Use of peridural catheters in the treatment of postoperative pain after spinal instrumentated fusion--an experience report

AIM: In a prospective randomized clinical study we investigated in a group of 20 patients after spinal instrumentation surgery the analgesic efficacy and the safety of epidural analgesia. Intraoperatively an epidural catheter was placed by the orthopedic surgeons for postoperative pain control. METHOD: For epidural catheter analgesia a mixture of the local anesthetic ropivacaine and the opioid sufentanil was used with an initial bolus, followed by a continuous infusion and the possibility of patient-controlled bolus administration (PCEA). Pain-scores (VAS) were measured pre- and postoperatively at rest, and during active mobilization maneuvers like turning around in bed and standing. The neurological status, side effects, and complications were evaluated. RESULTS: Mean pain-scores (VAS) were 3.8 pre-operatively at rest, after initiation of epidural analgesia 0.3 at rest, 1.6 at turning around in bed and 0.8 at standing (6.8 pre-operatively). Transient sensible or motoric deficits, due to the local anesthetics' effect, occurred in 8 respectively in 3 of the patients. Drug-induced typical side-effects were pruritus, nausea and emesis. No cardiopulmonary complications happened. CONCLUSION: The epidural lumbal analgesia is an effective and safe method to control postoperative pain after spinal instrumentation surgery. Precondition is the knowledge about the safe and standardized technique of intraoperative catheter placement by the orthopedic surgeon, the choice of the appropriate analgesic drugs and a good cooperation between the departments of anesthesiology and orthopedic surgery and nursing staff.     

Besonderheiten neuromuskulärer Skoliosen

Usually, neuromuscular scolioses become clinically symptomatic relatively early and are rapidly progressive even after the end of growth. Without sufficient treatment they lead to a severe reduction of quality of life, to a loss of the ability of walking, standing or sitting as well as to an impairment of the cardiopulmonary system resulting in an increased mortality. Therefore, an intensive interdisciplinary treatment by physio- and ergotherapists, internists, pediatricians, orthotists, and orthopedists is indispensable. In contrast to idiopathic scoliosis the treatment of patients with neuromuscular scoliosis with orthosis is controversially discussed, whereas physiotherapy is established and essential to prevent contractures and to maintain the residual sensorimotor function.     

Parameters influencing the outcome after total disc replacement at the lumbosacral junction. Part 2: distraction and posterior translation lead to clinical failure after a mean follow-up of 5 years

Purpose

The aim of the second part of the study was to investigate the influence of parameters that lead to increased facet joint contact or capsule tensile forces (disc height, lordosis, and sagittal misalignment) on the clinical outcome after total disc replacement (TDR) at the lumbosacral junction.

Methods

A total of 40 patients of a prospective cohort study who received TDR because of degenerative disc disease or osteochondrosis L5/S1 were invited to an additional follow-up for clinical (ODI and VAS for overall, back, and leg pain) and radiographic analysis (a change in disc height, lordosis, or sagittal vertebral misalignment compared with the preoperative state). Based on the final ODI, patients were retrospectively distributed into groups N (normal: <25 %) or F (failure ≥25 %) for radiographic parameter comparison. A correlation analysis was performed between the clinical and radiological results.

Results

A total of 34 patients were available at a mean follow-up of 59.5 months. Both groups (N = 24; F = 10 patients) presented a significant improvement in overall pain, back pain, and ODI over time. At the final follow-up, higher clinical scores correlated with a larger disc height, increased lordosis, and posterior translation of the superior vertebra, which was also reflected by significant differences in these parameters in the group comparison.

Conclusions

Parameters associated with increased facet joint capsule tensile forces lead to an inferior clinical outcome at mid-term follow-up. When performing TDR, we therefore suggest avoiding iatrogenic posterior translation and overdistraction (and consecutive lordosis).