Anaesthetic considerations for high-risk patient kyphoplasty.

Patients with vertebral compression fractures are often indicated for balloon kyphoplasty. Many of them are elderly with severe comorbidities, which puts them at high risk for general anaesthesia. Surgery under infiltration of local anaesthetic with or without mild sedation is therefore the preferred technique used by many surgeons. However, patients reported moderate­to­severe pain during the procedure. A combination of regional anaesthesia with analgo-sedation offers an interesting alternative to general anaesthesia as well as infiltration administered by the surgeon. In this article we present, apart from general anaesthesia, various regional anaesthetic techniques suitable for high-risk patients, including neuraxial anaesthesia, paravertebral block as well as a novel "erector spinae plane block" at the level of the fractured vertebra. We explore their effectiveness and safety profile, as well as advantage of supplementation of adequate analgo-sedation (Ref. 40). Keywords: erector spinae plane block, kyphoplasty, regional anaesthesia, paravertebral block, neuraxial anaesthesia.

A Randomized, Multicenter, Double-Blind, Parallel Pilot Study Assessing the Effect of Mechanical Adhesiolysis vs Adhesiolysis with Corticosteroid and Hyaluronidase Administration into the Epidural Space During Epiduroscopy.

OBJECTIVE: Epiduroscopy is a proven method of diagnosis and treatment for chronic radicular pain after spinal surgery, which is known as failed back surgery syndrome (FBSS). The aim of the study was to compare the efficacy of drugs (the enzyme hyaluronidase and corticosteroid DEPO-Medrol) administrated into the epidural space during epiduroscopy, performed within the ventral and ventro-lateral epidural space with a focus on releasing foraminal adhesions. METHODS: Forty-eight patients with diagnosed FBBS were randomized into two groups before epiduroscopy. Group A received the standard treatment-mechanical lysis of fibrotic tissue in the epidural space. Group B received hyaluronidase and corticosteroid methylprednisolone acetate during the procedure. Subjects were followed for six and 12 months via scheduled double-blinded examinations by pain physicians. Leg and back pain intensity was assessed by an 11-point numerical rating scale, and patients' functional disability was assessed by the Oswestry Disability Index (ODI). RESULTS: Study subjects showed a significant decrease in ODI score in both groups (P < 0.05). Significantly lower pain scores for leg pain (P < 0.05) and back pain (P < 0.05) were also recorded after the six-month follow-up. However, the one-year follow-up showed a return to the baseline ODI values of most monitored pain scores in both groups (P > 0.05). Improvement was only noted on the NRS for back pain at one-year follow-up (P < 0.05). CONCLUSIONS: A significant improvement of leg and back pain was found in both groups after six months. ODI was significantly improved only in group B in both the six- and 12-month intervals. Back pain at one-year follow-up was only improved in group B.

Comparison of ultrasound-guided and palpation-inserted peripheral venous cannula in -patients before primary hip or knee arthroplasty: study protocol for a randomized controlled trial.

BACKGROUND: More than 2 billion peripheral vascular cannulas are introduced globally each year. It is the most frequently performed invasive procedure in medicine worldwide. There is a group of patients with difficult intravenous access (DIVA). In experts' hands, ultrasound-guided vascular access appears to be a significantly better method. Investigators hypothesize that UGVA is superior also in short-term patency of cannula and even for blood draw through cannula. Repeated cannula pricks in the operating room setting not only puts a lot of stress on the patient and medical staff, but they also waste OR time. METHODS: This investigator-initiated prospective randomized monocentric controlled trial is designed to randomly allocate 200 patients undergoing elective primary total joint arthroplasty of hip or knee to one of two groups as follows: Group C (control group) - peripheral venous cannula insertion by palpation or Group USG (intervention) - cannula insertion by ultrasound-guided vascular access. Our primary endpoint is to compare the number of attempts for ultrasound-guided insertion of the peripheral venous cannula with common palpation insertion of the peripheral venous cannula in overweight/obese patients (BMI ≥ 25). The secondary endpoint is a failure rate of the peripheral venous cannula to administer intravenous therapy up to 5 days postoperatively. Tertiary endpoints include a portion of long PVCs that are able to ensure blood draw up to 5 days postoperatively, time needed to insert PVC in each group, number of needle tip redirections in both groups, and reinsertion of PVC needed in both groups for any reason. DISCUSSION: This study is pragmatic and is looking for clinically relevant data. After completion, it will answer the question of whether it is clinically relevant to use ultrasound-guided vascular access in the context of not only short-term benefit of insertion, but also up to 5 days after insertion. Also, if this method can ensure blood draw through a peripheral vein cannula, it can save resources in the perioperative period - valuable especially considering the ongoing shortage of medical staff worldwide. If this hypothesis is confirmed, this finding could contribute to more widespread implementation of ultrasound-guided peripheral vascular access in the perioperative period. TRIAL REGISTRATION: ClinicalTrials.gov NCT05156008. Registered on 13.12.2021.

Does Erector Spinae Plane Block Decrease Analgesia Requirements After Minimal-Invasive Posterior Transpedicular Stabilization in Patients With Vertebral Body Fracture? A Prospective, Randomized, Double-Blind Controlled Study.

STUDY DESIGN: Prospective randomized placebo controlled double blind trial. OBJECTIVE: To examine the effect of ESP block after minimally invasive posterior stabilization for vertebral fractures on opioid consumption, pain, blood loss, disability level, and wound healing complications. METHODOLOGY: Patients indicated for minimal invasive posterior stabilisation were included to the study. Our primary outcome was the opioid consumption and Visual Analogue Scale (VAS) measured during the first 48 hours. Secondary outcomes used to measure the short-term outcome included Oswestry Disability Index (ODI) and Patient Reported Outcome Spine Trauma (PROST). RESULTS: In total, 60 patients were included with a 93.3% follow-up. Average morphine consumption during the PACU (Post Anaesthesia Care Unit) period was 5.357 mg in ESP group and 8.607 mg in placebo group (P = .004). Average VAS during first 24 hour was 3.944 in ESP group and 5.193 in placebo group (P = .046). Blood loss was 14.8 g per screw in ESP group and 15.4 g in placebo group (P = .387). The day2 PROST value was 33.9 in ESP group and 28.8 in placebo group (P = .008) and after 4 weeks 55.2 in ESP group and 49.9 in placebo group (P = .036). No significant differences in ODI were detected. CONCLUSION: The use of ESP block in minimally invasive spinal surgery for posterior fracture stabilization leads to a significant reduction of opioid consumption during PACU stay by 37.7%. Reduction of opioid consumption was accompanied with lower pain (VAS). We found positive effect of the ESP block on short term outcome scores, but no effect on perioperative blood loss and wound healing.