Gabapentinoid Use in Perioperative Care and Current Controversies.

PURPOSE OF REVIEW: This review summarizes the risks and benefits of gabapentinoids (gabapentin and pregabalin) for perioperative pain control and the controversies surrounding their use in a variety of settings. We review current literature with the goal of providing patient-centric and procedure-specific recommendations for the use of these medications. RECENT FINDINGS: Gabapentinoids are among the most prescribed medications in the USA, and typically for off-label indications such as postoperative pain. In the perioperative setting, multimodal analgesic or "opioid-sparing" regimens have become the standard of care-and some clinical protocols include gabapentinoids. At the same time, guidelines regarding the perioperative use of gabapentinoids are conflicting and evidence supporting their broad use is lacking. Gabapentinoids administered perioperatively reduce opioid requirements and pain scores for a variety of surgeries. The extent of opioid and pain reduction, however, is not always clinically significant. These medications reduce postoperative nausea and vomiting as well as pruritis, likely as a feature of reducing opioid intake, but are associated with side effects such as dizziness, ataxia, and cognitive dysfunction. Gabapentinoids also increase the risk of respiratory depression, in particular when paired with opioids. There is thus evidence suggesting that the routine use of these medications for perioperative pain management is not recommended. An individualized, patient- and surgery-specific approach should be used, although research is still needed to determine risks and benefits during perioperative use.

Spatial Detection of the Shafts of Fractured Femur for Image-Guided Robotic Surgery.

Femur fractures due to traumatic forces often require surgical intervention. Such surgeries require alignment of the femur in the presence of large muscular forces up to 500 N. Currently, orthopedic surgeons perform this alignment manually before fixation, leading to extra soft tissue damage and inaccurate alignment. One of the limitations of femoral fracture surgery is the limited vision and two-dimensional nature of X-ray images, which typically guide the surgeon in diagnosing the position of the femur. Other limitations include the lack of precise intraoperative planning and the process of trial-and-error alignment. To alleviate the issues discussed, we develop a marker-based approach for detecting the position of femur fragments using two X-ray images. The relative spatial position of the femur fragments plays a key role in guiding an innovative robotic system, named Robossis, for femur fracture alignment surgeries. Using the derived three-dimensional data, we simulate pre-programmed movements to visualize the proposed steps of the alignment method, while the bone fragments are attached to the robot. Ultimately, Robossis aims to improve the accuracy of femur alignment, which results in improved patient outcomes.

The association between hypertension and colorectal cancer: a meta-analysis of observational studies.

The relationship between hypertension and risk of colorectal cancer (CRC) is unclear. This meta-analysis aims to explore the association between them. Six databases were searched for studies published before August 2019. The pooled relative risk (RR) and 95% confidence intervals (CIs) were calculated to estimate the association between the hypertension and CRC risk. A total of 2841 potentially relevant articles were obtained, and 25 studies with a pooled 1.95 million participants were finally included in the meta-analysis. These results suggested a positive association between hypertension and risk of CRC with a pooled RR of 1.15 (95% CI: 1.08, 1.23). Male patients with hypertension had a 13% (95% CI: 1.06, 1.20) increased risk of CRC. The risk of colon cancer and rectal cancer in male patients was 1.17 (95% CI: 1.01, 1.36) and 1.35 (95% CI: 1.04, 1.74), respectively, while no association between hypertension and the risk of CRC in females was elucidated. This meta-analysis demonstrated that a positive association between hypertension and CRC exists, with male patients having a higher risk of developing CRC than female patients.

Conolidine: A Novel Plant Extract for Chronic Pain.

Pain, the most common symptom reported among patients in the primary care setting, is complex to manage. Opioids are among the most potent analgesics agents for managing pain. Since the mid-1990s, the number of opioid prescriptions for the management of chronic non-cancer pain (CNCP) has increased by more than 400%, and this increased availability has significantly contributed to opioid diversion, overdose, tolerance, dependence, and addiction. Despite the questionable effectiveness of opioids in managing CNCP and their high rates of side effects, the absence of available alternative medications and their clinical limitations and slower onset of action has led to an overreliance on opioids. Conolidine is an indole alkaloid derived from the bark of the tropical flowering shrub Tabernaemontana divaricate used in traditional Chinese, Ayurvedic, and Thai medicine. Conolidine could represent the beginning of a new era of chronic pain management. It is now being investigated for its effects on the atypical chemokine receptor (ACK3). In a rat model, it was found that a competitor molecule binding to ACKR3 resulted in inhibition of ACKR3's inhibitory activity, causing an overall increase in opiate receptor activity. Although the identification of conolidine as a potential novel analgesic agent provides an additional avenue to address the opioid crisis and manage CNCP, further studies are necessary to understand its mechanism of action and utility and efficacy in managing CNCP.

Primary Malignant Melanoma of the Brain: A Population-Based Study.

BACKGROUND: Primary melanocytic neoplasms of the central nervous system (CNS) are rare and account for 1% of all melanomas. This study used the Surveillance, Epidemiology, and End Results (SEER) database to evaluate the epidemiology of primary CNS melanoma and further characterize their treatment. METHODS: Data from the National Cancer Institute SEER program, collected from 1973-2015, were retrospectively analyzed. A total of 86 records of malignant melanoma cases with CNS as the primary site were identified, and 54 patients were studied based on the inclusion criteria. Demographic, tumor, and treatment regimen effectiveness were studied. RESULTS: A total of 54 patients were included in this study. Tumors were distributed evenly in size and localized primarily to the cerebral meninges and spinal cord. A total of 13% of patients underwent biopsy, 40.7% gross total resection (GTR), 7.4% subtotal resection (STR), 46.3% radiation therapy (RT), and 27.3% chemotherapy (CT) in a variety of treatment combinations. GTR alone and STR + RT resulted in increased disease-specific survival compared to biopsy alone, but no survival benefit was found with biopsy with RT and/or CT as well as STR alone. CONCLUSIONS: To our knowledge, this is the largest single database study completed for primary malignant melanoma of the CNS. The study identified the need for tumor resection for the proper treatment of these lesions, particularly GTR. GTR could be paired with adjuvant RT or RT + CT providing survival benefit as well. In cases when GTR is unable to be completed, STR + RT provides significant improvement in survival compared to biopsy alone.

Supratentorial and Infratentorial Approaches to Pineal Surgery: A Database Analysis.

Objectives Neoplasms involving the pineal gland are rare. When they do occur, tumor resection is anatomically challenging and is traditionally addressed by either a supratentorial or an infratentorial approach. To date, no large, multicenter studies have been performed that systematically analyze outcomes comparing these two approaches. This study aimed to evaluate outcomes for patients undergoing pineal neoplasm resection, comparing supratentorial and infratentorial approaches. Design Retrospective database review. Setting Multi-institutional database. Participants From 2005 to 2016, 60 patients were identified, with 13 undergoing a supratentorial approach and 47 undergoing an infratentorial approach. Main Outcome Measures Patient demographics, comorbidities, and 30-day postoperative outcomes were investigated using the American College of Surgeons National Surgical Quality Improvement Program database. Demographics, readmission, reoperation, and complication rates were analyzed and compared with previous studies. Results Patient demographics were similar between these two groups. The overall complication rates for the supratentorial and infratentorial approaches were 30.8 and 17%, respectively, and the difference was not statistically significant. The most common medical complications encountered were respiratory and hematological. Conclusion As the first multi-institutional database analysis of approaches to the pineal gland, this study provides an analysis of patient demographics, comorbidities, and postoperative complications. After controlling for preoperative risk factors and demographic characteristics, no statistically significant differences in postoperative outcomes were found between infratentorial and supratentorial approaches. The mean readmission, reoperation, and complication rates were found to be 2.1, 8.3, and 20%, respectively. The lack of significant difference between approaches suggests that clinical decision-making should depend upon anatomical considerations and physician preference, although the complications illustrated here may provide some preoperative guidance.

Steroid Use Associated With Increased Odds of 30-Day Mortality in Surgical Patients With Metastatic Spinal Tumors in the Setting of Disseminated Disease.

BACKGROUND: Steroid administration is part of a standard treatment regimen in metastatic spinal cord compression, though the appropriate dose, duration, efficacy, and risks remain controversial. OBJECTIVE: To analyze the risk of preoperative steroid use on 30-d mortality in surgical metastatic spinal tumors with dissemination disease using a large multicenter national database. METHODS: Adult patients who underwent surgical treatment for metastatic spine tumors between 2005 and 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Demographic, preoperative risk factors, operative information, and postoperative events were extracted. Multivariate logistical regression modeling was used to investigate the association with preoperative steroid use with the outcome of interest, 30-d mortality. Other independent risk factors associated with 30-d mortality were also identified. RESULTS: Five hundred fifty-two patients underwent surgical treatment of spinal metastases with disseminated cancer present at time of surgery. Independent risk factors of 30-d mortality included prolonged steroid use (odds ratio [OR] 2.48, 95% confidence interval [CI]: 1.22-5.04, P = .012), dependent functional status (OR 2.91, 95% CI: 1.68-5.04, P < .001), history of bleeding disorder (OR 2.80, 95% CI: 1.16-6.74, P = .021), history of smoking (OR 2.26, 95% CI: 1.11-4.61, P = .024), preoperative transfusions (OR 2.91, 95% CI: 1.02-8.29, P = .049), and preoperative infection/sepsis (OR 2.67, 95% CI: 1.18-6.08, P = .02). Our model demonstrates very strong predictive capabilities, with an area under the receiver operating characteristic curve of 0.7447. CONCLUSION: Steroid use is associated with a significant increased risk of 30-d mortality in surgical metastatic spine tumor patients with disseminated disease. These findings warrant further investigation in controlled experimental environments.

C1-C2 Fusion Versus Occipito-Cervical Fusion for High Cervical Fractures: A Multi-Institutional Database Analysis and Review of the Literature.

OBJECTIVE: Type II odontoid fractures of the axis (C2) account for more than 20% of all cervical fractures. If an odontoid screw is contraindicated, the treatment approach for type II C2 fractures typically involves C1-C2 posterior fusion or occipito-cervical (O-C) fusion, each of which has distinct advantages and disadvantages. In this study, postoperative outcomes of C1-C2 fusion and O-C fusion for high cervical fractures were compared. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried to determine 30-day surgical outcomes of posterior C1-C2 fusion versus O-C fusion for adult patients with C2 fractures between 2005 and 2016. Demographics, operative factors, and postoperative events were analyzed, including returns to the operating room, readmission, and death. RESULTS: In total, 165 patients were identified. A majority of the patients (142, 86.1%) had independent functional status, although 133 (80.6%) had an American Society of Anesthesiologists classification ranging from 3 to 5, representing poor preoperative health. A significantly greater proportion of O-C (9.1%) versus C1-C2 fusion (1.7%) returned to the operating room (odds ratio 6.465, confidence interval 1.079-38.719, P = 0.041). The length of operation approached statistical significance (P = 0.053) between the 2 groups, with O-C fusion group having a longer average length of operation (196.4 minutes) versus the C1-C2 group (164.0 minutes). CONCLUSIONS: This study provides a snapshot of the risk profiles of C1-C2 and O-C fusion for C2 fracture, demonstrating a statistically higher risk of reoperation in O-C fusion versus C1-C2 fusion. Future randomized trials are needed to identify the preferred technique to improve patient outcomes.

Magnetic kyphoplasty: A novel drug delivery system for the spinal column.

Vertebral compression fractures (VCFs) caused by metastatic malignancies or osteoporosis are devastating injuries with debilitating outcomes for patients. Minimally invasive kyphoplasty is a common procedure used for symptomatic amelioration. However, it fails in treating the underlying etiologies of VCFs. Use of systemic therapy is limited due to low perfusion to the spinal column and systemic toxicity. Localized delivery of drugs to the vertebral column can provide a promising alternative approach. A porcine kyphoplasty model was developed to study the magnetically guided drug delivery of systemically injected magnetic nanoparticles (MNPs). Jamshidi cannulated pedicle needles were placed into the thoracic vertebra and, following inflatable bone tamp expansion, magnetic bone cement was injected to the vertebral body. Histological analysis was performed after intravenous injection of MNPs. Qualitative analysis of harvested tissues revealed successful placement of magnetic cement into the vertebral body. Further quantitative analysis of histological sections of several vertebral bodies demonstrated enhanced accumulation of MNPs to regions that had magnetic cement injected during kyphoplasty compared to those that did not. By modifying the kyphoplasty bone cement to include magnets, thereby providing a guidance stimulus and a localizer, we were successfully able to guide intravenously injected magnetic nanoparticles to the thoracic vertebra. These results demonstrate an in-vivo proof of concept of a novel drug delivery strategy that has the potential to treat the underlying causes of VCFs, in addition to providing symptomatic support.

Epidural Abscess: A Propensity Analysis of Surgical Treatment Strategies.

STUDY DESIGN: Observational analysis of retrospectively collected data. OBJECTIVE: A retrospective study was performed in order to compare the surgical profile of risk factors and perioperative complications for laminectomy and laminectomy with fusion procedures in the treatment of spinal epidural abscess (SEA). SUMMARY OF BACKGROUND DATA: SEA is a highly morbid condition typically presenting with back pain, fever, and neurologic deficits. Posterior fusion has been used to supplement traditional laminectomy of SEA to improve spinal stability. At present, the ideal surgical strategy-laminectomy with or without fusion-remains elusive. METHODS: Thirty-day outcomes such as reoperation and readmission following laminectomy and laminectomy with fusion in patients with SEA were investigated utilizing the American College of Surgeons National Quality Improvement Program database. Demographics and clinical risk factors were collected, and propensity matching was performed to account for differences in risk profiles between the groups. RESULTS: Seven hundred thirty-eight patients were studied (608 laminectomy alone, 130 fusion). The fusion population was in worse health. The fusion population experienced significantly greater rate of return to the operating room (odds ratio [OR] 1.892), with the difference primarily accounted for by cervical spine operations. Additionally, fusion patients had significantly greater rates of blood transfusion. Infection was the most common reason for reoperation in both populations. CONCLUSION: Both laminectomy and laminectomy with fusion effectively treat SEA, but addition of fusion is associated with significantly higher rates of transfusion and perioperative return to the operating room. In operative situations where either procedure is reasonable, surgeons should consider that fusion nearly doubles the odds of reoperation in the short-term, and weigh this risk against the benefit of added stability. LEVEL OF EVIDENCE: 3.

Anterior Versus Posterior Approach for Thoracic Corpectomy: An Analysis of Risk Factors, Outcomes, and Complications.

BACKGROUND: Thoracic corpectomies are performed for various reasons, including spinal deformity, trauma, neoplasms, and infection. Regardless of indication, both anterior and posterior approaches are surgical options, selected based on pathology, anatomy, patient characteristics, and surgical experience. Risk profiles and outcomes for these procedures are poorly characterized, however, and the choice between the 2 approaches remains inconclusive. OBJECTIVE: To compare risk factors and complications for adult patients undergoing anterior and posterior thoracic corpectomies. METHODS: A review of the American College of Surgeons National Quality Improvement Program database was performed, with 30-day patient outcomes after anterior or posterior thoracic corpectomy queried from 2005 to 2016. Preoperative risk factors and postoperative outcomes (e.g., deaths, reoperations, readmissions) were identified and compared. RESULTS: In total, 1327 corpectomies were studied, 861 (64.9%) by an anterior approach and 465 (35.1%) by a posterior approach. Patients undergoing a posterior approach were generally male, older, and had a greater American Association of Anesthesiologists class, whereas those subject to anterior approaches had a greater average body mass index. After we controlled for these baseline characteristics, no significant difference in postoperative events was observed, with 9.3% of anterior approach patients and 7.1% of posterior approach patients returning to the operating room within 30 days. CONCLUSIONS: No significant difference in rates of reoperation, readmission, death, average length of stay, or medical complications exists between anterior and posterior thoracic corpectomy approaches. Both have relatively low-risk profiles and, in situations in which either strategy is reasonable, each can be selected at the surgeon's discretion with comparable risk.