Liposomal bupivacaine in posterior spine surgery: A piece of the puzzle for postoperative pain.

Background: Liposomal bupivacaine (LB) is a local analgesic that may be used at the time of surgery to limit postoperative pain around the surgical site. Its efficacy in decreasing pain, decreasing narcotic consumption, decreasing length of stay, and improving mobility is an area of intense research. The purpose of this study was to determine whether LB use was associated with improved patient-reported pain scores in the first 72 h following posterior spinal surgery, decreased postoperative narcotic need, and decreased length of stay. Methods: One hundred and five patients undergoing elective posterior cervical or lumbar surgery were included in retrospective analysis. Forty-eight patients who received LB intraoperatively were compared with a historical cohort of 56 patients who underwent similar procedures and did not receive postsurgical infiltration with local analgesia. The same pain medication protocol was utilized postoperatively. Results: Demographics, clinical characteristics, and total morphine milligram equivalents did not differ significantly between the groups. The treatment group averaged a decreased length of stay (1.85 days treatment, 2.68 days control, p = 0.057). Treatment with LB was associated with lower pain levels at 24 h (5.2 treatment, 6.4 control, p = 0.04) and 48-72 h (4.9 treatment, 6.6 control, p = 0.007) after surgery. Conclusions: LB improved patient perception of pain in the acute postoperative time period.Intraoperative LB injection, coupled with focused early mobilization efforts and multimodal pain control, may lead to improved patient-reported outcomes, shorter length of stay, and decreased risk of perioperative complications.

Tension Pneumocephalus after Cervical Spine Surgery: A Case Report with Review of the Literature.

This is the case of a 66-year-old male with cervical myelopathy secondary to severe cervical stenosis manifesting as worsening dexterity and numbness in his right hand. The patient underwent C3-C6 laminoplasty with bilateral foraminotomies. During the procedure an incidental durotomy occurred which was patched intraoperatively with Duragen and Tisseel. At 1 month follow-up, the patient reported that he was doing well and skin sutures were removed. Two days later, the patient presented to the emergency department with postoperative wound dehiscence, cerebrospinal fluid (CSF) drainage, altered mental status and lethargy. At that time, a computed tomography (CT) scan confirmed a tension pneumocephalus which was treated with a cranial burr hole and revision durotomy repair. The patient improved and was discharged to a rehabilitation facility with intact motor and cognitive function. At the 1-year follow-up appointment, he continued to do well without sequelae.

Is the Marx Activity Scale Reliable in Patients Younger Than 18 Years?

BACKGROUND: There is no baseline activity scale yet validated in pediatric patients. The Marx and Tegner scales have been validated in adult patients only. The Tegner scale involves questions not pertinent to children, such as their work activity. The Marx scale is simple, and all its questions can be related to athletic activities. HYPOTHESIS: The Marx scale is reliable for use in a pediatric population. STUDY DESIGN: Cohort study. LEVEL OF EVIDENCE: Level 2. METHODS: Patients younger than 18 years were given the Marx activity scale in clinic and again 3 weeks later. The patients were divided into 3 groups, of at least 50 patients each, based on presenting diagnosis: knee injury, lower extremity (non-knee) injury, and upper extremity injury. Test-retest reliability was determined for the overall scores and the individual questions. Differences in scores were also compared based on age (<14 vs ≥14 years). RESULTS: A total of 162 patients (mean age, 14.4 years; range, 8-17 years) were included. The Marx scale had a high intraclass correlation coefficient (ICC) overall as well as for each of its 4 questions. Both older and younger patients had ICCs >0.80, though the older group generally had higher scores. The mean score was 13.55 (out of 16), and 50.6% scored the maximum; only 1.9% scored the minimum. Mean scores for the knee, lower extremity, and upper extremity groups were 13.71 (SD, 3.70), 13.22 (SD, 4.18), and 13.68 (SD, 3.33), respectively (P > 0.05). There also was no difference in total score based on age (P = 0.88). CONCLUSION: The Marx activity scale is reliable in patients younger than 18 years with injuries to the knee and lower extremities, though the scale was less reliable in patients younger than 14 years. There is a significant ceiling effect present, which limits its overall usefulness. CLINICAL RELEVANCE: Although there is no other current substitute, the Marx activity scale is not an ideal measurement of younger patients' baseline activity levels.