Bilateral pedicle stress fracture in the lumbar spine of a sedentary office worker

A case of bilateral pedicle fracture in the lumbar spine of a sedentary office worker is being presented. No such case has been reported in the literature previously. Bilateral pedicle fracture is a rare entity. Few cases have been reported in literature. All the reported cases had some underlying causative factors like degenerative spine disease, previous spinal surgery or stress-related activities, e.g. athletes. Our case is a 36-year-old sedentary office worker with none of the factors mentioned. We present a case of a 36-year-old sedentary worker with long-standing low backache. There were no root tension signs. Plain radiographs were inconclusive. The patient had a CT scan. The CT scan revealed long-standing defects in the pedicles of L2 vertebra with pseudoarthrosis. Infiltration with anaesthetic relieved the symptoms. Our patient was managed conservatively with spine rehabilitation physiotherapy program. Pedicle fracture can develop due to abnormal stresses in the pedicle either because of previous spinal surgery or spondylitic changes in the spine. Bilateral pedicle fracture in the absence of these conditions is extremely rare

Pain control after total knee arthroplasty: a randomized trial comparing local infiltration anesthesia and continuous femoral block

Local infiltration analgesia (LIA) is a new multimodal wound infiltration method. It has attracted growing interest in recent years and is widely used all over the world for treating postoperative pain after knee and hip arthroplasty. This method is based on systematic infiltration of a mixture of ropivacaine, a long acting local anesthetic, ketorolac, a cyclooxygenase inhibitor (NSAID), and adrenalin around all structures subject to surgical trauma inknee and hip arthroplasty. Two patient cohorts of 40 patients scheduled for elective total knee arthroplasty (TKA) and 15 patients scheduled for total hip arthroplasty (THA) contributed to the work presented in this thesis. In a randomized trial the efficacy of LIA in TKA with regard to pain at rest and upon movement was compared to femoral block. Both methods result in a high quality pain relief and similar morphine consumption, but fewer patients in the LIA group reported pain of 7/10 on any occasion during the 24 h monitoring period (paper I). In the same patient cohort the maximal total plasma concentration of ropivacaine was below the established toxic threshold for most patients although a few reached potentially toxic concentrations of 1.4-1.7 mg/L. The time to maximal detected plasma concentration was around 4-6 h after release of tourniquet in TKA (paper II). All patients in the THA cohort were subjected to the routine LIA protocol. In these patients both the total and unbound plasma concentration of ropivacaine was determined. The concentration was below the established toxic threshold. As ropivacaine binds to a-1 acid glycoprotein(AAG) we assessed the possibility that increased AAG may decrease the unbound concentration of ropivacaine. A40 % increase in AAG was detected during the first 24 h after surgery, however the fraction of unbound ropivacaine remained the same. There was a trend towards increased C max of ropivacaine with increasing age and decreasing creatinine clearance but the statistical power was too low to draw any conclusion (paper III). Administration of 30mg ketorolac according to the LIA protocol both in TKA and THA resulted in a similar Cmax as previously reported after 10 mg intramuscular ketorolac (paper II, paper IV). Neither age, nor body weight or BMI, nor creatinine clearance, correlates to maximal ketorolac plasma concentration or total exposure to ketorolac (AUC) (paper IV). In conclusion, LIA provides good postoperative analgesia which is similar to femoral block after total knee arthroplasty. The plasma concentration of ropivacaine seems to be below toxic levels in most TKA patients. The unbound plasma concentration of ropivcaine in THA seems to be below the toxic level. The use of ketorolac in LIA may not be safer than other routes of administration, and similar restrictions should be applied in patients at risk of developing side effects

The effect of local anaesthetic wound infiltration on chronic pain after lower limb joint replacement: A protocol for a double-blind randomised controlled trial

<p>Abstract</p> <p>Background</p> <p>For the majority of patients with osteoarthritis (OA), joint replacement is a successful intervention for relieving chronic joint pain. However, between 10-30% of patients continue to experience chronic pain after joint replacement. Evidence suggests that a risk factor for chronic pain after joint replacement is the severity of acute post-operative pain. The aim of this randomised controlled trial (RCT) is to determine if intra-operative local anaesthethic wound infiltration additional to a standard anaethesia regimen can reduce the severity of joint pain at 12-months after total knee replacement (TKR) and total hip replacement (THR) for OA.</p> <p>Methods</p> <p>300 TKR patients and 300 THR patients are being recruited into this single-centre double-blind RCT. Participants are recruited before surgery and randomised to either the standard care group or the intervention group. Participants and outcome assessors are blind to treatment allocation throughout the study. The intervention consists of an intra-operative local anaesthetic wound infiltration, consisting of 60 mls of 0.25% bupivacaine with 1 in 200,000 adrenaline. Participants are assessed on the first 5 days post-operative, and then at 3-months, 6-months and 12-months. The primary outcome is the WOMAC Pain Scale, a validated measure of joint pain at 12-months. Secondary outcomes include pain severity during the in-patient stay, post-operative nausea and vomiting, satisfaction with pain relief, length of hospital stay, joint pain and disability, pain sensitivity, complications and cost-effectiveness. A nested qualitative study within the RCT will examine the acceptability and feasibility of the intervention for both patients and healthcare professionals.</p> <p>Discussion</p> <p>Large-scale RCTs assessing the effectiveness of a surgical intervention are uncommon, particulary in orthopaedics. The results from this trial will inform evidence-based recommendations for both short-term and long-term pain management after lower limb joint replacement. If a local anaesthetic wound infiltration is found to be an effective and cost-effective intervention, implementation into clinical practice could improve long-term pain outcomes for patients undergoing lower limb joint replacement.</p> <p>Trial registration</p> <p>Current Controlled Trials <a href="http://www.controlled-trials.com/ISRCTN96095682">ISRCTN96095682</a></p

Multimodal Pain Management after Total Hip and Knee Arthroplasty at the Ranawat Orthopaedic Center

Improvements in pain management techniques in the last decade have had a major impact on the practice of total hip and knee arthroplasty (THA and TKA). Although there are a number of treatment options for postoperative pain, a gold standard has not been established. However, there appears to be a shift towards multimodal approaches using regional anesthesia to minimize narcotic consumption and to avoid narcotic-related side effects. Over the last 10 years, we have used intravenous patient-controlled analgesia (PCA), femoral nerve block (FNB), and continuous epidural infusions for 24 and 48 hours with and without FNB. Unfortunately, all of these techniques had shortcomings, not the least of which was suboptimal pain control and unwanted side effects. Our practice has currently evolved to using a multimodal protocol that emphasizes local periarticular injections while minimizing the use of parenteral narcotics. Multimodal protocols after THA and TKA have been a substantial advance; they provide better pain control and patient satisfaction, lower overall narcotic consumption, reduce hospital stay, and improve function while minimizing complications. Although no pain protocol is ideal, it is clear that patients should have optimum pain control after TKA and THA for enhanced satisfaction and function