Comparative study of iontophoresis-assisted transdermal delivery of bupivacaine and lidocaine as anesthetic drugs.

Postoperative pain management is an important aspect of the overall surgical care process. Effective pain management not only provides patient comfort but also promotes faster recovery and reduces the risk of complications. Bupivacaine (BUP) and Lidocaine (LID) transdermal drug deliveries via thermoplastic polyurethane matrix (TPU) and iontophoresis technique are proposed here as alternative routes for postoperative pain instead of the injection route. Under applied electric field, the amounts of BUP and LID released were 95% and 97% from the loaded amounts, which were higher than the passive patch of 40%. The time to equilibrium of BUP turned out to be faster than the time to equilibrium of LID by approximately 1.5 times. This was due to 2 factors namely the drug molecular weight and the drug pKa value; they play an important role in the selection of a suitable drug for fast-acting or long-acting for the postoperative patients. By using this transdermal patch via iontophoresis system, BUP was deemed as the suitable drug for fast-acting due to the shorter time to equilibrium, whereas LID was the suitable drug for long-acting. The in-vitro drug release - permeation study through a porcine skin indicated the efficiency and potential of the system with the amounts of drug permeated up to 76% for BUP and 81% for LID. The TPU transdermal system was demonstrated here as potential to deliver BUP and LID for postoperative patients.

Perioperative Intravenous Nefopam on Pain Management and Ambulation after Open Spine Surgery: A Randomized Double-Blind Controlled Study.

STUDY DESIGN: This was a randomized double-blind controlled study. PURPOSE: This study was designed to evaluate the effects of intravenous nefopam regarding its ability to reduce morphine consumption and postoperative pain and improve recovery in patients undergoing open spine surgery. OVERVIEW OF LITERATURE: Multimodal analgesia, including nonopioid medications, is essential for pain management in spine surgery. Evidence regarding the use of intravenous nefopam in open spine surgery as part of enhanced recovery after surgery is lacking. METHODS: In this study, 100 patients undergoing lumbar decompressive laminectomy with fusion were randomized into two groups. The nefopam group received 20-mg intravenous nefopam diluted in 100-mL normal saline intraoperatively, followed by 80-mg nefopam diluted in 500-mL normal saline, administered as a continuous infusion postoperatively for 24 hours. The control group received an identical volume of normal saline. Postoperative pain was managed using intravenous morphine via patient-controlled analgesia. Morphine consumption in the first 24 hours was recorded as the primary outcome. Secondary outcomes, including postoperative pain score, postoperative function, and length of hospital stay (LOS), were assessed. RESULTS: No statistically significant differences in the total morphine consumption and postoperative pain score in the first 24 hours postoperatively between the two groups. At the post-anesthesia care unit (PACU), the nefopam group demonstrated lower pain scores while at rest (p =0.03) and upon movement (p =0.02) than the normal saline group. However, the severity of postoperative pain between the two groups was similar from postoperative day 1 to day 3. LOS was significantly shorter in the nefopam group than in the control group (p <0.01). The time to first sitting and walking and PACU discharge between the two groups were comparable. CONCLUSIONS: Perioperative intravenous nefopam demonstrated significant pain reduction during the early postoperative period and shortened LOS. Nefopam is considered safe and effective as a part of multimodal analgesia in open spine surgery.

Comparative Outcome of Lidocaine Versus Bupivacaine for Cervical Medial Branch Block in Chronic Cervical Facet Arthropathy: A Randomized Double-Blind Study.

OBJECTIVE: This study evaluated the effect of prolonged concordant response and functional clinical improvement between lidocaine and bupivacaine for cervical medial branch block (CMBB) in chronic cervical facet syndrome. METHODS: Sixty-two patients diagnosed with chronic cervical facet syndrome were randomized into either lidocaine or bupivacaine groups. The therapeutic CMBB was performed under ultrasound guidance. Either 2% lidocaine or 0.5% bupivacaine with a volume of 0.5-1 mL per level was injected according to the patient's pain symptoms. The patients, pain assessor, and pain specialist were blinded. The primary outcome was the duration of pain reduction by at least 50%. The Numerical Rating Scale of 0-10 and the Neck Disability Index questionnaire were recorded. RESULTS: There was no significant difference in the duration of 50% and 75% pain reduction and Neck Disability Index between the lidocaine and bupivacaine groups. Lidocaine provided significant pain reduction up to 16 weeks (P < 0.05) and significant improvement in neck functional outcomes up to 8 weeks (P < 0.01) compared to the baseline. While bupivacaine yielded significant pain alleviation for up to 8 weeks for pain upon neck mobilization (P < 0.05) and demonstrated notable improvement in neck function up to 4 weeks (P < 0.01) compared to the baseline. CONCLUSION: CMBB using lidocaine or bupivacaine provided clinical benefits in prolonged analgesic effect and improving neck functions for chronic cervical facet syndrome. Lidocaine illustrated better performance and could be considered a local anesthetic of choice regarding the prolonged concordance response.

Ultrasound-guided pulsed radiofrequency of cervical nerve root for cervical radicular pain: a prospective randomized controlled trial.

BACKGROUND CONTEXT: Pulsed radiofrequency (PRF) on cervical dorsal root ganglion (DRG) for pain management in cervical radicular pain is mainly performed via a transforaminal approach under fluoroscopic guidance. Ultrasound-guidance periradicular cervical nerve root intervention raises concern about the neuromodulatory effect. This study aims to evaluate the effectiveness and duration of pain relief between PRF treatment and steroid injection on the cervical nerve roots. PURPOSE: To evaluate the efficacy of pulsed radiofrequency for cervical radicular pain. STUDY DESIGN: A prospective, double-blinded, randomized controlled clinical trial PATIENT SAMPLE: Patients who underwent ultrasound-guided periradicular cervical nerve root PRF or steroid injection from January 2020 to May 2021 at King Chulalongkorn Memorial Hospital (KCMH), Bangkok, Thailand. OUTCOME MEASURES: The primary outcome was the pain score at 3 months postprocedure. The secondary outcomes were the duration of pain relief of at least 50%, pain scores at other time points after pain intervention, the amount of rescue pain medications, procedural time, and complications. METHOD: Forty-two patients who presented with chronic cervical radicular pain were prospectively randomized into the PRF and steroid groups. Patients in the PRF group received PRF treatment at 42°C for 4 minutes, followed by the injection of 2% lidocaine 1.5 mL and dexamethasone 10 mg to the targeted cervical nerve root. The steroid group received the same injectate. Patients and pain assessors were blinded. The numerical rating scale (NRS) and the Neck Disability Index (NDI) questionnaires were used for pain intensity and neck functional assessment before and after the procedure. Pain reduction was recorded up to a 9-month follow-up. RESULTS: Data analysis was obtained from 20 and 21 patients receiving PRF and steroid treatment, respectively. At 3-month postprocedure, there were 70% of patients in the PRF group reported 50% pain reduction compared with 23.8% of patients in the steroid group (p<.01). Moreover, patients in the PRF group had significantly less pain (NRS 2.8±2.7) compared with patients in the steroid group (NRS 5.5±2.6) (p=.01). The neck disability index demonstrated significant improvement at 3 and 6 months (p<.01) after PRF treatment compared with steroid injection alone. The duration, in which pain relief was at least 50%, was significantly longer in patients who received PRF treatment (6.0±4.1 months) compared with those in the steroid group (2.3±2.1 months) (p<.01). CONCLUSION: Ultrasound-guided periradicular cervical nerve root PRF exhibited a neuromodulatory effect and was considered effective for patients with cervical radicular pain. It provided a longer duration of pain relief and improvement of neck function for up to 6 months.

Telomere Shortening and Increased Oxidative Stress in Lumbar Disc Degeneration.

Lumbar disc degeneration (LDD) contributes to low back pain. This study aimed to determine relative telomere length (RTL), oxidative stress status, and antioxidant levels and examine the relationships between RTL, oxidative stress, and the severity in LDD patients. A total of 100 subjects, 50 LDD patients and 50 healthy controls, were enrolled in the case−control study. Blood leukocyte RTL was analyzed using quantitative real-time polymerase chain reaction. Lipid peroxidation was determined by malondialdehyde (MDA) assay. Plasma 8-hydroxy 2'-deoxyguanosine (8-OHdG) values were determined using enzyme-linked immunosorbent assay. Total antioxidant capacity (TAC) and ferric reducing antioxidant power (FRAP) in plasma were also measured. The LDD patients had significantly shorter telomeres than the healthy controls (p = 0.04). Blood leukocyte RTL was inversely correlated with the LDD severity (r = −0.41, p = 0.005). Additionally, plasma MDA and 8-OHdG levels were markedly greater in LDD patients than in the controls (p = 0.01 and p = 0.002, respectively). Furthermore, the plasma MDA level showed a positive correlation with the radiographic severity (r = 0.49, p = 0.001). There was a positive correlation between plasma 8-OHdG and the severity (r = 0.60, p < 0.001). Moreover, plasma TAC and FRAP levels were significantly lower in LDD patients than in the controls (p = 0.04). No significant differences in plasma TAC and FRAP were observed among the three groups of LDD severity. We found that RTL was negatively correlated with the severity while plasma MDA and 8-OHdG levels were positively correlated with the severity. These findings suggest that blood leukocyte RTL, plasma MDA, and 8-OHdG may have potential as noninvasive biomarkers for the assessment of severity in LDD.

Effects of general anesthesia with and without thoracic epidural block on length of stay after open spine surgery: a single-blinded randomized controlled trial.

BACKGROUND CONTEXT: Length of hospital stay (LOS) is an important concern in all types of surgery, and the enhanced recovery after surgery (ERAS) protocol has been developed to improve perioperative management and outcomes, which require multidisciplinary management. In terms of pain control, intraoperative regional anesthesia and postoperative opioid-sparing analgesia are recommended. For open spine surgery, we aimed to combine thoracic epidural analgesia to reduce pain and opioid-related side effects, thereby hastening recovery. PURPOSE: This study aimed to compare the length of hospital stay after open complete laminectomy with fusion between general anesthesia and combined general anesthesia involving a single thoracic epidural injection. DESIGN: A randomized single-blinded controlled study. PATIENT SAMPLE: Thirty-eight patients scheduled for elective open laminectomy with fusion between I and III levels were selected. OUTCOME MEASURES: LOS, postoperative pain, patient-controlled morphine consumption at 24 hours, patient satisfaction score, and other opioid-related side effects were recorded. METHODS: Patients were randomly selected to receive standard general anesthesia (GA) or GA combined with a single-shot thoracic epidural at T11-T12 or T12-L1, a block with 10 mL of 0.25% bupivacaine, and 4 mg of morphine. RESULTS: There were no significant differences in the demographic variables between groups. LOS was significantly lower in the combined epidural and/or GA than in the control group (3.78±0.81 [mean±standard deviation] and 4.79±1.51 days, respectively; p=.017). Numeric rating score (at rest) at the post-anesthesia care unit, 24 hours postoperative morphine consumption (mg), operating time, and blood loss were significantly lower in the epidural group. Patients who received combined epidural and/or GA were more likely to report higher patient satisfaction (p=.008). However, the incidence of intraoperative hypotension was significantly higher in the epidural group (72.2% vs. 21.1%, p=.003). The incidences of adverse events and surgical field rating scores did not differ between the 2 patient groups. CONCLUSIONS: Combined lower thoracic epidural and/or GA in patients undergoing elective lumbar spine surgery was associated with decreased LOS.

Analgesic Effect of Intravenous Nefopam for Postoperative Pain in Minimally Invasive Spine Surgery: A Randomized Prospective Study.

STUDY DESIGN: Randomized double-blind control study. PURPOSE: To evaluate the effects of nefopam on reducing morphine consumption and postoperative pain in patients undergoing minimally invasive spine surgery (MISS) and to evaluate its effects on enhanced recovery after spine surgery. OVERVIEW OF LITERATURE: Enhanced recovery after surgery (ERAS) has become a major goal for spine surgery. Multimodal pain management combining non-opioid analgesics is a key element of this. However, there is little evidence regarding the use of nefopam in spine surgery as part of an ERAS protocol. METHODS: One hundred patients undergoing MISS were randomized into two groups. Patients in the nefopam group received 20 mg of intravenous nefopam diluted in 100 mL of normal saline intraoperatively, followed by 80 mg of nefopam diluted in 500 mL of normal saline, given as a continuous infusion postoperatively for 24 hours. The control group received an identical volume of normal saline. Postoperative pain was managed by patient-controlled analgesia in the form of intravenous morphine. Morphine consumption in the first 24 hours was recorded as a primary outcome. Secondary outcomes regarding ERAS were also collected. RESULTS: There were no significant differences in either total morphine consumption or postoperative pain score in the first 24 hours postoperatively between patients receiving nefopam and the control group. Morphine consumption in patients receiving nefopam was 13.54±10.64 mg compared with 15.86±16.2 mg in the control group (p=0.41). Time to postanesthetic care unit discharge, times to first sitting and walking, length of hospital stay, as well as duration of Foley catheter use and time until drain removal were also similar. There were no serious adverse effects of nefopam compared with normal saline. CONCLUSIONS: Nefopam did not significantly reduce opioid consumption or postoperative pain score. Adding nefopam as part of multimodal analgesia did not show beneficial effects for enhancing recovery after spine surgery.

Determination of dose and efficacy of atracurium for rapid sequence induction of anesthesia: A randomised prospective study.

BACKGROUND AND AIMS: Succinylcholine and high dose rocuronium are neuromuscular blocking agents commonly used for rapid sequence induction of anesthesia. Their usage is limited or contraindicated in some circumstances. The aim of this study is to determine the dosage and efficacy of atracurium without priming for rapid sequence induction of anesthesia. MATERIAL AND METHODS: One hundred fifteen surgical patients under general anesthesia were randomised into three groups. All patients were given 2-3 mg/kg propofol and 1 µg/kg fentanyl intravenously for the induction of anesthesia followed by different doses of atracurium (0.6 mg/kg, 0.75 mg/kg or 1 mg/kg) without a priming dose. Tracheal intubation was performed within one minute after the administration of the study drugs. The intubating conditions, vocal cord movement and diaphragm movement were graded as the primary endpoints. Statistical analysis was done using one-way analysis of variance (ANOVA) and Post Hoc tests. RESULTS: Atracurium doses of 1 mg/kg, 0.75 mg/kg, and 0.6 mg/kg provided 51.4%, 43.6% and 26.3% success rates of intubation without coughing or bucking, respectively (P = 0.03). The intubating conditions were graded as excellent or good in 86.5% of the 1 mg/kg atracurium group patients and in 84.6% of the 0.75 mg/kg group patients (P < 0.05). An atracurium dose of 1 mg/kg facilitated significant differences in vocal cord and diaphragm paralysis compared with the dose of 0.6 mg/kg (P = 0.03). CONCLUSION: The administration of a relatively high dose of atracurium without priming can be used as an alternative neuromuscular blocking agent for rapid sequence induction of anesthesia in some circumstances.

Noradrenaline, Serotonin, GABA, and Glycine in Cerebrospinal Fluid during Labor Pain: A Cross-Sectional Prospective Study.

BACKGROUND AND AIMS: The inhibitory pathways that play a role in spinal modulation include local interneurons and descending control. Clinical data regarding the role of these pathways in acute pain is lacking. Accordingly, the aim of this study was to evaluate cerebrospinal fluid (CSF) levels of noradrenaline, serotonin, gamma-aminobutyric acid (GABA), and glycine in parturients with labor pain compared to those without labor pain. METHODS: One hundred term uncomplicated pregnant women receiving spinal anesthesia for cesarean section were enrolled in this prospective cross-sectional study. CSF noradrenaline, serotonin, GABA, and glycine levels were analyzed by enzyme-linked immunosorbent assay. Labor pain score was assessed by numerical rating scale. RESULTS: Median CSF serotonin concentration in parturients with labor pain was significantly lower than in those without pain (p < 0.001). Median CSF glycine level in the labor pain group was significantly higher than in the control group (p < 0.001). There were no significant differences in median CSF level of noradrenaline or GABA between parturients with and without labor pain. Subsequent analysis showed labor pain scores to be negatively correlated with CSF serotonin (r = -0.217, p = 0.04) but positively correlated with CSF glycine (r = 0.415, p < 0.001). CONCLUSION: CSF serotonin and glycine were significantly correlated with labor pain scores. These findings suggest that the serotonergic and glycinergic systems may play a role in spinal modulation of visceral pain.

Real-Time Detection of Periforaminal Vessels in the Cervical Spine: An Ultrasound Survey.

BACKGROUND AND OBJECTIVES: Compared with the thoracic and lumbar spine, transforaminal epidural injections and medial branch blocks in the cervical spine are associated with a higher incidence of neurological complications. Accidental breach of small periforaminal arteries has been implicated in many instances. In this observational study, using ultrasonography, we surveyed the incidence of periforaminal bloods vessels in the cervical spine. METHODS: Patients undergoing ultrasound-guided cervical medial branch blocks were scanned using color power and pulsed wave Doppler. Five levels from C2/C3 to C6/C7 were studied. Incidental blood vessels located between the anterior tubercles of the transverses process and the posterior borders of the articular pillars were included for analysis. We recorded the diameter and position of arteries relative to contiguous bony landmarks as well the number of veins. RESULTS: In 102 patients, we performed a total 201 scans (1005 cervical levels). Of the 363 incidental vessels identified, 238 were arteries (mean diameter, 1.25 ± 0.45 mm). The latter were most commonly found at the posterior foraminal aspects of C5, C6, and C7 (13%, 11%, and 16% of scans, respectively); the transverse processes of C5 and C6 (10% and 16% of scans, respectively); and the articular pillars of C6 and C7 (19% and 16% of scans, respectively). CONCLUSIONS: Small periforaminal arteries are prevalent along the lateral aspect of the cervical spine, adjacent to areas commonly targeted by nerve block procedures. Further trials are required to determine if ultrasound guidance can reduce the incidence of complications related to accidental vascular breach.