Effect of continuous intra-incisional bupivacaine on postoperative pain in non-traumatic spinal fixation surgeries: a randomized controlled trial

Abstract Background Continuous injection of local anesthetics by using surgical wound catheters for postoperative pain relief has gained acceptance in recent years. However, whether this method can be alternatively used instead of systemic opioids in different surgical procedures has not yet been elucidated. Objectives The aim was to investigate the effect of continuous injection of bupivacaine through a catheter inside the surgical wound on reducing the postoperative pain of lumbar spine fusion surgeries. Methods In this clinical trial, 31 patients undergoing non-traumatic lumbar spine stabilization surgery were randomly assigned to receive (n = 15) or do not receive (n = 16) bupivacaine through a catheter inside the surgical wound, postoperatively. Pain intensity (NRS), dose of required morphine, and drug-related complications within 24 hours of intervention were assessed and compared by the Mann-Whitney and independent t-test. Results Mean pain intensity was significantly lower in the case group over the first postoperative hour in the recovery room (p < 0.001), which continued for the first 2 hours after entering the ward. The mean morphine intake was lower in the bupivacaine group during the first postoperative 24 hours (16 ± 0.88 vs. 7.33 ± 0.93 mg, p < 0.001). The two groups were not significantly different regarding drug-related complications. Conclusion Continuous intra-incisional infusion of bupivacaine helped better pain reduction during the early postoperative hours while sparing morphine consumption in the first postoperative day.

Effect of continuous intra-incisional bupivacaine on postoperative pain in non-traumatic spinal fixation surgeries: a randomized controlled trial.

BACKGROUND: Continuous injection of local anesthetics by using surgical wound catheters for postoperative pain relief has gained acceptance in recent years. However, whether this method can be alternatively used instead of systemic opioids in different surgical procedures has not yet been elucidated. OBJECTIVES: The aim was to investigate the effect of continuous injection of bupivacaine through a catheter inside the surgical wound on reducing the postoperative pain of lumbar spine fusion surgeries. METHODS: In this clinical trial, 31 patients undergoing non-traumatic lumbar spine stabilization surgery were randomly assigned to receive (n = 15) or do not receive (n = 16) bupivacaine through a catheter inside the surgical wound, postoperatively. Pain intensity (NRS), dose of required morphine, and drug-related complications within 24 hours of intervention were assessed and compared by the Mann-Whitney and independent t-test. RESULTS: Mean pain intensity was significantly lower in the case group over the first postoperative hour in the recovery room (p < 0.001), which continued for the first 2 hours after entering the ward. The mean morphine intake was lower in the bupivacaine group during the first postoperative 24 hours (16 ± 0.88 vs. 7.33 ± 0.93 mg, p < 0.001). The two groups were not significantly different regarding drug-related complications. CONCLUSION: Continuous intra-incisional infusion of bupivacaine helped better pain reduction during the early postoperative hours while sparing morphine consumption in the first postoperative day.

The effect of posterior tibial and sural nerve blocks on postoperative pain of patients following open reduction and internal fixation of calcaneal fractures.

INTRODUCTION: Postoperative pain control and achieving opioid-free anesthesia are major issues for surgically treated patients with calcaneal fractures. We evaluated the potential role of posterior tibial and sural nerve blocks as a part of multimodal pain control techniques in patients underwent open reduction and internal fixation (ORIF) of calcaneal fractures via extensile lateral approach. METHODS: Forty-eight patients randomly allocated to receive either posterior tibial and sural nerve blocks with bupivacaine (peripheral nerve block (PNB) group) or normal saline, after induction of general anesthesia. Patients were assessed for pain intensity, Interval from entrance to the recovery room to the first request for analgesic, recovery room and ward morphine consumption, global satisfaction and morphine side effects. RESULTS: PNB group had less pain score compared to sham block (SB) group at each time point measurement during recovery room stay. There was also significant difference between the 2 groups regarding the pain scores after 2, 4 and 6 h of the operation in the ward. Time to the first request for analgesic was significantly prolonged in the PNB group (P < 0.001). The recovery room and ward morphine consumption was significantly lower in the PNB group (P < 0.001). Global satisfaction in PNB group was significantly more than that of SB group. No complication related to the nerve block was detected at the first postoperative visit in the outpatient clinic. CONCLUSION: Peripheral nerve block could result in less postoperative pain especially in the early hours after ORIF of calcaneal fractures and reduce opioid administration within the first 24 h following the surgery.

Effectiveness of intradiscal injection of radiopaque gelified ethanol (DiscoGel®) versus percutaneous laser disc decompression in patients with chronic radicular low back pain.

BACKGROUND: Low back pain secondary to discopathy is a common pain disorder. Multiple minimally invasive therapeutic modalities have been proposed; however, to date no study has compared percutaneous laser disc decompression (PLDD) with intradiscal injection of radiopaque gelified ethanol (DiscoGel®). We are introducing the first study on patient-reported outcomes of DiscoGel® vs. PLDD for radiculopathy. METHODS: Seventy-two patients were randomly selected from either a previous strategy of PLDD or DiscoGel®, which had been performed in our center during 2016-2017. Participants were asked about their numeric rating scale (NRS) scores, Oswestry disability index (ODI) scores, and progression to secondary treatment. RESULTS: The mean NRS scores in the total cohort before intervention was 8.0, and was reduced to 4.3 in the DiscoGel® group and 4.2 in the PLDD group after 12 months, which was statistically significant. The mean ODI score before intervention was 81.25% which was reduced to 41.14% in the DiscoGel® group and 52.86% in the PLDD group after 12 months, which was statistically significant. Between-group comparison of NRS scores after two follow-ups were not statistically different (P = 0.62) but the ODI score in DiscoGel® was statistically lower (P = 0.001). Six cases (16.67%) from each group reported undergoing surgery after the follow-up period which was not statistically different. CONCLUSIONS: Both techniques were equivalent in pain reduction but DiscoGel® had a greater effect on decreasing disability after 12 months, although the rate of progression to secondary treatments and/or surgery was almost equal in the two groups.

The effect of methylnaltrexone on the side effects of intrathecal morphine after orthopedic surgery under spinal anesthesia.

Methylnaltrexone is a peripheral opioid receptor antagonist that does not cross the blood-brain barrier; so without interference with pain relief, it could reverse the peripheral opioid side effects such as constipation, pruritus, postoperative ileus, and urinary retention. This study has been designed to evaluate the effect of methylnaltrexone on postoperative side effects of intrathecal morphine. In seventy-two 18- to 55-year-old patients scheduled for elective orthopedic operations under spinal anesthesia, neuraxial blockade was achieved using 10 mg 0.5% hyperbaric bupivacaine and 0.1 mg preservative-free morphine sulfate. The first group (M) received 12 mg methylnaltrexone, while the second group (P) received normal saline, subcutaneously, immediately after spinal block in a randomized, double-blind fashion. There was a significant decrease in the rate of nausea and vomiting in group M, but there was no significant difference in the rate of pruritus or urinary retention between the two groups. Pain score was significantly lower in group M. Respiratory depression or decreased level of consciousness was not reported in any patient. Subcutaneous administration of methylnaltrexone was not effective in decreasing postoperative urinary retention and pruritus, but lowered the rate of nausea and vomiting and pain score after intrathecal bupivacaine and morphine.

Evaluation of the adequacy of general anesthesia in cesarean section by bispectral index.

BACKGROUND: Awareness and recall, though not common, are the major hazards of general anesthesia, especially in Cesarean section (C/S) because of the absence of benzodiazepine and opioids for a significant time during anesthesia. In this study, the Bispectral Index (BIS), end-tidal isoflurane, and hemodynamic parameters were examined to evaluate the depth of the routine general anesthetic technique in C/S. METHODS: This study was carried out on 60 parturient patients undergoing elective C/S. A standardized anesthetic technique was applied: induction with Thiopental (4-5 mg/kg) and Succinylcholine (1.5-2 mg/kg) as well as maintenance with O2, N2O, and isoflurane. Electrocardiogram, heart rate, blood pressure, Spo2, end-tidal isoflurane concentration, BIS, and any clinical signs of inadequate depth of anesthesia such as movement, sweating, lacrimation, coughing, and jerking were continuously monitored and recorded at 16 fixed time points during anesthesia. RESULTS: A median BIS of less than 70 (range: 42-68) was obtained on all occasions during surgery; however, at each milestone, at least 20% of the patients had BIS values above 60. Hemodynamic parameters increased significantly in some patients, especially during laryngoscopy and intubation. No patient experienced recall or awareness. CONCLUSION: The currently used general anesthetic technique in our center appears inadequate in some milestones to reliably produce BIS values less than 60, which are associated with lower risk of awareness. Therefore, with respect to such desirable outcomes as good Apgar and clinical status in neonates, we would recommend the application of this method (if confirmed by further studies) through larger dosages of anesthetic agents.

The relationship between tuberculin response, BCG vaccine scar and asthma.

Recent studies have proposed that a decline in bacterial infections such as tuberculosis is a factor underlying the rising prevalence and severity of atopic disorder in developed countries. There are conflicting ideas about the inverse relationship between BCG (Bacillus Calmette-Guerin) vaccination and asthma. Stronger response to tuberculin test as an indicator of more potent TH1 response is supposed to influence TH2 modulated allergic reactions. BCG scar considered as an indicator of TH1 - immunoresponse has been proposed to be smaller in asthmatic children in some studies.In a case-control study, 97 asthmatic and 97 control children younger than 5 years of age and BCG vaccinated at birth were tested with 5 units of tuberculin intradermaly. After 48-72 hours, the indurated area was measured in two diameters. Mean while, the scar of BCG in both groups was measured. Severity of asthma in the case group was recorded and categorized into mild, moderate and severe groups. The case group consisted of 63% boys and 37% girls and their tuberculin response was significantly smaller than that of the control (p=0.000), but no data supported the inverse relationship between the tuberculin response and severity of asthma (p=0.113). The scar of BCG was not significantly different in the asthmatic children with variable severity of asthma and control group (p=0.864).Children with definite asthma had a significant weaker response to tuberculin. This might be an indication of less potent TH1-reponse in allergic patients, but it was not associated with severity of asthma. No significant relationship between the size of BCG scar and asthma or its severity was found so perhaps BCG scar is not a sensitive indicator for development of asthma in future.