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Effects of myofascial release in erector spinae myoelectric activity and lumbar spine kinematics in non-specific chronic low back pain: Randomized controlled trial.
Arguisuelas, MD, Lisón, JF, Doménech-Fernández, J, Martínez-Hurtado, I, Salvador Coloma, P, Sánchez-Zuriaga, D
Clinical biomechanics (Bristol, Avon). 2019;:27-33
Abstract
BACKGROUND Flexion-relaxation response of the lumbar erector spinae has been previously studied after different interventions such as exercise programs or spinal manipulation, in subjects with chronic low back pain. The objective of the study was to investigate the effects of an isolated myofascial release protocol on erector spinae myoelectric activity and lumbar spine kinematics in chronic low back pain. METHODS Thirty-six participants, with nonspecific chronic low back pain, were randomized to myofascial release group (n = 18) receiving four sessions of myofascial treatment, each lasting 40 min, and to control group (n = 18) receiving a sham myofascial release. Electromyographic and kinematic variables as well as pain and disability questionnaires were analyzed. FINDINGS There was a bilateral reduction of the flexion relaxation ratio in individuals receiving myofascial release and who did not show myoelectric silence at baseline (right difference M = 0.34, 95% CI [0.16, 0.33], p ≤ .05 and left difference M = 0.45, 95% CI [0.16, 0.73], p ≤ .05). There was also a significant reduction in pain in the myofascial release group (difference M = -9.1, 95% CI [-16.3, -1.8], p ≤ .05) and disability (difference M = -5.6, 95% CI [-9.1, -2.1], p ≤ .05), compared with control group. No significant differences between groups were found for the kinematic variables. INTERPRETATION The myofascial release protocol contributed to the normalization of the flexion- relaxation response in individuals who did not show myoelectric silence before the intervention, and also showed a significant reduction in pain and disability compared with the sham group.
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Intraoperative ketorolac dose of 15mg versus the standard 30mg on early postoperative pain after spine surgery: A randomized, blinded, non-inferiority trial.
Duttchen, KM, Lo, A, Walker, A, McLuckie, D, De Guzman, C, Roman-Smith, H, Davis, M
Journal of clinical anesthesia. 2017;:11-15
Abstract
STUDY OBJECTIVE The primary aim of this study is to show the non-inferiority of 15mg intraoperative dose of ketorolac as compared to the standard 30mg ketorolac by looking at the visual analog scale pain (VAS) scores 4h after an adult spine surgery. DESIGN The study design is a prospective randomized non-inferiority clinical trial looking at non-inferiority of intraoperative 15mg ketorolac from the standard 30mg dose. SETTING Quaternary care center. PATIENTS 50 adult (18-65years of age) undergoing lumbar decompression spine surgery. INTERVENTIONS Group A received a single intraoperative dose of 15mg ketorolac at the end of surgery and group B received single intraoperative dose of 30mg ketorolac. MEASUREMENTS The primary outcome was the visual analog scale (VAS) pain scores 4h after an adult spine surgery. Secondary measures were morphine usage in the first 8 and 24h postoperatively, numeric rating scores (NRS) up to 24h, sedation, nausea, vomiting, respiratory depression, pruritus and bleeding complications. MAIN RESULTS Intention to treat analysis showed a mean increase in 4h VAS pain score of 7.9mm (95% CI: -4.5mm to 20.4mm) in patients administered 15mg ketorolac. This difference was neither statistically (P=0.207) nor clinically significant (<18mm on VAS scale). A similar increase in the 15mg group was noted through a per protocol analysis, 6.9mm (95% CI: -6.6mm to 20.5mm, P=0.307) greater in the 15mg group. Non-inferiority of 15mg was not confirmed. No significant difference was found in secondary endpoints. CONCLUSIONS Ketorolac 30mg intravenous was not superior to 15mg intravenous for post-operative pain management after spine surgery. However, 15mg failed to meet the pre-specified criteria for non-inferiority to the 30mg dose.
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MIS Expandable Interbody Spacers: A Literature Review and Biomechanical Comparison of an Expandable MIS TLIF With Conventional TLIF and ALIF.
Cannestra, AF, Peterson, MD, Parker, SR, Roush, TF, Bundy, JV, Turner, AW
Spine. 2016;:S44-9
Abstract
STUDY DESIGN Biomechanical study and review of literature on expandable lumbar interbody fusion constructs. OBJECTIVE To evaluate the biomechanical stability of expandable interbody devices. SUMMARY OF BACKGROUND DATA Lumbar interbody implants placed from an anterior or lateral approach are desirable due to their large size, providing a stable fusion environment. Posterior implants are typically limited by their access corridor. Expandable footprint transforaminal lumbar interbody fusion (TLIF) interbodies may allow for a minimally invasive TLIF approach with the biomechanical benefits of an anterior lumbar interbody fusion (ALIF)-sized graft; however, this requires experimental investigation. METHODS Six cadaveric L1-sacrum segments were tested intact with pure moments of ± 7.5 N m in flexion-extension, lateral bending, and axial rotation. Specimens received at L4-5 either a medial-lateral expandable TLIF cage (MLX-TLIF) or a conventional polyether ether ketone (PEEK) banana-shaped TLIF cage (Conv-TLIF) first. Both were tested with unilateral and bilateral pedicle screw (PS) fixation. Testing was repeated with the alternate cage and fixation. Motion marker arrays were fixed to L4 and L5 to assess range of motion. Results were compared with published data for a PEEK ALIF cage with anterior plate and a PEEK ALIF cage with bilateral PS fixation, tested under the same conditions. RESULTS The most rigid construct was ALIF with bilateral PS fixation in flexion-extension and axial rotation, whereas MLX with bilateral PS was most rigid in lateral bending. Conv-TLIF with unilateral PS was the least rigid construct. MLX-TLIF with unilateral PS provided similar range of motion to Conv-TLIF with bilateral PS in flexion-extension and lateral bending, and ALIF with anterior plate in lateral bending. CONCLUSION The MLX-TLIF cage with unilateral PS fixation provided comparable stability to conventional TLIF with bilateral PS fixation and ALIF with anterior plate treatments. The large footprint of the expandable cage may reduce the TLIF supplemental fixation demands and facilitate minimally invasive single-position surgery. If needed, additional stability may be achieved by using bilateral PS. LEVEL OF EVIDENCE N/A.
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Liposomal bupivacaine incisional injection in single-level lumbar spine surgery.
Puffer, RC, Tou, K, Winkel, RE, Bydon, M, Currier, B, Freedman, BA
The spine journal : official journal of the North American Spine Society. 2016;(11):1305-1308
Abstract
BACKGROUND CONTEXT Postsurgical pain control is important in spine surgery as it can lead to earlier mobilization, decreased length of stay, decreased side effects from narcotic medications, and improved patient satisfaction. Liposomal bupivacaine (LB) is an injectable formulation of bupivacaine, providing prolonged local anesthesia, up to 72 hours postinjection. Although, LB has been used with increasing frequency following other musculoskeletal procedures, specifically total joint replacements, its pre-emptive analgesic effect following lumbar microdiscectomy has hitherto not been reported. If administration of LB as a pre-emptive analgesic agent at the end of microdiscectomy resulted in reduced postoperative pain, then this could minimize adverse events related to narcotic pain medication use and improve acute clinical outcomes. PURPOSE The aim of the present study was to determine the comparative efficacy of infiltration of a standard dose and volume of LB in a comparative cohort analysis of single-level microdiscectomy procedures. DESIGN The present study made use of mixed prospective/retrospective observational cohort analysis. PATIENT SAMPLE Adult patients presenting with lumbar or sacral compressive disc disease treated with single-level microdiscectomy, at one institution utilizing a standard surgical technique. OUTCOME MEASURES Time spent on intravenous (IV) narcotics postoperatively (primary outcome), postoperative visual analog score (VAS), total morphine equivalent dose of narcotic pain medications, and 30-day emergency room visits for pain control were measured. METHODS Under an approved process improvement project, immediate outcome and process measures for a prospective cohort of 40 patients who received LB field blocks following single-level lumbar microdiscectomy were compared with a historical cohort of 40 patients who underwent the same surgical procedure but did not receive postsurgical infiltration of local anesthetic. All patients received a standard open surgical technique and postoperative convalescence protocol, which included overnight admission, oral narcotic pain medication as needed, scheduled IV ketorolac and IV narcotic pain medication for breakthrough. RESULTS Data from 80 subjects (67 males) operated on between January 2014 and 2015 were compared, including 40 cases, which occurred prior to using LB, and 40 cases after. There was no significant difference between mean age or body mass index (BMI) between groups. Patients who received LB infiltration spent significantly less time using IV narcotics in the postoperative period (LB patients 13.0±2.1 hours vs. non-LB patients 23.3±2.1 hours, p<.001). There was no significant difference noted between VAS at any point in the postoperative period, total injectable morphine equivalent doses, or 30-day emergency room visits for pain. CONCLUSIONS We found that patients who received LB field blocks required IV narcotic pain medication for a significantly decreased length of time (average delta=10.3 hours). Although this is a surrogate for earlier discharge, within the numbers studied, this did not translate into a significantdifference in VAS scores or total morphine equivalents. It is uncertain, if the independent effect of LB may have been masked by the multimodal postoperative pain control protocol in use. Further study is required to best understand the potential benefit of pre-emptive analgesia in elective spine surgery. Its impact would likely be more significant in more invasive procedures.
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Electromyographic assessment of isometric and dynamic activation characteristics of the latissimus dorsi muscle.
Beaudette, SM, Unni, R, Brown, SH
Journal of electromyography and kinesiology : official journal of the International Society of Electrophysiological Kinesiology. 2014;(3):430-6
Abstract
The aim of the current study was to analyze the activation characteristics and potential compartmentalization of the latissimus dorsi (LD) muscle during common maximal voluntary isometric contractions (MVICs) and functional dynamic tasks. Surface electromyography (sEMG) was used to measure activation magnitudes from four electrode sites (referenced to the T10, T12, L1 & L4 LD vertebral origins) across the fanning muscle belly of the LD. In addition, EMG waveforms were cross-correlated to study temporal activation timing between electrode sites (T10-T12, T12-L1, L1-L4 & T10-L4). The MVICs that were tested included a humeral adduction, humeral adduction with internal rotation, a chest-supported row and a humeral extension. Dynamic movements included sagittal lift/lowers from the floor to knee, knee to hip and hip to shoulder. No magnitude-based (p=0.6116) or temporal-based differences were observed between electrode sites during the MVIC trials. During dynamic movements no temporal-based, but some magnitude-based differences between electrode sites were observed to be present; these differences were small in magnitude and were observed for both the maximum (p=0.0002) and mean (p=0.0002) EMG magnitudes. No clear pattern of compartmentalization was uncovered in the contractions studied here. In addition to these findings, it was determined that the most effective MVIC technique for LD EMG normalization purposes was a chest-supported row MVIC, paired with a T12 electrode site.
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6.
Efficacy of intravenous paracetamol and dexketoprofen on postoperative pain and morphine consumption after a lumbar disk surgery.
Tunali, Y, Akçil, EF, Dilmen, OK, Tutuncu, AC, Koksal, GM, Akbas, S, Vehid, H, Yentur, E
Journal of neurosurgical anesthesiology. 2013;(2):143-7
Abstract
BACKGROUND We compared the analgesic effects of intravenous (IV) paracetamol with that of dexketoprofen on postoperative pain and morphine consumption during the first 24 hour after a lumbar disk surgery. METHODS This prospective, placebo-controlled, double blind study investigated the analgesic effects of IV paracetamol and dexketoprofen on postoperative pain, morphine consumption, and morphine-related side effects after a lumbar disk surgery. Sixty American Society of Anesthesiologists 1 or 2 status patients scheduled for elective lumbar disk surgery under general anesthesia were included in the study. Patients were treated using patient-controlled analgesia with morphine for 24 hours after a lumbar disk surgery and randomized to receive IV paracetamol 1 g, dexketoprofen 50 mg, or isotonic saline (placebo). The primary endpoint was pain intensity measured by the visual analogue scale, and secondary endpoints were morphine consumption and related side effects. RESULTS Pain intensity was lower in the dexketoprofen group (P=0.01) but not in the paracetamol group (P=0.21) when compared with the control group. Cumulative morphine consumption and morphine-related side effects did not reveal significant differences between the groups. CONCLUSIONS The study showed that pain intensity during 24 hours after the lumbar disk surgery was significantly lowered by dexketoprofen, but not with paracetamol, as a supplemental analgesic to morphine patient-controlled analgesia when compared with controls.