Methylprednisolone as an Adjunct to Local Infiltration on Laminoplasty or Laminectomy before Wound Closure: A Randomized Controlled Trial

Niti Shrestha, Bo Han, Xiying Wang, Wenqing Jia, Fang Luo, Niti Shrestha, Bo Han, Xiying Wang, Wenqing Jia, Fang Luo

Abstract

TrialDesign. Patients undergoing laminoplasty and laminectomy often experience severe postoperative pain. Local infiltration analgesia during spine surgery significantly reduces postoperative pain, which only upholds for a short time. Whether methylprednisolone and local anaesthetics are better than local anaesthetics alone in postoperative analgesia is yet to be determined. The primary aim of this research was the postoperative evaluation of efficacy and safety of methylprednisolone when used as an adjunct to local anaesthesia, ropivacaine, before wound closure after surgical procedures, laminoplasty or laminectomy. Methods. 132 patients were divided with a ratio of 1 : 1 into methylprednisolone-ropivacaine and ropivacaine alone groups. Every 30 ml of local infiltration solution consisted of 15 ml of 1% ropivacaine with 14 ml of saline along with 1 ml of 40 mg methylprednisolone and 15 ml of 1% ropivacaine with 15 ml of saline in methylprednisolone-ropivacaine group and ropivacaine group, respectively. The standardization of the study solution depended on the number of levels involved in surgery. Primary outcome was the 48-hour cumulative sufentanil demand. Results. Demographic characters and surgical variables among the groups were identical. The average 48-hour cumulative sufentanil demand was 32.5 ± 20.6 μg in the methylprednisolone-ropivacaine group and 50.9 ± 27.2 μg in the ropivacaine group (p < 0.001). The estimated median time of demand of the first analgesia via patient-controlled analgesia (PCA) pump was 2.5 hours and 2 hours in the methylprednisolone-ropivacaine group and the ropivacaine group, respectively (hazard ratio (HR) was 0.53, with 95% Cl 0.33 to 0.87 and Log-rank of p = 0.0019). Conclusion. The infiltration of methylprednisolone as adjunct ropivacaine before wound closure is a safe and efficient strategy for pain management following laminoplasty or laminectomy.

Conflict of interest statement

The authors declare no conflicts of interest.

Copyright © 2022 Niti Shrestha et al.

Figures

Figure 1
Figure 1
The CONSORT patient flow diagram showing numbers analysed in each group.
Figure 2
Figure 2
Comparison of estimated median time of analgesic demand via PCA between the MR (methylprednisolone plus ropivacaine) group and the R (ropivacaine) group.

References

    1. Joshi G. P., McCarroll S. M., O’Rourke K. Postoperative analgesia after lumbar laminectomy: epidural fentanyl infusion versus patient-controlled intravenous morphine. Anesthesia & Analgesia . 1995;80(3):511–514. doi: 10.1097/00000539-199503000-00013.
    1. Mesfin A., Park M. S., Piyaskulkaew C., et al. Neck pain following laminoplasty. Global Spine Journal . 2015;5(1):17–21. doi: 10.1055/s-0034-1394297.
    1. Leslie K., Troedel S., Irwin K., et al. Quality of recovery from anesthesia in neurosurgical patients. Anesthesiology . 2003;99(5):1158–1165. doi: 10.1097/00000542-200311000-00024.
    1. Devin C. J., McGirt M. J. Best evidence in multimodal pain management in spine surgery and means of assessing postoperative pain and functional outcomes. Journal of Clinical Neuroscience . 2015;22(6):930–938. doi: 10.1016/j.jocn.2015.01.003.
    1. Raja S D. C., Shetty A. P., Subramanian B., Kanna R. M., Rajasekaran S. A prospective randomized study to analyze the efficacy of balanced pre-emptive analgesia in spine surgery. The Spine Journal . 2019;19(4):569–577. doi: 10.1016/j.spinee.2018.10.010.
    1. Casey M., Googe M., Seibly J. Cervical laminoplasty vs cervical laminectomy with fusion. Techniques in Regional Anesthesia and Pain Management . 2013;17(2):27–31. doi: 10.1053/j.trap.2014.01.003.
    1. Nolte M. T., Elboghdady I. M., Iyer S. Anesthesia and postoperative pain control following spine surgery. Seminars in Spine Surgery . 2018;30(3):154–159. doi: 10.1053/j.semss.2018.07.013.
    1. Aglio L. S., Abd-El-Barr M. M., Orhurhu V., et al. Preemptive analgesia for postoperative pain relief in thoracolumbosacral spine operations: a double-blind, placebo-controlled randomized trial. Journal of Neurosurgery: Spine . 2018;29(6):647–653. doi: 10.3171/2018.5.SPINE171380.
    1. Mullen J. B., Cook W. A. Reduction of postoperative lumbar hemilaminectomy pain with marcaine. Journal of Neurosurgery . 1979;51(1):126–127. doi: 10.3171/jns.1979.51.1.0126.
    1. Ersayli D. T., Gurbet A., Bekar A., Uckunkaya N., Bilgin H. Effects of perioperatively administered bupivacaine and bupivacaine-methylprednisolone on pain after lumbar discectomy. Spine . 2006;31(19):2221–2226. doi: 10.1097/01.brs.0000232801.19965.a0.
    1. Gurbet A., Bekar A., Bılgın H., Ozdemir N., Kuytu T. Preemptive wound infiltration in lumbar laminectomy for postoperative pain: comparison of bupivacaine and levobupivacaine. Turkish Neurosurgery . 2014;24(1):48–53. doi: 10.5137/1019-5149.JTN.8431-13.0.
    1. Peene L., Le Cacheux P., Sauter A. R., Joshi G. P., Beloeil H. Pain management after laminectomy: a systematic review and procedure-specific post-operative pain management (prospect) recommendations. European Spine Journal . 2021;30(10):2925–2935. doi: 10.1007/s00586-020-06661-8.
    1. Han X., Ren T., Wang Y., Ji N., Luo F. Postoperative analgesic efficacy and safety of ropivacaine plus diprospan for preemptive scalp infiltration in patients undergoing craniotomy: a prospective randomized controlled trial. Anesthesia & Analgesia . 2022 doi: 10.1213/ANE.0000000000005971.
    1. Zhao C., Wang S., Pan Y., Ji N., Luo F. Pre-emptive incision-site infiltration with ropivacaine plus dexamethasone for postoperative pain after supratentorial craniotomy: a prospective randomized controlled trial. JPR . 2021;14:1071–1082. doi: 10.2147/JPR.S300943.
    1. Gurbet A., Bekar A., Bilgin H., Korfali G., Yilmazlar S., Tercan M. Pre-emptive infiltration of levobupivacaine is superior to at-closure administration in lumbar laminectomy patientsfiltration of levobupivacaine is superior to at-closure administration in lumbar laminectomy patients. European Spine Journal . 2008;17(9):1237–1241. doi: 10.1007/s00586-008-0676-z.
    1. Akcil E. F., Dilmen O. K., Vehid H., Ibısoglu L. S., Tunali Y. Which one is more effective for analgesia in infratentorial craniotomy? the scalp block or local anesthetic infiltration. Clinical Neurology and Neurosurgery . 2017;154:98–103. doi: 10.1016/j.clineuro.2017.01.018.
    1. Langford P., Wolfe R., Danks R. A. Wound healing after craniotomy: a randomized trial comparing scalp clips to artery forceps for scalp hemostasis: clinical article. JNS . 2009;111(6):1175–1178. doi: 10.3171/2009.5.JNS081481.
    1. Mirzai H., Tekin I., Alincak H. Perioperative use of corticosteroid and bupivacaine combination in lumbar disc surgery: a randomized controlled trial. Spine . 2002;27(4):343–346. doi: 10.1097/00007632-200202150-00003.
    1. Debi R., Halperin N., Mirovsky Y. Local application of steroids following lumbar discectomy. Journal of Spinal Disorders & Techniques . 2002;15(4):273–276. doi: 10.1097/00024720-200208000-00002.
    1. Schaible H. G., Ebersberger A., Natura G. Update on peripheral mechanisms of pain: beyond prostaglandins and cytokines. Arthritis Research and Therapy . 2011;13(2):p. 210. doi: 10.1186/ar3305.
    1. Jensen K., Tuxen C., Pedersen-Bjergaard U., Jansen I., Edvinsson L., Olesen J. Pain and tenderness in human temporal muscle induced by bradykinin and 5-hydroxytryptamine. Peptides . 1990;11(6):1127–1132. doi: 10.1016/0196-9781(90)90141-Q.
    1. Reddy A. V. G., Thayi C., Natarajan N., et al. Validating the role of steroid in analgesic cocktail preparation for local infiltration in total knee arthroplasty: A Comparative Study. Anesthesia Essays and Researches . 2018;12(4):p. 4.
    1. Kim J. I., Kim Y. T., Jung H. J., Lee J. K. Does adding corticosteroids to periarticular injection affect the postoperative acute phase response after total knee arthroplasty? Knee . 2020;27(2):493–499. doi: 10.1016/j.knee.2019.10.029.
    1. Cherian M. N., Mathews M. P., Chandy M. J. Local wound infiltration with bupivacaine in lumbar laminectomy. Surgical Neurology . 1997;47(2):120–122. doi: 10.1016/s0090-3019(96)00255-8.
    1. McEntarfer R. Multimodal analgesia for spinal surgery—what is the gold standard? Operative Techniques in Orthopaedics . 2019;29(2) doi: 10.1016/j.oto.2019.100715.100715
    1. Martins N., Polido-Pereira J., Caneira M., Fonseca J. E. Treatment of persistent cutaneous atrophy after corticosteroid injection with fat graft. Reumatología Clínica . 2019;15(6):e122–e124. doi: 10.1016/j.reumae.2017.09.008.
    1. Nichols A. W. Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clinical Journal of Sport Medicine . 2005;15(5):p. E370. doi: 10.1097/01.jsm.0000179233.17885.18.
    1. Habib G. S., Saliba W., Nashashibi M. Local effects of intra-articular corticosteroids. Clinical Rheumatology . 2010;29(4):347–356. doi: 10.1007/s10067-009-1357-y.
    1. Bisset L., Beller E., Jull G., Brooks P., Darnell R., Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ . 2006;333(7575):p. 939. doi: 10.1136/bmj.38961.584653.
    1. Tonks J. H., Pai S. K., Murali S. R. Steroid injection therapy is the best conservative treatment for lateral epicondylitis: a prospective randomised controlled trial: steroid injection therapy for lateral epicondylitis. International Journal of Clinical Practice . 2006;61(2):240–246. doi: 10.1111/j.1742-1241.2006.01140.x.
    1. Park S. K., Choi Y. S., Kim H. J. Hypopigmentation and subcutaneous fat, muscle atrophy after local corticosteroid injection. Korean Journal of Anesthesiology . 2013;65:p. S59. doi: 10.4097/kjae.2013.65.6S.S59.
    1. Cole B. J., Schumacher R. H. Injectable corticosteroids in modern practice. Journal of the American Academy of Orthopaedic Surgeons . 2005;13(1):37–46. doi: 10.5435/00124635-200501000-00006.
    1. Farshad M., Burgstaller J. M., Held U., Steurer J., Dennler C. Do preoperative corticosteroid injections increase the risk for infections or wound healing problems after spine surgery?: a Swiss prospective multicenter cohort study. Spine . 2018;43(15):1089–1094. doi: 10.1097/BRS.0000000000002542.
    1. Fang A., Hu S. S., Endres N., Bradford D. S. Risk factors for infection after spinal surgery. Spine . 2005;30(12):1460–1465. doi: 10.1097/01.brs.0000166532.58227.4f.
    1. Dammers J. W. H. H., Veering M. M., Vermeulen M. Injection with methylprednisolone proximal to the carpal tunnel: randomised double blind trial. BMJ . 1999;319(7214):884–886. doi: 10.1136/bmj.319.7214.884.
    1. Yue C., Wei R., Liu Y. Perioperative systemic steroid for rapid recovery in total knee and hip arthroplasty: a systematic review and meta-analysis of randomized trials. Journal of Orthopaedic Surgery and Research . 2017;12(1):p. 100. doi: 10.1186/s13018-017-0601-4.
    1. Mohammad H. R., Hamilton T. W., Strickland L., Trivella M., Murray D., Pandit H. Perioperative adjuvant corticosteroids for postoperative analgesia in knee arthroplasty: a meta-analysis of 1, 396 knees. Acta Orthopaedica . 2018;89(1):71–76. doi: 10.1080/17453674.2017.1391409.
    1. Baltin M. E., Sabirova D. E., Kiseleva E. I., et al. Comparison of systemic and localized carrier-mediated delivery of methylprednisolone succinate for treatment of acute spinal cord injury. Experimental Brain Research . 2021;239(2):627–638. doi: 10.1007/s00221-020-05974-w.
    1. Wong S. M., Hui A. C. F., Tang A., et al. Local vs systemic corticosteroids in the treatment of carpal tunnel syndrome. Neurology . 2001;56(11):1565–1567. doi: 10.1212/WNL.56.11.1565.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera