Ankle block in forefoot reconstruction before or after inflation of tourniquet—Does timing matter?

BackgroundForefoot surgery causes postoperative pain frequently requiring strong painkillers. Regional blocks are now increasingly used in order to control postoperative pain especially in the first 24 h when the pain is at its worst. We conducted a prospective study to see if timing of ankle block i.e. before or after inflation of tourniquet showed any difference in efficacy in postoperative pain control in first 24 h.MethodsA prospective randomised study was conducted between September 2010 and August 2011 involving 60 patients. Group A (n = 30) had the ankle block administered after and Group B (n = 30) had a block before inflation of a thigh tourniquet. Patients were given assessment forms to chart their pain on visual analogue scale (VAS) score at 4 h and 24 h postoperatively.ResultsBoth groups demonstrated good postoperative pain control. Average VAS pain score at four and twenty fours after surgery was 2.5 and 4.5 in Group A and 3.9 and 6.3 in Group B respectively. Pain control, both at 4 and 24 h surgery was better in Group A but this was statistically significant only at 24 h.ConclusionsA regional anaesthetic ankle block should be routinely used in forefoot surgery to control postoperative pain. The ankle block should be applied after the inflation of tourniquet as this appears to provide better pain control.     

Femoral nerve block in a representative sample of elderly people with hip fracture: A randomised controlled trial

IntroductionThe number of elderly people with hip fracture and dementia is increasing, and many of these patients suffer from pain. Opioids are difficult to adjust and side effects are common, especially with increased age and among patients with dementia. Preoperative femoral nerve block is an alternative pain treatment.AimTo investigate whether preoperative femoral nerve block reduced acute pain and opioid use after hip fracture among elderly patients, including those with dementia.Patients and methodsIn this randomised controlled trial involving patients aged ≥70 years with hip fracture (trochanteric and cervical), including those with dementia, we compared femoral nerve block with conventional pain management, with opioid use if required. The primary outcome was preoperative pain, measured at five timepoints using a visual analogue scale (VAS). Preoperative opioid consumption was also registered.ResultsThe study sample comprised 266 patients admitted consecutively to the Orthopaedic Ward. The mean age was 84.1 (±6.9) years, 64% of participants were women, 44% lived in residential care facilities, and 120 (45.1%) had dementia diagnoses. Patients receiving femoral nerve block had significantly lower self-rated pain scores from baseline to 12 h after admission than did controls. Self-rated and proxy VAS pain scores decreased significantly in these patients from baseline to 12 h compared with controls (p < 0.001 and p = 0.003, respectively). Patients receiving femoral nerve block required less opioids than did controls, overall (2.3 ± 4.0 vs. 5.7 ± 5.2 mg, p < 0.001) and in the subgroup with dementia (2.1 ± 3.3 vs. 5.8 ± 5.0 mg, p < 0.001).ConclusionPatients with hip fracture, including those with dementia, who received femoral nerve block had lower pain scores and required less opioids before surgery compared with those receiving conventional pain management. Femoral nerve block seems to be a feasible pain treatment for elderly people, including those with dementia.     

Efficacy of tibial nerve block,local steroid injection or both in the treatment of Plantar Heel Pain Syndrome

BackgroundPlantar Heel Pain Syndrome (PHPS) describes centralised plantar heel pain and tenderness. It can account for up to 15% of referrals to clinicians involved in the treatment of foot pain.ObjectiveTo compare tibial nerve block, local infiltration with steroid or both combined in the treatment of PHPS.MethodsPatients with PHPS were randomly assigned to three treatment groups: Group 1—steroid injection to heel; Group 2—local anaesthetic block to tibial nerve; Group 3—both procedures. Pain visual analogue scale (VAS) was measured at baseline and after 1, 6 and 26 weeks. Heel tenderness index (HTI) was measured at baseline and after 6 weeks. The patient rated their discomfort from the injection(s) using a VAS.ResultsForty-five patients (27 female) were recruited, 14 in Group 1, 12 in Group 2 and 19 in Group 3. Median age was 55, disease duration was 10 months and baseline pain VAS was 7.0 cm. All groups experienced a sustained improvement in pain VAS between baseline and weeks 1, 6 and 26 (all p < 0.0001). Group 1 reported significantly lower pain VAS that those in Group 2 (p < 0.01) or Group 3 (p < 0.05) at week 6. Group 2 found the procedure less uncomfortable than Group 1 (p < 0.01). The HTI was significantly higher in Group 2 at 6 weeks compared to Group 1 (p < 0.005) and Group 3 (p < 0.05).ConclusionsThis study suggests that the natural history of PHPS following an injection is encouraging, that a tibial nerve block reduces the discomfort of the procedure, that a steroid injection to the heel may accelerate improvement and that clinicians should consider a combination of both strategies.     

Dexametasona perineural em bloqueio de plexo braquial interescalênico com levobupivacaína guiado por ultrassonografia para artroscopia de ombro em regime ambulatorial: ensaio clínico controlado e randomizado

Background and objectivesIn shoulder arthroscopy, on an outpatient basis, the patient needs a good control of the postoperative pain that can be achieved through regional blocks. Perineural dexamethasone may prolong the effect of these blocks. The aim of this study was to evaluate the effect of perineural dexamethasone on the prolongation of the sensory block in the postoperative period for arthroscopic shoulder surgery in outpatient setting.MethodsAfter approval by the Research Ethics Committee and informed consent, patients undergoing arthroscopic shoulder surgery under general anesthesia and ultrasound‐guided interscalene brachial plexus block were randomized into Group D – blockade performed with 30 mL of 0.5% levobupivacaine with vasoconstrictor and 6 mg (1.5 mL) of dexamethasone and Group C – 30 mL of 0.5% levobupivacaine with vasoconstrictor and 1.5 mL of 0.9% saline. The duration of the sensory block was evaluated in 4 postoperative moments (0, 4, 12 and 24 hours) as well as the need for rescue analgesia, nausea and vomiting incidence, and Visual Analog Pain Scale (VAS).ResultsSeventy‐four patients were recruited and 71 completed the study (Group C, n = 37; Group D, n = 34). Our findings showed a prolongation of the mean time of the sensitive blockade in Group D (1440 ± 0 min vs. 1267 ± 164 min, p < 0.001). It was observed that Group C had a higher mean pain score according to VAS (2.08 ± 1.72 vs. 0.02 ± 0.17, p < 0.001) and a greater number of patients (68.4% vs. 0%, p < 0.001) required rescue analgesia in the first 24 hours. The incidence of postoperative nausea and vomiting was not statistically significant.ConclusionPerineural dexamethasone significantly prolonged the sensory blockade promoted by levobupivacaine in interscalene brachial plexus block, reduced pain intensity and rescue analgesia needs in the postoperative period.     

Eficácia do bloqueio do plano do músculo eretor da espinha guiado por ultrassom para analgesia após colecistectomia laparoscópica: um estudo controlado randômico

Background and objectivesThe primary aim of this study is to assess the effect of ultrasoung‐guided erector spinae block on postoperative opioid consumption after laparoscopic cholecystectomy. The secondary aims are to assess the effects of erector spinae plane block on intraoperative fentanyl need and postoperative pain scores.MethodsPatients between 18‐70 years old, ASA I‐II were included in the study and randomly allocated into two groups. In Group ESP, patients received bilateral US‐ESP with 40 ml of 0.25% bupivacaine at the level of T7, while in Group Control, they received bilateral US‐ESP with 40 ml of saline before the induction of anesthesia. Then a standard general anesthesia procedure was conducted in both groups. NRS scores at the postoperative 15th, 30th, 60th minutes, 12th and 24th hours, intraoperative fentanyl need and total postoperative tramadol consumption were recorded.ResultsThere were 21 patients in Group ESP and 20 patients in Group Control. Mean postoperative tramadol consumption was 100 ± 19.2 mg in Group ESP, while it was 143 ± 18.6 mg in Group Control (p < 0.001). The mean intraoperative fentanyl need was significantly lower in Group ESP (p = 0.022). NRS scores at the postoperative 15th, 30th min, 12th hour and 24th hour were significantly lower in ESP group (p < 0.05). According to repeated measures analysis, NRS score variation over time was significantly varied between two groups (F[1,39] = 24.061, p < 0.0005).ConclusionsBilateral US‐ESP block provided significant reduction in postoperative opioid consumption, intraoperative fentanyl need and postoperative pain scores of patients undergoing laparoscopic cholecystectomy.     

Lidocaine-tramadol versus lidocaine-dexmedetomidine for intravenous regional anesthesia

BackgroundIntravenous regional anesthesia (IVRA) has been used for more than a century. Both tramadol (synthetic opioid) and dexmedetomidine (α₂-agonist) can act locally.Aim of the workTo compare effects of adding tramadol versus dexmedetomidine to lidocaine during IVRA.Patients and methodsSixty patients were randomly assigned into: Group C (n = 20), Group T (n = 20), and Group D (n = 20). All patients received 3 mg/kg 0.5% lidocaine [+100 mg tramadol in Group T, or 1 μg/kg dexmedetomidine in Group D]. Times of onset and offset of sensory and motor blocks, and time to tourniquet pain were recorded. Postoperative VAS score, time to first dose, and total amounts of supplementary analgesia (Paracetamol) were recorded. Sedation was evaluated using Ramsay sedation scale (RSS).ResultsSignificantly shorter onset times and longer recovery times of sensory and motor block were recorded in Groups T and D compared to Group C (P < 0.05); while, with no significant differences between Groups T and D. Delayed onset of tourniquet pain occurred in Groups T and D compared to Group C (P < 0.05) with no significant differences between Groups T and D. Fourteen patients required fentanyl to control tourniquet pain in Group C compared to (5 and 4) in Groups T and D respectively. Significantly lower Postoperative VAS score, longer time to first dose and lower consumption of Paracetamol were recorded in Groups T and D than in Group C; with no significant differences between Groups T and D. Complications were skin rash in 30% of patients in Group T, bradycardia and sedation in 35% and 65% of patients in Group D respectively.ConclusionAddition of either tramadol or dexmedetomidine enhances lidocaine during IVRA with higher incidence of skin rash with tramadol and postoperative bradycardia and sedation with dexmedetomidine.     

Antibiotics for elevated prostate specific antigen: Where do we stand?

ObjectiveThe empiric use of antibiotics for elevated prostate specific antigen (PSA) is practiced by many urologists worldwide. This study aims to investigate the effect of antibiotics on the degree of PSA change, linking it with histopathology results.Materials and MethodsThis is a prospective randomized study. Patients presenting with a high PSA were randomized into two groups. Group 1 received antibiotics for a period of 4 weeks, while Group 2 did not receive any antibiotics. Both groups had repeated samples of PSA measured 6 weeks from their initial presentation. All patients underwent transrectal ultrasound-guided biopsy of the prostate. Results of PSA measurements and the degree of change were correlated with results of histopathology.ResultsEighty-four patients completed the study. Their mean age ± standard deviation was 66.8 ± 6.9 years. Group 1 included 44 patients, while Group 2 included 42 patients. Prostate cancer (PCa) was detected in 50% and 35.7% of Group 1 and Group 2 patients, respectively (p = 0.52). No statistically significant difference in the mean change in PSA level (Δ PSA) between both groups was noted (p = 0.54). In Group 1, a more significant lowering of PSA was documented in PCa than in non-PCa patients (p = 0.008). No statistically significant relationship between Δ PSA and Gleason score in both groups was present.ConclusionThe empiric use of antibiotics does not hold any benefit for patients presenting with an elevated PSA. Also, the degree of change in PSA does not correlate with results of transrectal ultrasound-guided biopsy of the prostate.     

Efeitos da musicoterapia sobre dor e estresse oxidativo na aspiração folicular: estudo clínico randomizado

Background and objectiveThe aim was to investigate the effects of Turkish classical music on pain and oxidative stress in patients undergoing oocyte pick‐up.MethodsThe study was a randomized, controlled trial. The groups included were Group NM (Non‐Music), control group; Group PM, which comprised patients who listened to music before the operation; and Group CM, which comprised patients who listened to music both before and during the operation. Blood was drawn prior to the operation to measure the oxidative stress values. Pain, hemodynamic parameters, oxidative stress values were assessed postoperatively.ResultsThe number of patients requiring additional propofol was higher in Group PM than in Groups NM and CM (p = 0.003). The postoperative Visual Analog Scale (VAS) score were lower in Groups PM and CM than in Group NM (p = 0.001, p = 0.007) in the 1^st and 60^th minutes. The postoperative VAS score was lower in Group CM than in Group NM (p = 0.045) in the 5^th minute. The postoperative additional analgesic requirements were lower in Groups PM and CM than in Group NM (p = 0.045). The postoperative blood glutathione peroxidase values were significantly higher in Groups PM and CM than in Group NM (p = 0.001). The postoperative catalase values were significantly higher in Groups PM and CM than in Group NM (p = 0.008 and p ≤ 0.001). The preoperative malondialdehyde values were significantly lower in Groups PM and CM than in Group NM. The preoperative nitric oxide values were higher in Groups PM and CM than in Group NM (p ≤ 0.001), whereas the postoperative nitric oxide values were lower in Groups PM and CM than in Group NM (p ≤ 0.001).ConclusionTurkish classical music has beneficial effects on pain and oxidative stress in oocyte pick‐up patients.     

Acupuntura na fibromialgia: um estudo randomizado‐controlado abordando a resposta imediata da dor

ObjectiveTo evaluate the efficacy of acupuncture in the treatment of fibromyalgia, considering the immediate response of the visual analogue pain scale (VAS) as its primary outcome.MethodsRandomized, controlled, double‐blind study including 36 patients with fibromyalgia (ACR 1990) selected from the outpatient rheumatology clinic, Santa Casa de Misericórdia, Ponta Grossa, PR. Twenty‐one patients underwent an acupuncture session, under the principles of the traditional Chinese medicine, and 15 patients underwent a placebo procedure (sham acupuncture). For pain assessment, the subjects completed a Visual Analogue Scale (VAS) before and immediately after the proposed procedure. The mean change in VAS was compared among groups.ResultsThe variation between the final and initial VAS values was –4.36 ± 3.23 (P = 0.0001) in the treatment group and –1.70 ± 1.55 in the control group (P = 0.06). The difference in terms of amplitude of variation of VAS (initial – final VAS) among groups favored the actual procedure (P = 0.005). The effect size (ES) for the treatment group was d = 1.7, which is considered a large effect. Although small, the statistical power of the sample for these results was very relevant (94.8%).ConclusionAcupuncture has proven effective in the immediate pain reduction in patients with fibromyalgia, with a quite significant effect size.     

Efficacy of preoperative melatonin versus pregabalin on perioperative anxiety and postoperative pain in gynecological surgeries

BackgroundWe compared the efficacy of melatonin and pregabalin on perioperative anxiety and postoperative pain in patients undergoing laparoscopic gynecological surgeries.MethodsIn this randomized double-blind study, 40 patients, 25–35 yr undergoing gynecological surgeries were divided into 2 equal groups to receive either melatonin capsule 6 mg (Group M), or pregabalin capsule 150 mg (Group P) 1 h before induction of general anesthesia. Our primary outcome was preoperative acute anxiety level 1 h after drug administration, 1, 6, and 12 h after operation. The secondary outcomes were postoperative visual analog scale (VAS) for pain, analgesic consumption, sedation level using the inverted observer’s assessment of alertness/sedation scale (OAA/S) scale, and incidence of adverse effects.ResultsThe anxiety scores decreased significantly >50% after premedication in both groups compared to baseline values (p < 0.01) with no statistically significant difference between the two groups (30.4 ± 4.5 in group M versus 31.7 ± 4.2 in group P, p > 0.05). Postoperative VAS for pain, time for first analgesic demand and number of patients requiring postoperative analgesia did not differ between groups, and the sedation score was higher in melatonin group compared to pregabalin group 1 h after drug (3.45 ± 0.7 versus 1.95 ± 0.6, p < 0.001, respectively) and at all the subsequent readings postoperatively with equal incidence of adverse effects in both groups.ConclusionOral melatonin 6 mg or pregabalin 150 mg administered 1 h before operation had reduced perioperative anxiety and postoperative pain in patients undergoing gynecological surgeries, without untoward sedative effects in the pregabalin group compared to melatonin group.     

The analgesic efficacy of continuous fascia iliaca block vs. continuous psoas compartment block after hip surgery: A comparative study

BackgroundBoth psoas compartment block and fascia iliaca compartment block have been shown to be reliable blocks for postoperative pain relief for procedures involving the hip joint. This study evaluated the efficacy of continuous psoas compartment block with continuous fascia iliaca block for postoperative analgesia after hip surgery.MethodsIn randomized blinded study Forty, ASA I–III patients aged 30–75 years, with BMI less than 40, scheduled for hip surgery, were divided to one of two groups. Group P: continuous psoas compartment block (n = 18) and group F: continuous fascia iliaca block (n = 19). Standard general anesthesia was induced after finishing the block technique. After recovery 30 ml of 0.125% levobupivacaine was injected through the catheter to all patients. Postoperative 24 h meperidine consumption, patient satisfaction, visual analogue scale pain scores at (1, 6, 12, 18, and 24 h) postoperative, postoperative hemodynamics (HR and MAp), evidence of sensory and motor blockades, and incidence of adverse effects were recorded.ResultsThere was no significant difference between the two groups in 24 h postoperative meperidine requirements, postoperative VAS, patient satisfaction, postoperative hemodynamics, and distribution of sensory and motor block of (femoral, lateral femoral cutaneous, and obturator nerves). The epidural anesthesia occurred in two patients in psoas group (11%).ConclusionBoth continuous fascia iliaca block and continuous psoas compartment block were comparable in providing safe and effective analgesia after hip surgery.     

Effects of 14 weeks of TNF alpha blockade treatment on lipid profile in ankylosing spondylitis

ObjectiveCardiovascular morbidity and mortality seem to be increased in ankylosing spondylitis, perhaps as the result of biological inflammation and consecutive dyslipidemia. This study aims to investigate the impact of TNF alpha-inhibitors, an effective treatment, on lipid profile.MethodsThirty-four ankylosing spondylitis (AS) patients with active disease undergoing anti-TNF alpha therapy (n = 20, infliximab; n = 7, etanercept; n = 7, adalimumab) were recruited. Disease activity parameters, total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides were assessed at baseline and after 14 weeks of treatment.ResultsAfter 14 weeks of TNF alpha blockade treatment, there was a significant increase in levels of total cholesterol (5.08 ± 1.20 vs. 4.73 ± 1.12 mmol/l; p = 0.01) and HDL-cholesterol (1.61 ± 0.47 vs. 1.47 ± 0.35 mmol/l; p = 0.008), but no resulting change in the atherogenic index (3.43 ± 1.13 vs. 3.35 ± 0.93; p = 0.87). There was also no change in concentrations of triglycerides (1.33 ± 1.22 vs. 1.27 ± 0.98 mmol/l; p = 0.794) and LDL-cholesterol (3.15 ± 0.99 vs. 2.91 ± 0.93 mmol/l; p = 0.24). TNF alpha inhibitor treatment was followed by a significant improvement in all disease activity parameters: VAS pain or VAS disease activity, BASDAI or BASFI and systemic inflammation. Sub-group analysis showed that monoclonal antibodies increased total and LDL-cholesterol levels but did not change the atherogenic index. Conversely, 14 weeks of etanercept treatment was followed by no change in lipid profile.ConclusionTNF alpha inhibitors may be successful in reducing cardiovascular risk in AS, as in RA, but not by affecting lipid profile. However, there is insufficient documented evidence, and long-term investigations are needed to define the possible protective mechanisms of TNFalpha inhibitor treatment in spondylarthropathies.     

Pectoralis-serratus interfascial plane block vs thoracic paravertebral block for unilateral radical mastectomy with axillary evacuation

Study ObjectiveThe aim of this study was to evaluate the analgesic efficacy and safety of pectoralis-serratus interfascial plane block in comparison with thoracic paravertebral block for postmastectomy pain.DesignA prospective randomized controlled study.SettingTertiary center, university hospital.PatientsSixty-four adult women, American Society of Anesthesiologists physical status classes I, II, and III, scheduled for unilateral modified radical mastectomy with axillary evacuation.InterventionsPatients were randomized to receive either pectoralis-serratus interfascial plane block, PS group (n = 32), or thoracic paravertebral block, PV group (n = 32).MeasurementsTwenty-four-hour morphine consumption and the time to rescue analgesic were recorded. The pain intensity evaluated by visual analog scale (VAS) score at 0, 2, 4, 8, 16, and 24 hours postoperatively was also recorded.Main ResultsThe median (interquartile range) postoperative 24-hour morphine consumption was significantly increased in PS group in comparison to PV group (PS vs PV), 20 mg (16-23 mg) vs 12 mg (10-14 mg) (P < .001). The median postoperative time to first analgesic request was significantly shorter in PS group compared to PV group (PS, 6 hours [5-7 hours], vs PV, 11 hours [9-13 hours]) (P < .001). The intensity of pain was low in both groups in VAS 0, 2, and 4 hours postoperatively. However, there was significant reduction in VAS in PV group compared to PS group at 8, 16, and 24 hours postoperatively.ConclusionsPectoralis-serratus interfascial plane block was safe and easy to perform and decreased intensity of postmastectomy pain, but it was inferior to thoracic paravertebral block.     

The role of intravenous paracetamol in conscious sedation during Internal Cardioverter Defibrillator (ICD) insertion in geriatric patients

BackgroundInsertion of Internal Cardioverter Defibrillator in high risk cardiac patients can be performed by many anesthetic techniques including local anesthesia with moderate sedation or general anesthesia. Many studies have proved that intravenous paracetamol infusion is effective in reducing narcotic requirements in many surgical procedures.PurposeThe aim of this study was to assess the effect of paracetamol in reducing pain as well as apnea and upper airway obstruction during conscious sedation for Internal Cardioverter Defibrillator placement.Patients and methodsIn this prospective, randomized study, 100 patients undergoing elective transvenous placement of Internal Cardioverter Defibrillator (ICD) were enrolled in this study. Pain, respiratory events as apnea and airway obstruction in patients receiving intravenous paracetamol infusion 1 g over 30 min have been compared with those receiving fentanyl in a total dose of 1.5 μg/kg.ResultsThe incidence of airway obstruction was lower in the paracetamol group than in the fentanyl one (P < 0.05). There was also a significant difference between the two groups as regards arterial carbon dioxide tension (PCO2), which was significantly higher in Group F (48.9 ± 0.63) in comparison to Group P (45.6 ± 0.64) (P < 0.001) as well as the degree of sedation where the sedation score was 2.2 ± 0.3 in group P. Also, the Visual Analog Scale (VAS) was significantly lower in Group P than in Group F (P < 0.05).ConclusionIntravenous paracetamol infusion was effective in reducing pain as well as the incidence of intraoperative respiratory events as upper airway obstruction in high risk cardiac patients undergoing Internal Cardioverter Defibrillator insertion.     

The use of phenylephrine to obtund oxytocin-induced hypotension and tachycardia during caesarean section

BackgroundOxytocin causes clinically significant hypotension and tachycardia. This study examined whether prior administration of phenylephrine obtunds these unwanted haemodynamic effects.MethodsForty pregnant women undergoing elective caesarean section under spinal anaesthesia were randomised to receive either an intravenous 50 μg bolus of phenylephrine (Group P) or saline (Group S) immediately before oxytocin (3 U over 15 s). Systolic blood pressure, diastolic blood pressure, mean arterial pressure and heart rate were recorded using a continuous non-invasive arterial pressure device. Baseline values were averaged for 20 s post-delivery. Between-group comparisons were made of the mean peak changes in blood pressure and heart rate, and the mean percentage changes from baseline, during the 150 s after oxytocin administration.ResultsThe mean ± SD peak percentage change in systolic blood pressure was −16.9 ± 2% in Group P, and −19.0 ± 1.9% in Group S and the estimated mean difference was 2.1% (95% CI −3.5% to 7.8%; P=0.44); corresponding changes in heart rate were 13.5 ± 2.3% and 14.0 ± 1.5% and the mean estimated difference was 0.5% (95% CI −6.0% to 5%; P=0.87). The mean percentage change from the baseline measurements during the 150 s period of measurement was greater for Group S than Group P: systolic blood pressure −5.9% vs −3.4% (P=0.149); diastolic blood pressure −7.2% vs −1.5% (P=0.014); mean arterial pressure −6.8% vs −1.5% (P=0.007); heart rate 2.1% vs −2.4% (P=0.033).ConclusionIntravenous phenylephrine 50 μg immediately before 3 U oxytocin during elective caesarean section does not prevent maternal hypotension and tachycardia.     

Clinical relevance of diffusion tensor imaging parameters in lumbar disco-radicular conflict

PurposeTo measure the fractional anisotropy (FA) and the mean diffusivity (MD) values of L4, L5 and S1 nerve roots using diffusion tensor imaging (DTI) and to correlate them with four different clinical patterns.Patients and methodsFifty-six human participants were prospectively included and divided between four groups: healthy subjects, patients with clinical symptomatic nerve root pain with and without anatomical discoradicular conflict and patients with incidental anatomical discoradicular conflict seen on magnetic resonance imaging (MRI). MRI protocol included anatomical sequences (sagittal T1- and T2-weighted, axial T2-weighted) and a 25 directions DTI sequence. FA and MD values were measured in consensus by two readers and compared between the four groups.ResultsMean FA and MD values were significantly different for patients with clinically symptomatic nerve root pain (n = 27) both with (n = 16) (FA = 0.187 ± 0.015; MD = 510 ± 40) and without (n = 11) (FA = 0.193 ± 0.011; MD = 490 ± 30.5) anatomical discoradicular conflict compared to healthy subjects (n = 29) (FA = 0.221 ± 0.011; MD = 460.9 ± 35.5) including 2 subjects with incidental anatomical discoradicular conflict (FA = 0.211 ± 0.013; MD = 450.8 ± 41.2) on MRI (P = 0.003).ConclusionMeasurement of FA and MD values of L4, L5 and S1 nerve roots using DTI could be useful in lumbar nerve root pain assessment. Further studies with different image processing methods are needed.     

Biomechanical comparison of plate and screw fixation in anterior pelvic ring fractures with low bone mineral density

IntroductionOsteosynthesis of anterior pubic ramus fractures can be challenging, especially in poor bone quality. The aim of the present study was to compare plate and retrograde endomedullary screw fixation of the superior pubic ramus with low bone mineral density (BMD).Materials and methodsTwelve human cadaveric hemi-pelvises were analyzed in a matched pair study design. BMD of the specimens was 35 ± 30 mgHA/cm³, as measured in the fifth lumbar vertebra. A simulated two-fragment superior pubic ramus fracture model was fixed with either a 7.3-mm cannulated retrograde screw (Group 1) or a 10-hole 3.5-mm reconstruction plate (Group 2). Cyclic progressively increasing axial loading was applied through the acetabulum. Relative interfragmentary movements were captured using an optical motion tracking system.ResultsInitial axial construct stiffness was 424 ± 116.1 N/mm in Group 1 and 464 ± 69.7 N/mm in Group 2, with no significant difference (p = 0.345). Displacement and gap angle at the fracture site during cyclic loading were significantly higher in Group 1 compared to Group 2. Cycles to failure, based on clinically relevant criteria, were significantly lower in Group 1 (3469 ± 1837) compared to Group 2 (10,226 ± 3295) (p = 0.028). Failure mode in Group 1 was characterized by screw cutting through the cancellous bone. In Group 2 the specimens exclusively failed by plate bending.ConclusionsFrom biomechanical point of view, pubic ramus stabilization with plate osteosynthesis is superior compared to a single retrograde screw fixation in osteoporotic bone. However, the extensive surgical approach needed for plating must be considered.     

Eficacia y seguridad de fosfomicina-trometamol en la profilaxis de la biopsia transrectal de la próstata: estudio prospectivo aleatorizado comparativo con ciprofloxacino

Objectiveprostate biopsy is the standardized diagnostic method for prostate cancer. However, although there is not a standardized protocol, there are recommendations in order to reduce the incidence of complications. The objective of the present work is to assess the efficacy and safety of antibiotic prophylaxis in the prostate biopsy by comparing two antibiotic regimes: two doses of fosfomycin-trometamol 3 g (FMT) every 48 hours with 10 doses of oral ciprofloxacin 500 mg every 12 hours during 5 days.Material and methodsrandomized prospective study was performed with 671 patients who had undergone to walking transrectal ultrasound guided prostate biopsy. Patients of group A (n = 312) were treated with ciprofloxacin, and patients of group B (n = 359) with FMT. Efficacy and tolerability of two prophylactic regimes were compared. Urine culture was carried out at 2 weeks after biopsy. Initially, patients with asymptomatic bacteriuria were not treated with antibiotics; urine culture was repeated after 1 month, persistent bacteriuria was treated according to antibiogram.Resultsno differences between groups were found in age (P = .78), cancer presence (P = .9) or number of biopsy cylinders (P = .93). The mean number of cores obtained was 11.3 ± 3.25 (range 6-20). Digestive intolerance was observed for 9 patients (2.9%) of group A and 10 patients (2.8%) in group B. One patient (.3%) of group A showed severe allergic reaction. In total, 167 patients (24.6%) had complications: 16 (2.4%) fever, 47 (6.9%) hemospermia, 81 (11.9%) hematuria, 7 (1%) rectal bleeding and 16 (2.4%) urinary retention. No statistically differences between groups were observed (27.6% vs. 22.6%; P = .17). However, hemospermia was more frequent in group A (9.9% vs. 4.5%; P = .006). Bacteriuria after biopsy was detected in 44 patients (6.6%), being more frequent in group B patients (4.2% vs. 8.6%; P = .02) although a higher number of second treatment cycles were not needed (53.9% vs. 29%; P = .17). The likelihood of resistance to ciprofloxacin in patients with bacteriuria in A was greater than that of FMT in B (69.2% vs. 41.9%; P = .0004).Conclusionsantibiotic prophylaxis with FMT (2 doses of 3 g) in prostate biopsy is an alternative as effective and safe as ciprofloxacin (10 doses of 500 mg), which carries lower rate of resistance. According to our experience, this drug is a safe, well-tolerated, and easily manageable prophylactic option, facilitating patient compliance. More prospective multicenter studies are necessary to confirm these findings.     

Effectiveness of CT-guided epidural infiltration of steroids and local anesthetics for acute and chronic herpes zoster neuralgia

PurposeThe purpose of this study was to evaluate the effectiveness and complication rate of computed tomography (CT)-guided epidural injection of steroids and local anesthetics for pain relief in patients with neuralgia due to acute or chronic herpes zoster (HZ).Materials and methodsA prospective study was conducted from April 2017 to February 2019 including patients with HZ neuralgia (HZN) at any stage (acute or chronic, the latter being defined as pain lasting more than 3 months and also called post herpetic neuralgia [PHN]). The sensory ganglion of the affected dermatome and/or the affected sensory nerve was targeted under CT-guidance and local injection of a mixture of two vials of methylprednisolone 40 mg/mL and 2 mL of Lidocaine 1% was performed. Using a visual analogue scale (VAS, 0 to 10), pain was assessed prior to the procedure, and at day 7, 1 month, 3 months and 6 months. Adverse effects were graded according to the Society of Interventional Radiology classification.ResultsTwenty patients were included. There were 9 men and 11 women with a mean age of 67 ± 13.9 (SD) years (range: 27–83 years). Of these, 14 patients had acute HZN and 6 had PHN. Mean VAS at baseline was 8.1 ± 1.2 (SD) (range: 6–10) with significant decrease (P < 0.0001) at day 7 (3.4 ± 3.2 [SD]; range: 0–10), day 30 (3.4 ± 3.2 [SD]; range: 0–9), day 90 (2.9 ± 3.2 [SD]; range: 0–9), and day 180 (2.5 ± 3.1 [SD]; range: 0–9). Infiltrations were significantly more effective on acute HZN than on PHN (P < 0.001) and required significantly fewer infiltrations for pain relef (P = 0.002). Only one grade A adverse event was reported.ConclusionEpidural injection of a mixture of steroids and local anesthetics under CT-guidance is effective on HZN with a persisting effect over 6 months.