Modern Perioperative Pain Management Strategies to Minimize Opioids after Total Knee Arthroplasty.

Total Knee Arthroplasty is associated with significant postoperative pain that can limit functional outcomes and patient satisfaction. In recent years, the standard of care for postoperative pain management has reduced reliance on opioids in favor of multimodal analgesia. These regimens consist of systemic medications such as COX-2 inhibitors, acetaminophen, corticosteroids, and gabapentinoids, as well as regional and local approaches such as peripheral nerve blocks and local infiltrative analgesics. Newer therapies, such as cryoneurolysis, are still being studied but have shown promising results. Additional studies are needed to determine the ideal pain regimen that will optimize pain control and eliminate the need for postoperative opioids.

Association Between Hypercholesterolemia and Neck Pain in a Cross-sectional Population-based Study.

STUDY DESIGN: Retrospective cross-sectional analysis. SUMMARY OF BACKGROUND DATA: Degenerative changes are a major contributor to chronic neck pain. According to the vascular hypothesis of disk disease, atherosclerosis of the segmental arteries contributes to ischemia of the lumbar disks and resulting degenerative changes. Prior studies have demonstrated an association between atherosclerotic risk factors and lumbar degenerative disease. Similarly, atherosclerosis may contribute to cervical disk degeneration. Cardiovascular disease is associated with the development of atherosclerosis, particularly in small vessels to the cervical spine. Hypercholesterolemia is a major contributor to the morbidity associated with cardiovascular disease. This study aims to examine the relationship between hypercholesterolemia and neck pain. MATERIALS AND METHODS: Analysis was focused on the respondents to neck pain items of the standardized questionnaire. Odds ratios were calculated, and logistic regression analyses adjusted for demographic, education, and mental health conditions. RESULTS: There were 30,461 participants in the 2018 Medicare Expenditure Panel Survey (MEPS) survey. Of those, 1049 (3.4%) subjects responded to presence of a diagnosis of cervical disorders with neck pain. Mean age of respondents was 62.6±16.1. Overall prevalence of neck pain was 21.1%. Prevalence of neck pain was similar by age, sex, education level, and occupation ( P >0.05 for each). Neck pain was more prevalent in white race and lower total family income ( P <0.05). Current everyday smokers also had higher prevalence of neck pain ( P <0.05). Logistic regression analysis revealed a higher prevalence of neck pain in those with hypercholesterolemia after controlling for relevant covariates (adjusted odds ratio=1.54, 95% CI: 1.08-2.22, P =0.018). CONCLUSIONS: Subjects with hypercholesterolemia were 54% more likely to have neck pain after controlling for confounders. This suggests that hypercholesterolemia has a role to play in degeneration of the cervical spine. Therefore, prevention and proper management of high cholesterol may curtail the development and progression of degenerative cervical disk disease and thus, neck pain.

Degenerative Cervical Myelopathy: Evaluation and Management.

Degenerative cervical myelopathy is most commonly caused by cervical spondylosis, with a predominant elderly population, and is the most common cause of spinal cord impairment. Patients typically present with gait dysfunction, hand impairment, and/or the presence of long tract signs: clonus, Hoffman sign, Babinski sign, or inverted radial reflexes. One of the key surgical strategies is deciding an approach, which is based on patient characteristics and cause of pathologic condition. Without operative intervention, there is a high rate of neurological decline. Most surgeons recommended surgical treatment given the favorable outcomes and well understood natural history of disease.

A Pathway for the Diagnosis and Treatment of Lumbar Spinal Stenosis.

Lumbar spinal stenosis is a prevalent condition with varied presentation. Most common in older populations, symptoms typically include back, buttock, and posterior thigh pain. Diagnosis is typically based on physical examination and clinical history, but confirmed on imaging studies. Nonsurgical management includes nonsteroidal anti-inflammatories, physical therapy, and epidural injections. If nonoperative management fails or patient presentation involves worsening symptoms, surgical intervention, most commonly in the form of a laminectomy, may be indicated. Recent literature has demonstrated improved pain and functional outcomes with surgery compared with conservative treatment in the middle to long term.

The Prevalence of Bacterial Infection in Patients Undergoing Elective ACDF for Degenerative Cervical Spine Conditions: A Prospective Cohort Study With Contaminant Control.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To determine the prevalence of bacterial infection, with the use of a contaminant control, in patients undergoing anterior cervical discectomy and fusion (ACDF). METHODS: After institutional review board approval, patients undergoing elective ACDF were prospectively enrolled. Samples of the longus colli muscle and disc tissue were obtained. The tissue was then homogenized, gram stained, and cultured in both aerobic and anaerobic medium. Patients were classified into 4 groups depending on culture results. Demographic, preoperative, and postoperative factors were evaluated. RESULTS: Ninety-six patients were enrolled, 41.7% were males with an average age of 54 ± 11 years and a body mass index of 29.7 ± 5.9 kg/m2. Seventeen patients (17.7%) were considered true positives, having a negative control and positive disc culture. Otherwise, no significant differences in culture positivity was found between groups of patients. However, our results show that patients were more likely to have both control and disc negative than being a true positive (odds ratio = 6.2, 95% confidence interval = 2.5-14.6). Propionibacterium acnes was the most commonly identified bacteria. Two patients with disc positive cultures returned to the operating room secondary to pseudarthrosis; however, age, body mass index, prior spine surgery or injection, postoperative infection, and reoperations were not associated with culture results. CONCLUSION: In our cohort, the prevalence of subclinical bacterial infection in patients undergoing ACDF was 17.7%. While our rates exclude patients with positive contaminant control, the possibility of contamination of disc cultures could not be entirely rejected. Overall, culture results did not have any influence on postoperative outcomes.

Delayed Diagnosis of Tandem Spinal Stenosis: A Retrospective Institutional Review.

BACKGROUND: Tandem spinal stenosis (TSS) is defined as simultaneous spinal stenosis in the cervical, thoracic, and/or lumbar regions and may present with both upper and lower motor neuron symptoms, neurogenic claudication, and gait disturbance. Current literature has focused mainly on the prevalence of TSS and treatment methods, while the incidence of delayed TSS diagnosis is not well defined. The purpose of this study was to determine the incidence of delayed TSS diagnosis at our institution and describe the clinical characteristics commonly observed in their particular presentation. METHODS: Following institutional review board approval, an institutional billing database review was performed for patients who underwent a spinal decompression procedure between 2006 and 2016. Thirty-three patients who underwent decompression on 2 separate spinal regions within 1 year were included for review. Patients with delayed diagnosis of TSS following the first surgery were differentiated from those with preoperative diagnosis of TSS. RESULTS: TSS requiring surgical decompression occurred in 33 patients, with the incidence being 2.06% in this cohort. Fifteen patients received a delayed diagnosis after the first surgical decompression (45%) and were found to have a longer interval between decompressions (7.6 ± 2.1 months versus 4.01 ± 3 months, P = .0004). Patients undergoing lumbar decompression as the initial procedure were more likely to have a delayed diagnosis of TSS (8 versus 2 patients, P = .0200). The most common presentation of delayed TSS was pain and myelopathic symptoms that persisted after decompressive surgery. CONCLUSION: TSS should remain within the differential diagnosis for patients at initial presentation of spinal stenosis. In addition, suspicion of TSS should be heightened if preoperative symptoms fail to expectedly improve following decompression even if overt myelopathic signs are not present. LEVEL OF EVIDENCE: 4.

Management of Sacroiliac Joint Pain.

Sacroiliac joint (SIJ)-based pain can be difficult to diagnose definitively through physical examination and conventional radiography. A fluoroscopically guided injection into the SIJ can be both diagnostic and therapeutic. The initial phase of treatment involves nonsurgical modalities such as activity modification, use of a sacroiliac (SI) belt, NSAIDs, and physical therapy. Prolotherapy and radiofrequency ablation may offer a potential benefit as therapeutic modalities, although limited data support their use as a primary treatment modality. Surgical treatment is indicated for patients with a positive response to an SI injection with >75% relief, failure of nonsurgical treatment, and continued or recurrent SIJ pain. Percutaneous SI arthrodesis may be recommended as a first-line surgical treatment because of its improved safety profile compared with open arthrodesis; however, in the case of revision surgery, nonunion, and aberrant anatomy, open arthrodesis should be performed.

Atlas Fractures: Diagnosis, Current Treatment Recommendations, and Implications for Elderly Patients.

Fractures of the C1 vertebrae (atlas) are commonly the result of falls and other trauma, which cause hyperextension, or axial compression of the cervical spine. Although historically thought as a benign injury with lower neurological risks, current data suggests that this may not hold true for geriatric patients (aged 65 y and older) who may be predisposed to these fractures even after lower-energy trauma such as ground-level falls. Advancements in orthopedic trauma care has increased our diagnostic abilities to identify and manage patients with C1 fractures and other upper cervical spine trauma. However, there are no universal treatment guidelines based on level I trials. Current treatment ranges from nonoperative to operative management depending on fracture-pattern and integrity of the surrounding ligaments. Furthermore, in the elderly patients these fractures present a unique dilemma due to preexisting comorbidities and contraindications to various treatment modalities. C1 fractures warrant greater recognition to provide optimal treatment to patients and minimize the risk for developing complications. The goal of this review is to highlight the most updated treatment guidelines and to discuss the complications of both operative and nonoperative management of C1 fractures especially among the elderly patient population.

Scoliosis Secondary to Dystonia: A Case Report and Review of the Literature.

CASE: An adolescent girl presented with an atypical scoliotic curve, pelvic obliquity, back pain, and lower-extremity paresthesias. A workup revealed generalized primary torsion dystonia. The condition was refractory to medical treatment and necessitated implantation of a deep brain stimulator. The scoliosis required operative correction, and the patient underwent posterior spinal arthrodesis with hook-rod instrumentation, which resulted in successful correction through 7 years of follow-up. CONCLUSION: The differential diagnosis for adolescent scoliosis should include dystonia as a potential cause, especially when a patient presents with muscular contractures, an atypical scoliotic curve, pelvic obliquity, or changing curve characteristics.

High Thoracic Disc Herniation Causing Horner Syndrome with the Intraoperative Finding of Conjoined Nerve Root Compression: A Case Report.

CASE: A 29-year-old man presented with right medial arm pain with paresthesia, as well as right-sided ptosis, miosis, and anhidrosis. Magnetic resonance imaging revealed a right paracentral disc herniation at the T1-T2 level. The patient underwent a hemilaminectomy with a medial facetectomy through a posterolateral approach to the T1-T2 disc space, followed by a discectomy. Intraoperative findings were notable for a conjoined nerve root. CONCLUSION: Although high thoracic disc herniation is rare, its diagnosis should be considered when patients present with radicular arm pain and Horner syndrome. A high index of suspicion should be maintained for nerve root anomalies to limit iatrogenic injury and to ensure successful decompression.

Traumatic Conus Medullaris Syndrome: A Case Report and Review of the Literature.

CASE: A twenty-six-year-old man was diagnosed with conus medullaris syndrome (CMS) after sustaining a traumatic L1 burst fracture. Surgical decompression and stabilization was performed within ninety-six hours of admission; postoperatively, normal bladder function rapidly returned. CONCLUSION: CMS is difficult to diagnose because of the clinically variable presentation. There is no consensus regarding the natural history of conus medullaris injury or regarding the necessity, approach, or timing for decompression. Higher-level evidence is needed to guide treatment for acute traumatic CMS.