Ultrasound-guided subcostal approach of transversus abdominis plane block compared with wound infiltration for postoperative analgesia following laparoscopic cholecystectomy: A systematic review and meta-analysis.

BACKGROUND: Despite laparoscopic cholecystectomy (LC) is a commonly performed operation under ambulatory setting, significant postoperative pain is still a major concern. The ultrasound-guided subcostal approach of transversus abdominis plane (sTAP) blocks and wound infiltration (WI) are both widely practiced techniques to reduce postoperative pain in patients undergoing LC. Although these methods have been shown to relieve postoperative pain effectively, the relative analgesic efficacy between ultrasound-guided sTAP blocks and WI is not well known. METHODS: We searched PubMed, EMBASE, and CENTRAL to identify all randomized controlled trials (RCTs) comparing ultrasound-guided sTAP block versus WI for postoperative pain control in adult patients undergone LC. The search was performed until May 2023. Primary outcome was defined as 24-hour cumulative opioid consumption. Secondary outcomes were postoperative pain scores and the incidence of postoperative nausea and vomiting (PONV). RESULTS: Finally, 6 RCTs were included, and data from 314 participants were retrieved. Postoperative 24-hour opioid consumption was significantly lower in ultrasound-guided sTAP group than in the WI group with a mean difference of -6.67 (95% confidence interval: -9.39 to - 3.95). The ultrasound-guided sTAP group also showed significantly lower pain scores. Incidence of PONV did not significantly differ between the 2 groups. CONCLUSIONS: We conclude that there is low to moderate evidence to advocate that ultrasound-guided sTAP block has better analgesic effects than WI in patients undergoing LC. Further trials are needed with robust methodology and clearly defined outcomes.

Comparing the effectiveness of pulsed radiofrequency treatment to lumbar dorsal root ganglion according to application times in patients with lumbar radicular pain: protocol for a randomised controlled trial.

INTRODUCTION: Lumbar radicular pain (LRP) is a common symptom characterised by a sharp, shooting or lancinating sensation localised to one or more dermatomes of the lumbar spine. Despite its high prevalence and significant impact on quality of life, the most effective conservative treatment for patients with LRP remains uncertain. When conventional treatment methods do not provide satisfactory results, the option of using epidural steroids and/or pulsed radiofrequency (PRF) treatment may be considered as a secondary approach for managing the condition. Ongoing advances in the field have led to a wide range of PRF parameters being investigated and extensively documented. Therefore, this study will aim to evaluate the treatment efficacy, sustainability and adverse effects of PRF application for different durations in patients with LRP. METHODS AND ANALYSIS: This study will be a double-blind, randomised, controlled trial. Eligible patients with LRP who visit the International St. Mary's Hospital pain clinic in Korea will be assigned to three groups (1:1:1 ratio) based on the duration of PRF application: 240, 360 and 480 s. Outcome measures will include an assessment of radicular pain intensity, physical function, global improvement, treatment satisfaction and adverse events. The primary outcome will be a Numeric Rating Scale (NRS) score 3 months after the procedure. The secondary outcomes will be the number of subjects in each group reporting successful treatment defined as a significant decrease of NRS or improved physical function score or high satisfaction at the 3 and 6 months follow-up. X2 or Fisher's exact test and one-way analysis of variance will be used to compare the outcomes. ETHICS AND DISSEMINATION: This trial was approved by the Ethics Committee of Catholic Kwandong University International St. Mary's Hospital (IS23EISE0018). The findings will be disseminated in peer-reviewed journals and at scientific conferences. TRIAL REGISTRATION NUMBER: KCT0008612.

Pulsed radiofrequency of lumbar dorsal root ganglion for lumbar radicular pain: A systematic review and meta-analysis.

BACKGROUND: Pulsed radiofrequency (PRF) of the lumbar dorsal root ganglion (DRG) has been widely used as a method to relieve lumbar radicular pain (LRP). However, the value of PRF application in LRP patients remains uncertain. This systematic review aimed to compare the effects of PRF of lumbar DRG and LEI in patients with LRP. METHODS: A literature search was performed using well-known databases for articles published up to May 2023. We included randomized controlled trials (RCTs) that evaluated the effects of PRF compared to LEI with or without steroids. We screened articles, extracted data, and assessed risk of bias in duplicate. The pain scores and Oswestry Disability Index (ODI) scores at 1, 3, and 6 months after procedures were obtained. A random-effects meta-analysis model was applied for outcomes. We evaluated evidence certainty for each outcome using the GRADE scoring system. This review was registered in the PROSPERO (ID: CRD42021253628). RESULTS: A total of 10 RCTs were included and data of 613 patients were retrieved. We assessed the overall quality of the evidence as very low to moderate. PRF showed no difference in pain scores at 1 (mean difference [MD] -0.80, 95% confidence interval [CI] -1.59 to 0.00, low certainty) and 6 months (MD -2.37, 95% CI -4.79 to 0.05, very low certainty), and significantly improved pain scores at 3 months (MD -1.31, 95% CI -2.29 to -0.33, low certainty). There was no significant difference in ODI score at any interval (very low to low certainty). In the subgroup who underwent a diagnostic block, did not use steroids, and PRF duration greater than 360 s, PRF significantly reduced pain scores at 3 months after procedures. CONCLUSIONS: We found low quality of the evidence supporting adjuvant PRF to the lumbar DRG has a greater analgesic effect at 3 months after procedures in patients with LRP than LEI. We identified no convincing evidence to show that this treatment improves function. High-quality evidence is lacking, and data were largely derived from short-term effects. Given these limitations, high-quality trials with data on long-term effects are needed.

Output Current and Efficacy of Pulsed Radiofrequency of the Lumbar Dorsal Root Ganglion in Patients With Lumbar Radiculopathy: A Prospective, Double-blind, Randomized Pilot Study.

BACKGROUND: Lumbar radicular pain (LRP) is a common but challenging clinical symptom. Pulsed radiofrequency (PRF), a neuromodulation technique that uses short pulses of radiofrequency current, is effective in treating various pain disorders. However, few studies have been conducted on the effects of PRF and its modifying parameters. OBJECTIVES: Our study aimed to determine the intraoperative parameters of PRF of the lumbar dorsal root ganglion (DRG) that are related to clinical effects in patients with LRP unresponsive to transforaminal epidural steroid injections (TFESI). STUDY DESIGN: Prospective double-blind randomized controlled trial, pilot study. SETTING: Single medical center in the Republic of Korea. METHODS: Patients were allocated to one of 2 groups, high-voltage (60 V) or standard-voltage (45 V), according to the preset maximum voltage at which the active tip temperature does not exceed 42°C. Intraoperative parameters, such as output current, sensory threshold, and impedance, were measured. The primary outcomes were radicular pain intensity, physical functioning, global improvement and satisfaction with treatment, and adverse events. The assessments were performed up to 3 months postprocedure. RESULTS: The patients in the standard-voltage group showed significant improvements in the Numeric Rating Scale pain score (P = 0.007) and Oswestry Disability Index (ODI) (P = 0.008) scores at 3 months post-PRF; however, no difference was observed in the high-voltage group. Among the intraoperative parameters, the output current showed a significant negative linear relationship with analgesic efficacy. The output current also showed a significant association with pain intensity (P = 0.005, R2 = 0.422) and ODI score (P = 0.004, R2 = 0.427) at 3 months postprocedure in a multiple regression analysis. The optimal cut-off value of the output current to lower pain intensity after 3 months was 163.5 mA with a sensitivity of 87.5%, specificity of 100%, and an area under the receiver operating characteristic curve value of 0.92 (95% CI. 0.76 - 1.00). LIMITATIONS: Limitations of our study include an imbalance of baseline characteristics, small sample sizes, and short follow-up periods. CONCLUSIONS: Lower output currents during PRF application to the lumbar DRG were associated with greater analgesic effects in patients who did not respond to therapeutic TFESI.

The cervical ligamentum flavum area: A new sensitive morphological parameter for identifying the cervical spinal stenosis.

Thickening of the cervical ligamentum flavum (CLF) has been considered as a main cause of cervical spinal stenosis (CSS). A previous study reported that cervical ligamentum flavum thickness (CLFT) is correlated with CSS. However, the whole hypertrophy is different from focal thickness. Therefore, to analyze hypertrophy of the CLF, we created a new morphological parameter, called the cervical ligamentum flavum area (CLFA). We hypothesized that the CLFA is an important morphological parameter in the diagnosis of CSS. CLF samples were acquired from 83 patients with CSS, and from 84 controls who underwent cervical magnetic resonance imaging (C-MRI). T2-weighted axial C-MRI images were acquired. We measured the CLFA and CLFT at the C6-C7 intervertebral level on C-MRI using appropriate image analysis software. The CLFA was measured as the cross-sectional area of the entire CLF at the level of C6-C7 stenosis. The CLFT was measured by drawing a straight line along the ligament side towards the spinal canal at the C6-C7 level. Mean CLFA was 25.24 ±â€…6.43 mm2 in the control group and 45.34 ±â€…9.09 mm2 in the CSS group. The average CLFT was 1.48 ±â€…0.28 mm in the control group and 2.09 ±â€…0.35 mm in the CSS group. CSS patients had significantly higher CLFA (P < .01) and CLFT (P < .01). For the validity of both CLFA and CLFT as predictors of CSS, a receiver operating characteristic curve analysis revealed an optimal cutoff point for the CLFA was 31.66 mm2, a sensitivity of 92.8%, specificity of 88.4%, and an area under the curve of 0.97 (95% CI, 0.94-0.99). The optimal cut off-point of the CLFT was 1.79 mm, with a sensitivity of 83.5%, specificity of 84.5%, and an area under the curve of 0.92 (95% CI, 0.87-0.96). Both CLFT and CLFA were significantly related to CSS, but CLFA was the more sensitive measurement parameter. Therefore, to evaluate patients with CSS, treating physicians should test for CLFA.

The arousal effect of sugammadex reversal of neuromuscular blockade differs with anesthetic depth in propofol-remifentanil anesthesia: a randomized controlled trial.

Sugammadex reverses neuromuscular blockade by encapsulating steroidal neuromuscular blockers; therefore, it does not pharmacologically affect sedation levels. However, some clinicians avoid using it because of sudden unwanted acting out or patient arousal. Previous studies suggested sugammadex-induced awakening, but frontal muscle contraction after sugammadex administration compromised reliability of results obtained from EEG-based anesthesia depth monitoring tools like bispectral index (BIS). We hypothesized that sugammadex would affect patients' arousal depending on their baseline levels of sedation. We evaluated arousal signs after sugammadex administration with BIS between 25 - 35 and 45 - 55 under steady-state propofol-remifentanil anesthesia at the end of a surgery (n = 33 in each group). After sugammadex administration, twelve patients with a BIS of 45 - 55 showed clinical signs of awakening but none with a BIS of 25 - 35 (36.4% vs. 0%, P = 0.001). The distribution of the modified observer's assessment of alertness/sedation scale scores was also significantly different between the two groups (P < 0.001). Changes in the BIS were significantly greater in the BIS 45 - 55 than in the 25 - 35 group (median difference, 7; 95% CI 2 - 19, P = 0.002). Arousal after sugammadex was affected by patient sedation levels, and clinical signs of awakening appeared only in those with BIS 45 - 55. Unwanted arousal of the patient should be considered when using sugammadex under shallow anesthesia.Clinical trial registry number: Clinical Trial Registry of Korea ( https://cris.nih.go.kr ; Principal investigator: Jieae Kim; Registration number: KCT0006248; Date of first registration: 11/06/2021).

Magnetic resonance imaging for assessment of the quadriceps tendon cross-sectional area as an adjunctive diagnostic parameter in patients with patellofemoral pain syndrome.

OBJECTIVES: In this study, we aimed to provide a more valuable diagnostic parameter and more equivocal assessment of the diagnostic potential of patellofemoral pain syndrome (PFPS) by comparing the quadriceps tendon cross-sectional area (QTCSA) with the quadriceps tendon thickness (QTT), a traditional measure of quadriceps tendon hypertrophy. PATIENTS AND METHODS: Between March 2014 and August 2020, a total of 30 patients with PFPS (16 males, 14 females; mean age, 30.4±11.2 years; range, 16 to 49 years) and 30 healthy individuals (19 males, 11 females; mean age: 30.8±13.8 years; range, 17 to 62 years) who underwent knee magnetic resonance imaging (MRI) were retrospectively analyzed. T1-weighted turbo spin-echo transverse MRI scans were obtained. The QTCSA was measured on the axial angled phases of the images by drawing outlines, and the QTT was measured at the most hypertrophied quadriceps tendon. RESULTS: The mean QTT and QTCSA in the patients with PFPS (6.33±0.80 mm and 155.77±36.60 mm2, respectively) were significantly higher than those in the control group (5.77±0.36 mm and 111.90±24.10 mm2, respectively; p<0.001, for both). The receiver operating characteristic curve was used to confirm the sensitivities and specificities for both the QTT and QTCSA as predictors of PFPS. The optimal diagnostic cut-off value for QTT was 5.98 mm, with a sensitivity of 66.7%, a specificity of 70.0%, and an area under the curve (AUC) of 0.75 (range, 0.62 to 0.88). The optimal diagnostic cut-off value for QTCSA was 121.04 mm2, with a sensitivity of 73.3%, a specificity of 70.0%, and an AUC of 0.83 (range, 0.74 to 0.93). CONCLUSION: Based on our study results, the QTCSA seems to be a more reliable diagnostic indicator for PFPS than QTT.

Comparison of ligamentum flavum thickness between central and lateral lesions in a patient with central lumbar spinal canal stenosis.

Thickened ligamentum flavum has been considered as a major cause of central lumbar spinal canal stenosis (CLSCS). Previous studies have demonstrated that ligamentum flavum thickness (LFT) is correlated with aging, degenerative spinal stenosis, and disc degeneration. Thus, hypertrophy of the ligamentum flavum is a major cause of CLSCS, and measurement of LFT has been considered a morphologic parameter in the diagnosis of CLSCS. To our knowledge, comparison of LFT between central and lateral lesions has not been reported. In addition, no research has analyzed best clinical cutoff values of central ligament flavum thickness (CLFT) and lateral ligament flavum thickness (LLFT). This study aimed to compare CLFT with LLFT in patients with CLSCS and further compare the CLFT and LLFT findings between the 2 groups to analyze LFT variation. Both CLFT and LLFT samples were collected from 101 participants with CLSCS and from 103 participants in the control group who underwent lumbar magnetic resonance imaging without evidence of CLSCS. Axial T2-weighted lumbar magnetic resonance scans were acquired at the L4 to 5 facet joint level from each participant. Average CLFT value was 2.25 ± 0.51 mm in the control group and 4.02 ± 0.74 mm in the CLSCS group. Average LLFT value was 2.50 ± 0.51 mm in the control group and 3.38 ± 0.66 mm in the CLSCS group. CLSCS patients had significantly higher CLFT and LLFT (both P < .001). Regarding the validity of both CLFT and LLFT as predictors of CLSCS, a receiver operating characteristic estimation revealed that the most suitable cutoff value for CLFT was 3.10 mm, with sensitivity of 95.0%, specificity of 94.2%, and an area under the curve of 0.97. The best cut-off value of LLFT was 2.92 mm, with sensitivity of 78.2%, specificity of 77.7%, and area under the curve of 0.87. We have 4 important new findings: The mean CLFT is significantly lower than that of the mean LLFT in the normal control group; CLFT and LLFT are both significantly associated with CLSCS; Increase rate of CLFT is faster than that of LLFT in the CLSCS group; and CLFT is a more sensitive measurement parameter to predict CLSCS than LLFT.

Comparison of efficacy according to voltage of pulsed radiofrequency treatment to lumbar dorsal root ganglion in patient with lumbar radiculopathy: Pilot study.

BACKGROUND: Lumbar radicular pain (LRP) is a common symptom, but a challenging clinical problem. Pulsed radiofrequency (PRF) is a more recently developed technique that uses short pulses of radiofrequency current with intervals of longer pauses to prevent temperature from rising to the level of permanent tissue damage and has been advocated in treatment of such patients. But there were no comparative studies on the analgesic effects according to output voltage during PRF in patients with LRP. The goal of this study is to determine the clinical effect of high-voltage (60V) versus standard-voltage (45V) PRF of lumbar dorsal root ganglion. METHODS/DESIGN: This study will be a prospective, double-blind randomized controlled pilot study. In this study, total 20 patients will be recruited and distributed equally into 2 groups: high-voltage (60V) PRF, low-voltage (45V) PRF. Outcomes will be radicular pain intensity; physical functioning; global improvement and satisfaction with treatment; and adverse events. The assessments will be performed at the 3-month follow-up period after the end of the treatments. The findings will be analyzed statistically considering a 5% significance level (P ≤ .05). DISCUSSION: The results of this trial will help determine which voltage could be applied for PRF to dorsal root ganglion in LRP and be a basis for subsequent trials.

A new diagnostic morphological parameter for the Carpal tunnel syndrome: The palmaris longus tendon cross-sectional area.

Carpal tunnel syndrome (CTS) is correlated with increased intracarpal canal pressure (ICP). The effect of palmaris longus tendon (PLT) loading on ICP is documented in previous researches. PLT loading induces the greatest absolute increase in ICP. Therefore, to analyze the connection between the PLT and CTS, we newly made the measurement of the PLT cross-sectional area (PLTCSA). We assumed that PLTCSA is a reliable diagnostic parameter in the CTS. PLTCSA measurement data were acquired from 21 patients with CTS, and from 21 normal subjects who underwent wrist magnetic resonance imaging (W-MRI). We measured the PLTCSA at the level of pisiform on W-MRI. The PLTCSA was measured on the outlining of PLT. The two different cutoff values in the analysis were determined using receiver operating characteristic (ROC) analysis. The mean PLTCSA was 2.34 ± 0.82 mm2 in the normal group and 3.97 ± 1.18 mm2 in the CTS group. ROC curve analysis concluded that the best cutoff point for the PLTCSA was 2.81 mm2, with 76.2% sensitivity, 71.4% specificity, and area under the curve of 0.88 (95% CI, 0.78-0.98). PLTCSA is a sensitive, new, objective morphological parameter for evaluating CTS.

The use of renin angiotensin aldosterone system inhibitors may be associated with decreased mortality after cancer surgery.

Renin-angiotensin-aldosterone system (RAAS) inhibitors are antihypertensive agents with conflicting results on protective effects against some types of cancer. In light of these controversies, we aimed to study the effects of RAAS inhibitors in patients undergoing cancer surgery. From March 2010 to December 2019, consecutive adult patients with antihypertensive drug prescription at discharge after cancer surgery were enrolled and divided into two groups according to RAAS inhibitors prescription. The primary outcome was 5-year mortality after surgery. Secondary outcomes included mortalities during 3-year and 1-year follow-ups and cancer-specific mortality and recurrence rates during 5-, 3-, and 1-year follow-ups. A total of 19,765 patients were divided into two groups according to RAAS inhibitor prescription at discharge: 8,374 (42.4%) patients in the no RAAS inhibitor group and 11,391 (57.6%) patients in the RAAS inhibitor group. In 5022 pairs of propensity-score matched population, 5-year mortality was significantly lower in the RAAS inhibitor group (11.4% vs. 7.4%, hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.64-0.83, P < 0.001), and 5-year recurrence rate was also lower for the RAAS inhibitor group (5.3% vs. 3.7%, HR 0.82, 95% CI 0.68-0.99, P = 0.04). In our analysis, RAAS inhibitor was associated with decreased 5-year mortality in hypertensive patients who underwent cancer surgery. Prescription of RAAS inhibitor in accordance with current guidelines may be associated with improved mortality after cancer surgery.

Association between preoperative neutrophil-lymphocyte ratio and mortality after plastic and reconstructive surgery.

Predictive factors associated with postoperative mortality have not been extensively studied in plastic and reconstructive surgery. Neutrophil-lymphocyte ratio (NLR), a systemic inflammation index, has been shown to have a predictive value in surgery. We aimed to evaluate association between preoperative NLR and postoperative outcomes in patients undergoing plastic and reconstructive surgery. From January 2011 to July 2019, we identified 7089 consecutive adult patients undergoing plastic and reconstructive surgery. The patients were divided according to median value of preoperative NLR of 1.84. The low NLR group was composed of 3535 patients (49.9%), and 3554 patients (50.1%) were in the high NLR group. The primary outcome was mortality during the first year, and overall mortality and acute kidney injury were also compared. In further analysis, outcomes were compared according to quartile of NLR, and a receiver operating characteristic curve was constructed to estimate the threshold associated with 1-year mortality. This observational study showed that mortality during the first year after plastic and reconstructive surgery was significantly increased in the high NLR group (0.7% vs. 3.5%; hazard ratio, 4.23; 95% confidence interval, 2.69-6.63; p < 0.001), and a graded association was observed between preoperative NLR and 1-year mortality. The estimated threshold of preoperative NLR was 2.5, with an area under curve of 0.788. Preoperative NLR may be associated with 1-year mortality after plastic and reconstructive surgery. Further studies are needed to confirm our findings.

Association between Intraoperative Hyperlactatemia and Myocardial Injury after Noncardiac Surgery.

BACKGROUND: Oxygen demand-supply mismatch is supposed to be one of the major causes of myocardial injuries after noncardiac surgery (MINS). Impaired tissue oxygenation during the surgery can lead to intraoperative hyperlactatemia. Therefore, we aimed to evaluate the relationship between intraoperative lactate level and MINS. METHODS: A total of 1905 patients divided into groups according to intraoperative hyperlactatemia: 1444 patients (75.8%) into normal (≤2.2 mmol/L) and 461 patients (24.2%) into hyperlactatemia (>2.2 mmol/L) groups. The primary outcome was the incidence of MINS, and all-cause mortality within 30 days was compared. RESULTS: In the crude population, the risks for MINS and 30-day mortality were higher for the hyperlactatemia group than the normal group (17.7% vs. 37.7%, odds ratio [OR]: 2.83, 95% confidence interval [CI]: 2.24-3.56, p < 0.001 and 0.8% vs. 4.8%, hazard ratio [HR]: 5.86, 95% CI: 2.9-12.84, p < 0.001, respectively). In 365 propensity score-matched pairs, intraoperative hyperlactatemia was consistently associated with MINS and 30-day mortality (21.6% vs. 31.8%, OR: 1.69, 95% CI: 1.21-1.36, p = 0.002 and 1.1% vs. 3.8%, HR: 3.55, 95% CI: 1.71-10.79, p < 0.03, respectively). CONCLUSION: Intraoperative lactate elevation was associated with a higher incidence of MINS and 30-day mortality.