrent validity of the MAP-BC evaluation tool was investigated by exploring correlations (Spearman’s rank Correlation Coefficient) between the subjective scores (0 –no adhesions to 3 –very strong adhesions) of the skin level using the MAP-BC evaluation tool and objective elasticity parameters (maximal skin extension and gross elasticity) generated by the Cutometer Dual MPA 580. Nine different examination points on and around the mastectomy scar were evaluated. 2) Face and content validity were explored by questioning therapists experienced with myofascial therapy in breast cancer patients about the comprehensibility and comprehensiveness of the MAP-BC evaluation tool.

Results

1) Only three meaningful correlations were found on the mastectomy scar. For the most lateral examination point on the mastectomy scar a moderate negative correlation (-0.44, p = 0.01) with the maximal skin extension and a moderate positive correlation with the resistance versus ability of returning or ‘gross elasticity’ (0.42, p = 0.02) were found. For the middle point on the mastectomy scar an almost moderate positive correlation with gross elasticity was found as well (0.38, p = 0.04) 2) Content and face validity have been found to be good. Eighty-nine percent of the respondent found the instructions understandable and 98% found the scoring system obvious. Thirty-seven percent of the therapists suggested to add the possibility to evaluate additional anatomical locations in case of reconstructive and/or bilateral surgery.

Conclusions

The MAP-BC evaluation tool for myofascial adhesions in breast cancer patients has good face and content validity. Evidence for good concurrent validity of the skin level was found only on the mastectomy scar itself.

Analgesic effects and pharmacologic mechanisms of the Gelsemium alkaloid koumine on a rat model of postoperative pain

Postoperative pain (POP) of various durations is a common complication of surgical procedures. POP is caused by nerve damage and inflammatory responses that are difficult to treat. The neuroinflammation-glia-steroid network is known to be important in POP. It has been reported that the Gelsemium alkaloid koumine possesses analgesic, anti-inflammatory and neurosteroid modulating activities. This study was undertaken to test the analgesic effects of koumine against POP and explore the underlying pharmacologic mechanisms. Our results showed that microglia and astroglia were activated in the spinal dorsal horn post-incision, along with an increase of proinflammatory cytokines (interleukin 1β, interleukin 6, and tumor necrosis factor α). Both subcutaneous and intrathecal (i.t.) koumine treatment after incision significantly prevented mechanical allodynia and thermal hyperalgesia, inhibited microglial and astroglial activation, and suppressed expression of proinflammatory cytokines. Moreover, the analgesic effects of koumine were antagonized by i.t. administration of translocator protein (18 kDa) (TSPO) antagonist PK11195 and GABAA receptor antagonist bicuculline. Together, koumine prevented mechanical allodynia and thermal hyperalgesia caused by POP. The pharmacologic mechanism of koumine-mediated analgesia might involve inhibition of spinal neuroinflammation and activation of TSPO. These data suggested that koumine might be a potential pharmacotherapy for the management of POP.

[THE COMPARATIVE ANALYSIS RESULTS OF ENDOVASCULAR LASER COAGULATION AND A STANDARD PHLEBECTOMY IN THE TREATMENT OF CHRONIC DISEASES OF THE LOWER EXTREMITIES VEINS]

The results of treatment of 58 patients, suffering chronic diseases of the lower extremities veins, were analyzed. In 28 patients a vertical reflux was eliminated using endovascular laser coagulation, in 32 patients--a standard phlebectomy in accordance to Babcock method was performed. The complications rate was compared as well as the term of the patients' stationary treatment. After elimination of endovascular laser coag- ulation the complications rate and severity is significantly lesser, than after a standard phiebectomy. In accordance to the ultrasonographic duplex scanning data in 12 mo in one patient a partial recanalization of large subcutaneous vein was noted. A total fibrous transformation of the coagulated venous trunks was achieved in 95.24% of the patients. Duration of postoperative stationary treatment have had reduced from (4.8 ± 0.8) to (1.2 ± 0.1) days (p < 0.001).

Activation of glial glutamate transporter via MAPK p38 prevents enhanced and long-lasting non-evoked resting pain after surgical incision in rats

Pain after surgery has recently become a major issue not only due to lack of treatment success in the acute phase; even more alarming is the large number of patients developing prolonged pain after surgery. Because spinal glutamate as well as spinal glia plays a major role in acute incisional pain, we investigated the role of the spinal glial glutamate transporters (GT), GLAST, GLT-1, for acute and prolonged pain and hyperalgesia caused by an incision. Spinal administration of the GT-inhibitor DL-TBOA increased non-evoked pain but not evoked pain behavior (hyperalgesia) up to 2 weeks after incision. In accordance, spinal GLAST (and to a lesser degree GLT-1) were upregulated after incision for several days. Long-term incision induced GT upregulation was prevented by long-lasting p38-inhibitor administration but not by long-lasting ERK1/2-inhibition after incision. In accordance, daily treatment with the p38-inhibitor (but not the ERK1/2 inhibitor) prolonged non-evoked but not evoked pain behavior after incision. In electrophysiological experiments, spontaneous activity of high threshold (HT) (but not wide dynamic range (WDR)) neurons known to transmit incision induced non-evoked pain was increased after prolonged treatment with the p38-inhibitor. In conclusion, our findings indicate a new spinal pathway by which non-evoked pain behavior after incision is modulated. The pathway is modality (non-evoked pain) and neuron (HT) specific and disturbance contributes to prolonged long-term pain after surgical incision. This may have therapeutic implications for the treatment of acute and - even more relevant - for prevention of chronic pain after surgery in patients.

[SURGICAL TREATMENT OF POSTOPERATIVE STRICTURE OF ANAL CHANNELL]

The results of treatment of 50 patients, suffering postoperative stricture of anal channell (SACH), who were treated in Proctology Department of Ivano-Frankivskiy Rural Clinical Hospital in 2006-2014 yrs, were analyzed. After conduction of hemorrhoidectomy in accordance to Milligan-Morgan method for chronic hemorrhoids grades III-IV a SACH have occurred in 46 (92%) patients, excision of a chronic anal fissura was performed in 3 (6%) and excision of perianal pointed condylomas--in 1 patient. In 2006-2007 yrs 11 (22%) patients were operated in accordance to approaches, which were conventional at that time (comparison group). In 2008 - 2014 yrs 39 (78%) patients were admitted to hospital (main group), in whom new approaches for diagnosis, conservative and surgical treatment were applied, 30 (76.9%) of them were operated. The proposed method on isolated roentgen contrast investigation of anal channell have permitted to determine objectively a form, diameter and grade of the anal channel stricture, and it may be applied as a screening procedure, as additional objective criterion while choosing a surgical tactic. Application of the improved operative technique for SACH have permitted to lower its occurrence rate from 45.4 to 6.7%.

Why Postoperative Pain Remains a Problem

Despite great progress in our understanding and management of pain, undertreatment of postoperative pain is still a major problem. There are individual patient differences in terms of nociception and perception, as well as varying responses to pain management. Postoperative pain can impact on the length of hospital stay, mobilization after surgery, and patient satisfaction. --This report is adapted from paineurope 2015: Issue 1, ©Haymarket Medical Publications Ltd, and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, LTD and is distributed free of charge to healthcare professionals in Europe. Archival issues can be viewed via the website: www.paineurope.com at which health professionals can find links to the original articles and request copies of the quarterly publication and access additional pain education and pain management resources.

The effect of intravenous magnesium sulfate infusion on sensory spinal block and postoperative pain score in abdominal hysterectomy

AIM

The aim of this study was to investigate the effect of i.v. infusion of magnesium sulphate during spinal anesthesia on duration of spinal block and postoperative pain.

METHODS

Forty ASA physical status I and status II, aged between 18 and 65, female patients undergoing abdominal hysterectomy under spinal anesthesia were enrolled in this study. Patients in the magnesium group (Group M, n = 20) received magnesium sulphate 65 mg kg(-1) infusion in 250 mL 5% dextrose at 3.5 mL/min rate, and control group (Group C, n = 20) received at the same volume of saline during operation in a double-blind randomized manner. Duration of sensory and motor block, systolic, diastolic, and mean arterial blood pressures, heart rates, pain scores (VAS values), and side effects were recorded for each patient. Blood and CSF samples were taken for analysis of magnesium concentrations.

RESULTS

Regression of sensorial block was longer in Group M when compared with that in Group C (175 ± 39 versus 136 ± 32 min) (P < 0.01). The VAS scores were lower in Group M than those in Group C at the 2 time points postoperatively (P < 0.01).

CONCLUSION

65 mg kg(-1) of magnesium sulphate i.v. infusion under spinal anesthesia prolongs spinal sensorial block duration and decreases pain VAS scores without complication in patients undergoing abdominal hysterectomy.

Comparative effects of vasectomy surgery and buprenorphine treatment on faecal corticosterone concentrations and behaviour assessed by manual and automated analysis methods in C57 and C3H mice

Establishing effective cage-side pain assessment methods is essential if post-surgical pain is to be controlled effectively in laboratory animals. Changes to overall activity levels are the most common methods of assessment, but may not be the most appropriate for establishing the analgesic properties of drugs, especially in mice, due their high activity levels. Use of drugs that can affect activity (e.g. opioids) is also a problem. The relative merits of both manual and automated behaviour data collection methods was determined in two inbred mouse strains undergoing vasectomy following treatment with one of 2 buprenorphine dose rates. Body weights and the effects of surgery and buprenorphine on faecal corticosterone were also measured.

Surgery caused abnormal behaviour and reduced activity levels, but high dose buprenorphine caused such large-scale increases in activity in controls that we could not establish analgesic effects in surgery groups. Only pain-specific behaviour scoring using the manual approach was effective in showing 0.05 mg/kg buprenorphine alleviated post-vasectomy pain. The C57 mice also responded better to buprenorphine than C3H mice, indicating they were either less painful, or more responsive to its analgesic effects. C3H mice were more susceptible to the confounding effects of buprenorphine irrespective of whether data were collected manually or via the automated approach. Faecal corticosterone levels, although variable, were higher in untreated surgery mice than in control groups, also indicating the presence of pain or distress.

Pain-specific scoring was superior to activity monitoring for assessing the analgesic properties of buprenorphine in vasectomised mice. Buprenorphine (0.01 mg/kg), in these strains of male mice, for this procedure, provided inadequate analgesia and although 0.05 mg/kg was more effective, not completely so. The findings support the recommendation that analgesic dose rates should be adjusted in relation to the potential severity of the surgical procedure, the mouse strain, and the individual animals' response.

[First experience of monoport laparoscopic surgery in the treatment of kidney diseases]

The results of research on the effectiveness of monoport laparoscopic surgery for kidney disease are presented. Operations using LESS method (Laparo-Endoscopic Single-Site Surgery) were performed in 21 patients, including 14 nephrectomies and 7 cyst resections. In five cases, nephrectomy was performed due to terminal hydronephrosis, in two cases--due to presence of arteriolosclerotic kidney, in seven cases--due to renal cell carcinoma (T1a-bN0M0). "Pain DETECT" questionnaire was used for assessment of pain symptom. Maximum longitudinal size of a removed organ was 14 cm, the average volume of intraoperative blood loss--80 ml. Duration of monoport laparoscopic radical nephrectomies ranged from 125 to 230 min (mean duration, 164 min). The time for renal cyst resection ranged from 40 to 120 minutes. Moderate intensity pain was observed in all patients but only at the first day after surgery. The average hospital stay was 4 days. The length of postoperative skin scar varied from 2.5 to 6.0 cm. Early and late postoperative complications were not observed. During follow-up period 6 to 8 months, tumor or cyst recurrence were not registered.

Does body mass index and position of impacted lower third molar affect the postoperative pain intensity?

The main objective of this study was to determine to which extent body mass index and position of impacted lower third molar was affecting the pain intensity in the first seven postoperative days. The study was conducted following the extraction of the lower third molar in 108 patients. Depending on the type of information given to each particular patient, the patients were divided in two groups: the test group where patients were given detailed standard written and verbal instructions and the control group which received only standard written instructions about treatment after surgery. Using canonical discriminant analysis we investigated the influence of body mass index and the position of impacted lower third molar on postoperative pain intensity in two groups of patients. Results of this study showed that the body mass index or the tooth position did not have influence on intensity of postoperative pain. The body mass index and the position of impacted lower third molar do not affect the postoperative pain intensity.

Evaluation of leukemia inhibitory factor (LIF) in a rat model of postoperative pain

Postoperative pain remains a significant problem despite optimal treatment with current pharmaceutical agents. In an effort to provide better postoperative pain control, there is a need to understand the factors that contribute to the development of pain after surgery. Leukemia inhibitory factor (LIF) is a pleiotropic cytokine released from tissues after injury. We hypothesized that LIF expression in skin, muscle, and dorsal root ganglion (DRG) would increase after plantar incision. The mRNA and protein expression of LIF and LIF receptor (LIF-R) were measured after plantar incision in the rat. Pain behaviors, immunohistochemistry, and C-fiber heat responses to LIF were also studied. LIF expression increased after incision in skin and muscle, and LIF-R was present in large and small DRG neurons. LIF administration to the hindpaw increased pain behaviors, a process that was reversed by anti-LIF. However, LIF and anti-LIF treatment at the time of incision did not augment or ameliorate pain behaviors. LIF treatment activated the second messenger system, JAK-STAT3, in cultured DRG neurons, but failed to alter spontaneous activity or heat responses in C-fiber nociceptors. In conclusion, LIF is not a target for postoperative analgesia; LIF may be important for skin and muscle repair and regeneration after incision.

PERSPECTIVE

This article highlights an incision pain model for the study of factors involved in nociception. The study demonstrates that LIF in is an unlikely target for novel early postoperative analgesics.

Prevention of scar tissue formation in spinal surgery: state of the art and review of the literature

Recurrent radicular pain after lumbar micro-discectomy may lead to reduced quality of life of the patient. Lumbar epidural fibrosis is believed to be one of the mechanisms involved in the genesis of the pain. The use of absorbable gel temporarily separating disc remnants, muscle or bone structures from the nerve roots could reduce the amount of scar tissue surrounding the nerve, reduce tethering and therefore pain, improve outcomes and facilitate revision surgery. The author reviews the literature on prevention techniques for lumbar epidural fibrosis. The most recent studies on new compounds are encouraging in terms of safety and clinical efficacy.

[Pasha-Cath in the treatment of neuropathic pain: case report]

In neuropathic pain, the nerve fibers themselves may be damaged, dysfunctional or injured. A 49-year-old female patient experienced radiating right anterior arm pain following an operation on the same arm. Visual analogue scale (VAS) score was 10. Tramadol, gabapentin and amitriptyline were started as medical treatment. In view of the persisting complaints, epidural pulsed radiofrequency with Pasha-Cath was scheduled. After 2 years, VAS remained at 1-2. It was concluded that epidural pulsed radiofrequency with Pasha-Cath is an alternative and effective choice of treatment in neuropathic pain when the medical treatment alone is not sufficient.

Consequences of persistent pain after lung cancer surgery: a nationwide questionnaire study

BACKGROUND

post-thoracotomy pain syndrome (PTPS) and its social consequences have been inconsistently investigated as most studies were either small sized, focused on a limited number of risk factors or included heterogeneous surgical procedures. The current objectives were to obtain detailed information on the consequences of PTPS after thoracotomy and video-assisted thoracic surgery (VATS) from homogenous unselected nationwide data, and to suggest mechanisms for the development of PTPS.

METHODS

data from 1327 patients were collected using a prospective national database and combined with a detailed questionnaire.

RESULTS

the response rate was 81.5%, resulting in 546 patients without prior thoracic surgery for the final analysis. Follow-up was 22 months (range 12-36). PTPS occurred in 33% thoracotomy patients and 25% VATS patients. Clinically relevant pain was present in 11-18% of the patients and severe pain in 4-12% depending on the level of physical activity. In PTPS patients, 64% also had pain from other locations on the body. Perceived sensory changes in the thoracic area were present in 63% of PTPS patients vs. 25% in pain-free patients (P<0.001). When comparing VATS with thoracotomy, no consistent differences in the prevalence, distribution of pain, sensory changes or effect of pain on daily activities were observed although clinically relevant and severe pain was reduced after VATS.

CONCLUSIONS

this nationwide study corroborates that PTPS is a clinically relevant problem influencing daily activities a long time after thoracotomy and VATS. Nerve injury and increased pain responsiveness may explain the majority of symptoms, the prevalence and distribution of pain including perceived sensory sensations.

[Complications of tongue base reduction with radiofrequency tissue ablation on obstructive sleep apnea hypopnea syndrome]

OBJECTIVE

To investigate the complications of tongue base reduction with radiofrequency tissue ablation on patients with obstructive sleep apnea hypopnea syndrome (OSAHS) and find out the effective prevention strategies.

METHODS

One hundred and ninety three OSAHS patients diagnosed by polysomnography were received tongue base reduction with radiofrequency tissue ablation between March 2008 and December 2009. The intraoperative and postoperative complications including bleeding, hematoma of tongue base, abscess of tongue base, altered taste, tongue numbness, deviation of tongue extension movement, dysfunctions of pronunciation and swallowing as well as the managements were analyzed retrospectively.

RESULTS

No perioperative complications occurred. There were 186 cases with postoperative pain (96.4%), 155 cases with submandibular edema (80.3%). Nocturnal sudden cardiac death was encountered in 1 case and secondary bleeding in 1 case. There was no ulceration of tongue base mucose, hematoma or abscess of tongue base, altered taste, tongue numbness, tongue deviations, speech, swallowing and taste disorder after operation. The scale of postoperative pain claimed by patients was ranged between mild to moderate. Diclofenac suppository had analgesic effect for these patients. The quantity of bleeding in patient with secondary hemorrhage was so little that after proper treatment the bleeding was stopped and never happened again. Patient with nocturnal sudden cardiac death occurred at thirty-seven hours after operation, because of swelling and pain of tongue base aggravated sleep apnea and night hypoxemia inducing fatal arrhythmia.

CONCLUSIONS

Postoperative pain and submandibular edema were 2 most common postoperative complications which can be easily controlled by antibiotics, Glucocorticoids and Diclofenac suppository. For those severe OSAHS patients accompanied by cardiopulmonary diseases, the tongue base reduction with radiofrequency tissue ablation can induce nocturnal sudden cardiac death. It is important to pay more attention on arrhythmias at night in severe OSAHS patients.

Evidence for a role of endocannabinoids, astrocytes and p38 phosphorylation in the resolution of postoperative pain

BACKGROUND

An alarming portion of patients develop persistent or chronic pain following surgical procedures, but the mechanisms underlying the transition from acute to chronic pain states are not fully understood. In general, endocannabinoids (ECBs) inhibit nociceptive processing by stimulating cannabinoid receptors type 1 (CB(1)) and type 2 (CB(2)). We have previously shown that intrathecal administration of a CB(2) receptor agonist reverses both surgical incision-induced behavioral hypersensitivity and associated over-expression of spinal glial markers. We therefore hypothesized that endocannabinoid signaling promotes the resolution of acute postoperative pain by modulating pro-inflammatory signaling in spinal cord glial cells.

METHODOLOGY/PRINCIPAL FINDINGS

To test this hypothesis, rats receiving paw incision surgery were used as a model of acute postoperative pain that spontaneously resolves. We first characterized the concentration of ECBs and localization of CB(1) and CB(2) receptors in the spinal cord following paw incision. We then administered concomitant CB(1) and CB(2) receptor antagonists/inverse agonists (AM281 and AM630, 1 mg x kg(-1) each, i.p.) during the acute phase of paw incision-induced mechanical allodynia and evaluated the expression of glial cell markers and phosphorylated p38 (a MAPK associated with inflammation) in the lumbar dorsal horn. Dual blockade of CB(1) and CB(2) receptor signaling prevented the resolution of postoperative allodynia and resulted in persistent over-expression of spinal Glial Fibrillary Acidic Protein (GFAP, an astrocytic marker) and phospho-p38 in astrocytes. We provide evidence for the functional significance of these astrocytic changes by demonstrating that intrathecal administration of propentofylline (50 microg, i.t.) attenuated both persistent behavioral hypersensitivity and over-expression of GFAP and phospho-p38 in antagonist-treated animals.

CONCLUSIONS/SIGNIFICANCE

Our results demonstrate that endocannabinoid signaling via CB(1) and CB(2) receptors is necessary for the resolution of paw incision-induced behavioral hypersensitivity and for the limitation of pro-inflammatory signaling in astrocytes following surgical insult. Our findings suggest that therapeutic strategies designed to enhance endocannabinoid signaling may prevent patients from developing persistent or chronic pain states following surgery.

Effects of ketamine added to ropivacaine in pediatric caudal block

OBJECTIVES

We aimed to determine the hemodynamic effects and postoperative pain control quality of ropivacaine and ketamine addition to ropivacaine in children undergoing inguinal hernia repair with caudal anesthesia.

METHODS

A total of 45 patients (1-4 years) scheduled to undergo inguinal hernia repair were studied. Anesthesia was induced with sevoflurane in O2/N2O and vecuronium was administered to facilitate endotracheal intubation. Anesthesia was maintained with sevoflurane in O2/N2O. Patients were randomly divided into three groups. Following endotracheal intubation, we administered 2 mg/kg 0.2% ropivacaine to Group R; 0.5 mg/kg ketamine to Group K; and 2 mg/kg 0.2% ropivacaine plus 0.5 mg/kg ketamine to Group R+K caudally. Pain levels were evaluated via modified CHEOPS, and sedation levels were assessed by the Wilson Sedation Scale.

RESULTS

At the postoperative 45th minute (min), the CHEOPS score was significantly higher in Group R compared to Group K and Group R+K (p<0.05). This score was significantly higher in Group R than in Group R+K at the postoperative 60th min (p<0.05). The effective analgesic period was significantly higher in Group K (852+/-309 min) and Group R+K (1032+/-270 min) than in Group R (435.5+/-273 min) (p<0.05). The analgesic requirement in the first 24 hours postoperatively was lower in Group R+K than the other groups. Sedation scores were below 2 in all groups. There were no significant differences between groups regarding adverse events.

CONCLUSION

The results of the present study indicate that caudal ropivacaine, ketamine and ropivacaine plus ketamine provided effective postoperative analgesia. Additionally, ketamine combined with ropivacaine lengthened the duration of analgesia while lowering analgesic requirements.

Utility of pathologic evaluation following removal of explanted orthopaedic internal fixation hardware

This report questions the cost and effectiveness of routinely sending explanted hardware to pathology for evaluation. Forty-six consecutive patients who had symptomatic hardware removed were enrolled in this study. Pathology reports following hardware removal were obtained, and charts were reviewed for these patients. The pathology department was contacted for related departmental procedure codes, and hospital billing records were obtained regarding the cost of the procedure. In all cases, the pathology reports gave the gross diagnosis of "hardware" and the gross description included the measurements of the internal fixation hardware removed. In no case did the report alter the plan of the attending physician. The healthcare system may benefit by subspecialty review of the current practice of sending internal fixation devices to pathology for evaluation. We recommend a single radiographic view along with proper documentation in the postoperative report to confirm the removal of internal fixation hardware in lieu of pathologic evaluation.

Redo kyphoplasty with vertebroplasty technique: a case report and review of the literature

Osteoporosis is a metabolic disorder which may result in devastating medical problems if not treated appropriately. However, even in the best treated patients fractures may occur. The most devastating fractures are spine and hip. Traditionally, treating fractures of the spine consisted of bed rest, opioid analgesic medications, and bracing. This resulted in increased risk of side-effects from medication, myocardial infarction, pulmonary embolism, pneumonia, admissions to nursing homes, and death. Vertebroplasty and kyphoplasty techniques were developed to decrease the detrimental effects of "conservative care" by decreasing or eliminating the pain and stabilizing the fracture. The safety and efficacy of vertebroplasty and kyphoplasty are similar with several biased opinions in the literature which denotes conflict. Choosing one technique over the other is a physician and/or facility performed preference. There are a small percentage of patients that either vertebroplasty or kyphoplasty does not help. Possibilities could be that not enough cement was used, an adjacent level fracture has occurred, or worsening fracture around the previously treated fracture is causing the pain. For the latter, a repeat vertebral augmentation could be medically necessary. Due to technical constraints, placing an additional kyphoplasty after one has already been accomplished may be technically dangerous and a simpler less costly vertebroplasty technique may be beneficial. This is a case report and review of the literature on the treatment of repeat vertebral augmentation after a previously treated vertebral fracture with kyphoplasty technique. To this date, this is the first article published regarding the use of vertebroplasty technique over a kyphoplasty treated patient. In this case report, a redo vertebroplasty was performed over a previously treated kyphoplasty or vertebroplasty. This procedure can give a patient significant pain relief when they are suffering with pain after a previously treated fracture.

Effect of intraarticular injection of lornoxicam on the articular cartilage & synovium in rat

BACKGROUND & OBJECTIVE

Intraarticular (i.a) drug application is consider to be a new therapeutic approach for the treatment of postoperative pain after arthroscopic knee surgery without any systemic adverse effects. Lornoxicam, a nonsteroid anti-inflammatory drug is a short acting agent, and its anti-inflammatory and analgesic activity may be effective in the postoperative pain management in minor surgery. In this study, the effects of intraarticular administration of lornoxicam on the synovium and articular cartilage in the rat knee joint were investigated.

METHODS

Lornoxicam (0.25 ml) was given as an injection into the right knee joint and 0.25 ml of 0.9 per cent saline solution by injection into the left knee joint as a control in 25 rats. Groups of five rats were sacrificed by a lethal injection of ketamine 1st, 2nd, 7th, 14th and 21st days after lornoxicam administration. Knee joints were detached, fixed in 10 per cent buffered formalin and decalcified. Serial sections of 5 microm were stained with haematoxylin-eosin and evaluated for the presence of inflammation in the articular, periarticular regions and synovium. Inflammatory changes in the joints were graded according to a five-point scale, histologically.

RESULTS

There were no significant differences in inflammation and cartilage degeneration, between control and lornoxicam applied knees. Grade 3 inflammatory changes occurred only in one knee in lornoxicam group, at 24 h after injection. No pathological changes were observed in both groups at any time point.

INTERPRETATION & CONCLUSION

Lornoxicam did not show significant effect on inflammation on rat synovia in knee joint. Further studies including in human need to be done before any recommendations are made for i.a. administration of lornoxicam.

Preponderance of sensory versus sympathetic nerve fibers and increased cellularity in the infrapatellar fat pad in anterior knee pain patients after primary arthroplasty

Sensory nerve fibers transmit pain perception and secrete pro-inflammatory substance P (SP). Sympathetic nerve fibers secrete anti-inflammatory norepinephrine and endogenous opioids, which inhibit pain perception in a bidirectional crosstalk with sensory fibers. In patients with anterior knee pain after primary arthroplasty of the knee (AKP), this study investigated in parallel the innervation of the infrapatellar fat pad by sensory and sympathetic nerve fibers. A total of 32 patients with osteoarthritis (OA) of the knee (n = 10), AKP after primary knee joint replacement (n = 7), and OA of the hip (n = 15) were included. Sensory nerve fibers were semiquantitatively detected by immunohistochemistry against SP, and sympathetic nerve fibers were stained with an antibody against tyrosine hydroxylase. Cellular density of the tissue was investigated by counting cell nuclei. The density of sympathetic nerve fibers in the fat tissue was similar in knee OA as compared to AKP. In the fat tissue, density of sensory substance P-positive nerve fibers was higher in AKP than in knee OA, which was not observed in the fibrosis capsule of the fat pad. The preponderance of sensory over sympathetic nerve fibers was accompanied by an increased cellular density in fat tissue in patients with AKP compared to knee OA. A positive correlation existed between cellularity and sensory nerve fiber density in fat tissue. This study revealed a preponderance of sensory over sympathetic innervation in the infrapatellar fat pad in AKP after primary arthroplasty of the knee, which possibly leads to aggravation and continuation of AKP and local inflammation.

Novel biomechanical quantification methodology for lumbar intraforaminal spinal nerve adhesion in a laminectomy and disc injury rat model

Spinal nerve fibrosis following injury or surgical intervention may play an important role in the pathophysiology of chronic back pain. In this current study, we demonstrate the role of biomechanical quantification of lumbar intraforaminal spinal nerve adhesion and tethering in the analysis of the post-laminectomy condition and describe a direct methodology to make this measurement. Twenty age-matched Sprague-Dawley male rats were divided into operative and non-operative (control) groups. Operative animals underwent a bilateral L5-L6 laminectomy with right-side L5-6 disc injury, a post-laminectomy pain model previously published by this lab. At eight weeks, animals were sacrificed and the strength of adhesion of the L5 intraforaminal spinal nerve to surrounding structures was quantified using a novel biomechanical methodology. Operative animals were found to have a significantly greater load to displace the intact right L5 spinal nerve through the intervertebral foramen when compared to control animals. The findings show that the post-laminectomy condition creates quantifiable fibrosis of the spinal nerve to surrounding structures and supports the conclusion that this fibrosis may play a role in the post-laminectomy pain syndrome.

Mid-term results of stapled hemorrhoidopexy for third- and fourth-degree hemorrhoids--correlation with the histological features of the resected tissue

BACKGROUND

Stapled hemorrhoidopexy is used to remove a circumferential strip of mucosa and submucosa about 4 cm above the dentate line, in order to restore the correct anatomical relationships of the anal canal structures. We evaluated the histological features of the resected tissue obtained after stapled hemorrhoidopexy with correlation to the short-term and mid-term results.

METHODS

This retrospective study evaluated 234 cases of stapled hemorrhoidopexy. Data concerning postoperative bleeding, anal pain, incontinence, stenosis, and recurrence of hemorrhoids were collected from hospital and outpatient clinic records. Histologic slides were examined for the type of epithelium, presence of muscle fibers, nerve endings, and degree of vascular ectasia.

RESULTS

Some 52% of the biopsies revealed on the surface a combination of glandular with squamous epithelium, meaning a stapling line at the level of the transitional zone/dentate line. Smooth muscle fibers were more frequent as the stapling line approached the level of the dentate line/transitional zone (p = 0.0028). Internal sphincter fibers were present in 36% of the cases, yet there were no cases of anal incontinence. Inclusion of merely squamous epithelium in the resected tissue correlated with severe postoperative pain persisting one week after surgery (p < 0.0001), whereas the concurrent presence of squamous and glandular epithelium correlated only with severe pain on the first postoperative day (p = 0.018). Nerve endings were more frequent in patients with anal pain one week after surgery (p = 0.02). The rate of recurrence of symptoms was 3%, which did not correlate with any of the histological parameters tested.

CONCLUSIONS

Though stapled hemorrhoidopexy is performed according to well-established technical guidelines, it is too difficult to be standardized.

Behavioral alterations and severity of pain in cats recovering at home following elective ovariohysterectomy or castration

OBJECTIVE

To identify behavioral alterations in client-owned cats recovering at home following elective ovariohysterectomy or castration and determine owner perceptions regarding severity of postoperative pain.

DESIGN

Cohort study. Animals-145 cats undergoing elective ovariohysterectomy (n = 80) or castration (65) at 4 veterinary clinics in Finland.

PROCEDURES

Owners were asked to complete a questionnaire on their cats' behavior during the 3 days after surgery. Owners were also asked to indicate their perceptions of the severity of postoperative pain during these days by use of a 100-mm visual analog scale.

RESULTS

Owners consistently indicated that there were changes in their cats' behavior, with the most commonly reported alterations being a decrease in overall activity level, an increase in the amount of time spent sleeping, a decrease in playfulness, and altered way of movement. Changes (ie, either an increase or decrease) in aggressive behavior were rare. Median pain score the day of surgery was 15.0 mm for male cats and 25.0 mm for female cats. Behavior score was significantly associated with day of observation, type of surgery (ovariohysterectomy vs castration), owner-assigned pain score, and veterinary clinic.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that behavioral alterations can be detected for several days after surgery in cats recovering at home following ovariohysterectomy or castration and emphasized owner concerns about the existence of postoperative pain.

Characterization of a model of persistent postoperative pain evoked by skin/muscle incision and retraction (SMIR)

Various surgical procedures, e.g. thoracotomy and inguinal hernia repair, frequently evoke persistent pain lasting for many months following the initial surgery. The essential prolonged tissue retraction required during such surgeries may account for the persistence and high incidence of postoperative pain in these patient populations. This study describes a new rat model of persistent postoperative pain evoked by skin/muscle incision and retraction (SMIR), akin to a clinical procedure. Under anaesthesia, skin and superficial muscle of the medial thigh were incised and a small pair of retractors inserted. This tissue was retracted for 1h causing potential stretch of the saphenous nerve. SMIR surgery evoked persistent significant mechanical hypersensitivity to von Frey stimulation of the plantar ipsilateral hindpaw, compared to either pre-surgery responses or concurrent responses of sham-operated rats. SMIR-evoked mechanical hypersensitivity was observed by postoperative day 3, most prominent between postoperative days 10 and 13, persisted until at least postoperative day 22 and had dissipated by postoperative day 32. Overall, mechanical sensitivity of the SMIR contralateral paw and the sham ipsilateral paw did not significantly change from pre-surgery responses. SMIR did not evoke significant heat hyperalgesia or cold allodynia. Light microscopy of saphenous nerve sections did not show degeneration or oedema in the saphenous nerve at, or proximally or distally to, the surgical site. In addition, very little to no degeneration was detected with ATF3 staining in DRG from SMIR-operated rats. These data suggest that prolonged retraction of superficial tissue evokes a persistent pain syndrome that is not driven by neuronal damage.

Cutaneous endothelin-A receptors elevate post-incisional pain

The contribution of endothelin-1 (ET-1), acting via endothelin-A receptors (ET(A)), on post-incisional pain was examined in a rat model of incision through the hairy skin of the lumbar dorsum. Post-incisional mechanical hyperesthesia was evaluated by cutaneous trunci muscle reflexes (CTMR) of subcutaneous muscles responding to stimulation with von Frey filaments near the wound (primary responses) and at a distance, especially on the contralateral dorsum (secondary responses, involving spinal circuits). The role of ET(A) was determined by pre-incisional, subcutaneous injection of the selective receptor antagonist BQ-123 at the incision site, 15 min or 24h before surgery. Control incisions showed both primary tactile allodynia and hyperalgesia, and a weaker secondary hyperesthesia, peaking 3-4h after surgery and lasting at least 24h. Primary allodynia, but not hyperalgesia, was dose-dependently suppressed by 15 min pre-incisional BQ-123. In contrast, both secondary allodynia and hyperalgesia were inhibited by local BQ-123. The suppression of primary allodynia by local antagonist disappeared in 24h, but that of secondary hyperesthesia remained strong for at least 24h. Systemically delivered BQ-123 was without effect on any post-incisional hyperesthesia, and if the antagonist was locally injected 24h before surgery there was no difference on hyperesthesia compared to vehicle injected at that time. We conclude that ET-1, released from skin by incision, activates nociceptors to cause primary allodynia and to sensitize spinal circuits through central sensitization. Blockade of ET(A) in the immediate peri-operative period prevents the later development of central sensitization.

Persistent pain in patients following scoliosis surgery

Chronic or persistent pain is increasingly recognised as a consequence of surgery in a number of different disciplines. The pain often exhibit qualities that differ from the acute post-operative pain and may represent changes in the central nervous system. There is lack of information regarding the incidence of persistent pain in patients following spinal surgery for scoliosis. This study aims to estimate the incidence of persistent pain following spinal surgery for scoliosis in a group of mainly adolescent patients. Questionnaires were distributed to consecutive patients attending the outpatient clinic of a hospital with specialist services in paediatric orthopaedics and spinal surgery. One hundred and five patients out of 122 eligible patients completed the survey. Fifty-two percent had ongoing pain upon hospital discharge either in the primary surgical site and/or in the iliac bone graft site. Approximately 10 and 7% of all patients had back and pelvic pain persisting beyond 12 months, respectively. A small proportion described elements of neuropathic pain. There was a trend suggesting that those who experienced more severe post-operative pain were more likely to develop persistent pain. These data are consistent with those reports that implicate surgery as the trigger for chronic pain.

From marrow oedema to osteonecrosis: common paths in the development of post-transplant bone pain

Osteonecrosis, the calcineurin-inhibitor-induced pain syndrome and transient marrow oedema may occur after renal transplantation, are generally painful and can be diagnosed by X-ray, radionuclide scan or magnetic resonance imaging. They share features of increased intraosseous pressure, compromised vascular supply, marrow oedema and the development of a 'bone compartment syndrome'. Glucocorticoid dosage is the most commonly implicated risk factor for osteonecrosis. Mechanisms may include the differentiation of mesenchymal stem cells to adipocytes causing increased intraosseous pressure and collapse of marrow sinusoids, as well as increased osteoblast and osteocyte apoptosis. Some of these effects may be ameliorated by lipid lowering drugs. Calcineurin-inhibitors, particularly cyclosporine, may increase the risk of osteonecrosis because of vasoconstrictive effects and sirolimus may influence the development of osteonecrosis by potentiating the effects of calcineurin inhibitors or by influencing the lipid profile. For osteonecrosis, early stages are generally managed conservatively or with core decompression sometimes accompanied by bone grafting and more recently the injection of bone morphogenic protein. The use of iloprost to improve blood flow and bisphosphonates and RANK-ligand inhibition to reduce osteoclastic resorption of remaining trabecular structures are as yet unproven strategies. Unfortunately, the rate of total hip arthroplasty remains high. For the calcineurin-inhibitor-induced pain syndrome and transient marrow oedema, calcium channel blockers, the reduction or withdrawal of calcineurin-inhibitors and core decompression have been used. Although a lack of randomized controlled trials makes management decisions difficult, early recognition of these bone pain syndromes affords the best opportunity for avoiding prolonged pain or joint replacement surgery.

Spinal glial activation contributes to postoperative mechanical hypersensitivity in the rat

The activation of spinal cord microglia and astrocytes after peripheral nerve injury or inflammation contributes to behavioral hypersensitivity. The contribution of spinal cord glia to mechanical hypersensitivity after hind paw incision has not been investigated previously. Male Sprague-Dawley rats underwent a unilateral plantar hind paw incision, and the development of mechanical hypersensitivity was assessed by using von Frey filaments. The activation of spinal cord microglia and astrocytes was measured 1, 2, 3, and 5 days after hind paw incision by using immunohistochemistry. The glial activation inhibitor, fluorocitrate, was administered intrathecally 24 hours after hind paw incision to determine glial involvement in mechanical hypersensitivity. Hind paw incision induced an activation of spinal astrocytes ipsilateral to incision within 24 hours. Both microglia and astrocytes reached a maximum activation 3 days after hind paw incision. Fluorocitrate produced a dose-dependent reduction in mechanical hypersensitivity when administered 24 hours after hind paw incision. Spinal cord glial activation contributes to the mechanical hypersensitivity that develops after hind paw incision.

PERSPECTIVE

Hind paw incision produces mechanical hypersensitivity that can be alleviated with the inhibition of spinal cord glia. Our results suggest that the activation of spinal cord astrocytes within 24 hours of incision contributes to mechanical hypersensitivity. Therefore, spinal cord astrocytes might represent a novel target for the treatment of postoperative pain.

Lactate Concentrations in Incisions Indicate Ischemic-like Conditions May Contribute to Postoperative Pain

The substances in wounds that cause incisional pain and hyperalgesia after surgery are poorly understood. We have developed and characterized rat models for incision-induced pain behaviors and measured increased tissue hydrogen ion concentration. Because lactate may facilitate nociceptor responses to low pH and contribute to ischemic pain mechanisms, we measured tissue lactate after incision of the plantar region of the hindpaw, gastrocnemius muscle, and paraspinal region in halothane anesthetized rats using in vivo microdialysis. Incisions were performed at 1 site (plantar, gastrocnemius, or paraspinal incision) in each rat. The corresponding contralateral side was used as the control. In anesthetized rats, a microdialysis fiber was passed into the incision and the control side. L-Lactate was measured using the lactate oxidase method. Tissue concentration was determined from postoperative day 0 to postoperative day 14 using the no net flux method. Lactate was increased on the day of hindpaw incision to 3.6 +/- 1.6 mmol/L compared with control (2.1 +/- .6 mmol/L) and remained increased through 7 days. In the gastrocnemius muscle, lactate was increased the day after incision (4.2 +/- 1.2 mmol/L vs 1.7 +/- .5 mmol/L) until postoperative day 7. On the day of the paraspinal incision, lactate was 3.4 +/- 1.1 mmol/L on the operated side and 2.2 +/- .6 mmol/L in the control side. Lactate remained increased through postoperative day 8 at the paraspinal incision. These experiments demonstrate that incision of the plantar hindpaw, the gastrocnemius muscle, and the paraspinal region increased tissue lactate concentration. The wound environment contains increased lactate at the same time that pH is decreased; lactate could potentially facilitate nociceptor activation by low pH and contribute to pain after surgery.

PERSPECTIVE

This study demonstrates that lactate is increased in wounds when pain behaviors and acid are increased. Lactate and low pH are present in incisions and indicate an ischemic pain mechanism that may contribute to postsurgical pain.