Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis.

BACKGROUND: The use of anticonvulsants (e.g., gabapentin, pregabalin) to treat low back pain has increased substantially in recent years despite limited supporting evidence. We aimed to determine the efficacy and tolerability of anticonvulsants in the treatment of low back pain and lumbar radicular pain compared with placebo. METHODS: A search was conducted in 5 databases for studies comparing an anticonvulsant to placebo in patients with nonspecific low back pain, sciatica or neurogenic claudication of any duration. The outcomes were self-reported pain, disability and adverse events. Risk of bias was assessed using the Physiotherapy Evidence Database (PEDro) scale, and quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Data were pooled and treatment effects were quantified using mean differences for continuous and risk ratios for dichotomous outcomes. RESULTS: Nine trials compared topiramate, gabapentin or pregabalin to placebo in 859 unique participants. Fourteen of 15 comparisons found anticonvulsants were not effective to reduce pain or disability in low back pain or lumbar radicular pain; for example, there was high-quality evidence of no effect of gabapentinoids versus placebo on chronic low back pain in the short term (pooled mean difference [MD] -0.0, 95% confidence interval [CI] -0.8 to 0.7) or for lumbar radicular pain in the immediate term (pooled MD -0.1, 95% CI -0.7 to 0.5). The lack of efficacy is accompanied by increased risk of adverse events from use of gabapentinoids, for which the level of evidence is high. INTERPRETATION: There is moderate- to high-quality evidence that anticonvulsants are ineffective for treatment of low back pain or lumbar radicular pain. There is high-quality evidence that gabapentinoids have a higher risk for adverse events. PROTOCOL REGISTRATION: PROSPERO-CRD42016046363.

Radiographic severity of knee osteoarthritis and its relationship to outcome post total knee arthroplasty: a systematic review.

BACKGROUND: Up to 20% of patients are dissatisfied after total knee arthroplasty (TKA). There are many contributing factors. The relationship between preoperative osteoarthritis (OA) severity and outcome post TKA remains unclear. This review explores the relationship between preoperative OA severity with patient reported pain, function and satisfaction post TKA. METHODS: A pre-registered systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Major databases were searched until September 2017. We included studies assessing adults undergoing TKA for OA. Minimum follow-up was 6 months. Methodological quality assessment was conducted using the Newcastle-Ottawa Scale. RESULTS: Twenty cohort studies with 7478 patients were included. There were 16 good, one fair and three poor quality studies. Knee OA was most commonly reported according to the Kellgren and Lawrence tool. Ten studies showed statistically significant pain outcomes for those with worse preoperative OA. This was supported by meta-analysis of the Knee Society Score pain change scores to final follow-up for those with Kellgren and Lawrence grade 4 OA. Six studies showed statistically significant results for various aspect of functional recovery, although meta-analysis of Knee Society Score function change scores identified no difference. Meta-analysis of final follow-up pain and function scores alone yielded no significant difference. Patients with more severe preoperative OA were more likely to be satisfied. There were no studies demonstrating that less severe OA resulted in better pain, function or satisfaction. CONCLUSION: Review of available research indicates that TKA for OA improves pain, function and satisfaction. Those with more severe preoperative radiological knee OA benefit most.

Accuracy of leg length and femoral offset restoration after total hip arthroplasty with the utilisation of an intraoperative calibration gauge.

BACKGROUND: Offset and leg length (LL) restoration are critical for the achievement of a stable, well-functioning hip following total hip arthroplasty (THA). Several techniques are described in the literature, including a hip calibration gauge. We question whether meticulous preoperative planning of a specific surgical technique in combination with the utilisation of a calibration gauge can provide an accurate offset and LL restoration. METHODS: Retrospective review of 101 unilateral THAs via a posterior approach by a single surgeon. Preoperative radiographic LL and offset were radiographically calculated. Intraoperatively prior to hip dislocation a calibration gauge was used to measure LL and offset with a pin inserted into the iliac crest acting as a static referencing point. All had pelvis x-ray performed 6 weeks postoperatively. A literature review was conducted to establish average postoperative LL/offset values for statistical comparison. RESULTS: The average absolute postoperative leg-length discrepancy (LLD) was 2.51 mm compared to preoperatively 3.54 mm (p = 0.018). A total of 93.1% and 100% had LLD of ⩽5 mm and ⩽10 mm, respectively. The mean postoperative offset difference was 2.39 mm. The investigated LLD and offset results were comparable with literature data of studies utilising an intraoperative measuring device. LLD was significantly decreased when compared to a free-hand technique (LLD 4.42 mm, p < 0.001). CONCLUSION: The technique utilising preoperative templating, intraoperative offset verification together with the use of hip calibration gauge yielded accurate LLD and offset restoration as in the literature. Precise offset restoration, which often is a neglected issue, can lead to better abductor vector restoration, hip function and less pain.

Effect of preoperative psychological interventions on elective orthopaedic surgery outcomes: a systematic review and meta-analysis.

BACKGROUND: Orthopaedic surgery is largely successful; however, a proportion of patients are dissatisfied and report pain and poor function. Psychological factors have been shown to influence orthopaedic surgical outcomes. This systematic review and meta-analysis investigates the types and effectiveness of preoperative psychological interventions in elective orthopaedic surgery. METHODS: A registered systematic review (PROSPERO CRD42017073833) was performed on literature (1960-January 2018) using eight databases. Prospective controlled clinical trials involving adult and adolescent elective orthopaedic surgery were included. Interventions examined included relaxation, cognitive behavioural therapy, hypnosis, emotional counselling and mixed psychotherapies; general procedural education was excluded. Outcomes extracted included pain, anxiety, quality of life and disability. RESULTS: A total of 19 studies met the inclusion criteria (n = 1893 patients). Meta-analyses were performed for pain, anxiety and quality of life. Analysis did not find enough evidence to confirm reduction in post-operative pain (seven studies, 666 patients; g = -0.15 (95% CI -0.42, 0.13), P = 0.305). Pooled data from six studies on acute post-operative anxiety (589 patients) showed a moderate statistically significant benefit (g = -0.26 (-0.49, -0.03), P = 0.024). There was an improved quality of life (mental component) at longer term follow-up (g = 0.25 (0.02, 0.49), P = 0.034). CONCLUSIONS: These studies provide evidence that psychological interventions have a positive effect on anxiety in the acute post-operative period, and on mental components of quality of life at longer term follow-up.

Efficacy and harms of orally, intramuscularly or intravenously administered glucocorticoids for sciatica: A systematic review and meta-analysis.

BACKGROUND: Sciatica can be a debilitating condition and there is limited guidance on the use of glucocorticoids administered via the oral, intramuscular or intravenous route for this condition. These represent viable treatment options in the primary care setting. OBJECTIVE: To evaluate the evidence on efficacy and harms of oral, IM and IV glucocorticoid administration for sciatica. DATABASES AND DATA TREATMENT: MEDLINE, EMBASE, CENTRAL, CINAHL, PsycINFO (inception to October 2018) were searched for randomised placebo-controlled trials evaluating oral, IV or IM glucocorticoid administration for sciatica. Two authors extracted outcomes data. Continuous pain and disability outcomes were converted to a 0 (no pain/disability) to 100 (worst pain/disability) scale. Data were pooled using a random effects model. Overall quality of evidence was assessed using GRADE. Primary outcomes were leg pain and disability. Primary follow-up period was the immediate-term (<2 weeks from administration). We also considered adverse events. RESULTS: Nine trials were eligible. One study [n = 27] provided low quality evidence of a small reduction in disability with early administration of oral prednisone (within 1 week); MD -13.4 [-23.3, -3.5] but not for pain MD -2.5 [-16.9, 11.9]. There was low quality evidence from one study [n = 78] of moderate reduction in disability and small reduction in pain with early (within 72 hr of symptom onset) single intramuscular administration of methylprednisolone acetate; MD -24.5 [-38.8, -10.2] and -14.0 [-27.4, -0.6], respectively. There were no immediate-term benefits with IV administration. CONCLUSION: The effects of glucocorticoids on immediate-term leg pain or disability are uncertain. Future large high quality trials are needed to resolve this uncertainty.

Giant lumbar pseudomeningocele after revision lumbar laminectomy: a case report and review of the literature.

INTRODUCTION: Incidental durotomy is a relatively common complication of spine surgery. Prevalence ranges from 3 to 5% in primary and 7 to 17% in revision procedures. Despite this relatively common occurrence the subsequent development of pseudomeningoceles following lumbar spine surgery is reported to be between 0.07 and 2%. Giant pseudomeningoceles (GP) are rare and therefore we report our experience with a case. CASE PRESENTATION: We report a case of an iatrogenic GP post revision lumbar surgery that extended 19 cm in length. The patient underwent revision L3-S1 laminectomy, laminotomy, excision of pseudomeningocele and successful direct dura repair. Postoperatively, a subcutaneous seroma persisted. This was managed with surgical exploration and prolonged drainage. This led to reduction of the seroma and symptomatic improvement for the patient. DISCUSSION: Incidental durotomy is a relatively common complication of spine surgery and if the durotomy is not addressed at the time of an operation a pseudomeningocele may develop. A pragmatic approach for GP is to individualise management based upon symptoms. Although GP are rare, prevention is likely the best approach. We outlined a structured approach to the management of an incidental dural leak that formed the largest reported pseudomeningocele reported to date.