Prolonged Pain Research Articles

CLINICAL AND LABORATORY CHANGES IN POSTSURGICAL PAIN MARKERS IN CHILDREN

Pos toperative pain in children remains a signifi cant problem in pediatric intensive care, possibly related to an imperfectalgorithm for its management. Prolonged postoperative pain delays recovery and rehabilitation, increases treatment costs,and prolongs opioid use. Inadequate perioperative pain management can lead to a variety of postoperative complications, the prediction of which remains elusive despite the use of commonly accepted clinical, laboratory, and instrumental indicators. The aim of this study was to evaluate clinical and laboratory changes in children after abdominal surgery and their correlation with acute pain scales.Material and Methods. The study included 83 children aged 7-18 years who underwent abdominal surgery under opioid anesthesia. Inclusion criteria: age 7-18 years; indication for surgery for acute appendicitis; American Society of Anesthesiologists (ASA) Anesthesia Risk Score I and II; parental consent for the children to participate in the study.Acute pain intensity was measured using the Visual Analog Scale (VAS) and the Face, Legs, Activity, Cry, Consolability(FLACC) scale. Key vital signs assessed included heart rate, respiratory rate, systolic and diastolic blood pressure, and oxygen saturation (SpO2). In addition, laboratory indicators including leukocyte count, blood glucose level, erythrocyte sedimentation rate, and TLR-4 and CD40L levels were determined. All clinical and laboratory studies were conducted in accordance with the World Medical Association Declaration of Helsinki«Ethical Principles for Medical Research Involving Human Subjects» (Minutes of the Ethics Committee No. 2, dated February 24, 2002). Statistical analysis was performed on a personal computer using Statistica 10 software, using parametric and nonparametric statistical methods. The study is a part of the research project of the Department of Children’s Diseases of the Postgraduate Medical Education Faculty of the Ivano- Frankivsk National Medical University «Health Status and Adaptation of Children from the Precarpathian Region with Somatic Diseases, Their Prevention» 2021-2026, state registration number 0121U111129; the author is a co-researcher.Results. The mean age of the children was 13.8±0.23 years, while the mean body weight was 40.9±1.6 kg. Gender assessment showed no diff erences between boys and girls (55.4 % and 44.6 %, respectively, р>0.05).The study showed very strong positive correlations (r=0.9-1.0) between acute pain assessment scores on the VAS and FLACCscale and heart rate, blood glucose levels; strong positive correlations (r=0.7-0. 9) with total leukocyte count and erythrocytesedimentation rate; moderate positive correlations (r=0.5-0.7) with serum TLR4 and CD40L levels; weak positive correlations(r<0.5) with diastolic blood pressure, SpO2, and opioid and non-opioid analgesic administration.Conclusions. The observed positive correlations between acute pain scores on the VAS and FLACC scale and proinflammatory indicators may support the theory of involvement of these markers in the generation of acute pain in pediatricpatients. However, further research is needed to investigate the mechanisms of acute postoperative pain generation, to identify markers related to nociception in chronic pain, and to develop preventive strategies for these conditions in children.

Evaluation of surgical complications after herniated spinal lumbar disc surgery

ObjectiveOne of the important and common complications of spinal surgery is Failed Back Surgery Syndrome (FBSS). The most significant symptom of this syndrome is prolonged pain after the surgery, which comes with many complications.Due to the importance of chronic pain after spinal surgeries and its complications, we have decided to investigate the prevalence of acute and chronic pain and other consequences after lumbar disc herniation surgery. MethodsIn this descriptive retrospective cohort study, 236 patients were selected using the available sampling method. Then, these patients were evaluated for complications such as worsening pain, the need for repeat surgery, mortality rate, and the level of symptom improvement.The checklist includes demographic information about the patient and information during and after surgery, which can be extracted from the patient's medical record. Additionally, the patient's preoperative pain severity and the occurrence and severity of acute and chronic pain after surgery, sensory and motor disability after surgery, and the need for repeat surgery are extracted through telephone contact with the patient, using the VAS scale as a criterion. ResultsIn this study, out of 236 patients who underwent discectomy surgery, 115 female patients (48.7 %) and 121 male patients (51.3 %). The mean age of this study was 51.81 years, with the minimum age being 36 and the maximum age being 60 years.70 patients (66.29%), experienced postoperative complications in this study. Of these, 15 patients (3.6%) experienced only acute pain, 16 patients (7.6%) experienced only chronic pain, and 39 patients (5.16%) experienced both acute and chronic pain. In addition, 42 patients (8.17%) experienced sensory-motor deficits after the operation, and 24 patients (2.10%) required further surgery after the first operation. ConclusionAge and smoking are among the influential factors in the surgical outcome for the patient. In addition, a history of underlying disease, especially diabetes, can have an impact on the occurrence of pain and sensory-motor disability after the operation. Among the effective therapeutic factors in the surgical outcome, the length of surgery and the use of postoperative narcotics can be mentioned. Additionally, the type of surgical technique and anesthesia can also be influential factors in the surgery, which require further study with a larger population and a variety of surgical techniques and anesthesia.

Local Anaesthetic Injection In To Both Angles of Rectus Sheath Incision for Post-Operative Pain Relief in Cesarean Delivery Have Any Benefit

Background: The use of CS for delivery is becoming more prevalent, and it is now one of the most common major operative procedures done worldwide. Prolonged pain reduces physical exercise and increases the risk of deep vein thrombosis and subsequent pulmonary embolism. Objectives: The purpose of this research was to see if a local anaesthetic "Bupivacaine" injection in both angles of the rectus sheath incision could decrease postoperative pain and opioid consumption after a caesarean section. Patients and methods: This study was conducted at obstetrics and gynecology department of Damanhur Medical National Institute from March 2023 to September 2023 and included 90 patients. 30 patients received saline infiltration in both angles of the rectus sheath incision, 30 patients received Bupivacaine infiltration in both angles of the rectus sheath incision, and 30 patients received both saline and Bupivacaine injections. Results: The research compared the three groups and discovered a significant difference in time for the first analgesic request, time interval before first ambulation, length of hospital stay, postoperative pain score, and postoperative nausea and vomiting, with group B having the best result. Conclusion: In patients getting general anesthesia, a local anesthetic "Bupivacaine" injection in both angles of the rectus sheath incision to block the ilioinguinal and iliohypogastric nerves bilaterally is an effective technique to reduce postoperative pain and analgesic consumption after caesarean section.

Anterior knee pain in young athletes: Osgood Schlatter or Sinding-Larsen-Johansson disease?

Osgood-Schlatter disease (OSD) and Sinding-Larsen-Johansson disease (SLJD) are commonly diagnosed conditions in young, athletic patients who present with anterior knee pain. Despite the familiarity many clinicians have with OSD because of its frequent diagnosis, it does not differ much from SLJD in clinical presentation. Although these diseases generally are self-limiting, diagnostic imaging studies can help clinicians make the correct diagnosis, helping patients avoid progressing to advanced disease states that would require extended rest time, prolonged pain, and potential surgical intervention.

P06 Think of hypophosphatasia if atypical fracture with persistent low ALP levels

Abstract Introduction Hypophosphatasia (HPP), a rare, underdiagnosed metabolic genetic bone disease caused by diminished or absent expression of the tissue non-specific alkaline phosphatase (TNSALP) enzyme. The mutation of alkaline phosphatase (ALPL) gene leads to wide-ranging clinical manifestations, broadly classified into six different types based on age of onset and severity of the disease. Fragility fractures are predominant characteristics of adult onset HPP and are often misdiagnosed as osteoporosis, stipulating antiresorptive treatment. However, bisphosphonates (BP) make HPP more susceptible to atypical fractures and thus are contraindicated. A recent study shows 1:4 atypical femoral fracture cases are linked with monogenic bone diseases including HPP. Case description A 63-year-old Caucasian female was referred to our osteoporosis clinic, at the age of 57 following an atypical right femur fracture while on bisphosphonate and steroids. Her past medical history includes multiple right thigh sarcoma at the age of 39, 45 and 49 years requiring multiple surgeries and localised radiotherapy. She was also diagnosed with ocular myasthenia gravis two years before the atypical fracture, requiring long term high dose steroids. Her other co-morbidities include type 2 diabetes and hypertension. Due to long term steroids, her primary care physician initiated weekly 70 mg oral alendronic acid. However, three months later she had a spontaneous right mid shaft femur fracture. The patient experienced one year of right thigh pain prior to fracture which was not brought to medical attention. She underwent intramedullary nailing and successful rehabilitation. A thorough assessment in fracture liaison service spotted the history of primary tooth loss with roots intact in childhood, and chronic dental problems crowning in adult life requiring many caps and crowns. Her mother has a history of “childhood onset rickets”, bowing of legs and complete loss of all her permanent teeth at the age of 30 years. A review of blood tests revealed normal calcium, vitamin D and parathyroid levels, multiple low alkaline phosphatase levels between 16 – 23 U/L(normal range 30-130 U/L) prior to bisphosphonates, vitamin B6 fasting blood test had shown raised result at 140 (normal range 40-100). Xray of the left femur was normal. The dual energy X-ray absorptiometry (DEXA) scan yielded normal T score. The genetic test confirmed heterozygous gene mutation in ALPL gene, confirming a diagnosis of hypophosphatasia. She recovered well from her fracture and manages to walk more than one mile unaided. She is currently under regular follow-up in our hypophosphatasia clinic and has stopped bisphosphonates indefinitely. Discussion The underlying cause for atypical femoral fracture (AFF) in this case is multifactorial; long-term steroids, radiotherapy, HPP and bisphosphonate usage. Regardless, there is a relationship between hypophosphatasia and AFF. Some studies have proved that more than 90% of the patients with AFF used long term BPs. The defective ALPL gene in HPP affects bone mineralisation, resulting in accumulation of inorganic pyrophosphate (PPi), which impairs hydroxyapatite crystal formation causing recurrent fractures, osteopenia, delayed wound healing, dental problems, atypical and pseudo fractures. Bisphosphonates are chemical derivates of PPi, and thus inversely affect bone mineralisation especially in cases of TNSALP mutations and thus are contraindicated in HPP. The atypical fractures often may remain undiagnosed for a long time despite often prolonged prodromal pain occurring before the actual fracture. Careful clinical evaluation and plain X-ray will help to make the diagnosis. Hypophosphatasia related fractures mostly occur laterally in the subtrochanteric diaphysis. AFF cases often require surgical repair with intramedullary nailing. If an imminent atypical fracture is diagnosed early, prophylactic surgery is sometimes recommended. After three months of alendronic acid, bone turnover markers are usually suppressed, therefore despite the short time of alendronate exposure, this is likely to have contributed to the atypical femur fracture. Also, genetic test revealed inherited autosomal dominant trait of HPP in this case, enabled family screening and prevention of potential use of future bisphosphonates in affected family members. Key learning points HPP presenting in adulthood may be more common than previously though with a recent study estimating prevalence of the mild HPP genotype to be 1:508, although not all cases will be symptomatic. A persistent low alkaline phosphatase together with a fragility or atypical fracture raises suspicion of hypophosphatasia. A thorough clinical evaluation, fasting vitamin B6 levels, urine phosphoethanol amine levels and ALPL genetic test will aid the diagnosis. Severe cases of hypophosphatasia are treated with asfotase alfa, enzyme replacement therapy, to prevent debilitating complications, while most mild and moderate cases are offered supportive management. Bisphosphonate treatment is contraindicated in hypophosphatasia. It is worth reviewing ALP levels prior to antiresorptive therapy in suspected cases, as bisphosphonates often reduce ALP levels, masking the diagnosis. High risk Osteoporosis cases should be discussed in a multidisciplinary setting with careful risk-benefit evaluation. Cases like this highlight the importance of early HPP diagnosis to avoid contraindicating treatments and their consequences.

Robot-assisted ileocystoplasty for the treatment of adult neurogenic bladder: A video demonstration and outcomes

Abstract Ileocystoplasty is one of the treatment options in the armamentarium for the management of adults with neurogenic bladder dysfunction, after failure of less invasive treatment alternatives, such as intravesical onabotulinum toxin A injection therapy and sacral neuromodulation. It has traditionally been performed as open surgery and can be associated with significant morbidity, especially in the early postoperative period.[1] Complications associated with open ileocystoplasty include prolonged postoperative ileus, wound infections, and pain. Performing robot-assisted ileocystoplasty can reduce the morbidity associated with open surgery[2] and has been shown to be safe and feasible in experienced hands,[3] although it may be associated with increased operative duration because of its learning curve. Our technique of robot-assisted ileocystoplasty and early postoperative outcomes is demonstrated in this video (Supplemental Digital Content, http://links.lww.com/CURRUROL/A47). Robotic console time was 180 minutes, with minimal blood loss. Eight-hourly catheter aspiration and flushes were performed to manage the mucus in the urine. There were no metabolic acidosis or electrolyte derangements postoperatively. The patient was discharged on postoperative day 5. Postoperative cystogram at week 2 showed no leak and the patient is doing well at 1 year postoperatively. Robotic ileocystoplasty is safe and feasible and can reduce the morbidity associated with open surgery with good outcomes.

Diagnosis and Management Controversies Illustrated by an Uncommon Case of Postpartum Pubic Symphysis Diastasis

Pubic symphysis diastasis is a complication of pregnancy that can lead to prolonged recovery, persistent pain, and functional disability if managed inappropriately. There is a lack of universally accepted clinical guidelines with regards to the timeframe and defect criteria for surgical management, which contributes to delayed care resulting in increased surgical complexity and subsequent impairments in functionality and quality of life. The current standard of care utilizes non-operative measures exclusively for separations measuring less than 2.5 cm correlating to symphyseal ligament sparing. Surgical interventions are typically reserved for severe cases or those resistant to initial non-operative treatment. Non-surgical methods have been attempted for 4–6 weeks, even in severe cases, with patients still requiring eventual surgery. We herein report an uncommon case of pubic symphysis diastasis measuring 5.5 cm and the successful implementation of non-surgical management to demonstrate the need for updated standardized treatment guidelines. The defect in this case was treated with early application of a pelvic binder resulting in anatomic alignment and full resolution of pain within 3 months, and full return to activity within 6 months. In conclusion, the establishment of management guidelines for pubic symphysis is recommended, including the use of non-surgical management early in the patient recovery process and in cases with diastasis greater than 2.5 cm. This treatment strategy may decrease morbidity, recovery time, and complications in affected patients.

Diagnostic trends of preoperative venous thromboembolism and its clinical implications in patients who underwent surgery for degenerative spinal diseases

BACKGROUND CONTEXTAlthough the risk of postoperative venous thromboembolism (VTE) in patients who undergo surgery for degenerative spinal disease has received attention, patients experiencing prolonged pain and disability while awaiting or considering surgery have not received adequate attention regarding the risk of VTE. PURPOSETo investigate the epidemiology of preoperative VTE in patients undergoing surgery for degenerative spinal disease. DESIGNRetrospective cohort study using a nationwide database. PATIENT SAMPLEPatients who underwent surgery for degenerative spinal disease. OUTCOME MEASURESPreoperative occurrence of VTE. METHODSData from 2014 to 2018 were obtained from the Korean National Health Insurance claims database. The occurrence of preoperative VTE within a 1-year period divided into 12 time intervals of 30 days each was investigated. The patients were categorized into two groups based on the presence of preoperative VTE. Multivariable logistic regression analysis was conducted to identify the factors associated with preoperative VTE. To validate the relationship between degenerative spinal disease and preoperative VTE, the diagnostic trends of preoperative VTE were analyzed in accordance with the identified risk factors. RESULTSThe overall incidence of preoperative VTE was 50 per 10,000 individuals. Multivariable analysis revealed that VTE occurred more frequently in older patients with specific medical comorbidities, particularly in those with a lumbar spinal lesion accompanied by arthritis of the hip, knee, or shoulder. We also found that the incidence rates of preoperative VTE, as well as the gradient of their increase, began to rise approximately 2 to 3 months prior to the index surgery, peaking just before the index surgery. This diagnostic trend was consistently observed in all patients irrespective of the presence of other risk factors. CONCLUSIONSThe incidence of preoperative VTE in patients with degenerative spinal disease exhibited a sharp increase immediately before surgery, with similar rates to those of postoperative VTE. Clinicians managing patients with degenerative spinal disease should be vigilant for preoperative as well as postoperative VTE.

Contaminated bone grafts and tuberculosis in three spine surgery patients: a case series

Tuberculosis (TB) is a global health issue affecting millions of people every year. Previous articles displayed cases of TB resulting from contaminated bone grafts used in spinal surgeries. However, deeper understanding about the serious health consequences for patients affected by TB-infected bone grafts is lacking. Here, we discuss three unique patients who contracted TB after undergoing lumbar spinal surgery. We describe three patient cases in which individuals initially presented with back pain, underwent required lumbar spinal fusion surgery with bone graft implants, and, afterwards, contracted TB. All patients were given RIPE therapy, had additional surgery to remove the faulty hardware, and lived with significant and prolonged pain. In addition, patient X experienced night sweats, patient Y had a subcutaneous abscess positive for TB, and patient Z had severe burning pain, rash, and sweats. Altogether, we emphasize the importance of increasing our awareness about the potential risks and complications associated with utilizing contaminated surgical products. We encourage healthcare professionals to take necessary precautions to ensure the safety of their patients by screening bone grafts for potential pathogens and practicing proper sterilization techniques.

The Role of Neuroinflammation in Complex Regional Pain Syndrome: A Comprehensive Review.

Complex Regional Pain Syndrome (CRPS) is an excess and/or prolonged pain and inflammation condition that follows an injury to a limb. The pathogenesis of CRPS is multifaceted that remains incompletely understood. Neuroinflammation is an inflammatory response in the peripheral and central nervous systems. Dysregulated neuroinflammation plays a crucial role in the initiation and maintenance of pain and nociceptive neuronal sensitization, which may contribute to the transition from acute to chronic pain and the perpetuation of chronic pain in CRPS. The key features of neuroinflammation encompass infiltration and activation of inflammatory cells and the production of inflammatory mediators in both the central and peripheral nervous systems. This article reviews the role of neuroinflammation in the onset and progression of CRPS from six perspectives: neurogenic inflammation, neuropeptides, glial cells, immune cells, cytokines, and keratinocytes. The objective is to provide insights that can inform future research and development of therapeutic targets for CRPS.

Treatment of Intra-Articular Lesions After Posterior Inferior Tibiofibular Ligament Injury: A Case Series of Elite Rugby Players.

Surgical intervention is not typically used to treat symptoms after mild tibiofibular ligament injuries without ankle dislocation or subluxation. To describe outcomes in patients arthroscopically treated for unique intra-articular lesions after sustaining syndesmosis injury of the ankle. Case series; Level of evidence, 4. A total of 11 elite male rugby players with a mean age of 21.0 years (range, 17-28 years) were referred to our hospital for prolonged posterior ankle pain after a high ankle sprain during rugby football. The patients were examined using standing view radiography, computed tomography (CT) and magnetic resonance imaging (MRI) to determine the extent of ligament damage. Posterior ankle arthroscopy was performed to examine intra-articular lesions. The patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot rating scale and sports activity score of the Self-Administered Foot Evaluation Questionnaire (SAFE-Q). The average reduced tibiofibular overlap on the standing mortise view was 1.2 mm (range, 0.5-2.0 mm) compared with the opposite ankles. Mason type 1 fracture was detected on CT in 6 patients, and ossification of the interosseous membrane was detected in 2 patients. A bone bruise in the posterior malleolus was observed on MRI in all but 1 patient. Intra-articular fragments located in the posterior ankle were observed and removed arthroscopically. Symptoms improved rapidly after arthroscopic treatment in all patients. All patients returned to rugby games at a median of 11 weeks postoperatively. The median AOFAS scores improved from 77 preoperatively to 100 postoperatively (P < .01), and the median SAFE-Q sports activity subscale score improved from 49.4 to 100 (P < .01). All unique intra-articular lesions that developed in rugby football players after syndesmosis injury were able to be treated arthroscopically. Patients returned to playing rugby football without syndesmosis reduction. Posterior ankle arthroscopy was effective in patients with residual symptoms after syndesmosis injury.

A randomized clinical study to compare postoperative pain relief in ilioinguinal nerve block versus transversus abdominis plane block following inguinal hernia repair surgery

Background: Inguinal hernia surgeries are associated with postoperative pain and discomfort. Transversus abdominis plane (TAP) block and Ilioinguinal/Iliohypogastric (IIIH) nerve blocks are widely used to control postoperative pain. In this study we have compared postoperative pain relief between TAP block and IIIH nerve block in the patients undergoing inguinal hernia surgery under spinal anesthesia. Aims and Objectives: The primary aim of this study was to compare postoperative pain relief of TAP block and IIIH block in patients undergoing inguinal hernia surgery. Secondary objectives were to observe hemodynamic parameters and to observe for postoperative side effects if any. Materials and Methods: Sixty patients of age group 18–65-year-old males, ASA grade I, II, were randomised into two groups TAP group (n=30) and IIIH group (n=30). TAP group received 30 mL of 0.25% ropivacaine TAP block and group IIIH received 20 mL, and wound infiltration with 10 mL of 0.25% ropivacaine. Duration of analgesia was recorded, visual analogue scale (VAS) score compared in first 24h postoperatively. Perioperative haemodynamic parameters were recorded. Results: VAS score was found significant at 1, 2, 3, 4, 5, 8, 10, 16 h (P&lt;0.001). The mean duration of analgesia was found to be 4.64±1.16 h and 6.3±1.84 h for IIIH group and TAP group respectively which was statistically significant (P&lt;0.001). Haemodynamic were stable and no complication was there in both the groups. Conclusion: As a part of multimodal analgesia regimen both TAP block and IIIH block provided good pain relief postoperatively in patients undergoing inguinal hernia. In this study TAP block provided prolonged pain relief than IIIH block after inguinal hernia repair.

Interaction between local blood flow and tolerance to prolonged pain in the elderly.

We aimed to explore the link between local vasodilation and pain perception in elderly subjects, testing the hypothesis that altered local cutaneous blood flow participates in the decrease in pain tolerance with age. Sixty-eight young and 83 older participants performed a pain tolerance test in which they hold their hand in an airtight box in which air temperature was regulated at 65°C until the pain became unbearable. Participants continuously estimated pain intensity. Skin temperature and local blood flow in the box-exposed hand were continuously monitored. In the young group, 97% of subjects resisted pain until the end of the test, whereas only 53% in the elderly group managed to do so, indicating that pain tolerance is impaired in the elderly. Among all participants, the skin temperature associated with the first pain sensation was below the threshold for nociceptor activation (43°C). Interestingly, blood flow in the elderly group was correlated with pain judgment, whereas no such correlation was observed in the young. Our results suggest that the local vasodilator response induced by local heating may be involved in pain perception and may influence thermal pain tolerance with aging. These results could contribute to a better understanding of vascular deficits and the development of chronic pain in vascular pathologies.

1093 Opioid Requirements and Predictive Factors for Total Hip and Knee Arthroplasties. a 7-Year Major Trauma Centre Study

Abstract Aim Total knee and hip arthroplasties have prolonged and uncertain pain and rehabilitation timelines, which can be debilitating for patients. In our study, we compare opioid requirements and analyse predictive factors between the two procedures. Method All patients undergoing primary total hip (THA) and knee (TKA) arthroplasties from 2015-2022 at a Major Trauma Centre were reviewed. Opioid prescriptions in the first post-operative year were calculated every month up to 6 months and then from the 7th-12th month. Overall prescribed Morphine Milligram Equivalents (MME) “strength” and days with at least one opioid prescription (“coverage”) were calculated. Demographic and comorbidity factors were also included in the multivariate model analysis. Results 2908 THAs and 2235 TKAs were included. Patients undergoing THAs were younger (68.5 vs 70.2 years-old, p&amp;lt;0.001) and more commonly female (61% vs 58%, p = 0.022) compared to TKA patients. TKAs (843 MME), compared to THAs (614 MME), had significantly higher postoperative opioid strength requirement (p&amp;lt;0.001) and coverage requirement (p&amp;lt;0.001). On comorbidity analysis, TKAs had the stronger comorbidity predictive value, with strength in the post-operative year being positively associated with heart failure (p = 0.04), kidney disease (p&amp;lt;0.001), connective-tissue disorders (p = 0.009), respiratory disease (p&amp;lt;0.001) and diabetes (p = 0.014). THA strength was associated with rheumatological conditions and diabetes (p&amp;lt;0.01). Both had numerous strong associations for first month opioid coverage requirements. Conclusions Our study enables a high-resolution breakdown of the rehabilitation and pain journey of patients undergoing THA and TKA and provides insight to patients and clinicians about factors predisposing to higher pain relief requirements.

The Effect of Adding Magnesium Sulphate to Epidural Bupivacaine Compared to the Addition of Fentanyl to Epidural Bupivacaine in Patients Undergoing Lower Limb and Pelvic Orthopedic Surgery under Combined Spinal Epidural Anesthesia

Abstract Background Epidural anesthesia is safe and inexpensive technique with the advantage of providing surgical anesthesia and prolonged postoperative pain relief. Research continues concerning different techniques and drugs that could provide better surgical anesthesia and postoperative pain relief. Aim of the Work to investigate how the addition of magnesium sulphate to 0.5% bupivacaine affects duration, quality, complications and dermatome spread of anesthesia in comparison to fentanyl. Patients and Methods The current study included 50 patients who had been scheduled to undergo lower limb or pelvic orthopedic surgery under combined spinal - epidural anesthesia. The study had been done after approval of the local ethics committee and after obtaining written informed consent from all patients enrolled in the study; which had been held at Ain Shams Hospital, Faculty of Medicine. Results Pain assessment using VAS showed no statistically significant difference between the two studied groups in the first and second hours postoperative. Starting from the third hour statistical significant differences were observed between the two groups, VAS was higher in groups (M) than in group (F); (1.82 ±0.6 vs. 1.42 ±0.4 in both groups respectively. At the fourth hour; VAS was higher in groups (M) than in group (F); (2.80±0.8 vs. 1.76 ± 0.6 in both groups respectively. The incidence of complications was significantly lower among group (M) where 52% of patients had no complications at all. Conclusion the use of both magnesium and fentanyl as adjuvants to local anesthetics in epidural anesthesia is safe and effective. No significant differences regarding quality of motor block and hemodynamics. But the study shows that fentanyl is significantly a better adjuvant regarding postoperative analgesia and time for first analgesic dose. While magnesium is a significantly better adjuvant regarding complications such as nausea, vomiting and pruritis.

Analgesic effect of a lidocaine-ropivacaine mixture for extraction of impacted mandibular third molars: a randomized controlled trial.

The painless postoperative period can be significantly prolonged by using long-acting local anesthetics such as ropivacaine, though these local anesthetics are known for their slower onset of action. To compensate for this, a mixture of short-onset (e.g., lidocaine) and long-acting local anesthetics is used. However, the efficacy of such an anesthetic cocktail has not been elucidated in the field of oral and maxillofacial surgery. To address the research purpose, this prospective randomized controlled trial included 56 patients scheduled for impacted mandibular third molar extraction. All patients received the inferior alveolar nerve block (IANB) using either 2% lidocaine with epinephrine or a 1:1 mixture of 2% lidocaine with epinephrine and 0.75% ropivacaine. Patients anesthetized using the lidocaine-ropivacaine mixture showed significantly prolonged postoperative analgesia and pain control than those anesthetized using lidocaine only. IANB using a lidocaine-ropivacaine mixture can provide prolonged postoperative anesthesia and pain control with extraction of mandibular third molars. This method can be a noteworthy addition to existing methods of local anesthesia for the extraction of mandibular third molars. Trial registration number University Hospital Medical Information Network (No. UMIN000044315).

Endovenous Thermal Ablation for Treatment of Symptomatic Saphenous Veins-Does the Body Weight Matter?

This study aimed to examine whether body weight may affect the effectiveness and safety of endovenous thermal ablation (ETA) for the treatment of symptomatic varicose veins. This retrospective single-center cohort study analyzed the outcomes and patient demographic data with a focus on the body weight of all patients who had ETA of symptomatic varicose veins between September 2017 and October 2020. A total of 1178 treated truncal veins from 636 patients were analyzed. The mean ± standard deviation body mass index (BMI) was 25.5 ± 4.9. In 2.3% of cases, the patients were underweight (BMI < 18.5), 31.0% were overweight (BMI > 25), and 16.6% were obese (BMI > 30). Complete truncal occlusion was observed 1 year post intervention in 97.6-100% and patients were satisfied or very satisfied in 96.2-100% across BMI groups. Pain was low but significantly higher in the patients with obesity 6 weeks post intervention (visual analog scale 0.84 ± 1.49) and a higher infection rate was observed in the patients with obesity (n = 4/132; 3.0%). No significant association was observed between BMI and bleeding or thromboembolic events. Patients with obesity experienced prolonged pain and more infections after ETA, but ETA for varicose vein treatment remains effective and safe, independent of the patient's BMI.

Diagnosis and Treatment of a Dynamic Strain Vector after a Motor Vehicle Accident

Abstract This report outlines a case of prolonged pain and somatic dysfunction after a motor vehicle accident where a strain-vector was diagnosed in the biofield and successfully treated with the dynamic strain-vector release (SVR) technique. The palpatory diagnostic approach and end-feel of a strain-vector in the biofield described in this case provides guidance for those wishing to incorporate it into clinical practice, particularly in cases where traditional osteopathic techniques are not effective.

Preoperative Versus Perioperative Risk Factors for Delayed Pain and Opioid Cessation After Total Joint Arthroplasty: A Prospective Cohort Study.

The evolution of pre- versus postoperative risk factors remains unknown in the development of persistent postoperative pain and opioid use. We identified preoperative versus comprehensive perioperative models of delayed pain and opioid cessation after total joint arthroplasty including time-varying postoperative changes in emotional distress. We hypothesized that time-varying longitudinal measures of postoperative psychological distress, as well as pre- and postoperative use of opioids would be the most significant risk factors for both outcomes. A prospective cohort of 188 patients undergoing total hip or knee arthroplasty at Stanford Hospital completed baseline pain, opioid use, and emotional distress assessments. After surgery, a modified Brief Pain Inventory was assessed daily for 3months, weekly thereafter up to 6months, and monthly thereafter up to 1year. Emotional distress and pain catastrophizing were assessed weekly to 6months, then monthly thereafter. Stepwise multivariate time-varying Cox regression modeled preoperative variables alone, followed by all perioperative variables (before and after surgery) with time to postoperative opioid and pain cessation. The median time to opioid and pain cessation was 54 and 152days, respectively. Preoperative total daily oral morphine equivalent use (hazard ratio-HR 0.97; 95% confidence interval-CI 0.96-0.98) was significantly associated with delayed postoperative opioid cessation in the perioperative model. In contrast, time-varying postoperative factors: elevated PROMIS (Patient-Reported Outcomes Measurement Information System) depression scores (HR 0.92; 95% CI 0.87-0.98), and higher Pain Catastrophizing Scale scores (HR 0.85; 95% CI 0.75-0.97) were independently associated with delayed postoperative pain resolution in the perioperative model. These findings highlight preoperative opioid use as a key determinant of delayed postoperative opioid cessation, while postoperative elevations in depressive symptoms and pain catastrophizing are associated with persistent pain after total joint arthroplasty providing the rationale for continued risk stratification before and after surgery to identify patients at highest risk for these distinct outcomes. Interventions targeting these perioperative risk factors may prevent prolonged postoperative pain and opioid use.

Continuous nerve block versus thoracic epidural analgesia for post-operative pain of pectus excavatum repair: a systematic review and meta-analysis

Surgery to repair pectus excavatum (PE) is often associated with severe postoperative pain, which can impact the length of hospital stay (LOS). While thoracic epidural analgesia (TEA) has traditionally been used for pain management in PE, its placement can sometimes result in severe neurological complications. Recently, paravertebral block (PVB) and erector spinae plane block (ESPB) have been recommended for many other chest and abdominal surgeries. However, due to the more severe and prolonged pain associated with PE repair, it is still unclear whether continuous administration of these blocks is as effective as TEA. Therefore, we conducted this systematic review and meta-analysis to demonstrate the equivalence of continuous PVB and ESPB to TEA.