26 Luglio 2001
Anesth Analg 2001 Jul;93(1):241-2
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PMID: 11429376, UI: 21322087
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Anesth Analg 2001 Jul;93(1):213-4
Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California 94143-0648, USA.
PMID: 11429368, UI: 21322079
Anesth Analg 2001 Jul;93(1):192-6
Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany. andregottschalk@hotmail.com
N-methyl-D-aspartate (NMDA) antagonists administered before surgery will improve postoperative analgesia, presumably by inhibiting spinal sensitization processes. However, current clinical formulations of NMDA antagonists either enable only an oral application (i.e., dextromethorphan) or are associated with psychotropic side effects, as with the IV delivery of ketamine. Because of its noncompetitive NMDA receptor antagonist characteristics, amantadine may improve postoperative analgesia when administered before surgically induced trauma. In this prospective, randomized clinical study, we examined whether female patients undergoing elective abdominal hysterectomy experienced less postoperative pain when IV amantadine was applied in comparison with placebo before the start of surgery. Thirty patients were randomly assigned to receive 500 mL saline IV before the induction of standardized general anesthesia in Group 1 (Control group) or, in a double-blinded manner, 200 mg amantadine IV in 500 mL saline in Group 2 (Treatment group). Postoperative pain control was provided via IV patient-controlled analgesia with piritramide. During the first 48 h after tracheal extubation, pain perception was assessed by visual analog scales, and all analgesic requirements were documented. There were no significant differences between the two groups with respect to pain scores, postoperative analgesic requirements, and the incidence of side effects. Because of no differences in postoperative pain or opioid consumption, we conclude that a preoperative dose of 200 mg amantadine IV fails to enhance postoperative analgesia in patients undergoing elective abdominal hysterectomy. Implications: Because of no differences in postoperative pain or opioid consumption, we conclude that a preoperative dose of 200 mg amantadine IV fails to enhance postoperative analgesia in patients undergoing elective abdominal hysterectomy.
PMID: 11429364, UI: 21322075
Anesth Analg 2001 Jul;93(1):121-7
Department of Anesthesia, McGill University, Montreal, Quebec, Canada.
We studied the effect of anesthesia on the kinetics of perioperative glucose metabolism by using stable isotope tracers. Twenty-three patients undergoing cystoprostatectomy were randomly assigned to receive epidural analgesia combined with general anesthesia (n = 8), fentanyl and midazolam anesthesia (n = 8), or inhaled anesthesia with isoflurane (n = 7). Whole-body glucose production and glucose clearance were measured before and during surgery. Glucose clearance significantly decreased during surgery independent of the type of anesthesia. Epidural analgesia caused a significant decrease in glucose production from 10.2 +/- 0.4 to 9.0 +/- 0.4 micromol. kg(-1). min(-1) (P < 0.05), whereas the plasma glucose concentration was not altered (before surgery, 5.0 +/- 0.2 mmol/L; during surgery, 5.2 +/- 0.1 mmol/L). Glucose production did not significantly change during fentanyl/midazolam anesthesia (before surgery, 10.5 +/- 0.5 micromol. kg(-1). min(-1); during surgery, 10.1 +/- 0.5 micromol. kg(-1). min(-1)), but plasma glucose concentration significantly increased from 4.8 +/- 0.1 mmol/L to 5.3 +/- 0.2 mmol/L during surgery (P < 0.05). Isoflurane anesthesia caused a significant increase in plasma glucose concentration (from 5.2 +/- 0.1 mmol/L to 7.2 +/- 0.5 mmol/L) and glucose production (from 10.8 +/- 0.5 micromol. kg(-1). min(-1) to 12.4 +/- 1.0 micromol. kg(-1). min(-1)) (P < 0.05). Epidural analgesia prevented the hyperglycemic response to surgery by a decrease in glucose production. The increased glucose plasma concentration during fentanyl/midazolam anesthesia was caused by a decrease in whole-body glucose clearance. The hyperglycemic response observed during isoflurane anesthesia was a consequence of both impaired glucose clearance and increased glucose production. Implications: Epidural analgesia combined with general anesthesia prevented the hyperglycemic response to surgery by decreasing endogenous glucose production.The increased glucose plasma concentration in patients receiving fentanyl/midazolam anesthesia was caused by a decrease in whole-body glucose clearance. The hyperglycemic response observed during inhaled anesthesia with isoflurane was a consequence of both impaired glucose clearance and increased glucose production.
PMID: 11429352, UI: 21322063
Anesth Analg 2001 Jul;93(1):116-20
Department of Anaesthesia & Pain Management, Alfred Hospital, Victoria, Australia.
In this double-blinded, randomized controlled trial we tested if the addition of ketamine to morphine for patient-controlled analgesia (PCA) resulted in improved analgesic efficacy and lower pain scores compared with morphine PCA alone after major abdominal surgery. Seventy-one patients were randomly allocated to receive either morphine 1 mg/mL (Group M) or morphine 1 mg/mL plus ketamine 1 mg/mL (Group MK) delivered via PCA after surgery. No other analgesics or regional blocks were permitted during the 48-h study period. Postoperatively there were no differences between the groups for subjective assessment of analgesic efficacy, pain scores at rest, and on movement, opioid consumption, or adverse events. Group MK patients performed worse in cognitive testing (P = 0.037). There was an increased risk of vivid dreaming in patients who received ketamine (relative risk = 1.8, 95% confidence interval 0.78-4.3). We conclude that small-dose ketamine combined with PCA morphine provides no benefit to patients undergoing major abdominal surgery. Implications: We performed a randomized, controlled trial comparing the use of ketamine and morphine with morphine alone to relieve pain after major abdominal surgery.Ketamine did not improve pain relief and merely increased side effects.
PMID: 11429351, UI: 21322062
Anesth Analg 2001 Jul;93(1):71-6
Department of Anesthesia and Intensive Care, IRCCS H "Casa Sollievo della Sofferenza" S. Giovanni Rotondo (FG), Italy. pdenegri@libero.it
Epidurally administered clonidine enhances the quality and duration of postoperative analgesia when it is used as an adjunct to local anesthetics in children. We investigated the dose-response relationship for epidural clonidine when added to a continuous postoperative epidural infusion of ropivacaine. By use of an observer-blinded design, 55 pediatric patients (1-4 yr old) were randomly given a postoperative epidural infusion of plain ropivacaine 0.1% 0.2 mg. kg(-1). h(-1) (Group R), ropivacaine 0.08% 0.16 mg. kg(-1). h(-1) plus clonidine 0.04 microg. kg(-1). h(-1) (Group RC1), ropivacaine 0.08% 0.16 mg. kg(-1). h(-1) plus clonidine 0.08 microg. kg(-1). h(-1) (Group RC2), or ropivacaine 0.08% 0.16 mg. kg(-1). h(-1) plus clonidine 0.12 microg. kg(-1). h(-1) (Group RC3). A clear dose-response relationship could be identified for a continuous infusion of epidural clonidine, with clonidine dosages in the 0.08-0.12 microg. kg(-1). h(-1) range providing improved postoperative analgesia (reduced Children's Hospital of Eastern Ontario pain score, increased time to first supplemental analgesic demand, and a reduced total number of doses of supplemental analgesics during the first 48 h after surgery). Analgesia was improved without any signs of increased sedation or other side effects. The adjunct use of epidural clonidine in the dosage range of 0.08-0.12 microg. kg(-1). h(-1) appears effective and safe for use in children. Implications: The addition of clonidine (0.08-0.12 microg.kg(-1).h(-1))to a continuous epidural infusion of ropivacaine was found to improve postoperative pain relief in children. No clinically significant signs of sedation or other side effects were observed.
PMID: 11429342, UI: 21322053
Anesthesiology 2001 Jun;94(6):1119-32
Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
[Medline record in process]
PMID: 11465606, UI: 21358167
Anesthesiology 2001 Jul;95(1):72-80
Department of Surgery, Maastricht University Hospital, The Netherlands. kemlerm@@mzv.nl
BACKGROUND: A randomized trial was performed to assess the effect of spinal cord stimulation (SCS) on detection and pain thresholds for pressure, warmth, and cold and on the extent of mechanical hyperalgesia in patients with chronic complex regional pain syndrome type I. METHODS: Fifty-four chronic complex regional pain syndrome type I patients were randomized to receive both SCS and physical therapy (SCS+PT; n = 36), or to receive only physical therapy (PT; n = 18). Twenty-four SCS+PT patients responded positively to trial stimulation and underwent SCS implantation. During a 12-month follow-up period, six quantitative sensory testing sessions were performed. The main analysis compared 24 SCS patients with 29 nonimplanted patients--one PT patient was excluded. RESULTS: SCS showed no effect on detection thresholds for warmth and cold or on pain thresholds for any sensation. The pressure detection threshold initially increased by SCS, but after 3 months, pressure detection thresholds returned to normal. Mechanical hyperalgesia, both dynamic and static, was reduced slightly with SCS. CONCLUSIONS: Although SCS has previously been shown to cause a significant pain reduction in complex regional pain syndrome type I, the treatment has no long-term effect on detection and pain thresholds for pressure, warmth, or cold. The treatment seems to have only minimal influence on mechanical hyperalgesia.
PMID: 11465587, UI: 21358084
Anesthesiology 2001 Jul;95(1):241-9
Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, USA. woolf.clifford@mgh.harvard.edu
PMID: 11465563, UI: 21358102
Anesthesiology 2001 Jul;95(1):22-9
Department of Anesthesiology, University Hospital of Bern, Switzerland. martin.luginbuehl@dkf2.unibe.ch
BACKGROUND: Several experimental pain models have been used to measure opioid effects in humans. The aim of the current study was to compare the qualities of five frequently used experimental pain tests to measure opioid effects. METHODS: The increase of electrical, heat, and pressure pain tolerance and the decrease of ice-water and ischemic pain perception was determined at baseline and at four different plasma concentrations of alfentanil (n = 7) administered as target controlled infusion or placebo (n = 7). A linear mixed-effects modeling (NONMEM) was performed to detect drug, placebo, and time effect as well as interindividual and intraindividual variation of effect. RESULTS: Only the electrical, ice-water, and pressure pain tests are sensitive to assess a concentration-response curve of alfentanil. At a plasma alfentanil concentration of 100 ng/ml, the increase in pain tolerance compared with baseline was 42.0% for electrical pain, 22.2% for pressure pain, and 21.7% for ice-water pain. The slope of the linear concentration-response curve had an interindividual coefficient of variation of 58.3% in electrical pain, 35.6% in pressure pain, and 60.0% in ice-water pain. The residual error including intraindividual variation at an alfentanil concentration of 100 ng/ml was 19.4% for electrical pain, 6.1% for pressure pain, and 13.0% for ice-water pain. Electrical pain was affected by a significant placebo effect, and pressure pain was affected by a significant time effect. CONCLUSION: Electrical, pressure, and ice-water pain, but not ischemic and heat pain, provide significant concentration-response curves in the clinically relevant range of 200 ng/ml alfentanil or lower. The power to detect a clinically relevant shift of the curve is similar in the three tests. The appropriate test(s) for pharmacodynamic studies should be chosen according to the investigated drug(s) and the study design.
PMID: 11465562, UI: 21358077
Anesthesiology 2001 Jul;95(1):216-40
PMID: 11465561, UI: 21358101
Br J Anaesth 2001 Jul;87(1):99-106
Center for Pain Studies, Rehabilitation Institute of Chicago, 1030 N. Clark Street, Suite 320, Chicago, IL 60610, USA.
PMID: 11460817, UI: 21353864
Br J Anaesth 2001 Jul;87(1):88-98
Pain Service, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK.
PMID: 11460816, UI: 21353863
Br J Anaesth 2001 Jul;87(1):3-11
St Bart's and Royal London School of Medicine, Turner Street, London E1 2AD, UK.
PMID: 11460811, UI: 21353856
Br J Anaesth 2001 Jul;87(1):144-52
Pain Management Unit, University of Bath, Bath BA2 7AY, UK.
Psychological factors are central to the experience of pain, the delivery of effective analgesia and for the specific treatment of chronic pain and disability. Improvement in pain management can often be brought about by very simple, if subtle, changes in clinical practice. Although simple, these changes can have significant effects in the experience of pain, distress and use of health-care resources. For the chronic pain patient, the presentation is much more complex and the treatment interdisciplinary and programmatic. The evidence for the effectiveness of cognitive behaviour therapy for adults with chronic pain is now well established. This treatment should be available as a core part of any chronic pain service.
PMID: 11460803, UI: 21353868
Br J Anaesth 2001 Jul;87(1):133-43
Pain Management Service, University Hospitals of Leicester, Leicester Royal Infirmary, Leicester LE1 5WW, UK.
PMID: 11460802, UI: 21353867
Br J Anaesth 2001 Jul;87(1):12-26
Department of Anaesthetics, Imperial College School of Medicine, Chelsea and Westminster Hospital Campus, London W2 1NY, UK.
PMID: 11460801, UI: 21353857
Br J Anaesth 2001 Jul;87(1):107-16
Department of Anaesthesiology, Aarhus University Hospital, DK-8000 Aarhus C, Denmark.
PMID: 11460799, UI: 21353865
Br J Anaesth 2001 Jul;87(1):1-2
PMID: 11460798, UI: 21353855
Eur J Pharmacol 2001 Apr 6;417(1-2):91-8
National Institute on Drug Abuse, 5500 Nathan Shock Drive Bldg. C, 21224, Baltimore, MD 21224, USA. vcampbel@intra.nida.nih.gov
ATP-gated K(+) channel openers produce antinociception that is attenuated by opioid receptor antagonists, indicating K-ATP openers produce antinociception, in part, via the release of endogenous opioid peptides. Utilizing the spinal perfusion method, male Sprague-Dawley rats were administered minoxidil intrathecally (i.t.) at doses ranging from 12.5 to 200 microg/rat for 3 min, tested for antinociception using the tail-flick test, and perfused with artificial cerebrospinal fluid (aCSF) to collect endogenous opioid peptides. Endogenous opioid peptide levels were measured by radioimmunoassay. Naltrindole, a delta-opioid receptor antagonist, at 4 mg/kg, subcutaneously (s.c.), blocked minoxidil-induced antinociception. beta-Funaltrexamine, a mu-opioid receptor antagonist, at 100 microg/rat, partially blocked minoxidil, whereas the kappa-opioid receptor antagonist nor-binaltorphimine, at a dose of 100 microg/rat, did not attenuate minoxidil. Although antagonists of the mu- and delta-opioid receptor attenuated minoxidil-induced antinociception, there was no increase in beta-endorphin, an endogenous ligand with affinity for both micro- and delta-opioid receptors or [Leu(5)]enkephalin, an endogenous ligand with affinity for delta-opioid receptors.
PMID: 11301063, UI: 21197983
N Engl J Med 2001 Jul 19;345(3):225
PMID: 11463032, UI: 21333067
Reg Anesth Pain Med 2001 Jul-Aug;26(4):376-8
Pain Management Centre, Guy's & St Thomas' Hospital Trust, London, United Kingdom.
BACKGROUND AND OBJECTIVES: The psoas compartment block is used to produce analgesia of the lumbar plexus mainly for hip and knee surgery. It has also been used for the management of a long-standing pain due to hip joint degeneration. CASE REPORT: A 55-year-old woman with severe left hip pain received repetitive psoas compartment blocks over 18 months. The blocks provided her with effective pain control. The quality and duration of the block was improved by the addition of opioid to the local anesthetic. CONCLUSION: We successfully performed repeated psoas compartment blocks with a local anesthetic and subsequently with added opioids, which produced substantial pain relief, especially after the addition of opioids. Reg Anesth Pain Med 2001;26:376-378.
PMID: 11464361, UI: 21357130
Reg Anesth Pain Med 2001 Jul-Aug;26(4):368-72
Wyllie Arthritis Centre, Shenton Park, Australia.
"A rheumatic affection of the nerves follows the course of the nerves, the pain is numb and of an aching kind, generally constant but occasionally exasperated by paroxysms; this invariably increases by pressure."(1)
PMID: 11464359, UI: 21357128
Reg Anesth Pain Med 2001 Jul-Aug;26(4):333-6
Department of Anesthesiology, Central Aizu General Hospital, Aizuwakamatsu, Japan.
BACKGROUND AND OBJECTIVES: We have recently demonstrated that a mixture of 1% lidocaine with water in a 1:3 ratio has less injection pain and is more effective than unaltered 1% lidocaine in treating chronic myofascial pain syndromes. Yet, the most suitable local anesthetic and the most effective dilution in water have not been evaluated. METHODS: Various mixtures of local anesthetics and water or saline were injected intramuscularly into the shoulder of 40 female volunteers, and pain scores on injection were evaluated in a randomized and double-blinded manner. In another portion of the study, 0.25% or 0.2% lidocaine in water were injected randomly into 1 side of 21 outpatients with chronic neck, shoulder, or lumbar myofascial pain to the same degree in both sides. The other solution was injected into the other side of the same patients. RESULTS: Less injection pain was experienced with the water-diluted 0.25% lidocaine and water-diluted 0.25% mepivacaine than the saline-diluted 0.25% lidocaine and water-diluted 0.0625% bupivacaine. Also, less injection pain was experienced with the water-diluted 0.25% and 0.2% lidocaine than the water-diluted 0.3% and 0.15% lidocaine. In the other study, there were no differences in either the effectiveness or duration of analgesia between the 0.25% and 0.2% water-diluted lidocaine. CONCLUSIONS: The suitable type of local anesthetic may be lidocaine or mepivacaine, and the most effective water-diluted concentration is considered to be 0.2% to 0.25%. Reg Anesth Pain Med 2001;26:333-336.
PMID: 11464352, UI: 21357121
Reg Anesth Pain Med 2001 Jul-Aug;26(4):322-8
Acute Pain Service, Departments of Anesthesiology and Surgical Gastroenterology, Hvidovre University Hospital, Copenhagen, Denmark.
BACKGROUND AND OBJECTIVES: The aim of the study was to examine the analgesic effects of the anticonvulsant, gabapentin, in a validated model of acute inflammatory pain. METHODS: Twenty-two volunteers were investigated in a double-blind, randomized, placebo-controlled cross-over study. Gabapentin 1,200 mg or placebo was given on 2 separate study days. Three hours after drug administration, a first-degree burn injury was produced on the medial aspect of the nondominant calf (12.5 cm(2), 47 degrees C for 7 minutes). Quantitative sensory testing (QST) included pain ratings to thermal and mechanical stimuli (visual analog scale [VAS]), assessments of thermal and mechanical detection thresholds, and areas of secondary hyperalgesia. Side effects drowsiness and postural instability were assessed by subjective ratings (VAS). RESULTS: The burn injury induced significant primary and secondary hyperalgesia (P <.0001). Gabapentin diminished the decrease in mechanical pain threshold in the burn area (P =.04) and reduced secondary hyperalgesia, but the reduction was not significant (P =.06). Heat pain thresholds, pain during the burn, and mechanical pain in the area of secondary hyperalgesia were not significantly changed by gabapentin (P <.2). Ratings of drowsiness and unsteadiness during walking were significantly higher for gabapentin than for placebo (P <.05). CONCLUSIONS: The study indicates that gabapentin has no analgesic effect in normal skin, but may reduce primary mechanical allodynia in acute inflammation following a thermal injury. These observations suggest a clinical potential of gabapentin in the treatment of postoperative pain. Reg Anesth Pain Med 2001;26:322-328.
PMID: 11464350, UI: 21357119
Reg Anesth Pain Med 2001 Jul-Aug;26(4):316-21
Vascular Surgery Unit and Department of Anaesthesia, Derriford Hospital, Plymouth, United Kingdom.
BACKGROUND AND OBJECTIVES: Acute stump pain and phantom limb pain after amputation is a significant problem among amputees with a reported incidence of phantom limb pain in the first year following amputation as high as 70%. Epidural analgesia before limb amputation is commonly used to reduce postamputation acute stump pain in the immediate postoperative period and phantom pain in the first year. We investigated whether immediate postamputation stump pain and phantom pain in the first year is reduced by preoperative epidural block with bupivacaine and diamorphine compared with intraoperative placement of a perineural catheter infusing bupivacaine. METHODS: In a randomized prospective trial, 30 patients scheduled for lower limb amputation were randomly assigned epidural bupivacaine at the standard rate used in our hospital (0.166%, 2 to 8 mL/h) and diamorphine (0.2 to 0.8 mg/h) for 24 hours before and during operation (14 patients; epidural group) and 3 days postoperatively, or an intraoperatively placed perineural catheter (16 patients; perineural group) for intra and postoperative administration of bupivacaine (0.25%, 10 mL/h). All patients had general anesthesia for the amputation and were asked about stump and phantom pain in the first 3 days and then at 6 and 12 months by an independent examiner. Study endpoints were rate of stump and phantom pain, intensity of stump and phantom pain, and consumption of opioids. The groups were well matched in baseline characteristics. RESULTS: Stump pain scores in the first 3 days were significantly higher in the perineural group compared with the epidural group (P <.01). After 3 days, 4 (29%) patients in the epidural group and 7 (44%) in the perineural group had phantom pain (P =.32). Numbers of patients with phantom pain for epidural versus perineural group were: 5 (63%) versus 7 (88%) (P =.25) at 6 months; 3 (38%) versus 4 (50%) (P =.61) at 12 months. Stump pain and phantom sensation were similar in both groups at 6 and 12 months. CONCLUSIONS: Using our regimen, perioperative epidural block started 24 hours before the amputation is not superior to infusion of local anaesthetic via a perineural catheter in preventing phantom pain, but gives better relief of stump pain in the immediate postoperative period. Reg Anesth Pain Med 2001;26:316-321.
PMID: 11464349, UI: 21357118
Reg Anesth Pain Med 2001 Jul-Aug;26(4):310-5
Department of Anesthesiology, American University of Beirut, Beirut, Lebanon.
BACKGROUND AND OBJECTIVES: A multimodal approach to postcesarean pain management may enhance analgesia and reduce side effects after surgery. This study evaluates the postoperative analgesic effects of propacetamol and/or diclofenac in parturients undergoing elective cesarean delivery under spinal anesthesia. METHODS: After randomization, 80 healthy parturients received the following: placebo (group M), 100 mg diclofenac rectally every 8 hours (group MD), 2 g propacetamol intravenously every 6 hours (group MP), or a combination of 2 g propacetamol and 100 mg diclofenac (group MDP) as described above. Drugs were administered for 24 hours after surgery. Postoperative pain was controlled with a patient controlled analgesia pump, using morphine. The visual analog scale (VAS) at rest and on coughing, as well as the morphine consumption, were evaluated at 2, 6, and 24 hours postoperatively. Also, the side effects experienced after undergoing the different regimens were compared. RESULTS: The patients' characteristics did not differ significantly between the 4 groups. VAS score at 2 hours, both at rest and on coughing were lower in group MDP and MD compared with group M (P <.05). At 24 hours, there was still a tendency toward lower pain scores in the groups MDP and MD; however, this difference was only statistically significant at rest between the MDP group and the MP and M groups. Morphine consumption at 2, 6, and 24 hours was lower in the MDP and MD groups compared with the MP and M groups (P <.05). The morphine-sparing effect was higher in groups MDP and MD compared with group MP (57% and 46%, respectively, v 8.2%, P <.05). The incidence of side effects was similar in all groups. However, the power of the study was too low to permit an evaluation of potential side effects. CONCLUSION: Diclofenac after cesarean delivery improves analgesia and has a highly significant morphine-sparing effect. We were unable to demonstrate significant morphine-sparing effect of propacetamol or additive effect of propacetamol and diclofenac in this group of patients. Reg Anesth Pain Med 2001;26:310-315.
PMID: 11464348, UI: 21357117
Reg Anesth Pain Med 2001 Jul-Aug;26(4):298-300
Department of Anesthesia, Sunnybrook and Women's College Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada.
PMID: 11464345, UI: 21357114
Rheum Dis Clin North Am 2001 Feb;27(1):187-96
Department of Medicine, University of California Los Angeles, USA. stuarts@OMCresearch.org
Calcitonin reduces the risk of vertebral fracture in postmenopausal women with osteoporosis. Calcitonin produces small increments in the bone mass of the spine and modestly reduces bone turnover in women with osteoporosis. No significant effect on nonvertebral fractures has been observed. Calcitonin may have analgesic benefit.
PMID: 11285994, UI: 21181158
Spine 2001 Jul 15;26(14):1631-8
Department of Orthopaedics, Cleveland Clinic Foundation, Cleveland, Ohio.
STUDY DESIGN: An Institutional Review Board-approved Phase I efficacy study of inflatable bone tamp usage in the treatment of symptomatic osteoporotic compression fractures. OBJECTIVES: To evaluate the safety and efficacy of inflatable bone tamp reduction and cement augmentation, "kyphoplasty," in the treatment of painful osteoporotic vertebral compression fractures. SUMMARY OF BACKGROUND DATA: Osteoporotic compression fractures can result in progressive kyphosis and chronic pain. Traditional treatment for these patients includes bed rest, analgesics, and bracing. Augmentation of vertebral compression fractures with polymethylmethacrylate, "vertebroplasty," has been used to treat pain. This technique, however, makes no attempt to restore the height of the collapsed vertebral body. Kyphoplasty is a new technique that involves the introduction of inflatable bone tamps into the vertebral body. Once inflated, the bone tamps restore the vertebral body back toward its original height while creating a cavity that can be filled with bone cement. PATIENTS AND METHODS: Seventy consecutive kyphoplasty procedures were performed in 30 patients. The indications included painful primary or secondary osteoporotic vertebral compression fractures. Mean duration of symptoms was 5.9 months. Symptomatic levels were identified by correlating the clinical data with MRI findings. Perioperative variables and bone tamp complications or issues were recorded and analyzed. Preoperative and postoperative radiographs were compared to calculate the percentage height restored. Outcome data were obtained by comparing preoperative and latest postoperative SF-36 data. RESULTS: At the completion of the Phase I study there were no major complications related directly to use of this technique or use of the inflatable bone tamp. In 70% of the vertebral bodies kyphoplasty restored 47% of the lost height. Cement leakage occurred at six levels (8.6%).SF-36 scores for Bodily Pain 11.6-58.7, (P = 0.0001) and Physical Function 11.7-47.4, (P = 0.002) were among those that showed significant improvement. CONCLUSIONS: The inflatable bone tamp was efficacious in the treatment of osteoporotic vertebral compression fractures. Kyphoplasty is associated with early clinical improvement of pain and function as well as restoration of vertebral body height in the treatment of painful osteoporotic compression fractures.
PMID: 11464159, UI: 21357264
Spine 2001 Jul 15;26(14):1511-5
University of California, San Diego, California, SUNY Health Centers, Syracuse, New York, and Berkeley Orthopaedic Medical Group, Inc., Berkeley, California.
STUDY DESIGN: LITERATURE REVIEW: OBJECTIVES: To describe new treatments for painful osteoporotic compression fractures in light of available scientific literature and clinical experience. SUMMARY OF BACKGROUND DATA: Painful vertebral osteoporotic compression fractures lead to significant morbidity and mortality. This relates to pulmonary dysfunction, eating disorders (nutritional deficits), pain, loss of independence, and mental status change (related to pain and medications). Medications to treat osteoporosis (primarily antiresorptive) do not effectively treat the pain or the fracture, and require over 1 year to reduce the degree of osteoporosis. Kyphoplasty and vertebroplasty are new techniques that help decrease the pain and improve function in fractured vertebrae. METHODS: This is a descriptive review of the background leading to vertebroplasty and kyphoplasty, a description of the techniques, a review of the literature, as well as current ongoing studies evaluating kyphoplasty. RESULTS: Both techniques have had a very high acceptance and use rate. There is 95% improvement in pain and significant improvement in function following treatment by either of these percutaneous techniques. Kyphoplasty improves height of the fractured vertebra, and improves kyphosis by over 50%, if performed within 3 months from the onset of the fracture (onset of pain). There is some height improvement, though not as marked, along with 95% clinical improvement, if the procedure is performed after 3 months. Complications occur with both and relate to cement leakage in both, and cement emboli with vertebroplasty. CONCLUSION: Kyphoplasty and vertebroplasty are safe and effective, and have a useful role in the treatment of painful osteoporotic vertebral compression fractures that do not respond to conventional treatments. Kyphoplasty offers the additional advantage of realigning the spinal column and regaining height of the fractured vertebra, which may help decrease the pulmonary, GI, and early morbidity consequences related to these fractures. Both procedures are technically demanding.
PMID: 11462078, UI: 21355255
Spine 2001 Apr 15;26(8):994-6
PMID: 11317128, UI: 21216962
Spine 2001 Apr 15;26(8):870-5
Department of Anesthesiology and Pathology (Neuropathology), VA Medical Center and the University of California at San Diego, La Jolla, California, USA.
STUDY DESIGN: An experimental study to clarify the effects of pentoxifylline, as an anti-tumor necrosis factor-alpha therapy on endoneurial fluid pressure in the dorsal root ganglion using an animal model of herniated nucleus pulposus. OBJECTIVES: To investigate the effects of anti-tumor necrosis factor-alpha therapy to nucleus pulposus-induced nerve root/dorsal root ganglion changes. SUMMARY OF BACKGROUND DATA: It has been reported experimentally that application of nucleus pulposus into epidural space induces morphologic and functional changes in the nerve roots and induces compartment syndrome in the dorsal root ganglia. Tumor necrosis factor-alpha has been considered a key pathogenic factor in the initiation and maintenance of neuropathic pain states. METHODS: A total of 11 adult, female Sprague-Dawley rats had their left L5 nerve roots and associated dorsal root ganglions exposed. Autologous nucleus pulposus was applied to the L5 nerve root just proximal to the dorsal root ganglion. A piece of Spongel (Yamanouchi Pharmaceutical Co., Tokyo) containing 20 microL of 1000 microg/mL pentoxifylline was applied with the nucleus pulposus (NP+PTX group). In control animals nucleus pulposus was applied with a piece of Spongel containing 20 microL of physiologic saline solution in a similar fashion (NP+PS group). Endoneurial fluid pressure was recorded with a servo-null micropipette system using glass micropipettes with tip diameters of 4 microm. Endoneurial fluid pressure in the dorsal root ganglion was measured before and 3 hours after application of test substances. After measurement of endoneurial fluid pressure, the nerve root and dorsal root ganglion were processed for histology and evaluated by light microscope. RESULTS: Values of endoneurial fluid pressure before application of test substances were as follows: 2.4 +/- 1.2 cm H2O in the NP+PS (control) group and 1.8 +/- 0.4 cm H2O in the NP+PTX group. There was no statistically significant difference between these two pretreatment measurements. However, values of endoneurial fluid pressure after application were as follows: 8.6 +/- 1.8 cm H2O in the NP+PS group and 2.9 +/- 0.8 cm H2O in the NP+PTX group. Values of endoneurial fluid pressure in the NP+PTX group were significantly lower compared with the NP+PS group. Histologic examination consistently showed only a slight degree of edema evident in the NP+PTX group compared with the NP+PS group. CONCLUSION: Pentoxifylline, an anti-tumor necrosis factor-alpha drug, prevented the dorsal root ganglion compartment syndrome caused by topical application of nucleus pulposus. Anti-inflammatory cytokine therapy may become an effective treatment of sciatica due to disc herniation.
PMID: 11317107, UI: 21216941
Spine 2001 Apr 15;26(8):863-9
Department of Orthopaedics, Goteborg University, Gothenburg, Sweden.
STUDY DESIGN: The possibility to prevent nucleus pulposus-induced functional and structural nerve root injury by selective tumor necrosis factor-alpha inhibition was assessed in an experimental model in the pig spine. OBJECTIVE: The objective of the study was to evaluate the role of tumor necrosis factor-alpha in the mediation of nucleus pulposus-induced nerve injury by using selective inhibition. SUMMARY OF BACKGROUND DATA: The cytokine tumor necrosis factor-alpha has been suggested to play a key role in the nerve root injury induced by local application of nucleus pulposus. However, previous studies have not been able to distinguish the effects between tumor necrosis factor-alpha and other disc-related cytokines because of the use of nonspecific cytokine inhibition. METHODS: Autologous nucleus pulposus was harvested from a lumbar disc and applied to the porcine sacrococcygeal cauda equina. The pigs were simultaneously treated with two selective tumor necrosis factor-alpha inhibitors (etanercept n = 8 and infliximab n = 5), a heparin analogue (enoxaparin n = 5) or saline for control (n = 5). After 7 days the nerve conduction velocity over the application zone was determined and samples of the exposed nerve roots were collected for light microscopic evaluation. RESULTS: The two tumor necrosis factor-alpha inhibitors prevented the reduction of nerve conduction velocity and also seemed to limit the nerve fiber injury, the intracapillary thrombus formation, and the intraneural edema formation. However, treatment with enoxaparin did not seem to be different from control regarding reduction of nerve conduction velocity or histologic changes. CONCLUSIONS: The data clearly indicate that tumor necrosis factor-alpha is involved in the basic pathophysiologic events leading to nerve root structural and functional changes after local application of nucleus pulposus. The study therefore provides a basic scientific platform with potential clinical implications regarding the use of anti-tumor necrosis factor-alpha medication as treatment in patients with disc herniation and sciatica.
PMID: 11317106, UI: 21216940
Spine 2001 Apr 15;26(8):857-61
McGill University, School of Physical and Occupational Therapy, Montreal, Quebec, Canada. swoodd@po-box.mcgill.ca
It is always gratifying to be acknowledged by a colleague and asked to give a talk in a faraway land about a topic of one's particular interest. To be invited, however, to give the Harry Farfan Presidential Lecture at the 27th Meeting of the International Society for the Study of the Lumbar Spine is, for me, a special honor and privilege. Too many years ago, when I was a very junior faculty member at the School of Physical and Occupational Therapy at McGill University in Montreal, Canada, we offered our students a course in Orthopedic Conditions. This course was primarily taught by orthopedic surgeons, rheumatologists, and other members of the medical profession with special interest in disorders of the musculoskeletal system. Teaching in this course was considered to be a professional obligation at McGill, and, while most individuals accepted the invitation, they did so with varying degrees of enthusiasm. Each year, Dr. Harry Farfan graciously agreed and provided several lectures for our students. He told them about the surgical management of problems of the lumbar spine and the necessity of treating the "whole" patient, as well as about his theory as to the cause of low back pain. At that point in time, we were not talking about quality of life as an outcome of care for our patients, but I cannot help but believe that he would keenly approve of the subject of this presentation.
PMID: 11317104, UI: 21216938
Spine 2001 Apr 15;26(8):851-6
Department of Orthopaedic Surgery, School of Medicine, New York University, New York 10014, USA. margareta.nordin@nyu.edu
PMID: 11317103, UI: 21216937
Spine 2001 Apr 1;26(7):E163-4
PMID: 11295918, UI: 21192757
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