A multimodal approach for postoperative pain management after lumbar decompression surgery: a prospective, randomized study.

STUDY DESIGN: A prospective and randomized study. OBJECTIVES: The objective of this study was to assess the efficacy of a novel multimodal analgesic regimen in reducing postoperative pain and intravenous morphine requirements after primary multilevel lumbar decompression surgery. SUMMARY OF BACKGROUND DATA: The use of opioid medications after surgery can lead to incomplete analgesia and may cause undesired side effects such as respiratory depression, somnolence, urinary retention, and nausea. Multimodal (opioid and nonopioid combination) analgesia may be an effective alternative to morphine administration leading to improved postoperative analgesia with diminished side effects. METHODS: After Institutional Review Board approval, 22 patients who underwent a primary multilevel lumbar decompression procedure were randomly assigned to receive either only intravenous morphine or a multimodal (celecoxib, pregabalin, extended release oxycodone) analgesic regimen. Postoperatively, all patients were allowed to receive intravenous morphine on an as needed basis. Intravenous morphine requirements were then recorded immediately postoperative, at 6, 12, 24 hours, and the total requirement before discharge. Patient postoperative pain levels were determined using the visual analog pain scale and were documented at 0, 4, 8, 12, 16, 24, and 36 hours postoperative. RESULTS: There were no significant differences in available patient demographics, intraoperative blood loss, or postoperative hemovac drain output between study groups. Total postoperative intravenous morphine requirements in addition to morphine requirements at all predetermined time points were less in patients randomized to receive the multimodal analgesic regimen. Visual analog pain scores were lower at all postoperative time points in patients randomized to receive the multimodal analgesic regimen. Time to solid food was significantly less in the multimodal group. There were no major identifiable postoperative complications in either treatment group. CONCLUSIONS: Opioid and nonopioid analgesic combinations appear to be safe and effective after lumbar laminectomy. Patients demonstrate lower intravenous morphine requirements, better pain scores, and earlier time to solid food intake.

Osteosarcoma Phenotype Is Inhibited by 3,4-Methylenedioxy-ß-nitrostyrene.

ß-nitrostyrene compounds, such as 3,4-methylenedioxy-ß-nitrostyrene (MNS), inhibit growth and induce apoptosis in tumor cells, but no reports have investigated their role in osteosarcoma. In this study, human osteosarcoma cell families with cell lines of varying tumorigenic and metastatic potential were utilized. Scrape motility assays, colony formation assays, and colony survival assays were performed with osteosarcoma cell lines, both in the presence and absence of MNS. Effects of MNS on human osteoblasts and airway epithelial cells were assessed in monolayer cultures. MNS decreased metastatic cell line motility by 72-76% and colony formation by 95-100%. MNS consistently disrupted preformed colonies in a time-dependent and dose-dependent manner. MNS had similar effects on human osteoblasts but little effect on airway epithelial cells. An inactive analog of MNS had no detectable effects, demonstrating specificity. MNS decreases motility and colony formation of osteosarcoma cells and disrupts preformed cell colonies, while producing little effect on pulmonary epithelial cells.

Progressive osteolysis and surface chondrolysis of the proximal humerus following influenza vaccination.

Influenza vaccination is a common annual event among individuals in the United States. Complications, although infrequent, are usually mild and self-limiting. This article describes the case of a 46-year-old man who experienced progressive osteolysis and surface chondrolysis of the proximal humerus following routine influenza vaccination. The patient presented with shoulder pain and limited range of motion 3 weeks following vaccination in the deltoid area. No skin changes were noted, inflammatory markers were normal, and the patient's pain and disability persisted despite nonsteroidal anti-inflammatory drugs and occupational therapy. Plain radiographs revealed a small lytic area involving the greater tuberosity of the humeral head. Magnetic resonance imaging (MRI) showed abnormal uptake and cystic changes involving the greater tuberosity of the humeral head; repeat MRI at 5 months showed progression in the cystic changes. Diagnostic arthroscopy of the shoulder revealed a hyperemic joint capsule and extensive, full-thickness chondrolysis of the humeral head. Cystic biopsy demonstrated inflammatory cells and granulation tissue, consistent with foreign body response. Cultures were negative. Surgical debridement of the cystic areas and resurfacing of the humeral head yielded a good outcome. To our knowledge, this is the first reported complication of influenza vaccination requiring surgical intervention. Physicians need to be aware of the potential for osteolysis and chondrolysis, which may require aggressive forms of management.

Surface contaminants inhibit osseointegration in a novel murine model.

Surface contaminants, such as bacterial debris and manufacturing residues, may remain on orthopedic implants after sterilization procedures and affect osseointegration. The goals of this study were to develop a murine model of osseointegration in order to determine whether removing surface contaminants enhances osseointegration. To develop the murine model, titanium alloy implants were implanted into a unicortical pilot hole in the mid-diaphysis of the femur and osseointegration was measured over a five week time course. Histology, backscatter scanning electron microscopy and X-ray energy dispersive spectroscopy showed areas of bone in intimate physical contact with the implant, confirming osseointegration. Histomorphometric quantification of bone-to-implant contact and peri-implant bone and biomechanical pullout quantification of ultimate force, stiffness and work to failure increased significantly over time, also demonstrating successful osseointegration. We also found that a rigorous cleaning procedure significantly enhances bone-to-implant contact and biomechanical pullout measures by two-fold compared with implants that were autoclaved, as recommended by the manufacturer. The most likely interpretation of these results is that surface contaminants inhibit osseointegration. The results of this study justify the need for the development of better detection and removal techniques for contaminants on orthopedic implants and other medical devices.

Osteosarcoma.

Osteosarcoma, the most common bone sarcoma, affects approximately 560 children and adolescents annually in the United States. The incidence of new diagnoses peaks in the second decade of life. Twenty percent of patients present with clinically detectable metastases, with micrometastases presumed to be present in many of the remaining patients. Treatment typically includes preoperative chemotherapy, surgical resection, and postoperative chemotherapy. Limb-salvage procedures with wide surgical margins are the mainstay of surgical intervention. Advances in chemotherapy protocols have led to a 5-year survival rate of 60% to 78%. Among the goals of future treatment regimens are improved chemotherapeutic agents with higher specificity and lower toxicity.

An evaluation of information on the Internet of a new device: the lumbar artificial disc replacement.

STUDY DESIGN: An analysis of websites, accessible to the public, was conducted pertaining to the lumbar artificial disc replacement. OBJECTIVE: The objective was to investigate the content of information available on the Internet pertaining to the lumbar artificial disc replacement. SUMMARY OF BACKGROUND DATA: The Internet is widely used by patients as an educational tool for health care information. Additionally, the Internet is used as a medium for direct-to-consumer marketing. Recent approval of the lumbar artificial disc replacement has led to the emergence of numerous websites offering information about this procedure. It is thought that patients can be influenced by information found on the Internet; therefore, it is imperative that this information be accurate and as complete as possible. METHODS: Three commonly used search engines were used to locate 105 (35/search engine) websites providing information about the lumbar artificial disc replacement. Each website was evaluated with regard to authorship and content. RESULTS: Fifty-nine percent of the websites reviewed were authorized by a private physician group, 9% by an academic physician group, 6% by industry, 11% were news reports, and 15% were not otherwise categorized. Seventy-two percent offered a mechanism for direct contact and 30% provided clear patient selection criteria. Benefits were expressed in 87% of websites, whereas associated risks were described in 28% or less. European experiences were noted in 53%, whereas only 22% of websites detailed the current US experience. CONCLUSIONS: The results of this study demonstrate that much of the content of Internet-derived information pertaining to the lumbar artificial disc replacement is potentially misleading. Until long-term data are available, patients should be cautioned when using the Internet as a source for health care information, particularly with regard to the lumbar artificial disc replacement.

Analysis of retrieved ultra-high-molecular-weight polyethylene tibial components from rotating-platform total knee arthroplasty.

Mobile-bearing total knee Arthroplasties (TKAs) were designed to increase conformity, decrease contact stresses, and decrease polyethylene damage. Our objective was to evaluate the performance of retrieved mobile-bearing TKAs with respect to wear damage of the polyethylene in a series of components obtained at revision surgery. Tibial component polyethylene superior and inferior surface damage and radiographic radiolucency analysis was conducted on 40 retrieved mobile-bearing TKAs. Higher levels of superior articulating surface damage were found to be associated with higher levels of inferior surface damage in this retrieval study. Greater levels of damage were present on both surfaces in components with greater radiographic radiolucency scores and mechanically loose components. The mobile-bearing TKA remains vulnerable to polyethylene wear damage at the superior surface and introduces an independent inferior surface also vulnerable to wear damage.

Specific tyrosine kinase inhibitors regulate human osteosarcoma cells in vitro.

Inhibitors of specific tyrosine kinases are attractive lead compounds for development of targeted chemotherapies for many tumors, including osteosarcoma. We asked whether inhibition of specific tyrosine kinases would decrease the motility, colony formation, and/or invasiveness by human osteosarcoma cell lines (TE85, MNNG, 143B, SAOS-2, LM-7). An EGF-R inhibitor reduced motility of all five cell lines by 50% to 80%. In contrast, an IGF-1R inhibitor preferentially reduced motility by 42% in LM-7 cells and a met inhibitor preferentially reduced motility by 80% in MNNG cells. The inhibitors of EGF-R, IGF-1R, and met reduced colony formation by more than 80% in all tested cell lines (TE85, MNNG, 143B). The EGF-R inhibitor reduced invasiveness by 62% in 143B cells. The JAK inhibitor increased motility of SAOS-2 and LM7 cells without affecting colony formation or invasiveness. Inhibitors of HER-2, NGF-R, and PDGF-Rs did not affect motility, invasiveness, or colony formation. These results support the hypothesis that specific tyrosine kinases regulate tumorigenesis and/or metastasis in osteosarcoma.

An anatomical study of the pediatric intercondylar notch.

BACKGROUND: Anterior cruciate ligament reconstructions in skeletally immature patients are becoming more commonplace. Complications of growth disturbance remain a major concern, especially at the distal femoral physis, and are often attributed to technical errors. A review of the literature revealed limited anatomical data of the skeletally immature intercondylar notch to guide surgical technique. METHODS: We studied 103 preserved femora aged 3 to 20 years, with 33 of these aged 7 to 15 years. The distance between the "resident's ridge" (lateral intercondylar ridge) and the "over-the-top" position (OTP) was measured at the 11-, 10-, and 9-o'clock positions in the right femora, and the 1-, 2-, and 3-o'clock positions in the left femora. The angles between the femoral surface, distal femoral physis, and femoral shaft were measured in the coronal and sagittal planes using a goniometer. RESULTS: Femora in the 13- to 15-year-old subgroup tended to have a more clearly defined resident's ridge than femora in the younger subgroups. The space between resident's ridge and the OTP was on average greater than 8 mm at all 3 positions in the 13- to 15-year-old subgroup, and greater than 7 mm at all 3 positions in the 10- to 12-year-old subgroup, with more space available with a more peripheral starting point. The average angles between the femoral surface and physis in the sagittal and coronal planes were 47 degrees and 36 degrees in the 13- to 15-year-old subgroup, and 58 degrees and 28 degrees in the 10- to 12-year-old subgroup. The average angles between the distal femoral shaft and physis in the sagittal and coronal planes were -9 degrees and 7 degrees in the 13- to 15-year-old subgroup, and -6 degrees and 7 degrees in the 10- to 12-year-old subgroup. Analysis of females versus males demonstrated larger distances between resident's ridge and the OTP in males, but no differences in the angular measurements. CONCLUSIONS: In younger patients, the resident's ridge is less commonly present and less clearly defined. The femoral tunnel can usually be drilled behind the resident's ridge at the 11-o'clock/1-o'clock position, although in females, the ridge is more likely to be included in the drill hole. In both males and females, the tunnel should be aimed posterior and medial with respect to the perpendicular of the femoral surface and anterior and medial with respect to the shaft to drill through the physis with less obliquity, and to provide a tunnel deep enough to avoid spanning the physis with bone or hardware.

Weight loss in overweight and obese patients following successful lumbar decompression.

BACKGROUND: Neurogenic claudication secondary to lumbar stenosis is often cited by overweight and obese patients as a factor limiting their ability to lose weight. Many patients believe that they will be able to increase their activity and subsequently lose weight following relief of symptoms. The objective of this study was to evaluate weight loss in overweight and obese patients who obtained substantial pain relief after lumbar decompression surgery for spinal stenosis. METHODS: Changes in the body weight and body mass index of overweight and obese patients after lumbar decompression surgery were assessed at a mean of 34.4 months postoperatively. Sixty-three patients (thirty-seven men and twenty-six women with a mean age of 53.4 years) were included in the study. Preoperative and postoperative body weight and body mass indices were calculated, and Zurich Claudication Questionnaire (ZCQ) Symptom Severity and Physical Function scores were obtained. RESULTS: The ZCQ Symptom Severity and Physical Function scores significantly improved, by a mean of 56.4% and 53.0%, respectively. At the time of follow-up, both the mean body weight and the mean body mass index significantly increased, by 2.48 kg and 0.83 kg/m(2), respectively. Overall, 35% of the patients gained >or=5% of their preoperative body weight, 6% of the patients lost >or=5% of their preoperative body weight, and 59% remained within 5% of their preoperative body weight. CONCLUSIONS: The majority of overweight and obese patients maintain or increase their body weight and body mass index following successful lumbar decompression surgery. Substantial relief of symptoms and functional improvements do not appear to help overweight or obese patients to lose weight. This suggests that obesity is an independent disease and not simply a function of symptomatic spinal stenosis, and patients should be counseled regarding these expectations.