Control del dolor postoperatorio mediante morfina intratecal en pacientes intervenidos por fusión vertebral instrumentada / Postoperative pain control with intrathecal morphine in patients undergoing vertebral fusion with instrumentation

Antecedentes: El manejo adecuado del dolor postoperatorio en pacientes intervenidos de artrodesis vertebral instrumentada es esencial para disminuir la morbimortalidad postoperatoria. El uso de morfina por vía intratecal podría proporcionar una analgesia efectiva minimizando la dosis necesaria y los efectos adversos secundarios. El objetivo del estudio es valorar la eficacia de la morfina intratecal en el control del dolor postoperatorio en pacientes intervenidos de artrodesis vertebral instrumentada. Material y métodos: Se realizó un estudio prospectivo aleatorizado incluyendo a 46 pacientes intervenidos de fusión vertebral instrumentada. Los pacientes fueron divididos mediante randomización al azar en dos grupos, uno de los cuales recibió una dosis de morfina intratecal de 0.003 mg/kg antes del cierre de la herida quirúrgica. Durante el postoperatorio se registró frecuencia respiratoria, PCO2, PO2, necesidad de analgesia coadyuvante y valoración subjetiva del dolor mediante la escala visual analógica (EVA) a las 6, 24 y 48 horas tras la intervención. Los resultados fueron analizados mediante pruebas no paramétricas. Resultados: Los pacientes que recibieron morfina intratecal presentaron una disminución estadísticamente significativa del dolor postoperatorio durante las primeras 48 h con una puntuación EVA promedio cercana a 3. En 24.1% de los pacientes presentaron complicaciones asociadas al uso de cloruro mórfico, tales como náuseas o vómitos, sin diferencias significativas respecto al grupo control. Conclusiones: El uso de morfina intratecal es una opción terapéutica segura y efectiva en el control del dolor postquirúrgico precoz en pacientes intervenidos de fusión vertebral instrumentada, permitiendo una recuperación más cómoda y rápida.

Background: Proper postoperative pain management in patients undergoing vertebral arthrodesis with instrumentation is essential to reduce postoperative morbidity and mortality. Intrathecal morphine may provide effective analgesia minimizing the dose required and adverse side effects. The objective of this study is to assess the efficacy of intrathecal morphine to control postoperative pain in patients undergoing vertebral arthrodesis with instrumentation. Material and methods: A prospective randomized trial was conducted; it included 46 patients who underwent vertebral fusion with instrumentation. Patients were randomly divided into two groups: one of them received a 0.003 mg/kg dose of intrathecal morphine before closing the surgical wound. The following parameters were recorded during the postoperative period: respiratory rate, PCO2, PO2, need for adjuvant anesthesia and subjective pain assessment with the visual analog scale (VAS), at 6, 24 and 48 hours after the surgery. The results were analyzed with non-parametric tests. Results: Patients who received intrathecal morphine had a statistically significant decrease in postoperative pain within 48 hours after the surgery, with a mean VAS score close to 3. In 24.1 percent of patients had complications associated with the use of morphine chloride, such as nausea and vomiting, without any statistically significant differences compared with the control group. Conclusions: Intrathecal morphine is a safe and effective treatment option to control early postoperative pain in patients undergoing vertebral fusion with instrumentation. This leads to a more convenient and quick recovery.

[Postoperative pain control with intrathecal morphine in patients undergoing vertebral fusion with instrumentation]. / Control del dolor postoperatorio mediante morfina intratecal en pacientes intervenidos por fusión vertebral instrumentada.

BACKGROUND: Proper postoperative pain management in patients undergoing vertebral arthrodesis with instrumentation is essential to reduce postoperative morbidity and mortality. Intrathecal morphine may provide effective analgesia minimizing the dose required and adverse side effects. The objective of this study is to assess the efficacy of intrathecal morphine to control postoperative pain in patients undergoing vertebral arthrodesis with instrumentation. MATERIAL AND METHODS: A prospective randomized trial was conducted; it included 46 patients who underwent vertebral fusion with instrumentation. Patients were randomly divided into two groups: one of them received a 0.003 mg/kg dose of intrathecal morphine before closing the surgical wound. The following parameters were recorded during the postoperative period: respiratory rate, PCO2, PO2, need for adjuvant anesthesia and subjective pain assessment with the visual analog scale (VAS), at 6, 24 and 48 hours after the surgery. The results were analyzed with non-parametric tests. RESULTS: Patients who received intrathecal morphine had a statistically significant decrease in postoperative pain within 48 hours after the surgery, with a mean VAS score close to 3. In 24.1 percent of patients had complications associated with the use of morphine chloride, such as nausea and vomiting, without any statistically significant differences compared with the control group. CONCLUSIONS: Intrathecal morphine is a safe and effective treatment option to control early postoperative pain in patients undergoing vertebral fusion with instrumentation. This leads to a more convenient and quick recovery.

Nuevas perspectivas en el tratamiento de la enfermedad discal lumbar / New horizons in the treatment of lumbar disc disease

Introducción. El dolor lumbar secundario a la degeneración del disco representa uno de los retos más importantes a los que se enfrenta la cirugía ortopédica actual. El objetivo de este trabajo es presentar una revisión bibliográfica de las actuales técnicas quirúrgicas utilizadas para el tratamiento del dolor lumbar de origen discal en sus distintas fases evolutivas. Revisión de la bibliografía. Se presentan diferentes alternativas quirúrgicas a la fusión lumbar convencional para el tratamiento de la degeneración del disco intervertebral. Entre las técnicas evaluadas cabe destacar la denominada «artrodesis optimizada», que incorpora la cirugía mínimamente invasiva, el uso de navegadores y la utilización de biomateriales que favorezcan la fusión lumbar; la prótesis discal y la estabilización dinámica lumbar. Para el tratamiento quirúrgico del disco degenerado en su fase más inicial se analizan la anuloplastia intradiscal, las prótesis de núcleo pulposo y la terapia celular en sus distintas modalidades. Se revisan las ventajas e inconvenientes de las distintas técnicas, el diseño y mecanismo de acción propuesto para cada implante, y los resultados clínicos publicados durante los últimos años. Conclusiones. Distintas posibilidades terapéuticas están al alcance de los cirujanos de columna para el tratamiento de la degeneración discal. No obstante, la mayoría de ellas no están suficientemente desarrolladas, se desconoce el momento más adecuado para su ejecución durante la evolución de la enfermedad o carecen de estudios clínicos comparativos de calidad. Debe alcanzarse un mayor nivel de experiencia con estas técnicas y limitar sus indicaciones a estrictos criterios de selección de pacientes

The most formidable challenges currently facing orthopedic surgery. The purpose of this paper is to present a bibliographical review of the techniques used at present for treating disc-related lumbar pain in its different evolutional stages. Review of the literature. There are several alternatives to conventional lumbar fusion for the treatment of intervertebral disc degeneration. Among the techniques reviewed we should mention the so-called optimized arthrodesis, which incorporates minimally invasive techniques, the use of navigation and biomaterials that promote lumbar fusion; disc prostheses and dynamic lumbar stabilization. For the disc's surgical treatment in the initial stages, the techniques of choice are: intrasdiscal annuloplasty, nucleus pulposus prostheses and several types of cell therapy. We weigh the pros and cons of the different techniques, of the designs and mechanisms of action of the various implants and the clinical results published in the last few years. Conclusions. Spine surgeons can avail themselves of several possibilities when treating disc degeneration. Nonetheless, most of these are either not sufficiently developed or have not been the subject of high quality comparative clinical studies. In other cases, it is difficult to determine at what point in the evolution of the degeneration they should be used. It is necessary to acquire a higher degree of experience of the use of these techniques and to limit their indications by to stringent patient selection criteria (AU)