A comparison of continuous femoral nerve block and periarticular local infiltration analgesia in the management of early period pain developing after total knee arthroplasty.

OBJECTIVE: This study aimed to compare the effects of 24-h continuous femoral nerve block (CFNB) and periarticular infiltration analgesia (PIA) on postoperative pain and functional results in the first 6 weeks after total knee arthroplasty (TKA). METHODS: Sixty patients who underwent unilateral TKA were included in this study. The patients were divided into two groups: Group A received CFNB and Group B received PIA. Each patient received 0.25% levobupivacaine and 1:100,000 epinephrine as infiltration to the posterior capsule. A patient-controlled analgesia (PCA) device was used for all patients, and 24-h tramadol usage by patients was recorded. We measured maximum range of motion (ROM), pain using a visual analog scale (VAS), 2-min walk test (2MWT), and the scores of Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Knee Society Score (KSS). RESULTS: Compared with Group B, Group A had lower postoperative opioid usage (p<0.05), less pain at rest (p<0.05), less pain with passive motion (p<0.05), less pain with movement and after active movement (p<0.05), and superior passive and active ROM (p<0.05). Group A also had better 2MWT results at 24 and 48 h after surgery (p<0.05), and superior WOMAC and KSS results at 6 weeks after surgery. CONCLUSION: As long as it is applied with infiltration analgesia to the posterior capsule, CFNB is an effective and safe analgesia method resulting in better postoperative patient comfort and greater ROM. Furthermore, it produces better results in the early postoperative period with a favorable side effect profile.

Intra-articular injection of dexketoprofen in rat knee joint: histopathologic assessment of cartilage & synovium.

BACKGROUND & OBJECTIVES: Effective pain control following outpatient surgical procedures is an important aspect of patient discharge. This study was carried out with an aim to investigate the histopathological effects of intra-articular dexketoprofen trometamol injection in knee joint on synovium and cartilage in an experimental rat model. METHODS: In each of 40 rats, the right knee was designated as the study group and the left knee as the control group (NS group). Under aseptic conditions, 35 rats received an injection of 0.25 ml (6.25 mg) dexketoprofen trometamol into the right knee joint and an injection of 0.25 ml 0.9 per cent normal saline solution into the left knee joint. On the 1st, 2nd, 7th, 14th, and 21st days after intra-articular injection, rats in specified groups were sacrificed by intraperitoneal injection of 120 mg/kg sodium thiopental. Knee joints were separated and sectioned for histopathological examination. Inflammatory changes in the joints were recorded according to a grade scale. RESULTS: No significant difference in terms of pathological changes both in synovium and cartilage was observed between the NS group and the study group on days 1, 2, 7, 14 and 21 after intra-articular injection of dexketoprofen or saline in the knee joint. INTERPRETATION & CONCLUSIONS: The findings showed no evidence of significant histopathological damage to the cartilage and synovia for a period up to 21 days following intra-articular administration of dexketoprofen trometamol in the knee joints of rats.

An unexpected complication of occipitocervical stabilization surgery: retropharyngeal hematoma.

BACKGROUND CONTEXT: To report a unique case of an unexpected complication of occipitocervical stabilization surgery that is retropharyngeal hematoma (RH). PURPOSE: Postoperative RH is a very rare complication and has never been reported after posterior occipitocervical surgery. STUDY DESIGN: Case report. METHODS: A 44-year-old woman being treated for rheumatoid arthritis for 20 years was admitted to our hospital in a wheelchair with the complaints of neck pain and weakness in both upper and lower extremities. She was diagnosed with basilar invagination, and occipitocervical (C0-C5) transpedicular fixation with osteosynthesis using iliac autograft was performed. The airway was seen as obstructed after extubation. The airway was maintained with laryngeal mask, and computed tomography revealed an RH. Emergent tracheotomy was performed. The patient was decannulated because of the resorption of RH after 10 days and was discharged. CONCLUSION: This patient is the first patient, to our knowledge, to be reported for unexplained RH after cervical posterior spinal surgery.

Preoperative ultrasound-guided suprascapular nerve block for postthoracotomy shoulder pain.

BACKGROUND: Acute postthoracotomy pain is a well-known potential problem, with pulmonary complications, ineffective respiratory rehabilitation, and delayed mobilization in the initial postoperative period, and it is followed by chronic pain. The type of thoracotomy, intercostal nerve damage, muscle retraction, costal fractures, pleural irritation, and incision scar are the most responsible mechanisms. OBJECTIVE: Our aim was to assess whether preoperative ultrasound suprascapular nerve block with thoracic epidural analgesia was effective for postthoracotomy shoulder pain relief. METHODS: Thirty-six American Society of Anesthesiologist classification physical status I-III patients (2011-2012), with a diagnosis of lung cancer and scheduled for elective open-lung surgery, were prospectively included in the study. Eighteen of the patients received an ultrasound-guided suprascapular nerve block with 10-mL 0.5% levobupivacaine, using a 22-gauge spinal needle, 1 hour before operation (group S); 18 other patients had thoracic epidural analgesia only, and no nerve block was performed. Standard general anesthesia was administered. Degree of shoulder pain was assessed by a blinded observer when discharging patients from the recovery room, and thereafter at 1, 3, 6, 12, 24, 36, 48, and 72 hours on infusion at rest and 12, 24, 36, 48, and 72 hours on coughing. The same blinded observer also recorded the total amount of epidural levobupivacaine and fentanyl used by the 2 groups. RESULTS: In the suprascapular block group, the total amount of levobupivacaine (P = 0.0001) and fentanyl (P = 0.005) used postoperatively was statistically lower than in the epidural group. Visual analogue scale measurements in the suprascapular group were statistically significantly lower at 0, 1, 3, 6, 12, 24, 36, and 48 hours than those in the epidural group, both at rest and coughing. CONCLUSION: Postthoracotomy shoulder pain reduces patient function and postsurgical rehabilitation potential after thoracotomy, and various studies on explaining the etiology and management of postthoracotomy shoulder pain have been conducted. Theories of the etiology involved either musculoskeletal origin or referred pain. In this study, we concluded that preoperative ultrasound-guided suprascapular nerve block with thoracic epidural analgesia could achieve effective shoulder pain relief for 72 hours postoperatively, both at rest and coughing.

Musculocutaneous neuropathy after anaesthesia for thyroid surgery: a case report.

Postoperative isolated injury of the musculocutaneous nerve is a rare disorder and complication. Reported cases are claimed to present with loss of biceps and brachialis power without neuropathic pain. When injury occurs to one of the terminal branches of the brachial plexus, the lateral cutaneous nerve of the forearm, pain is the major symptom and it typically radiates along the radial aspect of the forearm. In the literature, isolated lesions of the musculocutaneous nerve have been attributed to repeated microtrauma, indirect trauma or direct trauma to the nerve. It may also occur due to strenuous extension of the forearm for prolonged periods.

[Comparison of bupivacaine and levobupivacaine with epidural technique for labor analgesia]. / Epidural yöntem ile yapilan dogum analjezisinde bupivakain ve levobupivakainin karsilastirilmasi

OBJECTIVES: The labor pain is one of the most severe pains that a woman could ever be suffered. Today, many medical and psychological methods are used in an effort to reduce labor pain.Epidural analgesia is the best current method used for the purposes of obstetric analgesia. METHODS: The study was carried out on 60 ASA-I pregnant women whose 3 to 6 cm of cervical dilatation, treated in Health Ministry Istanbul Education and Research Hospital, Gynecology and Obstetrics Clinic, within vaginal labor process. With use of patient controlled epidural analgesia method, the bupivacaine combined with low dose fentanyl were administered to 30 pregnant women (Group B). Levobupivacaine, combined with low dose fentanyl applied with the same method was administered to another 30 pregnant women (Group L). Between the two groups, the hemodynamic parameters on the mother and fetus, the course of the labor process, severity of pain, its influences on newborn and mother satisfaction were compared. RESULTS: In our study, there was no difference as to motor block development between groups, but the sensory block was monitored less in group L at the minutes 15, 30, 45 and 90. Furthermore, the 5 minutes pain score was found lower in group L. The VAS values at the other times were similar between groups. CONCLUSION: In conclusion, with the usage of 0.125% bupivacaine or 0.125% levobupivacaine, sufficient labor analgesia is achieved with patient controlled epidural analgesia method at the same side effect frequency. Consequently, both local analgesic medicines are seemed to be safely used in labor analgesia.

[Combined spinal epidural anesthesia in a patient with advanced kyphoscoliosis]. / Ileri derecede kifoskolyotik hastada kombine spinal epidural anestezi deneyimimiz.

Kyphoscoliosis is a progressive disease that worsens with age. While applying anesthesia, kyphosis and/or scoliosis can lead to difficulty in both during endotracheal intubation and also performing regional interventional technics. In addition to aging and the direct effects of deformity such as neurological deficities and immobility; deterioration in cardiopulmonary functions can also develop in these patients. In this case, we aimed to report combined spinal epidural anesthesia experience in a-60-year-old woman with advanced kyphoscoliosis who underwent left femur periprostetic fracture operation. Spinal anesthesia was performed through L3-L4 intervertebral space by single dose of 10 mg %0.5 hyperbaric bupivacaine and epidural catheter was taken in for additional anesthesia and postoperative analgesia. Sufficient sensorial and motor block was provided and sensorial block was highen up to T6 dermatome level. There was no complication during the peroperative period and succesful anesthesia was established. Finally we conclude that combined spinal epidural anesthesia is a good alternative to general anesthesia in both reducing and preventing hemodynamic and respiratory complications for an elderly patient with kyphoscoliosis.

Multilevel decompressive laminectomy and transpedicular instrumented fusion for cervical spondylotic radiculopathy and myelopathy: A minimum follow-up of 3 years.

OBJECTIVE: Cervical laminectomies with transpedicular insertion technique is known to be a biomechanically stronger method in cervical pathologies. However, its frequency of use is low in the routine practice, as the pedicle is thin and risk of neurovascular damage is high. In this study, we emphasize the results of cervical laminectomies with transpedicular fixation using fluoroscopy in degenerative cervical spine disorder. MATERIALS AND METHODS: Postoperative malposition of the transpedicular screws of the 70 pedicles of the 10 patients we operated due to degenerative stenosis in the cervical region, were investigated. Fixation was performed between C3 and C7, and we used resected lamina bone chips for fusion. Clinical indicators included age, gender, neurologic status, surgical indication, and number of levels stabilized. Dominant vertebral artery of all the patients was evaluated with Doppler ultrasonography. Preoperative and postoperative Nurick grade of each patient was documented. RESULTS: No patients experienced neurovascular injury as a result of pedicle screw placement. Two patients had screw malposition, which did not require reoperation due to minor breaking. Most patients had 32-mm screws placed. Postoperative computed tomography scanning showed no compromise of the foramen transversarium. A total of 70 pedicle screws were placed. Good bony fusion was observed in all patients. At follow-up, 9/10 (90%) patients had improved in their Nurick grades. The cases were followed-up for an average of 35.7 months (30-37 months). CONCLUSIONS: Use of the cervical pedicular fixation (CPF) provides a very strong three-column stabilization but also carries vascular injury without nerve damage. Laminectomies technique may reduce the risk of malposition due to visualization of the spinal canal. CPF can be performed in a one-stage posterior procedure. This technique yielded good fusion rate without complications and can be considered as a good alternative compared other techniques.

[Assessment of the effect of intrathecal levobupivacaine combined with fentanyl or morphine on postoperative analgesia in patients undergoing cesarean section]. / Sezaryenlerde intratekal levobupivakaine ilave edilen fentanil ve morfinin postoperatif agri üzerine etkisinin degerlendirilmesi.

OBJECTIVES: Our prospective, randomized, double-blind study aimed to detect the effect of intrathecal levobupivacaine combined with fentanyl or morphine on the postoperative analgesia in patients undergoing cesarean section. METHODS: After approval by the hospital ethics committee and obtaining written informed consent, ASA I-II parturients undergoing elective cesarean section were enrolled in this study. None of the patients had any contraindication for spinal anesthesia or sensitivity to local anesthetics. Patients were randomly assigned in a double-blinded fashion to receive either intrathecal 10 mg 5% levobupivacaine + 0.1 mg morphine (Group M, n=30) or 10 mg 5% levobupivacaine + 20 mcg fentanyl (Group F, n=30). The onset of sensorial block and anesthesia, interval of effective analgesia until the first analgesic requirement, disappearance of motor block according to modified Bromage scale, duration of spinal analgesia, additional analgesic requirement, amount of additional analgesic, adverse effects, and postoperative patient satisfaction were recorded. RESULTS: The additional analgesic requirement period was significantly longer in Group M than Group F (p<0.001). Intraoperative and postoperative complications were significantly higher in Group F than Group M (p<0.05). Intended, delivered and total analgesic amount values were significantly higher in Group F than Group M (p<0.001). Patient satisfaction and presentation elsewhere were significantly higher in Group M than Group F (p<0.01). CONCLUSION: Despite more adverse effects, additional analgesic requirement is lower in Group M, and the long-term painless postoperative period accounts for the choice by mothers.

[The effect of perioperative infused dexmedetomidine on postoperative analgesic consumption in mastoidectomy operations]. / Mastoidektomi operasyonlarinda perioperatif verilen deksmedetomidinin postoperatif analjezik tüketimine etkisi.

OBJECTIVES: We aimed to investigate the effect of dexmedetomidine infusion on the amount of opioid that is consumed during the operation, the amount of analgesic that the patient requires after the operation and on pain scores. METHODS: Forty patients who were ASA I-II, between 18-50 years old, and who were scheduled for mastoidectomy operation were included in the study. Patients were randomized into two groups as group Dexmedetomidine (Group D) and group Placebo (Group P). Dexmedetomidine was administered at the rate of 0.5 mcg/kg/hour to the cases in Group D during operation and 9% NaCl was administered at the same rate and volume to the cases in Group P. Patients were connected to a Patient-Controlled Analgesia (PCA) device prepared with tramadol. Patients were followed for 24 hours. Ramsay Sedation Scale, visual analog scale (VAS), non-invasive systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), end-tidal sevoflurane, extubation times, total remifentanil consumption, total demand of PCA, and total tramadol consumption from PCA were recorded. RESULTS: No difference was determined between groups in demographic level and extubation times. Total remifentanil consumption, additional analgesic requirement, total demand of PCA, total amount of PCA consumption, and mean VAS were higher in the control group. First demand time of PCA was longer in the study group. CONCLUSION: Results of our study demonstrated that continuous infusion of dexmedetomidine during the operation could provide postoperative patient comfort without affecting the extubation time while concomitantly decreasing the consumption of tramadol.

Fibrous dysplasia in axis treated with vertebroplasty.

Vertebroplasty of the axis is a challenging procedure, and little is known about its therapeutic outcome. Cervical fibrous dysplasia with a distinct cyst is a rare entity and few cases have been reported in the literature. A 55-year-old man with fibrous dysplasia of axis presented with severe neck pain and left arm since six months. Computed tomography and magnetic resonance imaging revealed an expansile, destructive lesion involving the axis, and no spinal cord. He was submitted to retropharyngeal surgery and the lesion was fulled by vertebroplasty. Microscopic examination was consistent with the diagnosis of monostotic fibrous dysplasia. After the surgery no recurrence was observed. The patient had remarkable improvement in clinical relief of neck pain at 1-year follow-up. Although there are descriptions of vertebral fibrous dysplasia, this is the 13th case of monostotic fibrous dysplasia of the cervical spine, and the 3rd case of the axis described in the literature. The unique case who had treated with ope vertebroplasty.

Totally implantable venous access devices via subclavian vein: a retrospective study of 368 oncology patients.

Totally implantable catheters and totally implantable venous access devices (TIVADs) represent a valid method of administering long-term chemotherapy. TIVADs have several advantages over other methods of venous access: they are easy to implant under local anesthesia, they cause less discomfort for patients, and they can be implanted and managed on an outpatient basis. A total of 368 oncology patients were scheduled for percutaneous venous access devices. The purpose of this study was to examine the early and late complication rates of TIVADs used to deliver long-term chemotherapy. From June 2001 to January 2006, we placed 368 TIVADs, under x-ray guidance, for long-term chemotherapy in general oncology patients under local anesthesia (95% solid, 5% hematologic tumors). Percutaneous venous access devices were inserted into the subclavian vein, and adequate follow-up was provided in all cases (median, 145 d; range, 1-348 d). A total of 112 devices lpar;30%) remained in situ at the end of the study. Early complications of TIVADs included 9 (2.4%) arterial punctures, 2 (0.5%) malpositions, and 1 (0.3%) pneumothorax, which required no thoracic aspiration. Late complications included 3 cases (0.8%) of venous thrombosis, 2 cases (0.5%) of pocket infection, and 1 case (0.3%) of port-related bacteremia. This study describes a series of patients with subcutaneous infusion ports connected to various catheters. This device is a good option for long-term access to the subclavian vein; major complications related to implantation are rare, and ongoing management of these devices supports their increased use in oncology patients.

[The effects of clodronate for the pain treatment of bone metastasis due to prostate cancer]. / Kemik metastazi olan prostat kanserinde klodronat kullaniminin agri tedavisine etkisi.

Hormone refractory prostate cancer is dominated by osseous metastases. Bisphosphonates are able to reduce bone resorption. Sixteen hormone refractory prostate cancer patients with related bone metastases were included in the study. Group A consisted of patients who were not treated with bisphosphonates (n=9) and group B consisted of patients who had received bisphosphonates treatment previously, but not receiving currently (n=7). All patients were treated with the same analgesic medications. Clodronate 400 mg; 1200 mg/day (p.o.) was added to the treatment of the patients in group A. Visual Analogue Scale (VAS) scores, consumptions and side effects of analgesics were recorded by two week intervals. Alkaline phosphatase, creatinine and serum Ca++ levels were controlled by 4 week intervals. At the end of the 12th week, the study was ended. In Group A, VAS decreased at the end of the 2nd week but in Group B VAS decreased in the 4th week. VAS decreased 75% in group A and 65.7% in group B and the difference was considered statistically significant (p<0.0001). Clodronate treatment was stopped in 2 patients because of nausea, 7 patients are still being treated with clodronate. We conclude that bisphosphonates treatment of painful osseous metastasis due to hormone refractory prostate cancer results in significant pain decrease.

General anesthesia versus epidural and general anesthesia in radical cystectomy.

INTRODUCTION: The aim of this study is to compare two different anesthetic techniques in radical cystectomy with regard to blood loss, transfusional requirements, intraoperative complications and the quality of analgesia. MATERIALS AND METHODS: 50 patients scheduled for radical cystectomy were randomized to two groups: group GA - general anesthesia, n = 25 and group CEGA - combined epidural and general anesthesia. The patients were monitored and hemodynamic changes, intraoperative bleeding, transfusional requirements, quality of analgesia and postoperative complications were evaluated. RESULTS: There were no significant differences between the demographic characteristics of the two groups. Intraoperative bleeding which was 874.8 +/- 190.7 ml in the CEGA group and 1,248.3 +/- 343.4 ml in the GA group was statistically different (p < 0.05). Significantly more intraoperative blood transfusions in terms of units were required in the GA group. Analgesia was better in the CEGA group, with VAS values at 0, 1, 2, 4, 6, 12 and 24 h significantly (p < 0.05) lower than those observed in the GA group. No significant differences in intraoperative hemodynamic parameters or postoperative complications were noted between the two groups. CONCLUSIONS: Statistically significant differences in intraoperative bleeding were observed between the two groups: CEGA provides lower intraoperative bleeding and a better postoperative analgesia. Major operations such as radical cystectomy, which also is associated with considerable blood loss, a combination of general and epidural anesthesia may allow for less blood loss, with a better postoperative analgesia and without any increase in complications.

[Impact of surgery and trauma in developing chronic pain]. / Cerrahi ve travma sonrasi gelisen kronik agri.

Surgery and trauma are recognized as important causes of chronic pain. In this manuscript, we analyzed the patients who visited our clinic with posttraumatic or delayed surgical pain complaints between January 2001 and January 2004. Identification and evaluation of pain were done as defined in the taxonomy of IASP. Duration and severity of pain as well as diagnosis and etiology were evaluated as suggested in the taxonomy. Our results showed that 107 out of 2866 patients (4 %) were diagnosed of having chronic pain related to the history of trauma or surgery. The age range of the patients was from 32 to 66 years with an average of 48 years. Male/female ratio was 35/72. The duration of pain varied. 15 % of the patients complained of pain lasting for 1 to 6 months, 67 % complained of pain lasting for 6 to 24 months, and 18 % complained of pain lasting more than 24 months. A significant amount of patients (72 %) complained of very severe pain, 21 % complained of moderate pain, and finally only 7 % complained of mild pain. The diagnosis of pain were as follows: radiculopathy and postlaminectomy pain in 48 %, neuropathic pain in 33 %, phantom pain in 12 %, carpal syndrome in 6 %, and thalamic syndrome in 1 %. Pathogenesis of pain was evaluated to be originating from peripheral nervous system in 56 %, muscle and skeletal system in 43 %, and central nervous system in 1 % of the cases. Additionally, fifty-nine percent of the cases complained of back pain. Long-term (?1 year) and continuous follow up of postoperative and posttraumatic pain during acute course may prevent a significant amount of chronic pain complaints.

The effect of transdermal fentanyl treatment on serum cortisol concentrations in patients with non-cancer pain.

We treated 50 patients with chronic nonmalignant pain using transdermal fentanyl (TDF) 25 microg/hr and concurrently measured pain using a visual analog scale (VAS) and serum cortisol concentration. We determined these outcomes at baseline and on days 30, 60, and 90 of the therapy. The patients also were asked to document any adverse effects. We found that mean cortisol concentrations on days 30, 60, and 90 of therapy were significantly (P < 0.0001) lower than the basal mean cortisol level, and mean VAS scores at days 30, 60, and 90 of therapy were also significantly better than the initial mean value (P < 0.0001). Fourteen patients experienced severe adverse events. These observations suggest that serum cortisol concentrations may be elevated in chronic non-cancer pain states and that TDF therapy can reduce cortisol levels in parallel with reduction in pain.

Evaluation of adding preoperative or postoperative rectal paracetamol to caudal bupivacaine for postoperative analgesia in children.

BACKGROUND: Our aim was to investigate whether effects of caudal analgesia could be extended by preoperative or postoperative rectal paracetamol administration in children undergoing surgical repair of hypospadias. METHODS: The group consisted of 60 ASA I boys, aged 3-12 years, who were operated for surgical repair of hypospadias. The patients were randomized into three groups: patients in group I received rectal paracetamol (20-25 mg x kg(-1)) just before the operation. Group II received only caudal bupivacaine. Group III patients received rectal paracetamol (20-25 mg x kg(-1)) at the end of the operation. Pain was assessed by Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and the degree of sedation was evaluated. During the first 24 h, time to the patients' first analgesic requirement and the number of supplementary analgesics needed were recorded. RESULTS: There was no difference between the demographic and haemodynamic data of the three groups. In addition, the duration of surgery and anaesthesia, pain scores and sedation scores of the groups were not significantly different. CONCLUSIONS: Addition of preoperative or postoperative rectal paracetamol in the doses used did not show an effect on the duration and intensity of postoperative analgesia obtained by caudal bupivacaine.