Postoperative epidural analgesia: trials of bupivacaine combined with fentanyl or morphine after spinal fusion surgery

Background: major spinal fusion surgery causes severe postoperative pain, which persists for at least 3 days. Efficient and safe methods for postoperative analgesia after spinal fusion surgery are, therefore, mandatory. This study aimed to compare the analgesic effect of different epidural analgesia combinations and their effects on blood level of Beta-endorphin. We also studied the impact of these analgesic regimens on defined postoperative mobilization maneuvers and on patient satisfaction

Methods: This study was registered in clinical trials number NCT01838707. Sixty patients scheduled for elective posterior lumbar fusion surgery for correction of Spondylolisthesis were enrolled in this study. Patients were randomly allocated into three equal groups [20 each] according to analgesic drugs combinations administered through epidural catheter inserted intraoperatively. All patients received standard general anesthesia. Al the end of posterior instrumentation, the surgeon inserted the epidural catheter under direct vision in the midline. All patients in this study were nursed in a high dependency intensive care facility and received analgesics according to the following protocol. Continuous drug flow will be maintained with a syringe pump. The syringe pump was connected to the epidural catheter [with the reservoir contain either: 0.125% Bupivacaine HCI at flow rate of 4 5 ml/h [5-6.25mg/h bupivacaine]. 0.125% Bupivacaine HCI fentanyl 100 microg at flow rate of 3 5 ml/h [3.75-6.24 mg/h bupivacaine I 6-10 microg /h fentanyl] 0.125% Bupivacaine HCI morphine sulphate 3 mg at flow rate of 3 5 ml/h [3.75-6.24 mg/h bupivacaine 0.18-0.3 mg/h morphine]. Infusion was continued until the third postoperative day. The rate was increased if pain VAS >3 [visual analogue scale] at rest or VAS >6 with movement. The rate was decreased when patients have intolerable relevant motor block [Bromage score >0] or sensory disturbances [numbness], or hypotension [systolic blood pressure <90 mm Hg]. IV rescue analgesia will be Ketrolactromethamine 30 mg. Epidural catheters were removed on the third postoperative day. Pain was assessed using the VAS ranging from "0" [no pain] to "10" [worst imaginable pain]. Pain was evaluated at rest and during mobilization. Maneuvers of particular clinical importance for postoperative mobilization [alone and with help] were chosen: Turning in bed. Standing in front of the bed and walking, and using the toilet without help. The time needed until the patient can first successfully perform these maneuvers was documented. Three venous samples to measure serum B-endorphin level first one preoperative base line, second at first time VAS more three at rest and third sample when VAS less than three at rest. For assessment of patients satisfaction with postoperative pain management a verbal rating score was used. Motor block was quantified with the Bromage scale. Patients will be asked about sensory deficits. Verbal rating scores was used for sedation. Nausea and vomiting and the incidence of pruritus were recorded

Results: There were no significant differences observed between the studied groups regarding patient characteristics [age, sex, ASA status, anesthesia time, surgery duration and number of segments fused]. There were no significant differences in all hemodynamic variables between the three groups, the results of this study showed less pain scores as recorded by VAS all over the study time for group 3 [bupivacaine+ morphine]. Pain scores were lowest for group Ill [bupivacaine + morphine] all over the study time when testing pain during movement. The mean times to turn in bed with and without assistance were lowest in group Ill [bupivacaine morphine]. B-endorphin level, there was no significant differences between means of B-endorphin samples between the groups or within each group. Patients were more satisfied in group 3 all over the study period. The incidence of nausea, vomiting or itching within the observation period was significantly different between the three groups. It was more common in the bupivacaine morphine group

In Conclusion: Epidural analgesia after spine surgery improve pain control and enhance functional recovery, but potential cost issues related to maintenance of the epidural infusion and ICU slay versus potential cost savings in hospital stay and effect on long term outcome must be considered. Also the cost of use B-endorphin as a biomarker of pain severity needs to be revised against the subjective assessment of pain

Management of un-united fractures distal end radius report on 15 cases

15 cases of un-united fractures distal radius were treated at Assiut University Hospital during the period from January 1988 to January 1992. Union was achieved in 14 of them at a mean time of 3.5 months. The time required for union showed no relation to the patient age, the implant used or addition of bone graft. The functional result is related significantly to the radial articular surface inclination and the maintenance of a proper length of ulna and intact inferior radioulnar articulation

Subtrochanteric valgus osteotomy for the treatment of ununited fracture neck of femur

16 cases [10 females and 6 males] of ununited fracture neck of femur were treated by repositioning osteotomy on the principles postulated by Pauwel. Three of the cases followed congenital coxa vara. The majority of patients did not receive specific treatment before surgery. Only 6 patients were treated surgically with technical error ended in non-union. Fixation of the osteotomy was by a moulded DCP in 11 cases and repositioning plate in 5 cases, 3 of which were constructed from a one third tubular plate. The overall excellent results were achieved in 88% of cases after a mean time of union of 3 months

Surgical treatment of fractures of the acetabulum, early results of 13 cases

13 cases of acetabular fractures were treated surgically during the years 1991 and 1992 at Assiut University Hospital. Three were old posterior rim fracture with neglected dislocation. Four were transverse and another two were transverse with posterior rim. One case was T-shaped fracture with posterior wall, another case was a posterior hemitransverse extending to the iliac wing and posterior rim together with an anterior column, another case was a posterior column, the last case was an anterior column fracture. All, except the last case, were approached through a Kocher-Langenbeck incision. The anterior column was approached through ilio-inguinal incision. Follow up ranged from 4 months to 2 years. Clinical results were satisfactory in 70% of cases, operative complications included one case of infection and nerve palsy, 2 cases of significant displacement

New salvage procedure for the management of malignant bone tumors: preliminary report on 3 cases

Two cases of osteosarcoma and another of malignant fibrous histiocytoma of the lower end of the femur proved by biopsy were treated by wide resection of the tumor and knee joint. The resulting gap was closed primary bringing the end of the remaining femur and tibia into contact application of external fixator frame and compressing the bones together. In one of the osteosarcoma cases the bones were allowed to unite, followed by cortectomy and gradual lengthening. Chemotherapy was given to the osteosarcoma cases in courses starting preoperatively. In the malignant fibrous histiocytoma cases and in the other case of osteosarcoma distraction osteogenesis was started 3 weeks following resection. Adjuvant chemotherapy was also started at the same time in the malignant fibrous histiocytoma case

Results of high tibial osteotomy for varus gonarthrosis of the knee joint

31 high tibial osteotomies [in 30 patients] for varus gonarthrosis performed between 1985 - 1990 were evaluated to determine correction of deformity, functional results and subjective impression. 25 patients had satisfactory follow up evaluations. Factors contributing to success included careful patient selection, over-correction of the limb deformity and precise surgical technique

Radial shortening for Kienbock's disease

Seven patients with Kienbocks disease were treated with radial shortening procedure to remove compressive stress from the damaged lunate. After an average of one year follow-up, relief of pain was satisfactory and the postoperative motion of the wrist were moderately improved. No non-union at the site of the radial osteotomy. The procedure appears to help to maintain carpal height, prevent further collpase of the lunate, encourage consolidation of the - fragmented lunate and increase grip strength. It appears as preferable method for the treatment of kienbocks' disease with zero or positive variance

Open tibial fractures treated by anterior unilateral external fixation

20 tibial fractures have been managed with a unilateral external fixator due to severe tissue problems. Indications, technique of stabilization and follow-up of the fractures are presented. Eleven fractures healed with external stabilization alone. In seven cases the bone healing had achieved by the help of bone graft. Two fractures fixed with an intramedullary nail. This study proves that the unilateral external fixator is a helpful and harmless device which allows quick primary stable fixation for open tibial fractures without compromising further treatment of bone as well as soft tissue. It is therefore recommended mainly for initial treatment of polytraumatized patients with difficult lower leg fractures