Abstract Background: Preemptive analgesia is a method of administration of drugs prior to surgery involving blocking noxious stimuli across the perioperative period. It involves blocking the pain ...pathway preemptively before injury-induced hypersensitivity manifests. Objective: To compare the analgesic efficacy of duloxetine with pregabalin as preemptive analgesic in lumbar spine surgeries. Design: Randomised, double-blinded, prospective study. Methods: Fifty patients of both sexes between 18-55yrs undergoing elective lumbar spine surgery were randomly allocated into two groups, group P and group D of twenty-five patients each. Group P received 75 mg pregabalin once daily for three days, followed by 150 mg pregabalin daily for the next four days till the day of surgery. Group D received 20 mg duloxetine once daily for three days, followed by 40 mg duloxetine twice daily for the next four days till the day of surgery. Outcome Measure: Both the groups were primarily evaluated in terms of time for request of 1 st rescue analgesic and total intraoperative analgesic requirement in terms of fentanyl boluses required; among other parameters. Results: The time for request of 1 st rescue analgesic postoperatively was significantly longer in the pregabalin group (396 ± 267.77 min) than in the duloxetine group (218.4 ± 96.9 min), P = 0.003. Pregabalin recipients required considerably less rescue analgesics in terms of dosage, P = 0.006. Also, pregabalin exhibited better postoperative pain control than duloxetine as reflected by NRS comparative scores. No statistical difference was appreciated in terms of intraoperative fentanyl requirement, intraoperative hemodynamic control; nausea and sleepiness. Conclusion: Pregabalin is more efficacious as a preemptive analgesic than duloxetine in lumbar spine surgery.
STUDY DESIGN.Retrospective, comparative.
OBJECTIVE.i) To design an enhanced recovery after surgery (ERAS) protocol for elective lumbar spine fusion by posterior approach, ii) To compare the results ...after ERAS implementation in patients undergoing elective lumbar spine fusion with conventional perioperative care
SUMMARY OF BACKGROUND DATA.Despite wide adoption in other surgical disciplines, ERAS has only been recently implemented in spine surgery. The integrated multidisciplinary approach of ERAS aims to reduce surgical stress to achieve better outcomes.
METHODS.Hospital records of adult patients who underwent 1- to 3-level elective lumbar spine fusion by posterior approach at a single centre were retrospectively studied. An ERAS protocol was designed based on the prevalent hospital practices, local resources and supportive evidence from literature. The ERAS protocol was implemented at our institute in December 2016 – dividing patients into pre-ERAS and post-ERAS groups. The outcome measures for comparison werelength of hospital stay (LOS), postoperative complications, 60-day readmission rate, 60-day reoperation rate and patient reported outcome measures (VAS and ODI score) at stipulated time intervals.
RESULTS.A total of 812 patients were included – 496 in the pre-ERAS group and 316 in the post-ERAS group. There was no significant difference between the two groups in baseline demographic, clinical and surgery-related variables. Patients in the post-ERAS group had a significantly shorter LOS (2.94 days v/s 3.68 days). The rate of postoperative complications (13.5% v/s 11.7%), 60-day readmission (1.8% v/s 2.2%) and 60-day reoperation (1.2% v/s 1.3%) did not differ significantly between the pre-ERAS and post-ERAS groups. The VAS and ODI scores, similar at baseline – were significantly lower in the post-ERAS group (VAS49.8 ± 12.0 v/s 44 ± 10.8, ODI31.6 ± 14.2 v/s 28 ± 12.8) at 4 weeks after surgery. This difference however was not significant at intermediate term follow up (6 months and 12 months).
CONCLUSION.Implementation of an ERAS protocol is feasible for elective lumbar spine fusion, and leads to shorter LOS and improved early pain and functional outcome scores.Level of Evidence3
This study aimed to (1) define the prevalence of spinopelvic abnormalities among patients who have hip osteoarthritis (OA) and controls (asymptomatic volunteers) and (2) identify factors that ...reliably predict the presence of lumbar spine stiffness.
This is a prospective, cross-sectional, case-cohort study of patients who have end-stage primary hip OA, who underwent primary total hip arthroplasty (THA). Patients were compared with a cohort of asymptomatic volunteers, matched for age, sex, and body mass index (BMI), serving as a control group. Spinopelvic pathologies were defined as: lumbar spine flatback deformity (difference of 10 or more degrees for pelvic incidence minus lumbar lordosis angle), a standing sagittal pelvic tilt of 19° or more and lumbar spine stiffness (lumbar flexion of less than 20° between both postures).
The prevalence of spinopelvic pathologies was similar between patients and controls (flatback deformity: 16% versus 10%, P = .209; standing pelvic tilt >19°: 17% versus 24%, P = .218; lumbar spine stiffness: 6% versus 5%, P = .827). Age over 65 years-old and standing lumbar lordosis angle less than 45° were associated with high sensitivity and specificity for identifying lumbar spine stiffness (age >65 years: 82% and 66%; standing lumbar lordosis angle <45°: 85% and 73%).
The presence of end-stage hip osteoarthritis was not associated with increased prevalence of adverse spinopelvic characteristics compared to matched, asymptomatic volunteers. Age and LLstanding are the strongest predictors of lumbar spine flexion and can guide clinical practice on when to obtain additional radiographs for patients who have hip OA before arthroplasty to identify at-risk patients.
II (prospective, cohort study).
Purpose : To analyze extraosseous signal changes (ESCs) on magnetic resonance imaging (MRI) in pediatric patients with stress fractures occurring in the lamina. Methods : This study was a ...retrospective review of 69 consecutive pediatric patients with stress fractures occurring in the lamina. We analyzed MRI scans obtained at the first presentation. Results : We used mainly axial short tau inversion recovery images acquired through the pedicle of these 84 fracture sites to identify the ESCs. These were then divided into three groups: “invisible” when no ESC was detected, “periosteal” for ESC seen on only the dorsal side of the lamina, and “perimuscular” for ESC distinctly spread around / in the paravertebral muscles. In total, 78 (92.9%) fracture sites showed ESCs on the dorsal side of the lamina among which 72 ESCs were located on only the “dorsal” side, while 6 ESCs were on the ventral side against the transverse process. Conclusion : ESCs on MRI were detected in more than 90% of patients before stress fracture became apparent in the lamina, which was considered similar to findings of periosteal thickening / edema detected at the onset of stress fracture in long bone. J. Med. Invest. 68 : 136-139, February, 2021
This was a retrospective chart review.
This study aims to identify the prevalence of osteoporosis (OP) by lumbar computed tomography (CT) Hounsfield units (HUs) in patients who have normal or ...osteopenic bone determined by dual-energy x-ray absorptiometry (DEXA).
OP is a critical issue in the postmenopausal and aging population. Bone mineral density assessment by DEXA has been described as insensitive for diagnosing OP in the lumbar spine. Improving the detection of OP can bring more patients to treatment and reduce the risks associated with low bone mineral density.
We retrospectively reviewed all patients with DEXA scans and noncontrast CTs of the lumbar spine over a 15-year period. Patients were diagnosed as non-OP if they had a normal DEXA T-score (≥ -1) or osteopenic DEXA T-score (between -1.1 and -2.4). Patients in this cohort were considered osteoporotic by CT if L1-HU ≤110. Demographics and lumbar HUs were compared between these stratified groups.
A total of 74 patients were included for analysis. All patients were demographically, similar, and the average patient age was 70 years. The prevalence of OP determined by CT L1-HU ≤110 was 46% (normal DEXA: 9%, osteopenic DEXA: 63%). A significant number of males in our study were considered osteoporotic by L1-HU ≤110 (74%, P = 0.03). All individual axial and sagittal lumbar HU measurements including L1-L5 average lumbar HUs were statistically significant among non-OP and OP groups except for the lower lumbar levels (P > 0.05 for L4 axial HUs, and L4-L5 sagittal HUs).
The prevalence of OP in patients with normal or osteopenic T-scores is high. Among those with osteopenia by DEXA, more than 50% may lack appropriate medical treatment. The DEXA scan may be particularly insensitive to male bone quality making the CT HU the diagnostic method of choice for detecting OP.
Level III.
ObjectiveTo verify the effects of bisphosphonates (Bps) in combination with recombinant human GH (rGH) in pediatric osteogenesis imperfecta (OI) patients; we focused on possible improvement of bone ...mineral density (BMD), projected bone areas, growth velocity, and fractures risk.DesignA randomized controlled 1-year clinical trial on 30 prepubertal children (M:F=14:16) affected by OI (type I, IV, and III) being treated with neridronate.MethodsFollowing an observational period of 12 months during ongoing neridronate treatment, the patients were randomly divided into two groups: 15 were treated for 12 months with rGH and neridronate (group Bp+rGH) and 15 continued neridronate alone (group Bp). We evaluated auxological parameters, number of fractures, bone age (BA), bone metabolic parameters, and bone mass measurements (at lumbar spine and radius by dual-energy X-ray absorptiometry).ResultsThe mean variation in percentage of BMD (Δ%BMD) – at lumbar spine (L2–L4), at distal and ultradistal radius – and the projected area of lumbar spine increased significantly in group Bp+rGH (P<0.05). Growth velocity was significantly higher during rGH treatment in group Bp+rGH versus group Bp and versus pretreatment (P<0.05), with no difference in increase in BA or fracture risk rate. Patients with quantitative (-qt) collagen synthesis defects had a higher, although not significant, response to rGH in terms of growth velocity and BMD.ConclusionsIn OI patients, the combined rGH–Bp treatment may give better results than Bp treatment alone, in terms of BMD, lumbar spine projected area and growth velocity, particularly in patients with quantitative defects.
Percutaneous transforaminal endoscopic discectomy (PTED) has steep learning curves and a high incidence of complications, but currently, efficient and economical training methods are lacking. This ...study aimed to validate a novel simulator for PTED.
The simulated PTED included puncturing and establishing the working channel (PEWC) and endoscopic discectomy, with the PEWC being the tested module. Eleven experts and 21 novices were included and introduced to the simulator and tasks; all participants completed the PEWC. Outcomes included: total operation time, number of fluoroscopy for positioning the working sheath, number of spinal risk region invasion, Global Rating Scale (GRS) and a modified GRS, etc. The Mann-Whitney U test was used to compare 2 groups. Spearman's correlation coefficient analyzed continuous variables.
Experts outperformed novices in total operation time (P = 0.001), requiring fewer number of fluoroscopies for positioning the working sheath (P = 0.003). Additionally, experts had a lower number of spinal risk region invasions (P = 0.016) and higher scores on both the GRS (P < 0.001) and modified GRS (P < 0.001). PTED experience correlated with GRS scores (P = 0.001) and modified GRS (P < 0.001). The overall realism scored a median of 4 (3.75–5), and educational value had a median of 4 (range 3–5).
This study demonstrates the validity of the novel simulator, revealing significant associations between PTED experience and performance metrics in a simulated PEWC setting. Furthermore, the PEWC module also offers a good realistic design and high education value according to experts.
Retrospective review of prospectively collected data.
To determine the Oswestry Disability Index (ODI) cutoff for achieving Patient Acceptable Symptom State (PASS) at one year following minimally ...invasive lumbar spine surgery.
An absolute score denoting PASS, rather than a change score denoting minimal clinically important difference (MCID), might be a better metric to assess clinical outcomes.
Patients who underwent primary minimally invasive transforaminal lumbar interbody fusion or decompression were included. The outcome measure was ODI. The anchor question was the Global Rating Change: "Compared with preoperative, you feel (1) much better, (2) slightly better, (3) same, (4) slightly worse, or (5) much worse." For analysis, it was collapsed to a dichotomous outcome variable (acceptable=response of 1 or 2, unacceptable=response of 3, 4, or 5). Proportion of patients achieving PASS and the ODI cutoff using receiver operating characteristic curve analyses were assessed for the overall cohort as well as subgroups based on age, sex, type of surgery, and preoperative ODI. Differences between the PASS and MCID metrics were analyzed.
A total of 137 patients were included. In all, 87% of patients achieved PASS. Patients less than or equal to 65 years and those undergoing fusion were more likely to achieve PASS. The receiver operating characteristic curve analysis revealed an ODI cutoff of 25.2 to achieve PASS (area under the curve: 0.872, sensitivity: 82%, specificity: 83%). The subgroup analyses based on age, sex, and preoperative ODI revealed area under the curve >0.8 and ODI threshold values consistent between 25.2 and 25.5 (except 28.4 in patients with preoperative ODI >40). PASS was found to have significantly higher sensitivity compared with MCID (82% vs. 69%, P =0.01).
Patients with ODI <25 are expected to achieve PASS, irrespective of age, sex, and preoperative disability. PASS was found to have significantly higher sensitivity than MCID.
3.
A systematic review and meta-analysis was conducted to compare the efficacy and safety of cortical bone trajectory (CBT) screws and traditional pedicle screws in lumbar fusion.
Randomized controlled ...studies and cohort studies on CBT versus pedicle screws in lumbar fusion were searched in China Biology Medicine, China National Knowledge Infrastructure, Wanfang, VIP Database for Chinese Technical and Science Periodicals, PubMed, Cochrane Library, and Web of Science databases. The search period spanned from the establishment of the databases to December 2023. The Cochrane bias risk assessment tool and Newcastle-Ottawa scale were applied to assess the quality of the literature included. Clinical and imaging data as well as surgical outcomes, recovery, and postoperative complications were extracted from the relevant literature.
A total of 6 randomized controlled trials and 26 cohort studies were included after screening by inclusion and exclusion criteria with a total of 2478 patients. The meta-analysis demonstrated significant discrepancies between the CBT and TPS groups in Japanese Orthopaedic Association score at 3 and 6 months and final follow-up. Moreover, the TPS group exhibited a higher Oswestry disability index at final follow-up, a greater VAS for low back pain at both 1 week and final follow-up, as well as a higher VAS for leg pain at 1 month. Differences were also noted in surgical and recovery outcomes. However, there was no significant difference between the 2 groups in postoperative complications.
CBT and TPS have analogous safety profiles when applied to lumbar fusion, but the clinical efficacy of CBT is superior to that of TPS to some extent, and the procedure is less invasive with faster recovery.
Background:
Deep vein thrombosis (DVT) is a great postoperative challenge in all orthopaedic surgeries. To the authors’ knowledge, this study is the first to evaluate the efficacy of aspirin ...administration in the prevention of DVT in patients undergoing lumbar spinal surgery.
Methods:
In this double-blind parallel randomized clinical trial, a total of 126 candidates (age 40 yr and older) were admitted between June 2021 to December 2021. Patients were randomly assigned to the intervention chemoprophylaxis group (41 patients receiving 325 mg aspirin) and controls. The DVT occurrence was recorded by clinical features (Well’s criteria), Doppler lower limbs ultrasound, and D-dimer levels in all participants at baseline (24 hr before the time of surgery) and 2, 6, and 12 wk after surgery in postoperative visits.
Results:
The mean age of the participants was 63.72±6.87 yr. Baseline demographic values were similar in both groups (
P
>0.05). The mean follow-up duration was 6.11±2.33 mo. No cases of DVT or abnormal findings on Doppler ultrasound were observed in either group. The mean duration of hospitalization or intensive care unit (ICU) admission was similar between the two groups. Mean baseline D-dimer levels were significantly higher in the intervention group compared with the controls (
P
=0.047), while it was similar in both groups 3 mo after the operation (
P
=0.13).
Conclusions:
In the current study, no case of DVT was observed in either study group. These data do not support the use of aspirin as an anticoagulant for DVT prophylaxis following regular lumbar spinal surgeries.
Level of Evidence:
Level II.
PDF
