With the emergence of opioid-sparing and enhanced recovery pathways, cardiac anaesthesiologists are highly motivated to formulate regional analgesia-centric multimodal regimes, particularly prompted by the inclusion of safer fascial plane blocks to the analgesic repertoire. Ahead of the encouraging literature on perioperative pain relief with the thoracic fascial plane blocks, the fraternity continues to search for promising options for ensuring sternal analgesia. While the novel transversus thoracic muscle plane block emerges as the recent kid on the block for effective sternal analgesia , the sporadic case reports and feasibility studies primarily focus on an overall perioperative analgesic role of the block. The index case series describes a noteworthy experience with a pre-induction transversus thoracic muscle plane block administration for attenuating the intraoperative  haemodynamic response in adult cardiac surgical patients, with a potential to translate into reduced perioperative fentanyl requirement, augmented recovery, and fast-tracking. Pain following cardiac surgery is multifactorial with median sternotomy being a significant contributor to it.Previous studies have demonstrated a role of Transversus Thoracic Muscle Plane Block (TTPB) in decreasing pain following cardiac surgery alongside a reduction in perioperative opioid dependence in cardiac surgery.The index case series is a novel attempt where in a preanaesthetic TTPB in 15 consecutive homogenous category of patients, attenuated haemodynamic response to median sternotomy in the anatomico-clinical context with eventual positive effect on postoperative pain scores and augmented recovery following cardiac surgery.4While one cannot condescend to the role of opioids in the conduct of cardiac surgery, the paradigm shift towards opioid-sparing anaesthesia continues to be fuelled by the peculiar adverse effect and addiction profile of opioids. At the same time, the embracement of enhanced recovery pathways further motivates opioid-sparing, resulting in a recent interest in the safer fascial plane blocks for post-cardiotomy pain management.7 In this context, a recently described transversus thoracic muscle plane block (TTPB) has captivated attention for its potential role in ensuring perioperative sternal analgesia.11 While previous observations employing a TTPB have focused on postoperative pain scores and the use of rescue analgesics,11 the present case series describes the effect of a pre-induction TTPB on the intraoperative haemodynamic response, particularly, to median sternotomy. The perioperative fentanyl requirement, postoperative pain scores, and the recovery profile of the included patients have also been outlined.The literature is replete with the mechanisms of pain after cardiothoracic surgery with median sternotomy pain emerging as one of the important contributors.The case series included 15 consecutive patients aged 18-50 years, American Society of Anaesthesiologists (ASA) physical status II-III who received a planned pre-induction TTPB block prior to undergoing an elective cardiac surgery requiring median sternotomy in the time period from September 2020 to November 2020. The patients undergoing coronary artery bypass grafting, history of systemic hypertension, pre-existing renal and hepatic failure, uncontrolled diabetes mellitus, local anaesthetic (LA) allergy, coagulopathy, psychiatric illness, chronic opioid use, and those who did not consent were excluded.−1 and midazolam 0.02 mg kg−1), an ultrasonography (USG)-guided TTPB was performed using a high frequency (3-12 MHz) linear transducer  after infiltrating the skin with LA. The probe was placed in a parasagittal fashion just lateral to the lateral border of sternum over the third and fourth ribs. The intercostal muscles that lie between the ribs and transversus thoracic muscle (TTM) and the underlying pleura were identified. Herein, the transversus thoracis plane (TTP) that can be found between the internal intercostal muscle and the TTM classifies as the target site for the TTPB  that run between the intercostals and TTM  for pain assessment (dynamic [on coughing] and static component) while obtaining consent for the block. In the operation theatre, after achieving a Ramsay Sedation Score of 2-3  > 480 seconds. The cardiopulmonary bypass (CPB) was instituted and maintained under standard institutional protocol. 2 µg kg−1 of fentanyl was administered while going-on and coming-off CPB along with the supplemental rocuronium and midazolam boluses. The anaesthetic depth was monitored intraoperatively with a target bispectral index value of 40-60. Subsequent to CPB weaning, the heparin was adequately reversed with protamine in order to achieve the baseline ACT. After surgery, the intubated patients were shifted to cardiac intensive care unit (ICU) and weaned from mechanical ventilation subsequently.Following the block, general anaesthesia was induced using intravenous doses of 2-3 µg kg−1 was administered when the haemodynamic parameters (MAP and HR) demonstrated a rise of ≥20% above the baseline. Postoperatively pain (both static as well as dynamic components) was assessed using NRS scale at extubation, and then at 1 hour, 6 hour, 12 hours and 24 hours following extubation. Other parameters recorded were postoperative fentanyl rescue analgesia (0.5 kg−1), postoperative nausea and vomiting (PONV) were recorded. All the patients received intravenous paracetamol of 15 mg kg−1 every 8 postoperative hours.The heart rate (HR) and radial artery transduced systolic, diastolic, and mean arterial pressure (MAP) were monitored. Additional intraoperative fentanyl of 1.0 µg kg−1 which is less compared to the usual tune of 15-20 µg kg−1 of fentanyl consumed intraoperatively in cardiac cases at our institute. The mean postoperative fentanyl requirement was 0.5 ± 0.627 µg kg−1 and the patients could be fast-tracked (extubation within 6 hours of ICU admission)12 with none complaining of PONV.Out of the 15 patients, 3 demonstrated ≥20% increase in MAP and HR at skin incision (Ti) and 4 at median sternotomy (Ts), necessitating an intraoperative fentanyl supplementation. None of the patients manifested a significant haemodynamic response at intubation (Tt)  or at anThe elucidation of an attenuated median sternotomy haemodynamic response in the index case series is noteworthy and promising with regards to the sternal analgesic role of TTPB with the potential to translate into reduced perioperative fentanyl requirement, enhanced recovery, and fast-tracking.7While pain after cardiac surgery is essentially multifactorial, median sternotomy classifies as a major contributing factor. Inadequate pain management can aggravate the stress response with potential haemodynamic, metabolic, immunologic, and deleterious organ-function consequences. Sternotomy pain, in particular, interferes with breathing, pulmonary toileting, and ambulation and can culminate as chronic post-sternotomy pain in 17%-88%.8 Speaking strictly anatomically, the chest wall fascial plane blocks cannot truly provide sternal analgesia. However, TTPB can take care of the notorious sternotomy pain by anaesthetising the anterior branches of T2-T6 intercostal nerves.13 Moreover, it does not interfere with coagulation management and can be used both in adults and paediatrics. The documented complications include pneumothorax, haemothorax, pericardial puncture, and intravascular injection, and this mandates a meticulous approach.11 We did not encounter any block-related complications.Transversus thoracic muscle plane block has captivated interest for a role in ensuring effective sternal analgesia as first described by Ueshima et al.6 TTPB feasibility study in adult cardiac surgery and Zhang et al11 application of TTPB for postoperative analgesia in paediatric cardiac surgery constitute encouraging research endeavours in this area. However, the present case series is unique in the context of a pre-induction TTPB administration centralising the focus on intraoperative  haemodynamic response alongside pain scores and analgesic requirements.Fujii et al14 Talking of LA doses, we employed 30 mL of 0.2% ropivacaine as opposed to Fujii et al6 who employed 20 mL of 0.3%-0.5% ropivacaine. Nevertheless, the body weight-adjusted drug dosage was well within the permissible limits.While both TTPB and parasternal intercostal nerve block have been utilised in cardiac surgical settings, the classical description outlines the plane between the internal intercostal muscles and TTM as the site of LA deposition for TTPB, whereas the latter targets the plane between the external intercostal and pectoralis major muscles.15The case series suggests that TTPB can mitigate the haemodynamic perturbations at median sternotomy and can be an effective tool for ensuring sternal analgesia. Future randomised controlled trials with a larger sample size are warranted to validate the encouraging findings, in order to explore the potential of individualised procedure-specific analgesic management.


To systematically review the literature and provide a comprehensive understanding of the preemptive effects of oral pregabalin on perioperative pain management in lower limb orthopedic surgery.We searched three electronic databases for randomized controlled trials comparing the results of preoperative pregabalin and placebo in patients undergoing lower limb orthopedic surgery. Data analyses were conducted using RevMan 5.4.Twenty-one randomized controlled trials met our inclusion criteria. The cumulative opioid consumption within 24 and 48 h postoperatively in the pregabalin group was significantly less than that in the placebo group. The pooled static pain intensity at all time points within the first day was significantly lower in the pregabalin group than in the placebo group. Lower dynamic pain intensity at 48 h was detected in the pregabalin group than in the placebo group. Meanwhile, pregabalin led to a lower incidence of nausea but appeared to be associated with a higher incidence of dizziness and sedation. Subgroup analyses showed that no difference was detected between subgroups stratified by dosing regimen or pregabalin dose in the results of opioid consumption, pain intensity and incidence of complications.This meta-analysis supports the use of pregabalin preoperatively in patients undergoing lower limb orthopedic surgery. However, it was wary of the resulting increase in dizziness and sedation. There is no evidence to support the continued use of pregabalin postoperatively or using more than 150 mg of pregabalin per day.Trial registration: This study was registered on 09 November 2021 with INPLASY (registration number: INPLASY2021110031).The online version contains supplementary material available at 10.1186/s13018-022-03101-9. Acute postoperative pain is a common problem faced by patients undergoing surgical treatment and arises after activation of nociceptors, inflammation, and nerve injury , 2. UnrePregabalin can reduce the release of excitatory neurotransmitters and the excitability of synapses by inhibiting calcium influx through high-voltage gated channels , 8. It hPregabalin has been used in lower limb orthopedic surgery for more than 10 years, and several previous randomized trials have explored its effect on perioperative pain management –15. HoweIn this analysis, we aim to conduct a meta-analysis to compare the cumulative opioid consumption, pain intensity and incidence of complications after surgery between the pregabalin group and the placebo group to provide recommendations for surgeons and anesthesiologists.www.prisma-statement.org) and was registered on 10 November 2021 with INPLASY (registration number: INPLASY2021110031)  and pregabalin dose (> 150 mg/day vs ≤ 150 mg/day). We used the Chi2 test to test for subgroup interactions. Analysis was undertaken using RevMan 5.4  with a significance threshold of P < 0.05.The primary outcomes in this analysis were defined as the cumulative opioid consumption, static pain intensity and dynamic pain intensity. For opioid consumption, the reported data were converted to the oral morphine equivalent dose. For pain intensity, the data of VAS  were pooled. The secondary outcomes included the incidence of complications, such as nausea, vomiting, dizziness and sedation. Mean differences (MD) with a 95% CI were calculated using the inverse variance method for continuous variables, and risk ratios (RR) with a 95% CI were calculated using the Mantel–Haenszel analysis method for dichotomous variables. Heterogeneity was assessed using the ChiTwenty-one randomized controlled trials from 11 countries with a total sample size of 1520  were included in the current analysis , and substantial heterogeneity was observed (I2 = 84%). For the results at 48 h after surgery, a similarly lower morphine equivalent dose was detected in patients receiving pregabalin than in those receiving placebo . High heterogeneity was also seen (I2 = 68%) , 6 h , 12 h , and 24 h . However, no difference in static pain intensity was observed at 48 h between groups , with no substantial heterogeneity seen for static pain intensity . However, no difference in dynamic pain intensity at 24 h was seen between groups , with no heterogeneity seen for dynamic pain intensity . An increased postoperative incidence of dizziness and sedation was observed in patients treated with pregabalin  for the incidence of dizziness; RR 1.69, 95% CI , P = 0.03 for the incidence of sedation). No difference in the incidence of vomiting and drowsiness was seen in patients receiving pregabalin . No substantial heterogeneity was seen for the outcomes of complications  , 17. QuaP = 0.30) in the subgroups of patients receiving pregabalin only before surgery or in patients receiving pregabalin both before and after surgery. Similarly, no significant difference between subgroups was shown in the results of static pain intensity at 24 h and incidence of complications. Details are displayed in Table To compare the effectiveness of pregabalin in patients taking various dosing regimens, subgroup analyses were performed. A minimum of two comparisons per subgroup were available in the current analysis. There was no statistically significant difference in the results of cumulative opioid consumption within 24 h  between subgroups. Comparable results between subgroups were also detected in static pain intensity at 24 h , dynamic pain intensity at 24 h  and incidence of complications. Details are displayed in Table To further explore the effect of pregabalin dose in patients undergoing lower limb orthopedic surgery, post hoc subgroup analyses were conducted in studies stratified by pregabalin dose (> 150 mg/day vs ≤ 150 mg/day). A minimum of two arms per subgroup was available in the current analysis. There was no statistically significant difference in opioid consumption within 24 h (test for subgroup differences, The main findings of the current analysis were that the use of pregabalin preoperatively in patients undergoing lower limb orthopedic surgery appeared to be associated with lower morphine consumption at 24 h and 48 h. Similarly, decreased static pain intensity within 24 h and dynamic pain intensity at 48 h were detected in patients taking pregabalin. Compared with placebo, the use of pregabalin was associated with a reduction in the incidence of nausea but an increase in dizziness. No evidence was found with subgroup analyses to support the continued use of pregabalin postoperatively or using more than 150 mg of pregabalin per day.To our knowledge, this was the first meta-analysis focused on the efficacy of pregabalin in perioperative pain management in patients undergoing lower limb orthopedic surgery. The primary outcomes in the current analysis were pain intensity and cumulative opioid consumption. A small reduction in the pain intensity at rest, as described in existing research , was detSignificantly lower morphine consumption within 24 h and 48 h was observed in patients receiving pregabalin, indicating that preoperative pregabalin could effectively reduce opioid consumption postoperatively. A similar result was also detected in a study by Lee et al. [Recently, perioperative pain management has sought to reduce the incidence of opioid-related adverse effects . In the Only two trials that reported the incidence of chronic neuropathic pain were identified in this analysis. Formal meta-analysis was not performed because of the paucity of data. Buvanendran et al.  reportedSeveral limitations were detected in the current analysis. First, substantial heterogeneity among studies was observed regarding the results of morphine consumption, and further studies are needed to enhance the strength of the evidence or find the source of heterogeneity. Second, comparisons of the outcomes stratified by pregabalin dose or dosing regimen were indirect in the current analysis, and studies that compared different doses or dosing regimens directly would have to further evaluate the optimal dosage and dosing regimen of pregabalin. Third, the data presented in some studies were not suitable for pooling for meta-analyses. Finally, although the results were statistically significant, whether it is clinically significant requires further investigation, randomized controlled trials with a larger sample size are needed in future work.In summary, this meta-analysis supports the use of pregabalin preoperatively in patients undergoing lower limb orthopedic surgery with regard to opioid-sparing and analgesic effects. However, it is wary of the resulting increase in the incidence of dizziness and sedation. At present, there is no evidence to recommend the continued use of pregabalin postoperatively or the use of more than 150 mg of pregabalin per day.Additional file 1. The details of the registration information.Additional file 2. The details of the search trial.Additional file 3. The results of the sensitivity analyses,


Sacrifice of the tumor carrying nerve root and tumor recurrence also did not increase the risk for this condition. Persistent neuropathic pain requiring continuous treatment occurred in 7.2% of patients undergoing intradural spinal surgery in our cohort. This frequently underestimated postoperative adverse event represents a disabling condition leading to a substantial impairment in the quality of life among the affected patients.Neuropathic pain presents a burdening and impairing condition which may occasionally occur after spinal tumor surgery. While it has been described in peripheral nerve sheath tumors, data on other intradural tumor patients is sparse. We hereby present a large cohort population undergoing different intradural spinal tumor surgery with assessment of early postoperative and follow-up outcomes, focusing on the occurrence of neuropathic pain. We performed a retrospective monocentric study including all patients treated for intradural spinal tumors between 2009 and 2020. We extracted surgical aspects as well as pre- and postoperative clinical courses from the records. Statistical analysis of potential contributing prognostic factors was performed including matched pair analysis. In total, 360 patients were included for analysis. At a median follow-up of 2 years, 26/360 patients complained of a neuropathic pain syndrome (7.2%) requiring continuous medication. Of these patients only 50% complained preoperatively of pain. Tumor entity did not significantly influence the incidence of postoperative neuropathic pain ( Postoperative neuropathic pain syndromes, defined as “pain initiated or caused by a primary lesion or dysfunction in the nervous system” followinWhile most published literature focuses on overall and progression-free survival and postoperative functionality , long-teWe performed a monocentric retrospective cohort study of all patients undergoing surgical treatment for spinal intradural tumors between April 2009 and July 2020. Patients harboring malignant or high-graded tumors such as anaplastic ependymomas WHO grade III, astrocytomas WHO grade II and higher-graded, or intradural metastases were excluded from the analysis due to their aggressive behavior with a distinctly more complex pain syndrome.Gabapentine or Carbamazepine, as well as the neurological and clinical status using the Karnofsky Performance Status Scale (KPS). Tumor entities including tumor grading according to the World Health Organization (WHO) System were captured. We analyzed the extent of resection (EOR), location of the tumor regarding the spinal cord , surgical information , and the spinal level . The approach was classified into unilateral approach , laminectomy, laminoplasty, and dorsal fixation. We assessed the postoperative course and extracted long-term data from the follow-up examinations.First, we assessed preoperative data such as gender, age, type and duration of symptoms, and comorbidities. Secondly, we retrieved intraoperative information such as duration of surgery, surgical approach, and complications from the medical records. Postoperative follow-up assessment included the presence of postsurgical pain syndromes focusing on the occurrence of neuropathic pain with the need of pharmaceutical treatment, particularly including specific medication targeting neuropathic pain such as t test. To identify prognostic risk factors for neuropathic pain, we performed a matched pair analysis including all patients with a burdening neuropathic pain syndrome and matching patients without postoperative pain symptoms with corresponding age and tumor localization.Statistical analyses were performed using SPSS Statistics 26 . We compared categorical data using the chi-square test or Fisher’s exact test as needed. Mean values were compared using the independent samples The association between potential factors and the occurrence or persistence of preexisting neuropathic pain (last follow-up data or discharge data for those with missing follow-ups) was analyzed using ANOVA and linear regression modeling. We assumed the following factors to be potentially predictive: complete nerve root amputation, age, intra- vs. extramedullary tumors, preoperative radicular pain, gender, incomplete vs. gross total resection (GTR), and symptom duration. To assess the correlation, we used Kendall’s Tau correlation coefficient. All tests were performed two-sided, and a p-value < 0.05 was considered significant.We executed the presented study in accordance with the ethical standards outlined in the Declaration of Helsinki. Also, we obtained a positive vote by a local ethics committee beforehand (number 5766/13). Due to the retrospective nature of the study, prospective patient consent was not required and waived by our local ethics committee.In total, 486 surgeries were performed for benign intradural tumor resection between April 2009 and July 2020 in our neurosurgical department. Complete follow-up data was available on 385/486 (79.2%), and after reviewing the records, 10 patients resulting in 25 cases were additionally excluded because of previous tumor surgery on the same spinal level and duplicates or triplicates. In total 360 patients were included for further analysis.Overall, 197/360 patients were female (54.7%), and 163/360 patients were male (45.3%). Median age was 53 years (IQ range 40–66 years).The most common entities were benign peripheral nerve sheath tumors , ependymomas WHO° I-II , and spinal meningioma . Other tumor entities included intramedullary hemangioblastoma WHO grade I , pilocytic astrocytoma WHO°I , and paraganglioma   was performed on 252/360 patients (70%). In 42/360 patients, a laminectomy was performed (11.7%), and in 53/360 patients (14.7%), we opted for a laminoplasty to achieve tumor resection. In 12/360 patients, we performed a retroperitoneal (10/12) or transthoracic (2/12) approach. In addition to the posterior approach, one patient required a dorsal fixation (Table Mean surgery duration was 157 min (range 54–499 min). Overall, 326/360 required only one operation to achieve tumor resection (90.6%), and 34/360 patients underwent 2 or more surgeries for complete tumor resection (9.4%). Most surgeries were performed at the thoracic  or lumbar level , followed by the cervical spine , the thoracolumbar junction , sacral tumors , and the cervicothoracic junction . In 34.7%, the dura was sutured with a 5.0 Gore-Tex suture in a watertight manner; in 65.3% of the patients, the suture was covered by an absorbable fibrin sealant (TachoSil).Median length of hospital stay was 6.5 days . Intraoperative neuromonitoring was performed in 95 patients (26.4%).The median preoperative and postoperative Karnofsky performance index (KPS) was 90%. GTR could be achieved in 312/360 (86.7%) of cases. Tumor recurrence was observed in 19/360 cases (5.3%), ranging from 0% in hemangioblastoma patients to 4.8% in peripheral nerve sheath tumor and 6.5% in ependymoma patients.In our cohort study, 26/360 patients suffered from neuropathic pain requiring a medication at follow-up (7.2%), describing tingling and burning sensations as well as paresthesia either in one extremity or a specific dermatome.p = 0.212, OR 2.7) and patients undergoing surgery at the cervical or thoracic level  without reaching statistical significance. The occurrence of neuropathic pain was not associated with tumor recurrence (p = 0.493) or the extent of resection (GTR p = 0.764). Although patients suffering from neuropathic postoperative pain were predominantly female , the difference was not significant (p = 0.257). Depending on tumor entity, the percentage of patients suffering from postoperative neuropathic pain ranged from 0 (pilocytic astrocytoma) to 7.3%  and 8.8% (meningioma) (Table p = 0.91). While patients with entirely extramedullary tumors also suffered from neuropathic pain, the amount was higher in patients suffering from intramedullary tumors, but the difference did not reach statistical significance in the whole cohort analysis  (Table p = 0.801). Interestingly, patients suffering from postoperative neuropathic pain had neurological deficits in 73.1% of the cases , and the amount was lower in patients without neuropathic pain .Neuropathic pain was mostly observed in patients undergoing a combined dorsal/retroperitoneal tumor resection  and if tumors were intramedullary . The EOR and number of segments affected was not associated with the occurrence of neuropathic pain. In patients suffering from spinal meningioma, the location of the tumor again affected the occurrence of postoperative neuropathic pain (cervico-thoracic 10.3% pain vs. 0%) and incomplete tumor resection was associated with a higher risk of postoperative neuropathic pain without reaching statistical significance . Again, the number of segments did not affect postoperative neuropathic pain.In subgroup analysis, patients suffering from ependymoma had a higher risk for postoperative neuropathic pain at the cervico-thoracic location .p = 0.007). Detailed assessment of all patients describing a burdening neuropathic pain revealed no association of the pain with spinal nerve root amputation or any other of the applied potential risk factors in multivariate analysis including the surgical approach, tumor location, sex or extent of resection .In matched pair analysis, neuropathic pain significantly influenced the clinical status. Median KPS at follow-up was 100% in patients without neuropathic pain compared to a median KPS of 90% in patients suffering from neuropathic pain . Occasionally, in cases of acute exacerbation of the pain, the patient was advised to receive a periradicular corticosteroid injection. Additional promising treatment options for neuropathic pain which have been described recently are spinal cord stimulation by an implanted pulse generator or repetitive transcranial magnetic stimulation [In our cohort population, patients describing burdening neuropathic pain were administered medication such as anti-epileptic drugs mulation , 3.Unfortunately, literature on postoperative neuropathic pain is sparse. While most studies aim to describe the clinical status in terms of muscle strength, sensation, and functional independence, the postoperative disability caused by impairing pain is often underrepresented . All ourWe only included patients with follow-up in our neurosurgical department, which may distort the rate of complications and pain syndrome due to a possible selection bias. Furthermore, our study was performed retrospectively, therefore not investigating whether there is a real causative relationship between the occurrence of neuropathic pain and the performed surgery.Neuropathic pain may occur in patients suffering from preoperative diabetes mellitus , peripheUnfortunately, we did not perform any drug response analysis, nor did we assess the medication dosage. Due to the retrospective nature of the study, we cannot provide data on patient variability. Furthermore, neuropathic pain was diagnosed if the patient reported on a radicular burning and/or tingling painful sensation. Due to the retrospective nature of the study, the patients did not answer a specific neuropathic pain questionnaire, nor did we assess the timing of onset of the pain. The pain remained present in all patients during follow-up, requiring long-term pain medication. The intractable nature of neuropathic pain has been described in numerous studies , describOf course, including all patients suffering from benign spinal intradural tumors creates a strong heterogeneity regarding the acquired data. While pathological mechanisms of the occurrence of neuropathic cannot be drawn from our studied population, our aim was to report on its occurrence in other spinal tumors as most case reports and case series only include peripheral nerve sheath tumors and ependymomas. The heterogeneity presents a limitation, but our goal was to remain as broad as possible to include all spinal pathologies and to describe the prevalence of neuropathic pain, including also subgroup analysis.Neuropathic pain has been associated with reduced ability to work and a markedly impaired quality of life . UnfortuIn our study, we did not investigate the influence of postoperative neuropathic pain on reintegration to work or other daily living activities, but we would assume a significant negative impact on the quality of life among the affected patients.In total, 7.2% of patients complained of postoperative neuropathic pain at follow-up examinations and required regular pain medication at follow-up. Neuropathic pain occurred after various intradural spinal surgeries and should therefore be mentioned as a possible complication preoperatively. Patients were especially at risk when undergoing peripheral nerve sheath tumor, meningioma or ependymoma resection compared to other benign intradural spinal tumors.


Postoperative pain after open thoracotomy is known to be very severe and affects sleep quality. This study aimed to investigate the effects of a programmed intermittent epidural bolus injection versus continuous epidural injection for controlling nighttime pain and improving sleep quality after thoracotomy.Seventy-six patients scheduled for open thoracotomy for lung cancer or other lung diseases were enrolled. The participants were divided into 2 groups. Group A was continuously injected with 0.2% levobupivacaine at 1.1 mL/h, and group B was injected intermittently with 3 mL 0.2% levobupivacaine at 3 hours intervals through a thoracic epidural catheter via a programmed infusion pump. Within 48 hours after surgery, the degree of pain control using visual analog scale and the patients’ sleep conditions on postoperative day (POD) 0 and 1 were evaluated, and other adverse events were investigated.P = .009). Comparison of time to fall asleep showed no differences between 2 groups. Total sleep time was no difference on POD 0 but was longer in group B than that in group A on POD 1 (P = .042). Awakening from sleep on POD 0 was lower in group B than that in group A (P = .033), and satisfaction with sleep quality on POD 0 was superior in group B compared to group A (P = .005). Postoperative nausea and vomiting occurred more frequently in group B than in group A (P = .018).On POD 1 night, the visual analog scale in group B showed lower than group A (The programmed intermittent epidural bolus technique of patient-controlled epidural analgesia reduces postoperative nighttime pain and improves sleep quality in patients undergoing thoracotomy for lung cancer or other lung diseases. In addition, when nighttime breakthrough pain occurs after surgery, the patient requires additional analgesia, and the quality of sleep worsens. If pain control is not satisfied during the nighttime, sleep disturbance will occur, which then negatively affects recovery. Therefore, proper pain control after open thoracotomy is important, and it is known that pain control using epidural analgesia is the most effective method.Postoperative pain in patients undergoing open thoracotomy for lung cancer or other lung diseases is severe. In particular, recovery of spontaneous breathing after awakening from anesthesia is difficult immediately after thoracotomy.,5 Furthermore, studies on the effects of open or laparoscopic abdominal surgery are being actively conducted.–8 However, few cases of using PIEB injection in thoracotomy, and a study reported that using PIEB injection reduced the use of local anesthetics.Several studies have shown that the programmed intermittent epidural bolus (PIEB) injection is effective in epidural autologous pain control devices for labor pain.While previous studies have mainly investigated the pain control effect of the PIEB injection, this study hypothesized that using the PIEB injection at night would allow the patient to get good quality sleep without waking up to press the bolus of the patient-controlled epidural analgesia (PCEA) device for pain. Therefore, our study compared PIEB injection and continuous epidural injection using a PCEA device for nighttime pain control after thoracotomy.The present study aimed to investigate the effects of nighttime pain control after thoracotomy according to the administration method as the primary outcome and to examine the effects of these pain controls on sleep improvement and postoperative recovery of patients as secondary outcomes.https://cris.nih.go.kr/cris/search/detailSearch.do/). After obtaining written informed consent, we enrolled patients aged > 19 years with American Society of Anesthesiologists physical status I–III scheduled for open thoracotomy for lung cancer or other lung diseases. Only the first scheduled surgery in the morning was performed to match the post-surgery investigation time. Patients with neurological or intellectual disabilities, spinal deformities, blood coagulation disorders, neurologic defects at the site, sleep disorders, or patients taking sedatives or sleeping pills, or patients who had allergic reactions to levobupivacaine in previous surgeries, were excluded from the study.The study protocol was approved by the Institutional Review Board of Pusan National University Yangsan Hospital (ID 05–2020-115) and registered with the Clinical Research Information Service , before being accepted into the study. Randomization of patient into 2 groups were done using a list of random numbers generated program of Microsoft Office Excel . The participants were divided into the control group (group A in which 0.2% levobupivacaine was continuously injected at 1.1 mL/h) and an experimental group .An epidural catheter was inserted into T6–T7, or T7–T8 levels for PCEA. As a test dose, 60 mg lidocaine and 15 μg epinephrine were injected through the catheter, and after confirming no hemodynamic change or neurological change, general anesthesia induction was performed. General anesthesia was induced by intravenous administration of 2 mg/kg propofol, and 0.5–1.0 μg/kg/min remifentanil, then the conscious loss was identified, and 0.8 mg/kg rocuronium was administered to obtain muscle relaxation. The train-of-four count was 0, and intubation was performed using a dual-lumen endotracheal tube. After performing the intubation and stabilizing the hemodynamic state, a volume of 7.5 mL 0.2% levobupivacaine (15 mg levobupivacaine + 50 μg fentanyl) was administered as a loading dose through the epidural catheter. For thoracotomy, anesthesia was maintained with 2 vol% sevoflurane, and 0.2 mg/kg rocuronium was administered intraoperatively at 40 to 60 minutes intervals for muscle relaxation.After the surgery was completed, a total volume of 150 mL 0.2% levobupivacaine (levobupivacaine 300 mg + fentanyl 500 μg) was infused through the epidural catheter via a portable electronic infusion pump . In group A, the infusion pump was programmed such that 0.2% levobupivacaine was continuously injected at 1.1 mL/h; if the patients felt pain, further infusion of 3 mL of 0.2% levobupivacaine when the patient wanted an additional analgesic, and the lock-out time was 30 minutes. In group B, the infusion pump was programmed with 3 mL of 0.2% levobupivacaine periodically at 3 hours intervals, continuously injected at 0.1 mL/h, and a patient-requiring bolus dose of 3 mL with a lockout time of 30 minutes through the catheter, similar to group A. If the patients did not press the additional patient’s requirement button, both groups were set to infuse the same amount of local anesthetic. When the VAS score was > 4 and the patient wanted additional analgesics during the postoperative period, 30 mg ketorolac was injected. If pain with a VAS score > 4 persisted, 25–50 mg of pethidine was administered.An investigator blinded to the group assignments assessed study outcomes. The VAS was recorded when the patient could communicate voluntarily after admission in the postanesthetic care unit (PACU), and on postoperative day (POD) 0 night (between 9 p.m. and 11 p.m.), POD 1 day (between 9 a.m. and 11 a.m.) and night, and POD 2 day. Additional analgesic requirements within 48 hours after surgery were documented as the incidence and usage of patients requiring additional analgesics by the investigator. with 5 = very satisfied, 4 = satisfied, 3 = neutral, 2 = dissatisfied, and 1 = very dissatisfied. The investigator asked the patients if they woke up during sleep for reasons such as “to go to the bathroom,” “dyspnea,” “pain,” “anxiety,” and “noise” and recorded the incidences.To evaluate the patients’ sleep conditions, the time to fall asleep, total sleep time, number of times awakened from sleep, and quality of sleep were evaluated. The satisfaction of sleep quality was assessed using a 5-point scale,Adverse events, including postoperative nausea and vomiting (PONV), urinary retention, dizziness, and paresthesia, were also evaluated. Patient satisfaction for postoperative pain management was assessed using a 5-point scale, same as above.After the administration of the drug through the patient-controlled device, the portable electronic injection pump was collected and connected to the computer to analyze the pump usage patterns of the subjects for 48 hours after surgery. The definition of each usage pattern is as follows: total dose, total dose of local anesthetic administered for 48 hours after turning on the portable electronic injection pump; nightly dose, local anesthetic dose used from 10 p.m. to 6 a.m. the next day; frequency of bolus injection, frequency of bolus use in 48 hours after switching on the portable electronic injection pump; frequency of using bolus at night, frequency of bolus use from 10 pm to 6 am the next day. The analysis program used Acculinker, version 1.0 .t test was used for the numerical data, and the Chi-squared test was used for categorical data. A t test was used to compare the VAS score and total dose of local anesthetics. The incidences of adverse events, patient satisfaction with postoperative pain management, times of bolus injection using a local anesthetic delivery injection pump, and rescue analgesic administration were compared using the Chi-squared test or Fisher’s exact test. Statistical significance was set at P < .05.Statistical analysis was performed using IBM SPSS Statistics for Windows, version 27.0, . For the demographic data, a Student’s , the sample size was calculated with a standard deviation of 2.2 and a type I (α) and type II (β) error of 0.05 and 0.2, respectively. A total of 76 patients were recruited, of which 38 were assigned to each group.This study compared post-thoracotomy pain during the nighttime between 2 groups. The 2 groups assumed a clinically significant difference when the average difference in VAS measured after 12 hours of surgery was 1.5 or more. As the VAS was measured at 6.5 ± 2.2 in a previous studyThis study included 76 patients. There were 3 eliminated patients in both groups. Two patients in group A stopped infusion into the epidural catheter due to breathing difficulties, and one patient dislodged the epidural catheter unexpectedly. One patient in group B was hospitalized in intensive care for a long period of time after surgery due to intrathoracic surgical site bleeding, and 2 patients dislodged the epidural catheter unexpectedly. Two patients who were stopped due to breathing difficulties and 3 patients who dislodged the epidural catheter were replaced by opioid-based intravenous patient-controlled analgesia Fig. . There wP = .009, Fig. The VAS when the patient could communicate voluntarily after admission to the PACU, at POD 0 night, POD 1 day and night, and POD 2 day were shown in Fig. P = .005). On POD 1 night, the time to fall asleep did not make a difference, but the total sleep time was longer in group B (P = .042). When the researcher asked patients about the reason they woke up during the night, the percentage of respondents who said they woke up due to pain was higher in group A than in group B on POD 0 night (P = .002, Table The comparison of sleep conditions between the 2 groups showed no difference in the time to fall asleep and total sleep time. On the other hand, awakened from sleep showed a lower incidence in group B than in group A, and the quality of sleep was also more satisfactory for group B on POD 0 night (P = .018, Table Adverse events, including PONV, urinary retention, dizziness, and paresthesia were evaluated. Other adverse events did not show a difference between 2 groups, but PONV occurred more frequently in group B than in group A (–12This study was conducted to investigate the effects on patients through various observations of postoperative pain management when applying the PIEB injection with a patient-controlled analgesia device in patients who underwent open thoracotomy. Although postoperative pain management through epidural injection has already been proven to be effective, the results of each difference and the pros and cons of drug injection techniques remain unknown. However, several recent studies on PCEA have shown that the PIEB injection of the PCEA reduces motor block and shows a better analgesic effect. Meanwhile, the other study showed the limitation of continuous infusion of epidural technique, which is ununiformed spreading with inked injection to cadavers.A study has been demonstrated that the use of intermittent epidural bolus injection may result in a more extensive spread of local anesthetic in the epidural space due to the pressure effect. Furthermore, it is associated with a reduced dose of local anesthetic and better patient satisfaction than continuous epidural infusion. In the control of labor pain, a study showed that the PIEB injection had a lower rate of breakthrough pain and reduced the use of additional analgesics compared to the continuous epidural injection, whereas another study showed that the PIEB injection had less motor block, but there were no significant results in other outcomes. In gynecologic surgery, some studies showed that the PIEB injection used less total local anesthetic for 40 h after surgery and lower postoperative pain intensity. In thoracic surgery, the PIEB injection reduced the amount of local anesthetic, but the frequency of adverse events, such as hypotension, increased.In this study, the PIEB injection showed less pain at POD 1 night compared to the continuous epidural injection. However, there was no difference in the incidence of patients requiring additional analgesics within 48 hours after surgery when postoperative pain control was not satisfactory between 2 injections. When comparing the administration of the drug through the PCEA device in the 2 injections, the total consumption of local anesthetics and frequency of bolus injection in case of breakthrough pain did not show significant differences. Regarding the incidence of adverse events, the PIEB injection had a higher incidence of PONV. The results of this study were similar to those of previous studies but also showed contradicting results. In major abdominal and gynecological cancer surgery, the PIEB injection had fewer bolus uses, but there were no significant results in other outcomes, including additional morphine requirements and pain scores. There are various factors that affect the decline in sleep quality, but the greater the number of major surgeries, the greater the contribution of postoperative pain. Therefore, open thoracotomy with severe pain is likely to have a quality decline in sleep, and paradoxically, it can be an evaluation factor for pain control. In this study, local anesthetics were administered through an epidural catheter at intervals of 3 hours in the program using the PIEB injection to prevent patients from waking up due to pain during the night after the operation. It is assumed that local anesthetics are administered at a certain time before the patient wakes up in pain, which will improve the quality of sleep. Our research findings showed that the use of the PIEB injection resulted in less waking up on POD 0 due to pain, resulting in more satisfactory quality of sleep.Postoperative sleep disturbance is a problem that occurs frequently to the patients, and it is an element that can adversely affect prognostic cases in severe cases.In previous studies, if the PIEB injection was mainly evaluated for postoperative pain improvement, our study included not only pain improvement but also quality of sleep as an evaluation item, which is meaningful in that postoperative pain was evaluated in multiple ways, not just by scoring it.,17 In this study, there was no significant difference in the required additional analysis within 48 hours after surgery, and there was no significant difference in the total dose and frequency of bolus injection of local anesthetic into the epidural space, but there was a difference in PONV. When the PIEB technique is applied, the infusion rate is increased, and the drug spreads to high levels in the epidural space, causing hypotension, which seems to be the cause of PONV. In an article comparing the effects of PIEB technique during thoracic surgery, it was reported that hypotension was more common than the continuous infusion technique, and the incidence of hypotension was lower when the local anesthetic was slowly injected.Among the adverse events in this study, PONV was higher in patients who underwent the PIEB technique. Other studies using the PIEB technique have reported no significant difference compared to continuous infusion.As a limitation of this study, only the pain control effect of the PIEB injection was limited to improving sleep quality. It is considered that the effect on the improvement of the patient’s prognostic improvement will also be studied more diversely, and physiological functions such as postoperative lung capacity and respiratory function recovery, behavior, and activity conditions will be assessed extensively. In evaluating the patients’ sleep condition, the investigator obtained the results through a survey that relied on the patients’ subjective memory. In addition, our study lacked the number of samples, thus, it is necessary to study a larger sample. Some parameters such as night PCEA drug dose, frequency of bolus at night, and others are expected to be statically meaningful with large sample sizes. During the procedure, since the thoracic epidural catheter insertion is a procedure with large failure rates and adverse events, there is a need for a study that assesses the negative factors such as the successful post-procedural pain aspects, PONV, hypotension, and the procedure itself.In conclusion, the PIEB injection of PCEA reduces postoperative pain and improves sleep quality in patients who underwent thoracotomy for lung cancer or other lung diseases. This reduction in pain and improvement in sleep quality are due to PIEB injection that automatically administer bolus even during sleep, reducing the frequency of waking up from complaining of pain during sleep.Conceptualization: Su-Sung Lee, Gyeong-Jo Byeon.Data curation: Hye-Jin KimFormal analysis: Su-Sung Lee, Gyeong-Jo Byeon.Investigation: Ji-Hye Baek, Soon-Ji ParkMethodology: Su-Sung Lee, Gyeong-Jo Byeon.Supervision: Hee-Young KimWriting—original draft: Su-Sung Lee, Gyeong-Jo Byeon.Writing—review and editing: Gyeong-Jo Byeon.


Rapid-onset opioids (ROOs) are effective treatments for breakthrough cancer pain (BTcP) given their rapid onset of action and relatively short duration of analgesia. The aim of this article is to describe specific considerations for the use of ROOs in daily practice, focusing on dose titration and treatment of specific populations.We conducted a narrative review on the use of ROOs for BTcP. We selected papers according to the following search terms: “breakthrough cancer pain” and “rapid onset opioids”.ROOs may be considered as the most suitable drugs to treat BTcP and can be used “on-demand”. Several fentanyl formulations are available and have been associated with control of BTcP and with improvement in quality of life. Various titration schemes have been used to optimize ROO dosing; however, a dose-proportional scheme could be considered safe and effective in most patients. Specific formulations may be more suitable for specific patient subgroups; for example, patients with oral mucositis may prefer intranasal to oral formulations. Moreover, elderly patients or those without caregivers should be clearly educated on the use of these formulations. A key element in achieving successful treatment of BTcP is awareness of the barriers to pain management, including poor overall assessment, patient reluctance to take opioids or report pain, and physician reluctance to prescribe opioids.A personalized approach is fundamental when prescribing a medication for BTcP, and careful attention should be given to drug choice and route of administration, and to the need for alternative therapeutic options. While seemingly increased attention is being paid to adequate treatment of cancer pain, the proportion of cancer patients experiencing pain has changed little in recent years, with a high proportion still suffering from moderate to severe pain , 2. In aBTcP can be categorized into spontaneous and incident, where the former is idiopathic and the latter has a trigger such as movement or voiding . IncidenRapid-onset opioids (ROOs) have become a mainstay in the treatment of BTcP. In this article, we review the management of BTcP with the aim of providing specific considerations for daily practice, with a focus on dose titration and the treatment of specific patient groups. We performed a narrative review utilizing PubMed and Google Scholar Databases and identifying papers between 2000 and 2021, with the following search terms: “breakthrough cancer pain” and “rapid onset opioids”.The prevalence of BTcP depends on the individual patient and the specific type of cancer, but it is broadly reported by 40–80% of patients. In a large, pooled analysis of 19 studies, BTcP was reported by 59.2% of patients . In an oAs far as the characteristics of BTcP are concerned, the Italian Oncologic Pain multiSetting Multicentric Survey (IOPS-MS) study showed that among 1,500 patients BTcP occurred with a mean of 2.5 episodes per day, had a mean intensity of 7.5 on a scale from 0 to 10, and a mean duration of 43 min. Moreover, BTcP was predictable in one-third of cases . PatientBTcP is characterized by rapid onset and short duration over a background of well controlled persistent pain. Oral morphine should not be considered for the treatment of unpredictable BTcP, as the time to pain relief is usually more than 30 min , so woulA number of formulations of fentanyl are currently approved for the treatment of BTcP. These include oral transmucosal fentanyl citrate (lollipop format), fentanyl buccal tablet, fentanyl buccal soluble film, and sublingual fentanyl, in addition to nasal transmucosal formulations . A largeIt is widely believed that the dose of all opioid rescue medications should be determined by individual titration . When teThe use of a dose titration scheme and the titration protocol itself have varied somewhat among different studies. In some trials, the effective dose was considered as that allowing successful treatment of two consecutive episodes of BTcP .Furthermore, there has been some discussion about the use of proportional dosing , 30. It Each of the available formulations of rapid-onset fentanyl has characteristics and advantages that may render it more suited for some specific patient groups as highlighted below . HoweverMany patients undergoing radiotherapy and/or chemotherapy will experience painful oral mucositis to different degrees . The ratIn patients without caregivers, the choice of formulation obviously depends on the patient's preferences and functional abilities . All oraThe proportion of elderly people who experience pain is already high in those without cancer, but increases further in the presence of cancer , 42. Trevia the human cytochrome P450 3A4 isoenzyme system (CYP3A4), and thus potential drug-drug interactions may occur in patients cotreated with drugs that are CYP3A4 inhibitors or inducers  should be avoided. Lastly, it has been reported that drug interactions are unlikely to alter the onset or duration of analgesia, but they may affect its duration .Psychological symptoms such as anxiety and depression are common in cancer patients and have a significant negative impact on daily activities and functioning . While aWhile idiopathic BTcP is unpredictable, incident BTcP can be predicted. Any episode of pain that is linked to diagnostic or therapeutic procedures may be considered as BTcP. Often this pain is underestimated because diagnostic procedures and therapies are considered the main objective, so providers may give less consideration to procedure-related symptoms experienced by patients. Examples of these types of pain have been reported in detail, and can occur during procedures such as lumbar puncture, bone biopsy, endoscopy, and tumor embolization . Since tAs in all fields of medicine, adequate knowledge is key in achieving successful treatment. Pain is a complex issue, and its treatment warrants a multidisciplinary approach . PhysiciA survey of eight clinical vignettes among 570 oncologists highlighted knowledge deficiencies in the management of cancer pain, underscoring the need for improving knowledge on pain management through educational activities . LikewisWhile there is some evidence to suggest that overall knowledge is improving, gaps still remain and more education is needed in order to increase adherence to current guidelines and to optimize management of BTcP, especially considering that a number of valuable therapeutic options are currently available.A personalized approach is fundamental when prescribing a medication for BTcP, and careful attention should be given to drug choice and route of administration, and to the need for alternative therapeutic options. Clinicians should be confident that background pain medication has been optimized before prescribing any drug for BTcP. Attention should be given to the specific characteristics of the BTcP , possible clustering, underlying disease, adherence to medication regimens, and formulation preferences. In this regard, some patients may find inhalatory medications difficult or uncomfortable to use, and patients with severe mucositis may prefer to avoid oral formulations.Any decision regarding the use of a specific rescue medication for treatment of BTcP, usually an ROO formulation, should be based on four factors: (1) the characteristics of the BTcP, including duration and time to peak intensity; (2) the drug's characteristics, attempting to match the pharmacokinetic profile to the patient's BTcP; (3) previous responses to opioid therapy ; and (4) the patient's preference for route of administration. Additionally, more attention should be focused on the inappropriate use and misprescribing of all opioids. Patients must be evaluated for possible misuse, and be carefully assessed for risk factors of abuse and aberrant behavior . Some ceLooking forward to the future, recent studies have suggested that the optimal dose of BTcP opioids might depend on the dose of background opioids . If confThere are still a few unanswered questions regarding the management of BTcP and the possible impact of an optimal pain control on anticancer treatment tolerability and treatment intensity. It has not still been clearly defined whether a better pain management, including background and breakthrough cancer pain, could translate into greater adherence to oncologic therapy and definitely into higher possibility of obtaining tumor response.Another debate regards the possible immune depressing activity of opioids, thus potentially harming cancer patients under immune checkpoint inhibitors (ICI) treatment. This possible interaction has been demonstrated both as a repressive effect on the immune system and as a dysregulation of gut microbiota leading to an indirect effect on ICI effectiveness . While tvia the oral  and nasal transmucosal routes, thus allowing for a personalized approach when prescribing these medications. Careful attention should be paid to drug choice, route of administration and dose titration, as well as the need for alternative therapeutic options, as the tailoring of treatment approaches is essential to allow patients with BTcP to experience good pain control and thus improved quality of life. There are still a few unanswered questions about the interaction between opioid use and anticancer treatments that need to be fully investigated.ROOs have proven efficacy in the treatment of BTcP and they are available in a variety of formulations including for administration The paper was designed by and written with the contribution of all the authors. All authors discussed the content, commented on all drafts of the manuscript, contributed to the article, and approved the submitted version.This study was supported by an unrestricted grant from Angelini Pharma. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.The authors are fully responsible for all content and editorial decisions for this manuscript.PB has participated in advisory boards or received conference honoraria from Angelini and Molteni. YE has participated in advisory boards or received conference honoraria from Angelini, Kiowa Kirin, Grunenthal, Ferrer, Mundipharma, Vifor Pharma, Tesaro, Mylan, Merck Serono, Merck Sharp & Dome, BMS, Sanofi Aventis, and Astra Zeneca. FP has participated in the speaker bureau for Angelini, Basilea Pharmaceutica, Gilead, Hikma, Merck Sharp & Dohme, Nordic Pharma, Pfizer, and Sanofi Aventis, and in advisory boards for Angelini, Basilea Pharmaceutica, Correvio, Gilead, Merck Sharp & Dohme, Nordic Pharma, Novartis, Pfizer, and Thermo-Fisher.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


We aim to report the incidences of ED visits due to back pain, hospitalizations, and urgent spine surgeries during the first and second waves of COVID-19 in Finland. The number of emergency department visits and hospitalizations due to back pain as well as urgent spine surgeries in the adult population was collected from hospital discharge registers for the years 2017 through 2019 (reference years) and 2020.This study was conducted at three large Finnish hospitals. The monthly incidence with 95% confidence intervals (CI) of emergency department visits and hospitalizations due to back pain and spine surgeries in the three participating hospitals were calculated and compared by incidence rate ratios (IRR).Visits to ED due to back pain decreased during the pandemic. The incidence of ED visits due to back pain was similar in February , but a decrease was seen after lockdown began  compared to the reference years. A second decrease in visits was seen after regional restrictions were implemented in October . The most common diagnoses were non-specific back pain, lumbar disk herniation, and back contusion. Incidence of non-specific back pain decreased during the lockdown  and regional restrictions , whereas the rates of other diagnoses remained unchanged, and incidences of hospitalizations and urgent spine surgeries remained stable.A clear decrease in ED visits due to back pain was seen during the first and second waves of the pandemic. This decrease was mainly the result of patients with non-specific back pain avoiding visits to the ED. The incidence of specific back pain, hospitalizations, and urgent spine surgeries remained unchanged during the pandemic. Thereafter, guidelines emphasizing social distancing as a necessary strategy to reduce viral spread resulted in a rapid decrease in the number of COVID-19 cases. At the time of the lockdown in March, schools were closed, gatherings were limited to up to 10 persons, and public indoor premises were closed. In addition, traveling was restricted from March to June. Schools were reopened in mid-May.The rapid spread of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), more commonly known as COVID-19, has impacted health care across the world.The second wave of COVID-19 infections began in Finland in the fall of 2020. However, no state of emergency was declared. Instead, targeted regional restrictions were implemented, where necessary. Furthermore, the Finnish Institute for Health and Welfare (THL) recommended the wearing of facial masks for individuals 15 years and older in situations where keeping a safe distance was not possible. The epidemiologic situation was divided into three levels: base level, acceleration level, and spreading level.–5 During the first wave of the COVID-19 pandemic, however, a clear reduction in the number of ED visits due to lower back pain was reported.,7Back pain is a common complaint in the adult population and also a major cause of emergency department (ED) visits.,9 with the exception of the number of surgical decompressions performed for cauda equina syndrome, which did not decrease during the first wave of the COVID-19 pandemic.The COVID-19 pandemic also decreased the volume of spine surgeries performed,The aim of this study is to evaluate the incidence of ED visits and hospitalizations due to back pain and the rates of urgent spine surgery during the first and second waves of the COVID-19 pandemic in Finland.2 The number of emergency department visits and hospitalizations due to back pain as well as emergency spine surgery in the adult population (age 18 or older) was collected from patient information systems using the International Classification of Diseases 10th Revision (ICD-10) diagnostic codes for back pain. As our aim was to include all emergency department visits and operations due to back pain, we gathered all patients with spine specific ICD-10 codes , Mikkeli Central Hospital (secondary level unit with integrated primary care ED), and Central Finland Hospital (secondary level unit with integrated primary care ED) cover a catchment area of approximately 900,00 inhabitants. procedure codes (Finnish version). Spine surgeries were classified into the following groups: disk surgery, decompression, fracture, fusion, and other (Table Information on and the number of urgent spine surgeries (delay less than 14 days) during the year 2020 and the reference years were retrospectively collected and confirmed from the electronic medical record systems of the participating hospitals using NOMESCO Classification of Surgical Procedures (NCSP)Hospitalizations were classified into two groups: patients with non-specific back pain and patients with other back pain including all other reasons. Monthly incidences with 95% CI were counted per 100,00 person-months by Poisson exact method and compared by incidence rate ratios (IRR). The analyses and figures were performed using R version 3.6.2 .3A total of 4310 visits due to back pain occurred during the year 2020, and 376 urgent spine surgeries were performed during the same period. The mean age of patients visiting ED unit due to back pain was 54 years and 55% of them were women. For urgent spine surgeries, the mean age of patients was 56 years and 57% of them were men. During the reference years (2017–2019), the mean number of visits due to back pain was 4884 and 307 for urgent spine surgeries.The incidence of ED visits due to back pain decreased during the first and second waves of COVID-19 pandemic (Fig. The most common reasons for visits to the ED due to back pain were non-specific back pain, lumbar disk herniation, back contusion, and lumbar spine fracture Fig. B. The inThe incidence of hospitalizations remained stable during the COVID-19 pandemic Fig. . The IRRThe incidence of all urgent spine surgeries remained at the same level in comparison to the reference years Fig. A. In the4,7,14 In February and March, ED and ICU personnel were redeployed due to COVID-19, and citizens were advised to avoid all non-necessary health care visits. These steps likely led to a decreased number of visits to EDs due to nonspecific back pain, which may reflect the decreased willingness of patients with minor conditions to visit the ED. Further, the incidence of lumbar disk herniations, back contusions, and lumbar spine fractures were similar when compared to the reference years, indicating that patients with severe back pain visited the ED at a rate similar to that before the pandemic.The results of this study show that the incidence of visits to the ED due to back pain decreased during the first and second waves of the pandemic. Previous studies investigating the first wave of the COVID-19 pandemic have reported similar findings. However, the literature describing the changes in neurosurgical procedures during the COVID-19 pandemic has reported increased surgical cancellation rates and a decline in the number of operations, especially elective operations.–17 The stable number of urgent spine surgeries may indicate that cancellations of elective spine surgery have not caused patients on waiting lists for surgery to shift to become emergency patients. It may also be the case that a some of the elective operations may have been reorganized to emergency operations. However, we did not address this issue in our study.Consequently, during the study period, the incidence of hospitalizations and spine surgeries remained stable in comparison to the reference years. This also supports the finding that similar numbers of patients with severe pain and prominent symptoms were admitted to EDs in spite of the COVID-19 pandemic. A similar finding was reported in a previous study that showed that the volume of surgical decompressions performed for cauda equina syndrome did not decrease during the first wave of the COVID-19 pandemic.The strengths of our study include the broad data that included all visits and surgeries due to back pain in three large Finnish hospitals during the years 2017–2020. The data were comprehensive, and all patients within the study hospital districts were admitted to the study hospitals. Furthermore, we were able to collect follow-up data from all patients during the first and second waves of the COVID-19 pandemic. Our current study also has some limitations. The ICD-10 diagnostic codes for back pain only include specific codes and do not accurately define symptoms. Therefore, non-specific back pain includes a variety of symptoms. We were not able to use imaging to categorize the patients since we did not have access to imaging data. Even though we collected all the ED visits due to back pain and all spine surgeries from the three large study hospitals, data from those patients who received treatment only in primary health care and were not admitted to hospital are lacking. However, as all patients with severe symptoms are referred to our study hospitals, the missing data might only concern the number of patients with unspecific, non-severe back pain.In conclusion, the incidence of ED visits due to back pain decreased during the first wave of COVID-19 pandemic. A decrease was also seen during the second wave of pandemic. The decrease in incidence can be explained by patients with non-specific back pain avoiding visits to the ED. The incidence of hospitalizations and urgent spine surgeries did not, however, change during the pandemic. The results of this study can be used when preparing for future pandemics and additionally when planning ED triage for patients with back pain, as severe cases were still treated during the pandemic.Data curation: Saara Jäntti, Ville PonkilainenFormal analysis: Saara JänttiInvestigation: Heikki Mäntymäki, Ilari Kuitunen, Saara Jäntti, Ville Mattila, Ville PonkilainenMethodology: Ilari Kuitunen, Mikko Uimonen, Saara Jäntti, Ville Mattila, Ville PonkilainenProject administration: Ville MattilaResources: Saara JänttiSupervision: Heikki Mäntymäki, Ilari Kuitunen, Ville Mattila, Ville PonkilainenValidation: Heikki Mäntymäki, Mikko UimonenVisualization: Saara JänttiWriting – original draft: Saara JänttiWriting – review & editing: Heikki Mäntymäki, Ilari Kuitunen, Mikko Uimonen, Ville Mattila, Ville Ponkilainen


P ≤ .001) and lower cumulative opioid use than the EA group (P < .001). We found no difference in infection parameters, length of hospital stay or surgery-related complication rates. Our data demonstrate that epidural anesthesia was inferior to an opioid-based SA regime in reducing postoperative pain in patients undergoing spinal surgery. There is no benefit to the use of epidural catheters.Spinal dorsal instrumentation (SDI) is an established treatment for degenerative spinal diseases. Adequate and immediate postoperative pain control is important for patient recovery and may be compromised by uncertainty about its efficacy and concern about early postoperative surgical complications or adverse events. The aim of the current study was to compare the use of epidural analgesia (EA) with systemic analgesia (SA) as regards pain reduction and early postoperative complications after SDI. Pain management with epidural or systemic analgesia in patients undergoing SDI by posterior approach between January 2019 and July 2020 was evaluated by clinical functional testing, measuring total opioid amounts used, and evaluating numerical rating scale values 24 and 96 hours postoperatively. The following were also monitored: demographic data, number of affected segments, length of hospital stay, inflammatory markers (leukocytes and serum C-reactive protein), early postoperative surgical complication rates, and adverse events. In total 79 patients were included (33 in the EA and 46 in the SA group). The SA group had significantly lower numerical rating scale values at days 1 to 4 after surgery ( We also considered adverse effects and surgery-related postoperative complications.This retrospective single center cohort study evaluated postoperative pain management and analgesia regimes  in patients at our spine center after spinal posterior open instrumentation with or without interbody fusion of the lumbar spine between January 2019 and July 2020. Indications and inclusion criteria for surgery were spinal canal stenosis with spondylolisthesis and degenerative disc disease, all patients should have symptoms as back and/or leg pain, they should be treated maximal conservative with medication and physiotherapy before the operation, and the patients have no quality of life because of pain or neurological symptoms. Exclusion criteria were an incomplete medication history, an anesthetic or opioid allergy, and a history of chemical dependency. Furthermore, patients with other spinal pathologies  were excluded. Figure  was undertaken in our center. Early postoperative complications (both surgery-related and adverse events) were assessed using a publicly available list from the Agency for Healthcare Research and Quality and the Center for Medicare and Medicaid Services. They are referred to as patient safety indicators and hospital-acquired conditions.–22Records of patients undergoing spinal surgery were screened for the following: demographic data , type of analgesia regime, number of operated levels, operation duration, numerical rating scale (NRS) score, amount of opioid use, postoperative time between surgery and mobilization, preoperative use of opioids, and total length of hospital stay. Preoperative systemic inflammatory laboratory parameters such as white blood cell count and serum C-reactive protein were documented. Standard laboratory investigation of inflammatory markers , 1500 mg paracetamol or 90 mg codeine (3 × 500 or 3 × 30mg), 750 mg methocarbamol in the evening for muscle relaxation, and 40 mg pantoprazole, regardless of which analgesia regime was used.All patients were treated prior to surgery with oral pain medication according to world health organization guidelines.-1) was administered via an automatic pump with a starting rate of 14 mg/hour. Postoperative pain was measured with the NRS and a cold discrimination dermatomal test was performed 3 times per shift for the first 24 hours, then once per shift for the next 72 hours. Where pain relief was inadequate, the infusion rate was increased until functional failures occurred such as motor disorder or paresthesia. Patients could additionally receive parenteral piritramide  via a 15 to 30 minutes intravenous infusion in the interval of 4 to 6 hours. The epidural catheter was removed after the third day in all cases. Before removing the EC, Ropivacaine was reduced in steps of 2 to 4 mg according to the patient wishes.In the case of patients receiving epidural analgesics, a 16-gauge Portex catheter was placed in the epidural space under direct vision on completion of the surgical procedure in the operation segments or 1 segment above it. The epidural catheter was threaded through a skin puncture about 3 cm away from the surgical incisions to avoid inadequate surgical wound compression. Ropivacaine .2)] minimum 45 minutes interval was. routinely measured in both groups.To avoid respiratory failure, a mandatory [blood oxygen saturation  and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Study design: Retrospective clinical cohort study. The investigation was approved by the local ethics committee (protocol no. 084/21).® SPSS® Statistics V22.0 . In the descriptive analysis, the median distribution of continuous variables is presented along with the interquartile range , and the total number of categorical variables per category is presented along with the percentage. In the case of categorical variables, data are given as numbers and percentages. After normality testing via the Shapiro–Wilk test, continuous normally distributed data were compared using t tests, while the Mann–Whitney U test was used for non-parametric data. Nominal data was tested between groups using the Fisher´s exact test and in case of multinomial data with a Chi2-test. Univariate analysis using Fisher exact (2-sided) and independent t test was conducted. A P < .05 was considered significant.All analyzed data were performed using IBMA total of 79 patients were surgically treated between January 2019 and July 2020 and included in the study. The patients, who were aged 47 to 87 years, underwent reconstructive thoracolumbar surgery. Table P ≤ .001) and felt more pain from the first day after the operation (P ≤ .001) until the 4th day (P = .004). The percentage of patients who needed additional opioids after surgery was 90.9% in the EA group and 76.1% in the SA group. Figure P = .003), were able to leave their beds in < 24 hours after surgery compared to 24 to 48 hours with epidural analgesia (P ≤ .001), and needed less opioids  in total (P ≥ .001). We found no difference in blood cell count or C-reactive protein after surgery between the groups. Furthermore, we found no significant difference between the groups regarding hospital length of the stay or surgery-related parameters such as the number of stabilized segments, duration of operation, or complications; there was also no difference in the rate of adverse events, the revision rate or mortality.Our patients were divided into 2 groups, with the EA group receiving epidural analgesia via epidural catheter, and the SA group receiving IV systemic analgesia. Table Furthermore, we found no significant difference between the 2 groups in the short-term 3-month follow-up after surgery. There is an overall improvement in function .,11,27 Since the 1980s, many studies involving adult patients have compared the effectiveness of epidural and IV systemic analgesia, although not specifically considering patients with spinal surgery.–31 The optimal pain management and analgesia treatment after lumbar spine surgery with instrumentation and fusion in combination with spinal canal decompression remains a subject of debate.,33 Intrathecal analgesia approaches are various and include long-acting amide local anesthetics, intrathecal morphine, or a combination of both. Systemic analgesia uses a combination of non-steroidal anti-inflammatory drugs and stronger opioids. In the more recent past analgesic adjuncts such as ketamine, gabapentin or dexmedetomidine have shown benefit. While some reviews recommend epidural analgesia in spinal surgery,–38 some authors found only a modest and inconsistent clinical effect in pain reduction using epidural compared to intravenous SA techniques.,37Multilevel lumbar spine surgery results in severe pain lasting into the second postoperative day, with moderate pain persisting for up to 1 week after surgical treatment. described the use of epidural buprenorphine versus intramuscular morphine after spinal fusion surgery and reported that both produced excellent, equivalent analgesia.In this study, the epidural analgesic solutions revealed no significant improvement in postoperative pain control over IV analgesics alone for patients with posterior spinal fusion. We found a significant higher NRS score in the first 4 days for patients with EA than with SA, suggesting that the epidural option provided inadequate pain relief in patients after spinal surgery. This finding is contrary to our hypothesis, that patients with EC and supplementary SA would need less opioid medication than patients with SA alone. Murphy et al,40 our cohort showed the opposite. On the 1 hand, the patients may not receive enough pain medication from the epidural catheter, although 2 of 33 patients already suffered from temporary neurological deficit. It tempting to speculate, that the dorsal surgical approach might affect the posterior branches of the spinal nerves and that nerval trauma cause pain itself. Patient might more likely benefit from sedative and anxiolytic effects of the opioids itself then from the analgetic effects. Our hypothesis for the delayed mobilization of the EA group is the patients fear of dislocating the catheter. The fear of mobilization combined with the high need for pain medication resulted in the high dose of opioids and high NRS scores seen in our data on the group with the epidural catheter. Another possible reason why patients in the EA group needed more IV piritramide was that, this group of patients was more controlled due to the EC and were asked more often for pain and analgesia. We also think that the placing and localization of EC also played a major role in increasing the need of additionally IV analgesia in the EA group.The efficacy of an epidural analgesic should be indicated by the amount of IV medication consumed. In our study, patients with EA required supplemental IV piritramide to provide adequate analgesia after posterior spinal fusion surgery. Although there is a debate about whether EA provides a benefit over SA, A side effect of epidural local anesthetics used in patients undergoing posterior spinal fusion surgery is thigh numbness. Purnell reported a case in 1982 in which a patient received epidural bupivacaine 0.25%  that resulted in motor block lasting for 9.5 hours.Although intrathecal opioids have numerous advantages over systemically used opioids, reported side effects are similar to systemic opioid analgesia and include urinary retention, pruritus, nausea, unreliable delivery systems, and respiratory depression. evaluated thoracic EA versus IV analgesia in adolescents undergoing posterior spinal fusion. Although both methods were comparably effective and safe, the return of bowel function with EA accelerated recovery and speed of hospital discharge. They left this finding open to interpretation, but felt it could suggest that a primary limiting factor in postoperative recovery  is favorably impacted by epidural analgesia.In a small prospectively randomized comparison Cassady et alThe results of our data have changed our procedure. We do not use more EC after dorsal instrumentation. We are in the process of establishment an algorithm for SA, we hope to publish these results in the future.The present study has several limitations. Acquisition of data was retrospective. Furthermore, patients were not randomized, but treated according to the expert opinion of their neurosurgeon. Additionally, the present data represent only a single center experience. We have placed the catheter on the operated segments, or just 1 segment above it, this may have been the major reason why the patients who received epidural analgesics had inferior outcomes in this study. Other main limitation is the small number of cases in each group. Thus, the study might not have had sufficient power to detect smaller differences between the groups.,45Our Data demonstrate that our cohort has no addiotinally therapeutic benefit from EA with EC. Based on our results, the implantation of the EC schould be discussed critically and open with the patients. Sufficient postoperative SA seems usually to perform well on its own. Our recommendation meets the criteria for a level of evidence 3, based on the publication by Kaiser at al.Conceptualization: Motaz Hamed, Mohammed Banat, Lars Eichhorn.Data curation: Motaz Hamed, Lars Eichhorn.Formal analysis: Tim Lampmann, Martin Müller, Lars Eichhorn.Methodology: Motaz Hamed.Project administration: Motaz Hamed, Mohammed Banat.Resources: Motaz Hamed, Hartmut Vatter.Supervision: Mohammed Banat, Lars Eichhorn.Validation: Mohammed Banat.visualization: Mohammed Banat.Writing – original draft: Lars Eichhorn.Writing – review & editing: Motaz Hamed, Harun Asoglu, Tim Lampmann, Lena Marie Winkelmann, Abdallah Salemdawod, Mohammed Banat, Lars Eichhorn.


Aim: To compare the efficacy of postoperative analgesia using ketorolac and ketoprofen after UP3. Patients and Methods: A prospective, randomized, double-blind study was made of 24 patients that were divided into 2 groups (14 received ketorolac and 10 received ketoprofen). Pain intensity was based on an analog visual scale and the need for opioids (tramadol). Results: Of the 13 patients that received ketorolac, 3 (21%) required opioids; 7 of 10 (70%) patients in ketoprofen group used opioids. 12 hours after surgery, 71% of the patients that received ketorolac had mild or absence of pain. 70% of the ketoprofen users reported moderate to significant pain. 24 hours after surgery, 60% of the patients using ketoprofen reported moderate to significant pain, while 86% of the ketorolac users reported mild or absence of pain. Conclusion: We concluded that ketorolac is more effective compared to ketoprofen in the treatment of immediate postoperative pain after UP3, as patients using ketorolac had less pain and used opioids to a lesser degree.Postoperative pain is a serious problem, requiring an appropriate response from the medical doctor. In otolaryngology special attention is needed after uvulopala topharyngoplasty (UP3).  Pain is defined as an unpleasant sensory and emotional experience resulting from, or described in terms of, true or potential tissue injury. Pain sets in motion mechanisms in the body that result in incapacity and adverse biopsychosocial effects.The intensity and expression of pain vary considerably between subjects and between animal species. It is also affected by environmental, racial, religious, cultural, and philosophical factors, and by past experience and the mental state.2Measurement of pain is essential for its treatment. Being a subjective experience, pain cannot be measured objectively by physical instruments such as those that measure weight, temperature, and blood pressure. On the other hand a variety of tools for assessing subjectivity are available that allow patients to measure the intensity of pain with little mental or physical effort. Various scales are available: the Verbal Rating Scale, the Pain Relief Ordinal Scale, the Numeric Rating Scale, the Visual Analog Scale, and the Faces Pain Scale. Any pain assessment process should be systematic and continuous, and should be reported so that there is an effective contribution to the treatment of pain.Immediate postoperative pain (during the first 24 hours) is a difficult daily problem that requires adequate support from physicians. Special attention is required for the treatment of pain in otorhinolaryngology following tonsillectomy and uvulopalatopharyngoplasty (UPPP). UPPP is a procedure done by otorhinolaryngologists as an option to treat the obstructive sleep apnea and hypopnea syndrome (OSAHS). Regardless of the technique, pain after these procedures is classified as moderate to severe.®) is a non-steroidal anti-inflammatory drug (NSAID) that has an analgesic efficacy similar to commonly used opioids, and that recently has found wide acceptance in the treatment of postoperative pain in a variety of surgical procedures. Ketorolac is used for moderate pain relief; it may be used to treat severe pain when associated with opioids, reducing the opioid dose. The advantage of this association is the reduction of opioid side effects such as respiratory depression, pruritus, urinary retention, sedation and nausea.Various analgesic drugs have been used against postoperative pain following UPPP. Ketorolac tromethamine  and ketoprofen , and the need for rescue medication with an opioid (tramadol).The analgesic drug for each patients was chosen randomly based on the last digit of their medical chart number .Before surgery, the medical team handed a form over to the patient and family member containing their name, age, chart number, type of surgical procedure, analgesic medication used, and the visual pain scale; instructions on how to fill in the form correctly was given at this time. Furthermore, patients were told that if excessive pain was felt, they should call the nurse; the nurse would inform the medical team and administer tramadol.UPPP was done under general anesthesia to which was added local infiltration of bupivacaine 0.5% with adrenalin 1:80.000 on the base of the uvula and the palatine arch. Oblique bilateral incisions were made on the superior portion of the tonsillar pillars, followed by partial sectioning with electrocautery of the uvula. Vicryl 3.0 sutures were made on the posterior and anterior pillars.Results were assessed statistically using the chi-squared and Student’s t-test. The trial was approved by the Research Ethics Committee of the institution and given the number 025/04.UPPP was done on 24 patients, of which 14 received ketorolac and 10 received ketoprofen. The groups were compared according to gender and number of patients. There was no significant difference between the number of patients in each group, but males predominated in both groups .Table 1DTwenty one percent of 14 patients that received ketorolac used opioids postoperatively. Seventy percent of 10 patients that received ketoprofen used opioids for the treatment of postoperative pain following UPPP (p < 0.01) .Table 2DThe visual analog scale and the verbal rating scale revealed significant differences in the analysis of pain intensity 12 and 24 hours after surgery. Twelve hours postoperatively, mild or absent pain was present in 71% of patients that were medicated with ketorolac, and moderate or annoying pain was present in 70% of patients that were medicated with ketoprofen  p < 0.0  found that ketorolac was more effective than acetaminophen in the treatment of postoperative pain following tonsillectomy in children.Tarkkila and Saarnivaara (1999)O’Donovan et al.Many papers have shown that ketorolac used in subjects below 65 years, at an average dose of 100 mg/day or less, during 5 days or less, was not associated with a detectable increased risk of gastrointestinal or surgical wound bleeding. We concluded that ketorolac is more effective compared to ketoprofen to treat immediate postoperative pain following UPPP. Patients medicated with ketorolac had pain of lower intensity compared to those treated with ketoprofen, and required less opioids as supplementary treatment.