No Difference between Spinal Anesthesia with Hyperbaric Ropivacaine and Intravenous Dexmedetomidine Sedation with and without Intrathecal Fentanyl: A Randomized Noninferiority Trial

To enhance the duration of single-shot spinal anesthesia, intrathecal fentanyl and intravenous dexmedetomidine are widely used as adjuvants to local anesthetics. This noninferiority trial evaluated whether hyperbaric ropivacaine alone can produce a noninferior duration of sensory block in comparison to hyperbaric ropivacaine with intrathecal fentanyl in patients under dexmedetomidine sedation. Methods. Fifty patients scheduled for elective lower limb surgery under spinal anesthesia were randomly assigned in a double-blind fashion to receive either hyperbaric ropivacaine 15 mg (Group R) or hyperbaric ropivacaine 15 mg with intrathecal fentanyl 20 μg (Group RF). Intravenous dexmedetomidine (1 μg/kg for 10 min, followed by 0.5 μg/kg/h) was administered in both groups. The primary outcome of this study was the time to two-dermatomal regression of sensory block. The noninferiority margin for the mean difference was −10 min. Characteristics of the block, intraoperative and postoperative side effects, postoperative pain score, and analgesic consumption were assessed as secondary outcomes. Results. There was no difference in the two-dermatomal regressions of sensory block between the two groups (Group R 70.4 ± 10.2 min, Group RF 71.2 ± 12.4 min, p = 0.804) with a mean difference of 0.8 min (−7.2 to 5.6, 95% confidence interval). Thus, the noninferiority of hyperbaric ropivacaine alone was established. There were no significant differences in the secondary outcomes between the two groups. Conclusions. Under intravenous dexmedetomidine sedation, the duration of spinal anesthesia with hyperbaric ropivacaine alone was noninferior to that of hyperbaric ropivacaine with intrathecal fentanyl. This suggests that addition of intrathecal fentanyl to hyperbaric ropivacaine may not be necessary in patients receiving intravenous dexmedetomidine.

Changes in Paraspinal Muscles and Facet Joints after Minimally Invasive Posterior Lumbar Interbody Fusion Using the Cortical Bone Trajectory Technique: A Prospective Study

In this prospective cohort study, we aimed to determine the surgical and adjacent segment changes in paraspinal muscles and facet joints in patients with lumbar spinal stenosis after minimally invasive posterior lumbar interbody fusion (PLIF) using the cortical bone trajectory (CBT) technique. We enrolled 30 consecutive patients who underwent the single-level CBT technique between October 2017 and October 2018. We evaluated preoperative and 1-month, 3-month, 6-month, and 1-year postoperative clinical data including Visual Analogue Scale (VAS) scores and Oswestry Disability Index (ODI). Magnetic resonance imaging (MRI) was performed a year after surgery. The erector spinae (ES) muscle area, volume, and fat infiltration (FI) on the surgical and adjacent segments were evaluated using the thresholding method, and the degree of adjacent facet joint degeneration was calculated using the Weishaupt scale. FI rate was graded using the Kjaer method. All patients underwent a 12-month follow-up. The VAS and ODI scores significantly improved after surgery in all patients. No patient showed degeneration of the adjacent facet joints ( P > 0.05 ) during the 1-year follow-up postoperation. There was no significant difference in ES muscle volume, area, and FI on the surgical and adjacent segments ( P > 0.05 ). The FI rate of the upper ES muscles increased postoperatively ( P < 0.05 ); however, there were no significant changes in FI rate of the lower ES muscles. Patients with lumbar spinal stenosis could obtain satisfactory short-term clinical outcomes via minimally invasive PLIF using the CBT technique. Moreover, this technique may reduce the impact on the paravertebral muscles, especially the ES muscle, and the adjacent facet joints.

Automatic Coding of Facial Expressions of Pain: Are We There Yet?

Introduction. The experience of pain is regularly accompanied by facial expressions. The gold standard for analyzing these facial expressions is the Facial Action Coding System (FACS), which provides so-called action units (AUs) as parametrical indicators of facial muscular activity. Particular combinations of AUs have appeared to be pain-indicative. The manual coding of AUs is, however, too time- and labor-intensive in clinical practice. New developments in automatic facial expression analysis have promised to enable automatic detection of AUs, which might be used for pain detection. Objective. Our aim is to compare manual with automatic AU coding of facial expressions of pain. Methods. FaceReader7 was used for automatic AU detection. We compared the performance of FaceReader7 using videos of 40 participants (20 younger with a mean age of 25.7 years and 20 older with a mean age of 52.1 years) undergoing experimentally induced heat pain to manually coded AUs as gold standard labeling. Percentages of correctly and falsely classified AUs were calculated, and we computed as indicators of congruency, “sensitivity/recall,” “precision,” and “overall agreement (F1).” Results. The automatic coding of AUs only showed poor to moderate outcomes regarding sensitivity/recall, precision, and F1. The congruency was better for younger compared to older faces and was better for pain-indicative AUs compared to other AUs. Conclusion. At the moment, automatic analyses of genuine facial expressions of pain may qualify at best as semiautomatic systems, which require further validation by human observers before they can be used to validly assess facial expressions of pain.

The Effect of Improving Preoperative Sleep Quality on Perioperative Pain by Zolpidem in Patients Undergoing Laparoscopic Colorectal Surgery: A Prospective, Randomized Study

Background and Objectives. Opioids are essential in pain management after laparoscopic colorectal surgery while large dose may induce constipation and pneumonia. Ample evidence has demonstrated that postoperative analgesia can improve sleep quality. But the effects of improvement in sleep quality on postoperative pain have yet to be determined. The aim of this study was to investigate the effect of improving preoperative sleep quality by zolpidem on intraoperative analgesia and postoperative pain. Methods. A prospective, randomized study was conducted with 88 patients undergoing laparoscopic colorectal surgery. The experimental group (S group, n = 44) was given 10 mg of zolpidem tartrate one night before the surgical procedure, while no medication was given to the control group (C group, n = 44). The primary outcome was the intraoperative remifentanil consumption. Sufentanil consumption, average patient-controlled analgesia (PCA) effective press times, the visual analog scale (VAS) scores, and incidences of postoperative nausea and vomiting (PONV) were recorded at 6 h (T1), 12 h (T2), and 24 h (T3) postoperatively. Results. The intraoperative remifentanil consumption was significantly lower in the S group than that in the C group ( p < 0.01 ). Sufentanil consumption at 6 h and 12 h postoperatively was significantly lower in the S group than that in the C group ( p < 0.05 ); average PCA effective press times and VAS scores, at 6 h and 12 h postoperatively, were significantly lower in the S group than those in the C group ( p < 0.01 ); differences between groups 24 h postoperatively were not significant. No significant between-group difference was noted in the incidence of nausea and vomiting. Conclusion. Improving patients’ sleep quality the night before surgical procedure by zolpidem can decrease the usage of intraoperative analgesics and reduce postoperative pain.

Dry Needling and Antithrombotic Drugs

Many clinicians increasingly use dry needling in clinical practice. However, whether patients’ intake of antithrombotic drugs should be considered as a contraindication for dry needling has not been investigated to date. As far as we know, there are no publications in analyzing the intake of antiplatelet or anticoagulant agents in the context of dry needling techniques. A thorough analysis of existing medications and how they may impact various needling approaches may contribute to improved evidence-informed clinical practice. The primary purpose of this paper is to review the current knowledge of antithrombotic therapy in the context of dry needling. In addition, reviewing guidelines of other needling approaches, such as electromyography, acupuncture, botulinum toxin infiltration, and neck ultrasound-guided fine-needle aspiration biopsy, may provide specific insights relevant for dry needling. Based on published data, taking antithrombotic medication should not be considered an absolute contraindication for dry needling techniques. As long as specific dry needling and individual risks are properly considered, it does not change the risk and safety profile of dry needling. Under specific circumstances, the use of ultrasound guidance is recommended when available.

Caffeine Consumption Influences Lidocaine Action via Pain-Related Voltage-Gated Sodium Channels: An In Vivo Animal Study

Several factors might influence the duration and efficiency of local anesthesia. This study investigates the effect of habitual caffeine intake on lidocaine action and explores the potential involvement of voltage-gated sodium channels in the interaction effect. Wistar rats were divided into four groups: (i) control (Ctrl), (ii) lidocaine intraplantar injection (LIDO), (iii) habitual caffeine intake (CAF), and (iv) lidocaine intraplantar injection and habitual caffeine intake (LIDO + CAF). Behavioral assessments, consisting of a paw pressure test for mechanical pressure sensation and a paw withdrawal latency test for thermal pain sensation, were performed at 0, 30, 60, and 90 minutes following lidocaine injection and after 10, 11, and 12 weeks of CAF intake. Pressure sensation was significantly reduced in the LIDO + CAF group compared with the control group. Moreover, the LIDO + CAF group exhibited reduced sensation compared to LIDO alone group. The LIDO + CAF combination exerted a synergistic effect at 30 and 60 minutes compared with the control. This synergistic effect was noted at 60 minutes (11 weeks of CAF intake) and at 30 minutes (12 weeks of CAF intake) compared with LIDO alone. Augmented thermal pain-relieving effects were observed in the LIDO + CAF group at all weeks compared to the control group and at 10 weeks compared to LIDO alone group. The molecular analysis of dorsal root ganglia suggested that CAF upregulated the mRNA expression of the Nav1.3, Nav1.7, and Nav1.8 sodium channel subtypes. Chronic caffeine consumption potentiates the local anesthetic action of lidocaine in an experimental animal model through mechanisms that involve the upregulation of voltage-gated sodium channels in the dorsal root ganglia.

Effect of Discectomy on Dynesys Dynamic Fixation in the Treatment of Lumbar Degenerative Diseases

Objective. To compare the effect of decompression of the spinal canal with or without discectomy on the clinical efficacy of Dynesys dynamic fixation treatment in lumbar degenerative diseases. Methods. A total of 62 patients treated for single-segment lumbar degenerative disease from October 2010 to November 2017 were retrospectively analyzed. All patients underwent decompression of the spinal canal with Dynesys dynamic fixation and were divided into two groups. Twenty-seven patients in group A did not undergo discectomy, and 35 patients in group B underwent discectomy. The intervertebral height, range of motion, Pfirrmann grade of the surgical segment and the upper adjacent segment, function scores, and operation information were compared. Results. All patients were followed up for an average of 30.7 ± 11.5 months. At the final follow-up, the intervertebral height and range of motion of the surgical segment decreased significantly in both group A and B ( p < 0.05 ), the range of motion of the upper adjacent segment increased significantly ( p < 0.05 ), and the intervertebral height did not change significantly ( p < 0.05 ). The retained percentages of surgical segment intervertebral height and ROM in group A were significantly better than those in group B ( p < 0.05 ). The intervertebral height ( p > 0.05 ) and range of motion ( p < 0.05 ) of the surgical segment in group A were higher than those in group B. The surgical segment Pfirrmann grading of group A was better than that of group B ( p < 0.05 ). Conclusion. Dynesys in the treatment of lumbar degenerative diseases may lead to a good clinical effect. In selected cases without discectomy, the range of motion and intervertebral height may be better preserved, and disc degeneration may be reduced.

Posterior Dynamic Stabilization with Limited Rediscectomy for Recurrent Lumbar Disc Herniation

Objective. Recurrent lumbar disc herniation (RLDH) is the most common cause of sciatica after primary discectomy. The purpose of this study was to evaluate the efficacy of transpedicular dynamic stabilization (TDS) combined with limited rediscectomy in the treatment of single-level RLDH. Methods. We retrospectively evaluated a consecutive series of 24 middle-aged patients who underwent TDS (Dynesys system) combined with limited rediscectomy (i.e., removing only extruded or loose disc fragments) for single-level Carragee type II and type IV RLDH between April 2012 and September 2017. Clinical results were evaluated with visual analog scale (VAS) for leg and low back pain, Oswestry Disability Index (ODI) scores, and complications. Imaging data include lumbar segment motion and intervertebral height. Results. The mean follow-up period was 38 months. The VAS and ODI scores were significantly improved at the last follow-up. The average range of motion (ROM) at the stabilized segment was 6.4° before surgery and 4.2° at the last follow-up, with a 78.6% mean preservation ( P < 0.05). Intervertebral height at the stabilized segment decreased slightly after surgery ( P < 0.05). However, there was no further decline at the last follow-up. There were no cases of reherniation, screw loosening, or segmental instability. Conclusions. TDS combined with limited rediscectomy resulted in an effective procedure in middle-aged patients with Carragee type II and type IV RLDH. It was able to stabilize the operated segment with partial motion preservation. Moreover, it could maintain disc height and decrease the risk of recurrence in patients with a large posterior annular defect.

Usefulness of the Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP) for Predicting Poor Outcomes in Patients Undergoing Lumbar Decompression Surgery

Background. The Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP) is an original questionnaire that evaluates psychosocial problems in orthopaedic patients. The purpose of this study was to clarify the relationship between BS-POP scores and surgical outcomes in patients with lumbar spinal stenosis (LSS). Methods. From our database, a total of 157 patients with LSS who had undergone decompression surgery and completed a 1-year follow-up were retrospectively observed. The primary outcome was the numerical rating scale (NRS) score for satisfaction with surgery (from 0: not satisfied to 10: completely satisfied). Patients with an NRS score ≥8 were classified into the satisfied group. The secondary outcomes were NRS scores for low back pain, leg pain, and leg numbness and scores on the Roland–Morris Disability Questionnaire (RDQ). BS-POP was used to detect psychiatric problems before surgery. A BS-POP score ≥11 on the physician version or a combination of 10 on the physician version and ≥15 on the patient version was considered to indicate the presence of psychiatric problems. The patients were classified into two groups and compared based on preoperative BS-POP scores at the 1-year follow-up. Results. Preoperatively, 22 and 135 patients showed high and low BS-POP scores, respectively. No significant differences in preoperative symptoms were found between the two groups. At 1 year after surgery, patients with high BS-POP scores showed significantly lower satisfaction with surgery, higher NRS scores for low back pain, leg pain, and leg numbness, and lower RDQ deviation scores than did the low BS-POP group ( p < 0.05 ). The results of the multivariable analysis indicated that preoperative high BS-POP scores were independently associated with low satisfaction with surgery (odds ratio: 5.2, 95% confidence interval: 1.9–15.1). Conclusion. High preoperative BS-POP scores were associated with poor outcomes for decompression surgery in patients with LSS at 1 year after surgery. These results suggest that BS-POP is a useful tool for predicting surgical outcomes in patients with LSS.

Accuracy of Robot-Assisted Percutaneous Pedicle Screw Placement under Regional Anesthesia: A Retrospective Cohort Study

Background. Robot-assisted pedicle screw placement is usually performed under general anesthesia to keep the body still. The aim of this study was to compare the accuracy of the robot-assisted technique under regional anesthesia with that of conventional fluoroscopy-guided percutaneous pedicle screw placement under general anesthesia in minimally invasive lumbar fusion surgery. Methods. This study recruited patients who underwent robot-assisted percutaneous endoscopic lumbar interbody fusion (PELIF) or fluoroscopy-guided minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) between December 2017 and February 2020 at a single center. Based on the method of percutaneous pedicle screw placement used, patients were divided into the robot-assisted under regional anesthesia (group RE-RO) and fluoroscopy-guided under general anesthesia (group GE-FLU) groups. The primary outcome measures were screw accuracy and the incidence of facet joint violation (FJV). Secondary outcome measures included X-ray and visual analogue scale (VAS) scores which were used to evaluate the degree of the postoperative pain at 4 hours and on postoperative days 1, 2, and 3. Intraoperative adverse events were also recorded. Results. Eighteen patients were included in group RE-RO, and 23 patients were included in group GE-FLU. The percentages of clinically acceptable screws (Gertzbein and Robbins grades A and B) were 94.4% and 91.5%, respectively. There was no significant difference in the percentages of clinically acceptable screws ( p = 0.44 ) or overall Gertzbein and Robbins screw accuracy grades ( p = 0.35 ). Only the top screws were included in the analysis of FJVs. The percentages of FJV (Babu grades 1, 2, and 3) were 5.6% and 28.3%, respectively. This difference was statistically significant ( p = 0.01 ). Overall, the FJV grades in group RE-RO were significantly better than those in group GE-FLU ( p = 0.009 ). The mean fluoroscopy time for each screw in group RE-RO was significantly shorter than that in group GE-FLU (group RE-RO: 5.4 ± 1.9 seconds and group GE-FLU: 6.8 ± 2.0 seconds; p = 0.03 ). The postoperative pain between the RE-RO and GE-FLU groups was not statistically significant. The intraoperative adverse events included 1 case of registration failure and 1 case of guide-wire dislodgment in group RE-RO, as well as 2 cases of screw misplacement in group GE-FLU. No complications related to anesthesia were observed. Conclusion. Robot-assisted pedicle screw placement under regional anesthesia can be performed effectively and safely. The accuracy is comparable to the conventional technique. Moreover, this technique has the advantage of fewer FJVs and a lower radiation time.