Percutaneously implanted plates in failed back surgery syndrome (FBSS).

OBJECTIVE: To evaluate the clinical efficacy of pain suppression in back area and lower extremities by recently developed plate electrodes for spinal cord stimulation through percutaneous access. METHODS: A retrospective analysis is performed: 20 consecutive patients with both lower extremity pain and low back pain, with low back counting for at least 30% of the overall pain were implanted with a small profile plate type lead, S-Series (SJM), via percutaneous approach. Patients were asked to rate their back and leg pain as well as their overall satisfaction and data on quality of life (QOL) on a (0-10 point) visual analog scale (VAS) before and after implantation. Medication use, functional pain (pain when bending forward, moving), and patient satisfaction scores also were collected. RESULTS: A significant reduction of 55% and 45.7% in, respectively, VAS legs and VAS back pain was found. One year postoperatively the reduction was still present, respectively, 43% and 27% for the legs and the back. In 17 patients (85%) a clinically relevant reduction (defined as reduction of 2 points or 30% in VAS) in back pain was seen, with a mean decrease of 4.3 points (2.0-10.0) or 52% (22-100). Only three patients had no reduction in back pain, although they had reduction of their pain in the lower extremities. A significant and clinically relevant improvement of 66% and 70% was seen, respectively, for general satisfaction and QOL, respectively. One year postoperatively this improvement was still present, respectively, 69% and 75% for the satisfaction and QOL. Importantly functional pain also decreased by 51%. No infections occurred. Mean duration of post-op wound pain was 13.5 hours. CONCLUSION: Percutaneous implantation of the S-Series plate electrodes using a 10 gauge epidural needle combines the advantages of a minimal invasive technique with the possibility to cover the back area supplementing leg coverage in 85% of the failed back surgery syndrome patients.

Evaluation of MP4OX for prevention of perioperative hypotension in patients undergoing primary hip arthroplasty with spinal anesthesia: a randomized, double-blind, multicenter study.

BACKGROUND: MP4OX (oxygenated polyethylene glycol-modified hemoglobin) is an oxygen therapeutic agent with potential applications in clinical settings where targeted delivery of oxygen to ischemic tissues is required. The primary goal of this study was to investigate MP4OX for preventing hypotensive episodes. An additional goal was to establish the safety profile of MP4OX in a large surgical population. METHODS: Patients (n = 367) from 18 active study sites in six countries, undergoing elective primary hip arthroplasty with spinal anesthesia, were randomized to receive MP4OX or hydroxyethyl starch 130/0.4. Patients received a 250-ml dose at induction of spinal anesthesia and a second 250-ml dose if the protocol-specified trigger (predefined decrease in systolic blood pressure) was reached. The primary end point was the proportion of patients who developed one or more hypotensive episodes. RESULTS: The proportion of patients with one or more hypotensive episodes was significantly lower (P < 0.0001) in the MP4OX group (66.1%) versus controls receiving hydroxyethyl starch 130/0.4 (90.2%). More MP4OX-treated patients experienced adverse events compared with controls (72.7% vs. 61.4%; P = 0.026). Transient elevations in laboratory values (e.g., alanine aminotransferase, aspartate aminotransferase, lipase, and troponin concentrations) occurred more frequently in the MP4OX group. There were no significant differences in the incidence of serious adverse events or in the composite morbidity and ischemia outcome end points, but nausea and hypertension were reported more often in MP4OX-treated patients. CONCLUSION: MP4OX significantly reduced the incidence of hypotensive episodes in patients undergoing hip arthroplasty, but the adverse event profile does not support use in routine low-risk surgical patients for the indication evaluated in this study.

An algorithm to reduce allogenic red blood cell transfusions for major orthopedic surgery.

In a previous prospective study, we confirmed that transfusion-related immunosuppression predisposes to postoperative infections, impairs the postoperative healing of wound and thereby prolongs hospitalization. This increases the well-known risks, such as transmission of infection or transfusion reactions, and has obliged us to revise our transfusion guidelines. We used a relational database containing information about 28,861 orthopedic surgery patients was used to determine when and how to improve these guidelines for transfusions. The survey showed the circumstances surrounding a high incidence of allogenic red cell infusions: failure to follow the guidelines, the preoperative use of nonselective NSAIDs, low preoperative Hb level, failure to retrieve blood, and high cut-off values for allogenic red cell transfusion. The first step was to determine the Hb level before giving red cell infusions and ensure compliance with predefined cut-off values. Subsequent measures included: use of COX 2-selective NSAIDs alone in the perioperative period; erythropoietin and iron therapy when the Hb level fell below 13 g/dL; use of cell salvage during and after surgery; administration of aprotinin to patients expected to have a high blood loss. The type of anesthesia had no blood-sparing effect. Although these steps can not be regarded as a new approach, we show that by following a strict rules with appropriate steps and in a concerted fashion, the use of allogenic red blood cells was reduced by 80%. Moreover, the amount of blood saved had other effects--e.g., the incidence of deep wound infections was reduced by 40%. The outcome is described in an algorithm summarizing the steps in a comprehensive perioperative diagram for giving blood.

Prior ibuprofen exposure does not augment opioid drug potency or modify opioid requirements for pain inhibition in total hip surgery.

PURPOSE: In previous animal studies, a prior exposure to non-steroidal anti-inflammatory drugs (NSAID) augmented opioid drug potency. This study was designed to answer the question whether a similar effect can be attained in man. The objective was to use NSAID for preoperative pain reduction and at the same time use the NSAID exposure to reduce opioid requirements for pain inhibition in major orthopedic surgery. METHODS: In this double-blind, randomized study, 50 patients scheduled for total hip surgery were included. Patients of Group I received a placebo drug three times a day two weeks before surgery, and those allocated to Group II received ibuprofen (600 mg) three times a day. For surgical anesthesia, all patients received intrathecal bupivacaine 20 mg plus 0.1 mg morphine in a total volume of 4 mL. RESULTS: The preoperative or postoperative visual analogue scale pain scores or the amount of iv morphine showed no differences between the two groups in the first 24 hr after surgery. The median total blood loss in the ibuprofen group was 1161 mL vs 796 mL in the placebo group (P < 0.01). CONCLUSION: Pretreatment with ibuprofen before major hip surgery does not improve the pain scores or reduce morphine requirement but significantly increases blood loss. Considering the presence of relevant adverse effects, pretreatment with a non-selective NSAID is not recommended.