Incidence and predictive factors of spinal cord stimulation treatment after lumbar spine surgery.

INTRODUCTION: Spinal cord stimulation (SCS) is recommended for the treatment of postsurgical chronic back and leg pain refractory to other treatments. We wanted to estimate the incidence and predictive factors of SCS treatment in our lumbar surgery cohort. PATIENTS AND METHODS: Three questionnaires (a self-made questionnaire, the Oswestry Low Back Pain Disability Questionnaire, and the Beck Depression Inventory) were sent to patients aged 18-65 years with no contraindications for the use of SCS, and who had undergone non-traumatic lumbar spine surgery in the Oulu University Hospital between June 2005 and May 2008. Patients who had a daily pain intensity of ≥5/10 with predominant radicular component were interviewed by telephone. RESULTS: After exclusions, 814 patients remained in this cohort. Of those, 21 patients had received SCS by the end of June 2015. Fifteen (71%) of these received benefit and continued with the treatment. Complications were rare. The number of patients who replied to the postal survey were 537 (66%). Eleven of them had undergone SCS treatment after their reply. Features predicting SCS implantation were daily or continuous pain, higher intensities of pain with predominant radicular pain, more severe pain-related functional disability, a higher prevalence of depressive symptoms, and reduced benefit from pain medication. The mean waiting time was 65 months (26-93 months). One hundred patients were interviewed by telephone. Fourteen seemed to be potential SCS candidates. From the eleven patients who underwent SCS after responding to the survey, two were classified as potential candidates in the phone interview, while nine were other patients. Twelve patients are still waiting for treatment to commence. CONCLUSION: In our region, the SCS treatment is used only for very serious pain conditions. Waiting time is too long and it may be the reason why this treatment option is not offered to all candidates.

Obesity has an impact on outcome in lumbar disc surgery.

PURPOSE: To investigate the effect of obesity on outcome in lumbar discectomy. METHODS: A cross-sectional postal survey; a self-made questionnaire, Beck depression inventory IA (BDI IA) and the Oswestry low back disability questionnaire (ODI) were sent to the patients, who had undergone lumbar disc surgery in the Oulu University Hospital between June 2005 and May 2008. Patients were divided into three groups according to BMI: normal, pre-obese and obese. The ODI was also examined in the framework of the international classification of functioning, disability and health (ICF) to investigate its ability to describe various dimensions of functioning (body structure and functions, activities and participation). RESULTS: The postal survey was sent to 642 patients, of whom 355 (55%) replied. Males dominated in the pre-obese (66%) and obese (62%) groups (p=0.01). Normal-weighted and pre-obese patients had lower BDI scores compared to obese patients (mean BDI: 8.0, 7.6, 11.2, respectively, p=0.035). Total ODI score was highest in the obese group compared to normal-weighted or pre-obese (20.3, 18.6, 26.4, respectively, p=0.011). When ODI was linked to the ICF there were significant differences in all activity domains (mobility, self-care and interpersonal interactions and relationships) and the mobility component of the participation domain between the weight groups. CONCLUSIONS AND IMPLICATIONS: Obesity has an impact on outcome in lumbar discectomy. Obese patients had higher scores in BDI and ODI indicating mild mood disturbances and moderate functional disability. According to ICF, functional disability of obese patients was observed to some extent in all activity domains. Obese patients will be more frequently present for disc surgery and increased morbidity risk must be recognized. We need a strategy to rehabilitate and activate obese patients pre- and postoperatively.

Peripheral morphine reduces acute pain in inflamed tissue after third molar extraction: A double-blind, randomized, active-controlled clinical trial.

BACKGROUND: The clinical use of peripheral analgesic effects of opioids has been investigated in numerous controlled clinical trials. The majorities of these have tested the local, intra-articular administration of morphine in knee surgery and have demonstrated marginal postoperative analgesia. OBJECTIVE: We examined direct morphine infiltration of the surgical site in a clinical model of tooth pain under two different conditions. Eighty-eight patients undergoing surgical tooth removal entered into the two prospective, parallel, randomized, double-blind studies. METHODS: Patients undergoing surgical tooth removal received a standard local anaesthetic solution (articaine plus epinephrine) before surgery. Patients were assigned to an injection of peripheral 2mg morphine either into non-inflamed (Trial I) or inflamed (Trial II) submucous tissue before the surgery. Patients who received an intramuscular morphine in the upper arm were concomitantly given 1ml isotonic saline (NaCl) as a submucous injection. Patients who received a submucous injection of morphine peripherally were concomitantly given an intramuscular injection (IM) of 1ml of NaCl in the upper arm. Postoperative pain intensity was assessed by the numeric rating scale every 30min for the first 2h and then every hour for the next 8h after surgery. In addition, patients recorded the occurrence of side effects and the supplemental consumption of ibuprophen and codeine+paracetamol combination tablets. RESULTS: Of the eighty-eight original participants, nine patients (4 patients in Trial I and 5 patients in Trial II) were withdrawn for protocol noncompliance and loss at follow-up. Thirty-one patients in trial I and forty-eight patients in trial II were analyzed. Patients receiving 2mg morphine into non-inflamed tissue did not show any further reduction in pain scores and pain medication consumption compared to IM morphine group (Trial I). In patients receiving 2mg morphine into inflamed tissue, pain scores at rest were reduced to a similar extent in both groups at all measurement times up to 10h in the follow-up (Trial II). At the same time, in the area under the curves pain scores on swallowing between 2 and 6h in the peripheral morphine group (5.2±5.6) were significantly lower than in the IM morphine group (9.3±7.3, p=0.03), demonstrating the marginal analgesic efficacy of additional morphine. Sedation scores were significantly higher in the peripheral morphine group only 1h after surgery in Trial I (p=0.008). The time to first analgesic intake was similar between groups. No serious side effects were reported. CONCLUSIONS: Our results showed in patients undergoing surgical tooth removal that injection of 2mg of morphine into inflamed tissue results in significantly lower pain scores on swallowing in the early postoperative state while administration into non-inflamed tissue is not effective. IMPLICATIONS: Our studies indicate that the peripheral administration of opioids, at the doses and conditions set out for these two studies, produces significant analgesia by a pharmacologically specific mechanism that is active in chronically, but not acutely, inflamed tissue. Thus, consistent with preclinical experimental studies, the requirement of an inflammatory process for the occurrence of the peripheral opioid effects is also found in the clinical setting.

Depressive symptoms are associated with poor outcome for lumbar spine surgery.

BACKGROUND AND AIMS: The symptoms of pain and depression often present concomitantly, but little is known as to how the different subtypes of depression affect surgical outcome. The aim of this study was to determine whether there is a difference in outcome after lumbar spine surgery between non-depressed patients and patients with different subtypes of depressive symptoms: non-melancholic (NmDS) and melancholic depression (MDS). METHODS: This was a cross-sectional postal survey. A self-made questionnaire, the Beck Depression Inventory (BDI) and the Oswestery Low Back Disability Questionnaire (ODI) were sent to patients who had undergone lumbar spine surgery in the Oulu University Hospital between June, 2005 and May, 2008. BDI≥10 were further classified into NmDS or MDS. RESULTS: A total of 537 patients (66%) completed the survey. Of these, 361 (67%) underwent disc surgery, 85 (16%) stabilizing surgery and 91 (17%) decompression. Participants were divided into three groups: BDI<10 N=324 (60%), NmDS N=153 (29%) and MDS N=60 (11%). The mean ODI (SD) in the BDI<10 group was 16 (15), in the NmDS group 36 (15), and in the MDS group 41 (18) (p<0.001). The ODI profiles were different between the groups (p<0.001). Pain was more frequent in depressive patients (88% of MDS, 81% in NmDS and 40% in BDI<10 patients experienced pain, p<0.001). The intensity of pain and pain-related disability was lowest among the patients in the BDI<10 group and highest among the MDS patients. Regular pain medication was used by 87% of patients in the MDS group, 93% of patients in the NmDS group, and 71% of patients in the BDI<10 group (p<0.001). Response to pain medication with NRS (0-10) was 5.6 among MDS, 5.8 among NmDS and 6.5 among BDI<10 patients (p<0.001). CONCLUSION: Different types of depressive symptoms are associated with poor outcome after lumbar spine surgery. The outcome was worst in patients suffering from the MDS subtype. This was observed in pain intensity, functional disability and response to pain medication. IMPLICATION: It would be important to evaluate depression pre- and postoperatively. Offering a tailored rehabilitation programme to MDS patients should be considered.

Results of lumbar spine surgery: A postal survey.

Background and aim No studies have been published regarding the results of lumbar spine surgery a in population-based setting in Finland. Our objective was to investigate functional capacity and quality of life after lumbar spine surgery in a population-based cohort in Northern Finland, focusing on working-age patients. Methods This was a cross-sectional postal survey. Three questionnaires (a self-made questionnaire, the Oswestry Low Back Disability Questionnaire and the SF-36) were sent the patients aged 18-65 years who had undergone lumbar spine surgery due to disc herniation, instability or spinal stenosis in the Oulu University Hospital between June 2005 and May 2008. Results The postal survey was sent to 814 patients, of whom 537 patients (66%) replied. Of these, 361 (67%) underwent disc surgery, 85 (16%) stabilizing surgery and 91 (17%) decompression. Pain was absent or present only occasional in 51% in the disc surgery group, whereas it was present daily in 59% in the stabilizing surgery group and in 58% in the decompression group (P < 0.001). Axial pain was slightly more intense than radicular pain. Pain was milder in the disc surgery group compared with the stabilizing surgery and decompression groups: mean (SD) axial pain with 0-10 NRS was 4.0 (2.3), 4.7 (2.4) and 4 (2.3) respectively (P = 0.002) and radicular pain 3.5 (2.6), 4.2 (2.8), 4.5 (2.6) respectively (P < 0.001). The total ODI score (mean, SD) was 20 (17) in the disc surgery group, 35 (17) in the stabilizing surgery group and 32 (17) in the decompression group (P < 0.001). The physical dimension sum score from the SF-was 42 (11) in the disc surgery group and 34 (10) in the stabilizing surgery and decompression grou (P < 0.001). Mental sum scores did not vary significantly between the groups. Conclusions and Implications Outcome was good after lumbar disc operations but less favourable after stabilizing surgery and decompression regarding pain, functional capacity and quality of life. IMPLICATIONS: This study offers important information about outcome after lumbar spine surgery in Oulu University Hospital. It also brings out that in Finland we need systematic national spine register, with accurate pre-and postoperative data.

MR-guided neurolytic celiac plexus ablation: an evaluation of effect and injection spread pattern in cancer patients with celiac tumor infiltration.

OBJECTIVE: The purpose of this study was to evaluate the feasibility, the initial accuracy, and the effects of the MR-guided neurolytic celiac plexus ablation as a method to treat cancer-induced chronic abdominal pain. METHODS: Thirteen celiac plexus ablations were performed for 12 patients. A 0.23-T open MRI scanner with optical navigation was used for procedural guidance. As an adjunct to the MR-guided needle positioning, the needle location was confirmed with saline injection and consequent MR imaging (STIR sequence). The spread of the ablative injection material (alcohol-lidocaine mix) was observed by repeating this sequence after the therapeutic injection. Pain scores from seven patients (eight ablations) were used to assess the therapy effect. RESULTS: MR guidance allowed adequate needle positioning and visualization of injection material in all cases. The rest pain scores significantly decreased from 4 (median) at baseline to 1 (median) at 2 weeks (p < 0.05). Average and worst pain experienced during the past week were significantly lower at the 2-week time point compared with the baseline (p < 0.05). However, the intervention did not result in reduction of opioid use at 2 weeks. CONCLUSIONS: MR guidance is an accurate and safe method for celiac plexus ablation with positive therapeutic effect.

Effects of combination treatment with ketoprofen 100 mg + acetaminophen 1000 mg on postoperative dental pain: a single-dose, 10-hour, randomized, double-blind, active- and placebo-controlled clinical trial.

BACKGROUND: A combination of analgesic drugs with different pharmacologic properties may be more effective, with fewer adverse events, than either agent used alone. OBJECTIVE: This study assessed whether the combination of acetaminophen and ketoprofen is more effective and better tolerated than either drug used alone in treating postoperative pain. METHODS: This single-dose randomized, double-blind, active- and placebo-controlled study was conducted at the Finnish Student Health Service, Oulu, Finland. Patients aged 18 to 40 years with moderate or severe pain (>or=3 on a numerical rating scale [NRS] of 0-10) after surgical removal of impacted third molars were randomly assigned to receive one of the following drugs in single oral doses: ketoprofen 100 mg + acetaminophen 1000 mg, ketoprofen 100 mg, acetaminophen 1000 mg, or placebo tablets. Effectiveness was assessed by the onset of analgesia, pain intensity difference (PID) from baseline, sum of PID (SPID), and duration of analgesic effect. Patients rated pain intensity on the NRS at rest and on dry swallowing. Onset of pain relief was measured using time to PID in >or=1 category at rest or on dry swallowing (PID >or=1). Patients recorded the occurrence of adverse events and the supplemental consumption of rescue medication (ibuprofen). RESULTS: The study included 76 patients, accounting for 78 cases (2 patients were operated on twice and were assessed as 4 individual patients) (59% women, 41% men; mean age, 22.8 years; white race, 100%; and mean weight, 68.3 kg). At 1.5 hours, mean SPIDs at rest and on swallowing were significantly greater in the combination group than in the acetaminophen, ketoprofen, and placebo groups (all, P < 0.05). Mean time to onset of pain relief (PID >or=1) at rest and on swallowing were significantly less in the combination group than the acetaminophen, ketoprofen, and placebo groups (all, P < 0.05). Median time to use of rescue medication was significantly longer in the combination group than in the acetaminophen group (P = 0.006) and the placebo group (P < 0.001) but not the ketoprofen group. At 1.5 hours after administration, maximum sedation scores were not significantly different between the study groups. The prevalences of trismus, bleeding, and edema were not significantly different between the study groups. CONCLUSIONS: The results from this study suggest that the combination of ketoprofen 100 mg + acetaminophen 1000 mg provided a significantly more rapid onset of analgesia than either drug given alone in the management of pain after oral surgery in this patient population. Adverse events were not significantly different between the study groups. These results support the clinical practice of combining ketoprofen with acetaminophen for the management of acute pain.