Clinical utility of a cluster of tests as a diagnostic support tool for clinical lumbar instability.

BACKGROUND: Numerous clinical tests have been proposed for the diagnosis of clinical lumbar instability (CLI), but a cluster of clinical tests is still needed to increase the accuracy of CLI diagnosis. OBJECTIVE: To evaluate a diagnostic support tool intended to identify the presence of CLI using a cluster of clinical tests. DESIGN: Analytical cross-sectional study. METHODS: Two hundred participants with chronic low back pain (LBP) were diagnosed with or without CLI by an orthopedic surgeon. The orthopedic surgeon made the diagnosis from classic clinical symptoms and signs. The diagnosis was used as the reference standard. An orthopedic physical therapist used four clinical tests to identify CLI in each participant, including the apprehension sign, the instability catch sign with/without the abdominal drawing-in maneuver (ADIM), the painful catch sign with/without the ADIM, and the prone instability test. RESULTS: For an individual test, the apprehension sign showed a high specificity (92.6%) and a positive likelihood ratio (LR+; 2.4) but a very low sensitivity of 17.4%. A cluster of three of the four examined tests provided the most diagnostic accuracy for CLI, with a high LR+ (5.8) and a high specificity (91.7%) but low sensitivity (47.8%) and a negative likelihood ratio (LR-; 0.6). CONCLUSIONS: A cluster of three of the four examined tests was determined to comprise a powerful clinical support tool for the identification of CLI patients as tested against a reference standard diagnosis. CLINICAL TRIAL REGISTRATION: Name of the registry: Thai Clinical Trials Registry. Registration number: TCTR20190426002.

The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ): A validation of the reliability of the Thai version.

BACKGROUND: The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) was developed by the Japanese Orthopedic Association (JOA) for assessment of lower back pain and lumbar spinal disease. We aimed to translate the JOABPEQ into Thai and test its reliability and validity in the Thai context. METHODS: The original JOABPEQ was translated into Thai in accordance with international recommendations. Then 180 lumbar spinal disease patients (mean age 58.58 ± 11.97, 68.3% female) were asked to complete the Thai version of the JOABPEQ twice at 2-week intervals. Test-retest reliability was analyzed using the intra-class correlation coefficient (ICC). Internal consistencies were analyzed using Cronbach's alpha, while the construct validity was compared with the Thai version of the modified SF-36, and tested using the Spearman's rank correlation coefficient. RESULTS: The Thai JOABPEQ showed satisfactory test-retest reliability in all parameters (Intra-class Correlation Coefficient 0.761-0.862). The variables low back pain, walking ability, social life function, and mental health had satisfactory internal consistency (the respective Cronbach's α was 0.798, 0.721, 0.707, and 0.795). Only the lumbar function parameter showed moderate reliability (Cronbach's α = 0.654). All of the variables in the Thai JOABPEQ had a statistically positive correlation with the correspondent Thai SF-36 subscales (Spearman's rank correlation p value < 0.05). CONCLUSION: The Thai version of JOABPEQ had satisfactory internal consistency, test-retest reliability, and construct validity; it can be used as a reliable tool for assessing quality of life for lumbar spinal disease patients in Thailand.

Outcomes of lumbar facet syndrome treated with oral diclofenac or methylprednisolone facet injection: a randomized trial.

PURPOSE: This prospective randomized trial is to determine the effectiveness of treating lumbar facet syndrome with oral diclofenac, methylprednisolone facet joint injection or both. METHODS: We enrolled lumbar facet syndrome patients treated at Srinagarind Hospital. Enrolled patients were randomly assigned to receive 100 mg/day oral diclofenac, an 80 mg injection of methylprednisolone into each symptomatic facet joint, or both. Endpoints were the Oswestry disability index (ODI) and visual analogue scale (VAS) before treatment, and at four and 12 weeks after treatment. RESULTS: Of the 99 patients, the mean age was 46.4 years and 48 were men. The initial ODI (mean ± SD) for the diclofenac, methylprednisolone and combined treatment was 45.1 ± 9.3, 42.9 ± 15.6, and 42.2 ± 11.5, respectively. The respective four week ODI was 30.1 ± 8.1, 20.2 ± 8.0, and 15.1 ± 5.5. The 12-week ODI was 42.4 ± 9.0, 32.2 ± 15.6, and 26.2 ± 11.7. The initial VAS was 7.1 ± 1.2, 7.6 ± 1.1, and 7.3 ± 1.0. The four week VAS was 5.3 ± 1.4, 3.6 ± 0.7, and 3.3 ± 1.1. The 12-week VAS was 6.1 ± 1.1, 5.8 ± 1.4, and 5.1 ± 0.9. The four week ODI and VAS for the combined treatment and the methylprednisolone treatment were significantly less than the diclofenac alone. The combined treatment also showed better scores than the methylprednisolone injection. Within each treatment, the best treatment effect was found at four weeks after which the ODI and VAS gradually increased but were still less than the initial scores. CONCLUSIONS: The combined treatment was more effective in reducing lumbar facet pain and improving the functional index than either treatment alone. This approach should be the preferred treatment.

Validation of the reliability of the Thai version of the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ).

BACKGROUND: The Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) was developed to resolve problems associated with the original evaluation of cervical myelopathic patients. The aim of this study was to translate the JOACMEQ into Thai as per international recommendations, and to test its reliability and validity in the Thai context METHODS: The JOACMEQ was translated into Thai, using international guidelines. Cervical myelopathy patients (n = 70; 31 males) were asked to complete the Thai version JOACMEQ twice (4 weeks apart). Test-retest reliability was analyzed using the intra-class correlation coefficient (ICC). Internal consistencies were analyzed using Cronbach's alpha, while the construct validity was compared with the Thai version modified SF-36; using the Spearman's rank correlation coefficient. RESULTS: The Thai JOACMEQ produced good reliability (i.e., the ICC was >0.9 in 2 parameters and >0.8 in one). Overall the Cronbach's α for the 24 questions showed very high internal consistency (Cronbach's α > 0.8) and almost all Cronbach's α showed satisfactory internal consistency except for bladder function. The Spearman's rank correlation for all the JOACMEQ parameters had a positive correlation with all Thai SF 36 subscales, especially the quality of life parameter, which showed a strong correlation with all SF-36 subscales. CONCLUSION: The Thai version of the JOACMEQ had satisfactory internal consistency and test-retest reliability: it also had good construct validity. It can therefore be used as a reliable tool for assessing quality of life for cervical myelopathy patients in Thailand.

Interrater Reliability of the Postoperative Epidural Fibrosis Classification: A Histopathologic Study in the Rat Model.

STUDY DESIGN: Agreement study. PURPOSE: To validate the interrater reliability of the histopathological classification of the post-laminectomy epidural fibrosis in an animal model. OVERVIEW OF LITERATURE: Epidural fibrosis is a common cause of failed back surgery syndrome. Many animal experiments have been developed to investigate the prevention of epidural fibrosis. One of the common outcome measurements is the epidural fibrous adherence grading, but the classification has not yet been validated. METHODS: Five identical sets of histopathological digital files of L5-L6 laminectomized adult Sprague-Dawley rats, representing various degrees of postoperative epidural fibrous adherence were randomized and evaluated by five independent assessors masked to the study processes. Epidural fibrosis was rated as grade 0 (no fibrosis), grade 1 (thin fibrous band), grade 2 (continuous fibrous adherence for less than two-thirds of the laminectomy area), or grade 3 (large fibrotic tissue for more than two-thirds of the laminectomy area). A statistical analysis was performed. RESULTS: Four hundred slides were independently evaluated by each assessor. The percent agreement and intraclass correlation coefficient (ICC) between each pair of assessors varied from 73.5% to 81.3% and from 0.81 to 0.86, respectively. The overall ICC was 0.83 (95% confidence interval, 0.81-0.86). CONCLUSIONS: The postoperative epidural fibrosis classification showed almost perfect agreement among the assessors. This classification can be used in research involving the histopathology of postoperative epidural fibrosis; for example, for the development of preventions of postoperative epidural fibrosis or treatment in an animal model.

Prevention of peridural fibrosis using a cyclooxygenase-2 inhibitor (nonsteroidal anti-inflammatory drug) soaked in absorbable gelatin sponge: an experimental comparative animal model.

STUDY DESIGN: Experimental study. OBJECTIVE: To evaluate the efficacy and safety of peridural parecoxib-soaked absorbable gelatin sponge, and cellulose membrane on peridural fibrosis prevention in an animal model. SUMMARY OF BACKGROUND DATA: Postoperative peridural fibrosis is one of the causes of failed back surgery syndrome. Nonsteroidal anti-inflammatory drugs inhibit the inflammatory response, while an absorbable gelatin sponge or cellulose membrane interposes between the dura and the paraspinal muscle to staunch the surgical bleeding. These mechanisms may prevent peridural fibrosis. METHODS: Forty L5-L6 laminectomized adult Sprague-Dawley rats were randomly allocated into 4 groups. The high parecoxib group received 6 mg of parecoxib soaked into an absorbable gelatin sponge placed over the dura. The low parecoxib group was given 2 mg of parecoxib soaked into an absorbable gelatin sponge. The dura in the cellulose group was covered with a cellulose membrane, while the control group received normal saline drip before surgical wound closure. All rats were killed at 6 weeks for histopathological assessment. The fibroblast density, inflammatory cell density, fibrous adherence, and adverse events were quantified. The obtained results were analyzed statistically. RESULTS: The respective mean fibroblast density in the high parecoxib, low parecoxib, cellulose, and control groups was 217.77 ± 51.76, 317.51 ± 126.92, 321.80 ± 90.94, and 328.48 ± 73.41 cells/mm², while the respective mean inflammatory cell density was 539.65 ± 236.52, 910.17 ± 242.59, 1011.84 ± 239.30, and 1261.78 ± 319.68 cells/mm². The mean fibroblast and inflammatory cell densities of the high parecoxib group were significantly lower than the control. The high parecoxib group also showed statistically less fibrous adherence than low parecoxib, cellulose, and control groups. CONCLUSION: The high-dose parecoxib-soaked absorbable gelatin sponge can prevent peridural fibrosis without complications. The low-dose parecoxib and cellulose membrane provided no significant benefit vis-à-vis prevention of peridural fibrosis, as adduced from the lack of any statistically significant difference between the test and control rats.

Clinical correlation of cervical myelopathy and the hyperactive pectoralis reflex.

STUDY DESIGN: A diagnostic study. OBJECTIVE: To validate the correlation between hyperactive pectoralis reflex and the level of cervical myelopathy. SUMMARY OF BACKGROUND DATA: The hyperactive pectoralis reflex was proposed to be present in patients with spinal cord compression at the C2-3 and/or C3-4 level. Nevertheless, in a validation study on the correlation of various hyperactive reflexes and the cervical myelopathic level, this particular reflex was not evaluated. METHODS: All patients presenting with cervical myelopathy between August 2009 and June 2012 were included in this study. Each patient underwent neurological examination for cervical myelopathy focusing on the examination of pathologic reflexes, including the hyperactive pectoralis reflex. We recorded the presence or absence of these reflexes and the level of cervical myelopathy as detected on magnetic resonance imaging. We used the level of spinal cord compression-cranial to C4 of the vertebral body-as the reference level to validate a hyperactive pectoralis reflex. RESULTS: The study included 95 cervical myelopathy patients: 33 patients had most of their compressed cervical cord somewhere above the C4 vertebral body. The hyperactive pectoralis reflex for cervical myelopathy at this level had a respective sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 84.8%, 96.7%, 26.67, and 0.16. CONCLUSIONS: The high sensitivity and specificity of the hyperactive pectoralis reflex is very useful for screening and diagnosis of the cervical myelopathic level when it is above the C4 vertebral body.

Correction with instrumented fusion versus non-corrective surgery for degenerative lumbar scoliosis: a systematic review.

OBJECTIVE: To evaluate the effect of surgical treatment between correction and non-correction surgery for degenerative lumbar scoliosis by systematic review method. MATERIAL AND METHOD: The database inclusions were PubMed (January 1, 1960 to March 31, 2009), EMBASE (January 1, 1985 to March 31, 2009), The Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and various articles. Grey literature was searched from Scirus. The quality of the studies was graded by MINORS. Studies that were classified level I to IV were included in analysis of surgical treatment outcome in degenerative lumbar scoliosis. Patient centered outcomes, surgical outcomes, and complication were collected. Two reviewers independently assessed trial quality and extracted data. RESULTS: Seventeen studies were included in analysis comprising 598 patients with degenerative lumbar scoliosis and treated by operative treatment. Overall, 451 patients received correction procedure. All trials were non-randomized and noncomparative studies. Almost all level evidence of the study was level III to IV Overall results were comparable between correction and non-corrective operation. CONCLUSION: There were insufficient good-quality comparative studies for surgical treatment outcome comparing between corrective deformity and non-corrective procedures. The correction of deformity in degenerative lumbar scoliosis was classified Level 2C (very weak recommendations).

Nonsteroidal antiinflammatory drugs for postoperative pain management after lumbar spine surgery: a meta-analysis of randomized controlled trials.

OBJECT: The authors undertook this meta-analysis to assess the efficacy and safety of nonsteroidal antiinflammatory drugs (NSAIDs) in addition to opioid analgesics on perioperative pain management in lumbar spine surgery. METHODS: The authors searched MEDLINE, Excerpta Medica (EMBASE), The Cochrane Library, CINAHL, PsycINFO, Allied and Complementary Medicine (AMED), and Science Citation Index Expanded databases. In addition, they manually searched key journals and their references. They included randomized trials comparing the use of NSAIDs in addition to opioid analgesics versus opioid analgesics alone after posterior lumbar discectomy, laminectomy, or spinal fusion. Two independent reviewers performed an assessment of the quality of the methods. RESULTS: Seventeen studies comprising 400 patients who received NSAIDs in addition to opioid analgesics and 389 patients receiving opioid analgesics alone were included. Patients receiving NSAIDs in addition to opioid analgesics had lower pain scores and consumed fewer opioids than the group receiving opioid analgesics alone. There was no difference in the incidence of adverse effects. CONCLUSIONS: This meta-analysis provides evidence that the addition of NSAIDs to opioid analgesics in lumbar spine surgery provided better pain control than opioid analgesics alone.

Effect of parecoxib on postoperative pain after lumbar spine surgery: a bicenter, randomized, double-blinded, placebo-controlled trial.

STUDY DESIGN: A bicenter randomized, patients, healthcare providers, and data collectors blind placebo-controlled trial in multimodal analgesia for postoperative lumbar spine surgery was conducted. OBJECTIVE: To assess the efficacy and safety of parecoxib on postoperative pain management after posterior lumbar spine surgery. SUMMARY OF BACKGROUND DATA: Systematic reviews suggest that cyclo-oxygenase-2 inhibitors are an effective treatment for acute postoperative pain. However, previous trials on lumbar spine surgery showed equivocal efficacy of cyclo-oxygenase-2 inhibitors for postoperative pain relief. METHODS: In this study, 120 patients undergoing posterior lumbar discectomy, spinal decompression, or spinal fusion were stratified based on the surgical procedure to 3 groups (n = 40) and randomly allocated to receive multidoses of parecoxib 40 mg/dose or placebo. Efficacy was assessed by total morphine used from patient-controlled analgesic pump, pain intensity, pain relief, and the patient's subjective rating of the medication. RESULTS: Parecoxib 40 mg reduced the total amount of morphine required over 48 hours by 39% relative morphine reduction compared with placebo (P = 0.0001). Pain at rest was reduced by 30% (P = 0.0001). Ninety percent of patients given parecoxib experienced at least 50% maximum total pain relief compared with 58% treated with placebo. The number-needed-to-treat for 1 patient to have at least half pain relief was 3.1 (2.0-4.6). Patients' subjective rating of the medication was described as "excellent, good, and fair" by 48%, 43%, and 8% in the parecoxib group, respectively, compared with 21%, 50%, and 28% of placebo patients (P = 0.004). Overall adverse effects of patients receiving parecoxib and morphine were comparable to those receiving morphine alone. CONCLUSION: The present study demonstrates that the perioperative administration of parecoxib with patient-controlled analgesic morphine after lumber spine surgery resulted in significantly improved postoperative analgesic management as defined by reduction in opioid requirement, lower pain scores, and higher patients' subjective rating of the medication.

The invention of new anterior spinal instrumentation prototype: a structural analysis of KKU expandable cage.

OBJECTIVE: Report the invention and structural analysis of the new model of anterior spinal instrumentation (KKU expandable cage) that is expandable for space filling after vertebral body resection while simultaneously stabilize the upper vertebra with the lower vertebra, to tolerate the thoracolumbar physiologic load and augment the interbody arthrodesis of the spine. MATERIAL AND METHOD: The new model of expandable anterior spinal instrumentation, named KKU expandable cage, was invented and designed using the computer. The structural property of this instrumentation was tested and analyzed using the computer based structural analysis software. RESULTS: The KKU expandable cage made out of 316L stainless steel is 0.0301044 kg in mass and 3.76305 x 10(-6) m3 for volume. The outer diameter of the device is 23 mm and the height can expand from 20 mm to 35 mm for space filling after thoracolumbar vertebrectomy. The stress in the device after applying the maximal thoracolumbar physiologic compression load (1250N) is between 11692.7 N/m2 to 94.7266 x 10(6) N/m2, less than compression strength of the 316L stainless steel (170 x 10(6) N/m2). CONCLUSION: The stainless steel 316 L KKU expandable cage for anterior spinal instrumentation can withstand the maximal thoracolumbar physiologic compression load without failure whereas its expandable property enable it to fill and fit in the space reaching the height of 35 mm. Therefore, the insertion of this device into a space after thoracolumbar or lumbar corpectomy or vertebrectomy for the vertebral osteomyelitis or vertebral metastasis is appropriate. The device can also stabilize the spine and tolerate the maximal physiologic compression load of the thoracolumbar vertebrae. Therefore, the device helps decrease the need for bone graft or bone substitute in these patients.

KKU knee compression-rotation test for detection of meniscal tears: a comparative study of its diagnostic accuracy with McMurray test.

OBJECTIVE: The purpose of the present study was to compare the sensitivity, specificity and diagnostic accuracy of a new test, named "KKU Knee Compression-Rotation Test", with the most widely used examination, McMurray test. MATERIAL AND METHOD: Sixty-eight patients aged 18 to 39 years old were included in the present study. All of these patients were interviewed for their knee injury histories and examined with both KKU knee compression-rotation and McMurray tests preoperatively. For these clinical examination tests, the sensitivity, specificity, false positive, false negative and diagnostic accuracy rates were calculated and compared with the arthroscopic findings of these patients. RESULTS: The KKU knee compression-rotation test had sensitivity, specificity, and diagnostic accuracy for detection of meniscal tear as 86.27, 88.23, and 86.76% respectively, which superior to McMurray test that was 70.59, 82.35, and 73.53%. In addition, the KKU knee compression-rotation test had false positive and false negative rates of 11.76 and 13.73% less than the 17.65 and 29.41% of McMurray test. The combination of these two tests had diagnostic sensitivity of 90.20% and positive result of both tests suggested torn meniscus with the probability of 97.14%. CONCLUSION: The KKU knee compression-rotation test for detection of torn meniscus had better rates of diagnostic sensitivity, specificity, and accuracy than McMurray test. Therefore, the KKU knee compression-rotation test can be the first line screening examination for detection of torn meniscus. However, if the patient is tested by both the KKU knee compression-rotation and the McMurray tests, it will be a better screening test because a high sensitivity and positive result of both tests suggests a diagnosis of torn meniscus accurately.

Peridural methylprednisolone and wound infiltration with bupivacaine for postoperative pain control after posterior lumbar spine surgery: a randomized double-blinded placebo-controlled trial.

STUDY DESIGN: A randomized, double-blind placebo controlled trial in multimodal analgesia for postoperative pain was conducted. OBJECTIVE: To examine whether combination of corticosteroid and bupivacaine administered in patients undergoing posterior lumbosacral spine surgery reduces postoperative morphine consumption, back and leg pain relief, and improves functional disability and general health status. SUMMARY OF BACKGROUND DATA: Patients with lumbar spine surgery had moderate to severe postoperative pain. Administration of corticosteroid or injection of local anesthetic agent has been additive treatment methods for opioid drugs. There is uncertainty as to whether corticosteroid and bupivacaine combination improves outcomes in lumbosacral spine surgery. METHODS: A total of 103 patients who were scheduled to undergo elective posterior lumbar discectomy, decompressive laminectomy with or without instrumented fusion for degenerative spinal diseases, received either methylprednisolone locally applied to the affected nerve roots (and bupivacaine was infiltrated into the wound) or injected placebo. Morphine consumption and pain scores were recorded at 1, 2, 3, 6, 12, 24, and 48 hours after surgery. Oswestry Index and Short Form SF-36 scores were recorded before surgery and at 1 and 3 months later. RESULTS: Demographic data between the 2 groups were comparable. The cumulative morphine dose and postoperative pain was significantly lower in the study group than in the placebo group (P = 0.01 and P = 0.001, respectively). When performing subgroup analyses, the beneficial effects were found in all groups of surgery but could not demonstrated statistically significant difference for all subgroup comparisons. There was no significant difference between the 2 groups with regard to pain on cough, Oswestry Index, and SF-36 scores. No complications were associated with the perioperative use of methylprednisolone or bupivacaine. CONCLUSIONS: Administration of methylprednisolone-bupivacaine provided a favorable effect immediately after posterior lumbosacral spine surgery for discectomy, decompression, and/or spinal fusion without complication.

Reliability of the Roland - Morris Disability Questionnaire (Thai version) for the evaluation of low back pain patients.

OBJECTIVE: To determine the reliability of the Thai version of the Roland - Morris disability questionnaire in low back pain patients. MATERIAL AND METHOD: To develop Thai version of the Roland - Morris disability questionnaire and test it in 120 low back pain patients. Reliability of the Thai version of the Roland - Morris disability questionnaire was assessed by internal consistency using Cronbach's alpha coefficient. RESULTS: The overall Cronbach's alpha coefficient of the scale was 0.83. The Cronbach's alpha coefficient of each question in the Thai version of the Roland - Morris disability questionnaire exceeded 0.7 (range, 0.71- 0.93). The Cronbach's alpha coefficient tested in acute or chronic low back pain patients whether they have back pain only or back pain with radiculopathy which also exceeded 0.7 (range, 0.83-0.87). CONCLUSION: The Thai version of the Roland - Morris disability questionnaire is a reliable tool for assessing functional disability of low back pain in Thai patients.

Reliability of the medical outcomes study short-form survey version 2.0 (Thai version) for the evaluation of low back pain patients.

OBJECTIVES: To determine the reliability of Thai version of the medical outcomes study short-form survey version 2.0 (SF-36V2) in low back pain patients. MATERIAL AND METHOD: The authors developed the Thai version of the Medical Outcomes Study Short-Form Survey version 2.0 (SF-36V2) and tested it in 100 low back pain patients. Reliability of the Thai version of SF-36V2 was assessed by internal consistency using Chronbach's alpha coefficient and item-scale correlation. RESULTS: The authors demonstrated that the Chronbach's alpha coefficient of the physical health and mental health summary scales were 0.93 and 0.92 respectively. The Chronbach's alpha coefficient of eight scales in the Thai version of the SF-36V2 ranging was 0.72 - 0.94. The Chronbach's alpha coefficient tested in acute or chronic low back pain patients whether they have back pain only or back pain with radiculopathy ranging was 0.72-0.93. The item correlation coefficient for the 35 items within the eight health aspects ranged from 0.43 to 0.8. CONCLUSION: The Thai version of the Medical Outcomes Study Short-Form Survey version 2.0 (SF-36V2) is a reliable tool for assessing functional disability of low back pain in Thai patients.

Treatment of de Quervain disease with triamcinolone injection with or without nimesulide. A randomized, double-blind, placebo-controlled trial.

BACKGROUND: There is uncertainty as to whether supplemental oral nonsteroidal anti-inflammatory medication improves the effectiveness of steroid injections in the treatment of de Quervain disease. We tested the hypothesis that there are no significant differences in the success rates when this condition is treated with triamcinolone injection with or without supplemental oral nimesulide. METHODS: In a randomized, double-blind trial, 160 patients with de Quervain disease received an injection of 10 mg of triamcinolone acetonide and either 200 mg of oral nimesulide for seven days (eighty patients) or placebo tablets for seven days (eighty patients). An independent, blinded evaluator assessed the primary outcomes (tenderness, pain, and the result on the Finkelstein test) at three weeks after injection. Adverse reactions were assessed, and probabilities of recurrence for both groups were compared. Factors possibly predictive of disease recurrence were also assessed. RESULTS: The success rate after one injection was 67% in the nimesulide group and 68% in the placebo group. The overall success rates after single or multiple injections with a mean follow-up of 13.6 months were 95% for both groups. No significant differences were noted with respect to the success rates (p = 0.69) or pain scores after treatment (p = 0.11). The most common adverse reactions to triamcinolone injection and nimesulide were pain after injection and dyspepsia, respectively. The symptoms of de Quervain disease recurred in 33% of the patients in the nimesulide group and in 37% of those in the placebo group. The median time of recurrence was at the fifth month in the nimesulide group and at the fourth month in the placebo group. The recurrence of symptoms was significantly (p = 0.01) related to the presence of crepitation (relative risk, 2.13; 95% confidence interval, 1.19 to 3.80). CONCLUSIONS: Supplemental oral administration of the nonsteroidal anti-inflammatory drug nimesulide does not improve the effectiveness of a single injection of triamcinolone acetonide in the treatment of de Quervain disease. Patients with crepitation in the first dorsal compartment during thumb extension or abduction are at increased risk for recurrence of this disease. LEVEL OF EVIDENCE: Therapeutic study, Level I-1b (randomized controlled trial [no significant difference but narrow confidence intervals]).

Treatment of pain after spinal surgery in the recovery room by single dose lornoxicam: a randomized, double blind, placebo-controlled trial.

BACKGROUND: Lornoxicam has been used in microsurgical lumbar discectomy. However, there is no data about controlling pain after open discectomy or laminectomy. OBJECTIVE: To compare the efficacy of a single dose of 16 mg of lornoxicam for the treatment of pain after disectomy or laminectomy with placebo in the PACU. STUDY DESIGN: Randomized, double blind, placebo-controlled trial. MATERIAL AND METHOD: Fifty-six patients who underwent discectomy or laminectomy were randomly allocated to receive 16 mg lornoxicam (Group L), or placebo (Group P) at the beginning of wound closure. Pain scores at rest (using a verbal numeric rating scale: VNRS 0-10), time to first analgesia requirement, morphine consumption during the first 2 hr after surgery and adverse effects were all recorded. The outcomes were assessed on admission to the PACU (T0), then at 1 (T1) and 2 (T2) hr after surgery. RESULTS: Baseline data were comparable between the two groups. The proportion of patients with VNRS > 5 at T0 in both groups were not significantly different (44.4% in group P vs 50.0% in group L, CI of difference: - 32.4%, 21.3%, p = 0.68). The mean VNRS scores, at T0 and T1 were > 5 and at T2 was < 5 in both groups. There was no difference between the two groups. The morphine consumption in both groups was not different (9.0 mg vs 9.3 mg) as well as the time to first analgesia requirement (35 min vs 40 min). Patients in the two groups had no significant difference in the symptoms or degree of nausea/vomiting. The number of patients with excessive sedation and the proportion of patients needing oxygen during transportation to the ward were not different. CONCLUSION: Lornoxicam 16 mg given intravenously before wound closure provides inadequate pain relief immediately after disectomy or laminectomy in the PACU. However, adequate pain relief was demonstrated at 2 hr after surgery, which was similar to the placebo.