Navigated Anterior Full-Endoscopic Transcervical Approach Odontoidectomy for Traumatic Posterior Atlantoaxial Dislocation Without Odontoid Fracture.

BACKGROUND AND IMPORTANCE: Complete posterior atlantoaxial dislocation (PAAD) with an unfractured odontoid process is a rare condition where a dislocated but intact odontoid process is positioned ventrally to the anterior arch of C1. This lesion is related to transverse and alar ligament rupture secondary to hyperextension and rotatory traumatic injury and is often associated with neurological deficit. The treatment strategy remains controversial, and in many cases, odontoidectomy is required. Traditional approaches for odontoidectomy (transnasal and transoral) are technically demanding and are related to several complications. This article describes a 360° reduction and stabilization technique through a navigated anterior full-endoscopic transcervical approach (nAFETA) as a novel technique for odontoidectomy and C1-C2 anterior transarticular fixation supplemented with posterior fusion. CLINICAL PRESENTATION: A 21-year-old man presented to the emergency room by ambulance after a motorcycle accident. On evaluation, incomplete ASIA B spinal cord injury was documented. Imaging revealed a complete PAAD. We performed a two-staged procedure, a nAFETA odontoidectomy plus C1-C2 anterior transarticular fixation followed by posterior C1-C2 wired fusion. At a 2-year follow-up, the patient had a 10-point Oswestry Disability Index score and neurological improvement to ASIA E. CONCLUSION: PAAD can be successfully treated through minimally invasive nAFETA. Noteworthy, the risks of the transoral and endonasal routes were avoided through this approach. In addition, nAFETA allows anterior transarticular fixation during the same procedure providing spinal stability. Further studies are required to expand the use of nAFETA in this field.

Codeine/acetaminophen and hydrocodone/acetaminophen combination tablets for the management of chronic cancer pain in adults: a 23-day, prospective, double-blind, randomized, parallel-group study.

BACKGROUND: Analgesics are an essential component of the treatment of cancer-associated pain. Pharmacologic treatment is usually begun with nonopioid analgesics, most frequently acetaminophen. If pain relief is not achieved, the so-called "weak" opioids, such as codeine and hydrocodone, may be used in combination with acetaminophen. Adverse effects (AEs) of the opioids include constipation, somnolence, nausea, and vomiting. Based on the results of a literature search, data comparing the effects of the opioids are lacking. OBJECTIVE: The purpose of this study was to compare the analgesic efficacy and tolerability of codeine phosphate versus hydrocodone bitartrate in combination with acetaminophen in the relief of cancer-related pain. METHODS: This 23-day, prospective, double-blind, randomized, parallel-group study was conducted at 3 Colombian centers: University Libre, Social Security Institute, and General Hospital of Medellín, Cali, Colombia. Outpatients with cancer were eligible for the study if they were aged >-18 years and had chronic (duration, >/= 3 months) moderate to severe cancer-related pain (score on 10-cm visual analog scale [VAS], > 3 cm [moderate]; score on a 4-point verbal pain-intensity scale, > 1 [moderate]). Eligible patients were randomly assigned to receive 1 tablet of codeine/acetaminophen (C/A) 30/500 mg or hydrocodone/acetaminophen (H/A) 5/500 mg PO q4h (total daily doses, 150/2500 and 25/2500 mg, respectively) for 23 days. In both groups, if pain intensity was rated as > 3 on the VAS at week 1 or 2, the dosage was doubled. The primary end point was the proportion of patients who achieved pain relief (defined as a score of > 1 on a 5-point verbal rating scale [VRS] (0 = none; 1 = a little; 2 = some; 3 = a lot; and 4 = complete) on study days 1 and 2 and weeks 1, 2, and 3. The secondary end point was the proportion of patients in whom pain was decreased (VAS score, <- 3 cm). AEs were self-reported on a 4-point VRS (0 = absent; 1 = mild; 2 = moderate; and 3 = severe). RESULTS: Of the 121 patients who participated, 59 received C/A and 62 received H/A. Of the total number of cases, 59% were aged 60 to 89 years, and 55% were men. At baseline, 88% of the patients described their pain intensity as moderate; 12%, severe. Of the patients who received C/A, 58% responded to the initial dosage of 150/2500 mg/d, and 8% of the patients responded to the double dosage; 34% did not experience pain relief. In patients with H/A, pain was reported as absent or mild in 56% of patients at the starting dosage of 25/2500 mg/d; an additional 15% of the patients responded to the double dosage; the remaining 29% of patients did not experience any pain relief. None of the between-group differences in response rates were significant. The most common AEs in the C/A and H/A groups were constipation (36% and 29%, respectively), dizziness (24% and 19%), vomiting (24% and 16%), and dry mouth (15% and 18%), with no significant differences between groups. CONCLUSION: In this study, efficacy and tolerability were comparable between C/A and H/A over 23 days of treatment in these patients with moderate or severe, chronic, cancer-related pain.

Incidence of weak opioids adverse events in the management of cancer pain: a double-blind comparative trial.

With the objective of comparing incidence of adverse events of the opioids codeine, hydrocodone, and tramadol in the relief of cancer pain, we conducted a randomized controlled trial in which patients with cancer were randomly assigned according to a computer-generated schedule to receive one of the three opioids. Of the 177 patients who participated, 62 patients received hydrocodone, 59 patients received codeine, and 56 patients received tramadol. The pain experienced by the participants originated most frequently from the stomach, breast, or prostate gland and was classified as either somatic (33%), visceral (52%), mixed (6%), or neuropathic (9%). At the first visit, 60% of the patients described their pain intensity as moderate (4-6/10), with the remaining 40% of the patients describing their pain as severe (7-10/10). The symptoms most associated with pain were weakness, insomnia. and anorexia. In 77% of the total number of cases, the patient was aware of his/her diagnosis prior to admittance to the palliative care unit. Of the total number of cases, 57% fell in the age range of 60-89 years old and 50% of the participants were female. No significant statistical difference in the analgesic efficacy of the three opioids was found (p: 0.69; chi(2): 0.73). Use of tramadol produced higher rates of adverse events than codeine and hydrocodone: vomiting, dizziness, loss of appetite, and weakness (p < 0.05).

Uso de buprenorfina transdérmica en el alivio del dolor por cáncer / Use of transdérmica buprenorfina in the lightening of the pain by cancer

Los fármacos opioides tienen un papel importante en el control del dolor crónico moderado o severo, con una firme posición de preferencia en el tratamiento del dolor por cáncer y su uso expreso y ampliamente aceptado por el sistema escalonado con arreglo a la disposición de la Organización Mundial de la Salud. Dentro de los principios generales de aplicación, las guías establecen que los analgésicos usados en el manejo del dolor crónico no deben inducir concentraciones séricas en forma de pico, a menudo responsables de los efectos adversos. Además, las guías de la OMS recomiendan la formulación de sustancias de liberación sostenida, las cuales resultan efectivas y fáciles de autoadministrar. Los métodos de liberación transdérmica generan una solución efectiva al problema de aplicar analgésicos al paciente con dolor crónico. El compuesto activo difunde pasivamente en la circulación sistémica y permite que el método de liberación transdérmica mantenga niveles terapéuticos séricos por 72 horas, a continuación de una aplicación simple. La buprenorfina tiene un bajo peso molecular, de alta potencia y liposolubilidad combinada a una favorable tolerabilidad y un bajo potencial de abuso. Por dichas razones la buprenorfina es ideal para aplicación transdérmica. El nuevo esquema libera la droga a dosis de 35 mcg/h en 72 horas, que corresponden a 0,8mg/día...

Tratamiento farmacológico del dolor en pacientes con cáncer: [revisión] / Pharmacological treatment of patients with cancer pain: [review]

La Organización Mundial de la Salud define el cuidado paliativo como el cuidado total y activo en aquellos pacientes que no responden a un tratamiento curativo. El control del dolor, otros síntomas y los problemas psicológicos, sociales y espirituales son de fundamental importancia. La meta del cuidado paliativo es brindar la mejor calidad de vida a los pacientes y a sus familias. En el cuidado paliativo es necesario el manejo multidisciplinario. Nuevas estrategias como rotación de opioides y sus diferentes vías de administración pueden ofrecer analgesia con pocos efectos adversos.

The World Health Organisation defines palliative care as the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems, is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Palliative care is necessarily multidisciplinary. New strategies such as the switching opioids and/or their route of administration may offer improved analgesia with fewer adverse effects, thus providing therapeutic alternatives for the clinical community.

Estudio comparativo de premedicación en paciente adulto ambulatorio con brotizolam sublingual / Premedication in the adult with sublingual brotizolam

Se realizó ensayo clínico doble ciego, para premedicación utilizando una novedosa vía de administración para este tipo de fármacos, la sublingual, con BROTIZOLAM una nueva benzodiazepina, en noventa (90) pacientes programados para cirugía ambulatoria en el Hospital Regional Simón Bolívar, adultos con clasificación de ASA 1 II, divididos en tres (3) grupos de treinta (30) pacientes cada uno así: Grupo Uno eran premedicados con BROTIZOLAM sublingual a una dosis de 0.25 mg. Grupo Dos con 0.50 mg. calculando siempre (30) minutos antes de pasar a salas de cirugía; y el Grupo Tres o control a los cuales no se les administraba ninguna premedicación. El objetivo era evaluar el grado de sedación y facilidad de inducción en los pacientes premedicados, en contra de los no premedicados, mediante una evaluación subjetiva por parte del anestesiólogo encargado, valorada en una escala ordinal diseñada para tal fín. En la totalidad de los pacientes premedicados se pudo controlar la ansiedad en un tiempo mínimo (20 minutos) a las dósis más bajas utilizadas en el estudio; cuando se aumentó la dosis a 0.50 mg. el BROTIZOLAM presentó efectos tanto ansiolíticos como hipnóticos, no así en los pacientes no premedicados, en los cuales se presentó ansiedad en mayor o menor grado. El peso y el tiempo de evaluación no tuvieron diferencias estadísticamente significativas no así la edad, la cual sí influyó sobre el grado de sedación de los pacientes premedicados, comportándose el BROTIZOLAM como otras benzodiazepinas.Por lo anterior, consideramos el BROTIZOLAM como una excelente alternativa en la premedicación por vía sublingual, de los pacientes que van a ser sometidos a una cirugía ambulatoria