Is cooling effective before upper lid blepharoplasty?

Periarticular liposomal bupivacaine mixture injection vs. single-shot interscalene block for postoperative pain in arthroscopic rotator cuff repair: a prospective randomized controlled trial.

To determine whether Endotine-assisted endoscopic brow lift with concomitant upper lid blepharoplasty provides long-term brow elevation. Pre- and post-operative photographs from 35 patients who underwent endoscopic brow lift using Endotine Forehead 3 mm implants with concomitant upper lid blepharoplasty were measured to determine changes in brow height with surgery and up to 55 months post-operatively. Photographs of 20 control subjects who did not undergo periorbital surgery and 11 control subjects who underwent upper blepharoplasty without brow lifting were also measured to provide a basis for comparison. Emotrics software was used to perform automated brow height measurements in order to determine elevation and longevity achieved with endoscopic brow lifting in conjunction with upper lid blepharoplasty. There was a statistically significant increase in brow height post-operatively, averaging 1.6 mm (P < .0001, 95% confidence interval 0.95-2.18 mm). Fifty-four percent of patients had follow-up beyond 6 months post-operatively and 40% had follow-up beyond 1 year. Elevation remained stable over time with no statistically significant change across all serial post-operative visits. There was no statistically significant difference in brow elevation based on gender or age, or between right and left sides. Endotine-assisted endoscopic brow lift in conjunction with upper lid blepharoplasty provides modest brow elevation and long-term brow fixation as demonstrated by stable post-operative brow height measurements for up to 55 months.

Chapter Four - Upper Lid Blepharoplasty

Chapter 4 - Upper Lid Blepharoplasty With Skin, Muscle, and Fat Excision

Efficacy of complex decongestive therapy in managing limb swelling, pain, and enhancing functional recovery after arthroscopic reconstruction of anterior cruciate ligament.

Adequate pain control after total hip arthroplasty is essential for patient satisfaction and surgical outcome. A retrospective study with before and after design was performed in 210 elective total hip arthroplasty patients. The control group (N=132) received spinal anesthesia with periarticular injection (PAI) and the treatment group (N=78) received transmuscular quadratus lumborum block and lateral femoral cutaneous nerve block in addition to spinal anesthesia and PAI. The primary outcome was visual analog scale (VAS) pain score on postoperative day (POD) 1, and secondary outcomes included VAS and opioid consumption on each POD, hospitalization cost, length of stay, and discharge acuity. The mean VAS and opioid consumption (MME) were significantly lower in the treatment group than that in the control group on POD 1, with VAS difference -1.10 (95% confidence interval, -1.64 to -0.55), false discover rate corrected (P<0.001), and MME difference -26.19 (95% confidence interval, -39.16 to -13.23, P<0.001). A significant difference was also found for both VAS (P=0.007) and opioid consumption (P=0.018) on POD 2 and for opioid consumption on POD 3 (P=0.008). Length of stay (days) in the control group versus the treatment group was 2.50±1.38 versus 1.36±0.95 (P=0.002), and the total cost of hospitalization was over 20% higher in the control group than that in the treatment group (P=0.002). The addition of transmuscular quadratus lumborum and lateral femoral cutaneous nerve block in total hip arthroplasty provides improved analgesia indicated by lower pain scores and opioid reduction and accelerated recovery with shorter hospitalization and decreased hospitalization cost.

Objective To evaluate the application of adding ondansetron in morphine intravenous analgesia pump for prevention of postoperative nausea and vomiting(PONV)in women. Methods Data of surgical female inpatients who received general anesthesia and postoperative intravenous analgesia with morphine in our center from January 1st,2013 to December 31st,2014 were retrospectively analyzed. Based on whether ondansetron was added,patients were divided into the observation group(n=834) and the control group(n=856). Outcome variables including morphine consumption,visual analogue scale(VAS) score,nausea score,and total times of vomiting within 48 hours after surgery were collected and compared. Results Age(t=0.432,P=0.665),morphine consumption during the first post-operative day(t=0.599,P=0.548) and during the second post-operative day(t=0.236,P=0.813),maximum VAS score of postoperative pain during movement during the first post-operative day [3(2,4) vs. 3(2,5);Z=1.850,P=0.064] and at rest during the second post-operative day [0(0,1) vs. 0(0,1);Z=1.511,P=0.131] were not significantly different between two groups. While the maximum VAS score of postoperative pain at rest during the first post-operative day [0(0,2) vs.0(0,2);Z=2.435,P=0.015] and during movement during the second post-operative day [3(1,3)vs.3(2,4);Z=3.445,P=0.001] were significantly different between two groups. The maximum score of postoperative nausea(χ2=9.810,P=0.020) and cumulative frequency of postoperative vomiting(Z=3.726,P=0.002)in the observation group were significantly lower than those in the control group during the first post-operative day;however,there was no significant difference during the second post-operative day(χ2=5.017,P=0.170;Z=0.000,P=1.000). Logistic regression analysis showed that adding ondansetron in morphine intravenous analgesia pump was an independent influencing factor of reduced postoperative nausea. The probability of nausea during the first post-operative day was 0.781 time(P=0.015)of that in the control group and 0.736 time(P=0.030)during the second post-operative day. Conclusion Adding ondansetron in morphine intravenous analgesia pump may reduce PONV in women.

Objectives An assessment of the effects of ginger on pain, nausea, vomiting, bleeding, and wound site healing that occur after tonsillectomy.Methods This prospective clinical study was participated by 49 patients aged 18–45 years out of 56 patients that underwent tonsillectomy and regularly attended follow-up visits. The patients were randomly divided into two groups. Group 1 consisted of 23 patients that used ginger capsules and group 2 consisted of 26 patients that did not use ginger capsules in addition to the routine antibiotic and paracetamol treatment following tonsillectomy. The pain, nausea, vomiting, and bleeding scores of patients were assessed on days 1, 4, 7, and 10 by using the visual analogue scale. Similarly, the epithelialization degrees of tonsillar bed were assessed on postoperative days 1, 4, 7, and 10 and regular oral intake times of patients were recorded.Results There were no differences between groups in terms of age and sex. On the postoperative days 1, 4, 7, and 10, the pain scores were lower in the group 1 (all P<0.001) and there were no differences between the two groups in terms of postoperative nausea, vomiting, and bleeding scores (P=0.35 and P=0.53). On the postoperative days 7 and 10, epithelialization in the tonsil bed was quicker in the group 1 (P=0.041 and P=0.026) and the regular oral intake time was earlier in group 1 (P<0.001).Conclusion In this study, ginger relieved pain, accelerated wound site epithelialization, and decreased duration of oral intake following tonsillectomy. It did not result in postoperative bleeding or any other complications. Ginger can be recommended as an adjunct to routine medical treatment for decreasing morbidity following tonsillectomy.

What's New in Spine Surgery.

What's New in Shoulder and Elbow Surgery.

Retrospective review. To compare perioperative and postoperative clinical outcomes between minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and lateral lumbar interbody fusion (LLIF) in patients presenting with predominant back pain. Two popular techniques utilized for lumbar arthrodesis are MIS-TLIF and LLIF. Both techniques have reported high fusion rates and suitable postoperative clinical outcomes. Scarce literature exists, however, comparing these 2 common fusion techniques in a subset population of patients presenting with predominant back pain preoperatively. A retrospective review of lumbar procedures performed between November 2005 and December 2021 was conducted using a prospectively maintained single-surgeon database. Inclusion criteria were set as primary, elective, single, or multilevel MIS-TLIF or LLIF procedures for degenerative spinal pathology in patients with predominant preoperative back pain [visual analog scale (VAS) back pain preoperative score > VAS leg preoperative score]. Patients undergoing a revision procedure, single-level procedure at L5-S1, or surgery indicated for infectious, malignant, or traumatic etiologies were excluded. In addition, patients with VAS leg preoperative scores ≥ to VAS back preoperative scores were excluded. Patient demographics, perioperative characteristics, postoperative complications, and patient-reported outcome measures (PROMs) were collected. PROMs included VAS for back and leg pain, Oswestry Disability Index (ODI), and Short Form-12 (SF-12) Item Survey Mental (MCS) and Physical (PCS) Composite Scores with all values collected at the preoperative, 6-week, 12-week, 6-month, 1-year, and 2-year follow-up time point. Patients were grouped into 2 cohorts, depending on whether a patient underwent a MIS-TLIF or LLIF. Demographic and perioperative characteristics were compared between groups using χ 2 and Student t test for categorical and continuous variables, respectively. Mean PROM scores were compared between cohorts at each time point utilizing an unpaired Student t test. Postoperative improvement from preoperative baseline within each cohort was assessed with paired samples t test. Achievement of minimum clinical important difference (MCID) was determined by comparing ΔPROM scores to previously established threshold values. MCID achievement rates were compared between groups with χ 2 analysis. Statistical significance was noted as a P value <0.05. Eligible study cohort included 153 patients, split into 106 patients in the MIS-TLIF cohort and 47 patients in the LLIF cohort. The mean age was 55.9 years, the majority (57.5%) of patients were males, the mean body mass index was 30.8kg/m 2 , and the majority of the included cohort were nondiabetic and nonhypertensive. No significant demographic differences were noted between cohorts. The MIS-TLIF cohort had a significantly greater proportion of patients with preoperative spinal pathology of recurrent herniated nucleus pulposus, whereas a significantly greater proportion of patients in the LLIF cohort demonstrated isthmic spondylolisthesis ( P < 0.046, all). No significant differences were noted between cohorts for operative duration, estimated blood loss, 1-year rate of arthrodesis, postoperative length of stay, postoperative VAS pain scores on postoperative day 0 or 1, and postoperative narcotic consumption on postoperative day 0 or 1. Patients in the LLIF cohort showed greater rates of postoperative ileus (4.3% vs 0.0%). No other significant differences were noted between cohorts for postoperative complications. Between cohorts, preoperative PROM scores did not significantly differ. The following significant postoperative mean PROM scores were demonstrated: VAS back at 12 weeks and ODI at 12 weeks with both mean scores favoring the LLIF cohort. The MIS-TLIF cohort reported significant improvement from preoperative baseline to the 2-year time point for all PROMs collected at all individual postoperative time points except SF-12 MCS at 6 weeks ( P < 0.0, all). LLIF cohort reported significant improvement from preoperative baseline to the 1-year time point for all PROMs collected at all individual postoperative time points except for ODI at 6 weeks, 1 year, and 2 years, SF-12 MCS at 6 weeks and 2 years, and SF-12 PCS at 2 years( P < 0.042, all). The majority of patients in both cohorts achieved overall MCID for VAS back, VAS leg, ODI, and SF-12 PCS. A significantly greater proportion of patients in the LLIF cohort achieved MCID for SF-12 PCS at 12 weeks (94.4% vs 61.1%; P < 0.008). Patients with predominant back pain undergoing MIS-TLIF or LLIF for degenerative spinal pathology demonstrated similar 2-year mean clinical outcomes for physical function, disability, leg pain, and back pain. At the 12-week time point, mean outcome scores for back pain and disability favored the lateral approach with concurrent higher rates of MCID achievement for physical function at that time point.

To date, there is limited data on evaluation of the cordotomy lesion and predicting clinical outcome. To evaluate the utility of magnetic resonance (MR)-based radiomic analysis to quantify microstructural changes created by the cordotomy lesion and predict outcome in patients undergoing percutaneous cordotomy for medically refractory cancer pain. This is a retrospective interpretation of prospectively acquired data in 10 patients (5 males, age range 43-76 yr) who underwent percutaneous computed tomography-guided high cervical cordotomy for medically refractory cancer pain between 2015 and 2016. All patients underwent magnetic resonance imaging (MRI) of the cordotomy lesion on postoperative day 1. After segmentation of T2-weighted images, 310 radiomic features were extracted. Pain outcomes were recorded on postoperative day 1 and day 7 using the visual analog scale. R software was used to build statistical models based on MRI radiomic features for prediction of pain outcomes. A total of 20 relevant radiomic features were identified using the maximum relevance minimum redundanc method. Radiomics predicted postoperative day 1 pain scores with an accuracy of 90% (P=.046), 100% sensitivity, 75% specificity, 85.7% positive predictive value, and 100% negative predictive value. The radiomics model also predicted if the postoperative day 1 pain score was sustained on postoperative day 7 with an accuracy of 100% (P=.028), 100% sensitivity, 100% specificity, and 100% positive and negative predictive value. MR-based radiomic analysis of the cordotomy lesion was predictive of pain outcomes at 1 wk after percutaneous cordotomy for intractable cancer pain.

The aim of our study was to evaluate the role of flavonoids in the improvement of post-operative symptoms after endovenous thermal ablation (EVTA). A prospective comparative study of 120 consecutive patients undergoing EVTA of the greater saphenous vein associated with phlebectomies was undertaken. Patients were grouped in those receiving micronized purified flavonoid fraction (MPFF- 60 patients) agent 500 mg Bid 7 days pre- and 30 days post- operatively (MPFF group) and those in the control group (60 patients) who did not. Demographics, intra-operative details, Clinical -Etiology- Anatomy- Pathophysiology (CEAP) clinical class, 10-cm Visual Analog Scale (VAS) for pain, Venous Clinical Severity Score (VCSS) and Chronic Venous Insufficiency Quality-of-Life Questionnaire (CΙVIQ-20) were recorded. Primary outcome was the postoperative pain assessement using the VAS scale and CIVIQ pain score. Secondary outcomes included assessement of VCSS and CΙVIQ-20 scores. There were no significant differences between the groups regarding demographics, clinical and procedural characteristics. Patients in MPFF group reported significantly lower VAS pain levels than control group at 7- (-3.6 ± 1.2 vs -2.7 ± 1.9, p < .0001) and 30- post-operative day (-4.9 ± 0.1 vs -4.2 ± 1, p < .0001). MPFF group also showed better outcome in terms of CIVIQ pain score at 7- (-3.7 ± 1.3 vs -3.5 ± 1.8, p = .008) and 30- post-operative day (-5.3. ± 1.1 vs -4.4 ± 1, p = .017). Both groups showed a significant improvement in VAS pain score (p = .047), global CIVIQ-20 (p = .009) and VCSS (p = .008) at 7- and 30-days post-operatively. Administration of flavonoids in patients undergoing EVTA associated with phlebectomies reduces pain by a small amount during early postoperative period.

Background Postoperative pain management practices vary widely among anesthetists in hospitals despite evidence-based pain management guidelines. This study explores a specific practice in managing acute post-operative pain by comparing the use of intrathecal bupivacaine (ITB) and morphine (ITBM) combined with oral multi-modal analgesia (MMA) versus ITB and oral MMA in patients who have undergone total knee arthroscopy (TKA) and total hip arthroscopy (THA) and the effect on pain scores. This study seeks to determine whether the practice of using ITBM is beneficial to patients during the post-operative phase. A total of 153 patients undergoing TKA and THA orthopedic surgery were randomly assigned to one of the two pain management techniques: (1) 3.5ml of 0.5% isobaric bupivacaine injected intrathecally and MMA (500mg of acetaminophen, 200mg gabapentin, 200mg of celecoxib, 10mg of controlled release oxycodone, and 5-15mg of immediate release oxycodone) was initiated on postop day 0; and (2) 3.5ml of 0.5% isobaric bupivacaine and 0.1mg of morphine was injected intrathecally and MMA (500mg of acetaminophen, 200mg gabapentin, 200mg of celecoxib, 10mg of controlled release oxycodone, 5-15mg of immediate release oxycodone). Verbal pain scores were monitored for the first 24 hours post-operatively using the Visual Analog Scale (VAS). Side effects of nausea and vomiting were also monitored for each patient for the first 24 hours post operatively. Results The VAS were similar in the ITBM group and the ITB group during the first 24 hours post-operative. The mean VAS 24 hours post-operative for TKA patients who received ITBM was 4.98, and 5.45 for patients who received ITB. Post-operative nausea and vomiting (PONV) in the TKA group varied according to the treatment group, 12.7% of patients in the ITBM group reported nausea or vomiting, compared to 13.2% in the group of patients who received ITB. The significance is set at P value < 0.05, based off this set value, the significance is shown to be P=0.629 (N.S.). There was no significance in VAS when treated with ITB or ITBM. The mean pain score 24-hour post-operative for THA patients who received ITBM was 3.63 and 4.04 for patients who received ITB. In the THA group, 9.1% of patients in the ITBM group reported PONV, whereas no one experienced PONV in the ITB group. The significance is set at P value < 0.05, based off this set value, the significance is shown to be 0.708 (N.S.). There is no significance in pain scores when treated with ITB or ITBM in patients who have undergone a total hip arthroplasty. In Conclusion, the use of ITBM fails to show superior analgesic effect on patients undergoing TKA and THA compared to ITB combined with MMA. Without superior pain control benefits and mild increase risk of causing nausea and vomiting post operatively in the TKA group, intrathecal morphine shows to provide no additional superior benefits to patients in managing their pain or significantly decreasing severity of onset of pain post operatively.

This was a retrospective cohort study. This study evaluates if an association exists between preoperative depression and postoperative outcomes following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Few studies have quantified preoperative depression symptoms using Patient Health Questionnaire-9 (PHQ-9) to predict postoperative outcomes after lumbar fusion, especially MIS TLIF. A surgical database of patients undergoing primary, single-level MIS TLIF was retrospectively reviewed. Patients were stratified by predefined preoperative PHQ-9 scores: no depression (<5), mild depression (5-9), and moderate to severe depression (≥10). Inpatient pain scores and narcotics use were recorded. Oswestry Disability Index, Veterans RAND-12 Mental Component Score and Physical Component Score, and Visual Analog Scale (VAS) back and leg pain scores were collected preoperatively and at 6-week, 12-week, and 6-month follow-up. One-way analysis of variance and χ analysis determined if an association existed between PHQ-9 subgroups and baseline characteristics or perioperative outcomes. Multivariate linear regression assessed for an association between PHQ-9 and postoperative patient-reported outcomes. In total, 94 patients were included. Patients with higher PHQ-9 scores were younger, obese, and carried workers' compensation insurance. Higher PHQ-9 scores were associated with worse preoperative Oswestry Disability Index, Veterans RAND-12 Mental Component Score and Physical Component Score, and VAS back and leg pain scores. Patients with higher PHQ-9 reported greater inpatient VAS pain scores on postoperative day 0 and 1 and demonstrated greater hourly narcotics consumption on postoperative day 0. Furthermore, higher PHQ-9 scores exhibited less improvement in all patient-reported outcomes. Patients with severe depression symptoms reported greater pain, increased narcotics consumption, and less clinical improvement after MIS TLIF. Therefore, patients with greater PHQ-9 scores should be monitored more closely and may benefit from additional counseling with regard to postoperative outcomes to better manage pain control and expectations of recovery.