Multimodal anesthesia with the addition of methadone is superior to epidural analgesia: A retrospective comparison of intraoperative anesthetic techniques and pain management for 124 pediatric patients undergoing the Nuss procedure.

BACKGROUND: The Nuss procedure corrects pectus excavatum by forceful displacement of the sternum with metal bars. Optimal pain management remains a challenge. Mutimodal anesthesia alleviates pain through blockade of multiple nociceptive and inflammatory pain receptors. METHODS: A retrospective chart review of anesthetic and postoperative mangement of 125 children undergoing the Nuss procedure was conducted. Anesthetic mangement strategies were analyzed in four groups: opioid during general anesthesia (GA), epidural with general anesthesia (Epidural), multimodal anesthesia (MM), and multimodal anesthesia with methadone (MM+M). Data collection included total opioid use (as equivalent milligrams of morphine (Mmg)), pain scores, length of stay (LOS), and adverse effects. RESULTS: Total opioid use varied by group (median, IQR (in Mg)): Epidural 213 [149, 293], GA 179 [134, 298], MM (150 [123, 281]), and MM+M (106 [87, 149]), as did severe pain (in minutes): Epidural (208 [73, 323]), GA (115 [7, 255]), MM (54 [0, 210]), and MM+M (49 [0, 151]). LOS was shortest for the MM+M group (MM+M=3.8+1.0days; MM=4.5+1.3days; GA=4.9+1.4days, Epidural=5.5+2.3days). CONCLUSION: Multimodal anesthesia is associated with less postoperative pain and shorter LOS compared to epidural or traditional anesthetic techniques for the Nuss procedure. Multimodal anesthesia with a single intraoperative dose of methadone was associated with lowest total opioid use, time with uncontrolled pain, and shortest LOS.

Does expansion thoracoplasty improve the volume of the convex lung in a windswept thorax?

BACKGROUND: Expansion thoracoplasty using the Vertical Expandable Prosthetic Titanium Rib increases the measured height and volume of the concave hemi thorax, but the effect on the convex, non-instrumented lung is unknown. The purpose of this study was to measure changes in lung volume and density in the convex lung after expansion thoracoplasty. METHODS: The volume and density of the lungs was measured in 12 children with congenital scoliosis and fused ribs before and after concave expansion thoracoplasty using serial computed tomography scans. RESULTS: There were 8 boys and 4 girls with an average age of 6.4 years at initial implant. The average length of follow-up was 17.5 months. All patients showed increased total lung volumes by an average of 250 cc (range 24 to 795 cc). The volume of the concave lung increased by an average of 55% and the lung density decreased by an average of 6%. The volume of the convex lung increased by an average of 60%, and the density decreased by an average of 7%. Nine of 12 patients showed improvement in density of the convex lung. DISCUSSION: These findings suggest that concave expansion thoracoplasty increases overall lung volume in children with congenital scoliosis and fused ribs as measured by computed tomography scan. In addition, expansion thoracoplasty seems to have a beneficial effect on the convex, non-operated hemi thorax. Decreases in measured lung density suggest improved aeration of the lung, which may prove to be beneficial to overall pulmonary function. LEVEL OF EVIDENCE: Level 4 therapeutic studies: case series.

Acute versus chronic vertebral compression fractures treated with kyphoplasty: early results.

BACKGROUND CONTEXT: Kyphoplasty, a minimally invasive technique for fracture reduction and stabilization, has been shown to reduce pain and restore vertebral body height in patients with vertebral compression fractures (VCFs). Analyses comparing treatment outcomes of acute versus chronic VCFs have not yet been reported. PURPOSE: To assess whether kyphoplasty results in better clinical outcome and fracture reduction in patients with either acute or chronic VCFs. STUDY DESIGN: A prospective, consecutive cohort study of patients who underwent kyphoplasty between March 2000 and December 2001 to treat osteoporotic VCFs that were either less than 10 weeks old (acute) or more than 4 months old (chronic). Fifteen subacute fractures (treated 10 to 16 weeks after fracture) were excluded from analyses. PATIENT SAMPLE: Eighty-six VCFs in 47 patients (35 female and 12 male) were treated during 55 kyphoplasty procedures. Mean patient age was 74 years (range, 47 to 91). METHODS: Clinical outcomes were determined by comparison of preoperative and postoperative data from patient-reported indexes (pain assessment, pain medication usage and Oswestry Disability Index for Back Pain). Radiographs were assessed as to percent vertebral collapse, vertebral height restoration and local kyphosis correction. RESULTS: By 2 weeks after surgery, 90% of acute and 87% of chronic fractures were associated with pain relief. Narcotic usage decreased and Oswestry scores improved in almost all patients. Mean vertebral body height significantly improved after kyphoplasty (acute: 58% to 86% of estimated normal vertebral height, p< .001; chronic: 56% to 79% of estimated normal vertebral height, p< .001). Restoration to 89% or greater estimated normal vertebral height was achieved in 60% of acute fractures and 26% of chronic fractures. In addition, more acute fractures were reducible (greater than 80% restoration of height lost) compared with chronic fractures (p= .01). After kyphoplasty, less than 10% correction of height lost occurred in 8% of acute fractures and 20% of chronic fractures. Local kyphosis significantly improved after kyphoplasty (mean local Cobb angle: acute, 15 to 8 degrees, p< .001; chronic, 15 to 10 degrees, p< .001). CONCLUSION: Fracture reduction was best achieved in acute fractures. Symptomatic chronic fractures may also remain candidates for kyphoplasty because pain relief and improvement in patient function are reliable and some kyphosis correction can still be achieved in many of these patients.