Effect of bilateral ultrasound-guided erector spinae plane block on postoperative pain after open lumbar spinal surgery: a double-blind, randomized controlled trial.

PURPOSE: The peripheral nerve blocks (PNB) are an important part of the multimodal analgesia for reducing postoperative pain, opioids consumption and its side effects. A new PNB, Erector spinae plane block (ESPB), has been revealed postoperative analgesic effect in various surgical procedures such as breast, thoracic and abdominal surgery, with the limitation of the studies for spine surgery. We aimed to evaluate the analgesic effect of ultrasound-guided bilateral erector spinae plane block (ESPB) after open lumbar spinal surgery. METHODS: A double-blind, randomized controlled trial was conducted. Sixty-two patients undergoing posterior lumbar spinal surgery were randomly allocated into two groups. The ESPB group (n = 31) received ultrasound (US)-guided bilateral ESPB using 20 ml of 0.375% bupivacaine with adrenaline 5 mcg/ml per side. The control group (n = 31) received no intervention. The same postoperative analgesia regimen was applied by oral acetaminophen 10-15 mg/kg every 6 h, naproxen 250 mg twice daily, and intravenous (IV) morphine via patient-controlled analgesia (PCA) device. The postoperative morphine consumption, numerical pain score (NRS) and the side effects were recorded. RESULTS: The bilateral ESPB group reduced the 24 h-morphine consumption by 42.9% (P < 0.001), decreased overall pain score at rest by 1.4 points (P = 0.02), and decreased overall pain score on movement by 2.2 points (P < 0.001). No severe complications related to the block technique or morphine used occurred. CONCLUSION: The US-guided bilateral ESPB demonstrated the effectiveness for postoperative analgesia management after open lumbar spinal surgery regarding reduced opioid consumption and pain score without any serious complications.

Effect of intermediate dose dexamethasone on post-operative pain in lumbar spine surgery: A randomized, triple-blind, placebo-controlled trial.

OBJECTIVES: Dexamethasone has demonstrated analgesic properties and is used as an adjunctive pain agent for many procedures. We evaluated the efficacy of a single, intermediate dose of dexamethasone on post-operative analgesic consumption, and pain scores for lumbar spine surgery. METHODS: Eighty patients aged between 18 and 70 scheduled for lumbar decompressive laminectomy were randomly allocated into two groups to receive either intravenous 0.2 mg/kg dexamethasone (group D = 40) or normal saline (group P = 40) before anesthetic induction. Post-operative total morphine consumption and the respective pain score at the PACU, 4, 6, 12, 24 and 48 h were evaluated. In addition, any adverse events were recorded. RESULTS: Total post-operative morphine consumption within 48 h was significantly lower in group D (34.5 vs. 42.5 mg, p = 0.031); however, the respective morphine consumption at each assessment was similar between groups. The respective NRS pain score at rest and upon movement in both groups was not significantly different for any time comparison. The average NRS pain score at rest and upon movement within 48 h was similar in both groups (i.e., NRS at rest Group D 3.6 vs. Group P 3.8, p = 0.936, and NRS for movement Group D 6.2 vs. Group P 6.3, p = 0.791). The adverse events within 48 h were also similar and serious complications (i.e., respiratory depression or surgical infection) were not found in either group. CONCLUSION: A single, intermediate dose of dexamethasone before anesthetic induction could minimally decrease post-operative morphine consumption within 48 h after lumbar decompressive laminectomy without any effect on the pain score.

Interrater Reliability of the Postoperative Epidural Fibrosis Classification: A Histopathologic Study in the Rat Model.

STUDY DESIGN: Agreement study. PURPOSE: To validate the interrater reliability of the histopathological classification of the post-laminectomy epidural fibrosis in an animal model. OVERVIEW OF LITERATURE: Epidural fibrosis is a common cause of failed back surgery syndrome. Many animal experiments have been developed to investigate the prevention of epidural fibrosis. One of the common outcome measurements is the epidural fibrous adherence grading, but the classification has not yet been validated. METHODS: Five identical sets of histopathological digital files of L5-L6 laminectomized adult Sprague-Dawley rats, representing various degrees of postoperative epidural fibrous adherence were randomized and evaluated by five independent assessors masked to the study processes. Epidural fibrosis was rated as grade 0 (no fibrosis), grade 1 (thin fibrous band), grade 2 (continuous fibrous adherence for less than two-thirds of the laminectomy area), or grade 3 (large fibrotic tissue for more than two-thirds of the laminectomy area). A statistical analysis was performed. RESULTS: Four hundred slides were independently evaluated by each assessor. The percent agreement and intraclass correlation coefficient (ICC) between each pair of assessors varied from 73.5% to 81.3% and from 0.81 to 0.86, respectively. The overall ICC was 0.83 (95% confidence interval, 0.81-0.86). CONCLUSIONS: The postoperative epidural fibrosis classification showed almost perfect agreement among the assessors. This classification can be used in research involving the histopathology of postoperative epidural fibrosis; for example, for the development of preventions of postoperative epidural fibrosis or treatment in an animal model.

Long-term result of posterolateral fusion of the lumbar spine using the Tadpole system.

BACKGROUND: Failure of pedicle screw fixation is often seen in patients with severe osteoporosis. We developed new lumbar spinal instrumentation (Tadpole system) for elderly patients who have osteoporotic bone and poor general health status. The objective of this study was to document the long-term clinical outcomes after Tadpole system fixation, the rate of spinal fusion, the incidence of adjacent segment degeneration, the rate of instrumentation failure, and the overall complications. METHODS: Sixty patients who underwent posterolateral spinal fusion using the Tadpole system, in whom a radiograph of the lumbar spine was taken at more than 5 years after operation, were involved in this study. The improvement rate of the Japanese Orthopaedic Association (JOA) score, rate of spinal fusion, presence or absence of adjacent segment degeneration, rate of instrumentation failure, and postoperative complications of each patient were assessed at 5 years postoperatively. RESULTS: The mean JOA score improvement was 72.5%, and the posterolateral spinal fusion rate was 93.3% (56 of 60 patients) at the last follow-up. Adjacent segment degeneration occurred in only two patients who showed decreased intervertebral disc height, and instrumentation failure (hook deviation) was observed in one patient. No other complications were observed in any patients. CONCLUSION: Tadpole system fixation shows favorable long-term clinical outcomes.

Clinical correlation of cervical myelopathy and the hyperactive pectoralis reflex.

STUDY DESIGN: A diagnostic study. OBJECTIVE: To validate the correlation between hyperactive pectoralis reflex and the level of cervical myelopathy. SUMMARY OF BACKGROUND DATA: The hyperactive pectoralis reflex was proposed to be present in patients with spinal cord compression at the C2-3 and/or C3-4 level. Nevertheless, in a validation study on the correlation of various hyperactive reflexes and the cervical myelopathic level, this particular reflex was not evaluated. METHODS: All patients presenting with cervical myelopathy between August 2009 and June 2012 were included in this study. Each patient underwent neurological examination for cervical myelopathy focusing on the examination of pathologic reflexes, including the hyperactive pectoralis reflex. We recorded the presence or absence of these reflexes and the level of cervical myelopathy as detected on magnetic resonance imaging. We used the level of spinal cord compression-cranial to C4 of the vertebral body-as the reference level to validate a hyperactive pectoralis reflex. RESULTS: The study included 95 cervical myelopathy patients: 33 patients had most of their compressed cervical cord somewhere above the C4 vertebral body. The hyperactive pectoralis reflex for cervical myelopathy at this level had a respective sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 84.8%, 96.7%, 26.67, and 0.16. CONCLUSIONS: The high sensitivity and specificity of the hyperactive pectoralis reflex is very useful for screening and diagnosis of the cervical myelopathic level when it is above the C4 vertebral body.