Total Knee Arthroplasty (TKA) improves the quality of life of osteoarthritic and rheumatoid arthritis patients, however, is associated with moderate to severe postoperative pain. There are multiple methods of managing postoperative pain that include epidural anesthesia but it prevents early mobilization and results in postoperative hypotension and spinal infection. Controlling local pain pathways through intra-articular administration of analgesics is a novel method and is inexpensive and simple. Hence, we assess the effects of postoperative epidural bupivacaine injection along with intra-articular injection in total knee replacement patients. The methodology included 100 patients undergoing TKA randomly divided into two groups, one administered with only epidural bupivacaine injection and the other with intra-articular cocktail injection. The results were measured based on a 10-point pain assessment scale, knee's range of motion (ROM), and Lysholm knee score. The VAS score was lower in the intra-articular cocktail group compared to the bupivacaine injection group until the end of 1-week post-administration (p<0.01). Among inter-group comparisons, we observed that the range of motion was significantly more in cocktail injection as compared to the bupivacaine group till the end of one week (p<0.05). Lysholm's score was significantly more in cocktail injection as compared to the bupivacaine group till the end of one week (p<0.05). Our study showed that both epidural bupivacaine injection and intra-articular injection were effective in reducing pain after TKA and have a comparable functional outcome at the end of 4 weeks follow up. However, the pain relief was faster in cases with intra-articular injection, providing the opportunity for early rehabilitation. Thus, we recommend the use of intra-articular cocktail injection for postoperative management of pain after total knee arthroplasty, which enables early rehabilitation and faster functional recovery of these patients

Background. NICE guidance suggests that caudal epidural injections of steroid and local anaesthetic may be considered for acute and severe sciatica, however studies have demonstrated limited long-term benefit and impact on future surgery. This study aimed to investigate the use of caudal epidural injections in a district general hospital setting and the rate of subsequent operation. Methods. All patients undergoing caudal epidural injection between 1. st. January and 30. th. June 2015 were included. Records were reviewed to obtain diagnosis, pre- and post-epidural clinical findings, prior interventions, and subsequent operations. Results. A total of 141 patients underwent a caudal epidural, with a median age of 63 (18 – 90). 37 patients went on to surgical intervention within 3 years, resulting in a conversion rate of 26.1%. Amongst those not requiring surgery, 59 (56.19%) had disc herniation, 42 (40%) stenosis, 4 spondylolisthesis, and 1 a facet cyst. Pre-operatively 63.81% reported back pain and 93.33% sciatica. 39.05% of patients had sensorimotor changes. Post-operatively, 27.62% reported an improvement in their back pain, compared to 62.86% reporting improved leg pain. 36.59% of those with sensorimotor changes reported improvement. 32 later had a further caudal epidural or foraminal block, and 25 had facet and sacroiliac joint injections. Amongst those requiring surgery, 21 (56.76%) had disc herniation, 15 (40.54%) stenosis, and 1 spondylolisthesis (2.7%). Conclusion. In our series, approximately three quarters of patients undergoing caudal epidural injection did not subsequently require surgery. Lumbosacral radicular symptoms improved in two thirds, however the epidural was less effective at treating back pain. No conflicts of interest. No funding obtained

Introduction: The ideal regimen for safe and effective post operative pain relief inspinal surgery remains elusive. Numerous studies have been conducted comparing epidural with patient controlled analgesia with no firm conclusion as to which is best. Aims: To determine the efficacy of acute pain relief between surgical placed epidural catheter and patient controlled analgesia for lumbar spinal surgery. Method: A 42 month retrospective survey of 82 spinal surgery patients case notes and anaesthetic charts performed by a consultant spinal surgeon and his registrar from 2002 to 2005. There were 34 epidural and 48 PCA patients. Visual analogue Score (0–10) at 6 hourly intervals up to 36 hours, complications and age of patient were looked at. Exclusion criteria for epidural were dural tear, history of hypotension, unexplained neurological symptoms, and bleeding disorders and surgeon choice. Epidural infusion consisted of bupivacaine 0.1% with 5mls loading dose and 10mls/ hour infusion and PCA consisted of morphine sulphate 2mg/ml with a 1ml loading dose and 5 minute lockout interval.All patients were on standard analgesia which included oromorph 5mg four hourly orally and paracetamol 1gram six hourly as required orally. No radiographic evidence of epidural catheter placement was performed. Post-operative complications which included hypotension, nausea, vomiting, and drowsiness were monitored. Results: The average age for the epidural group was 46.9 and PCA group 49.8. The most striking finding was that the average pain score at each six hourly interval waslower in the epidural group. This was significant in the first 18 hours post-operatively.However, 3 complications occurred in the epidural group which included hypotension. In addition, 3 epidural infusions were stopped and changed to PCA most likely due to improper placement of catheter. There were no complications with the PCA group. Conclusion: This observational study demonstrates clinically and statistically that in the acute post-operative phase and up to 36 hours that epidural analgesia for lumbar spine surgery is more effective than PCA. From this survey, the risk of epidural was higher, although no serious complications occurred. Surgeon placement of catheter is also important in the effective delivery of epidural pain relief. The lower efficacy of the PCA may have been due to poor patient understanding of the concept of PCA and thereforeits

Background. Guidelines recommend epidural steroid injections (ESI) for treating severe disc-related sciatica based on trial data showing modest reductions in leg pain, disability and surgery avoidance. Despite their widespread use, there is no clear evidence about which patients are more likely to benefit from ESI. The aim of this study was to generate consensus on potential predictors of outcome following ESI for disc-related sciatica to include in data collection in a future cohort study. Methods. A list of potential predictors of outcome following ESI was generated from existing literature and a consensus meeting with seven experts. Items were subsequently presented in a two-round on-line modified Delphi study to generate consensus among experts on which items are agreed as potential predictors of outcome from ESI (consensus defined as 70% agreement with ranking of remaining items). Results. An initial list of 53 items was generated and 90 experts were invited from seven countries to participate in the on-line Delphi study. Response rates were 48% (n=44) and 73% (n=33) for round 1 and 2 respectively. Twenty-eight additional items suggested by participants in round 1 were included in round 2. Of the 81 items, 14 reached consensus; across domains of medication use, previous surgery, pain intensity, psychosocial factors, imaging findings and type of injection. Highest ranked of remaining items included work-related and clinical assessment items. Conclusion. Based on expert consensus, items that can be routinely collected in clinical practice were identified as potential predictors of outcomes following ESI. These will be tested in a future multicentre cohort study. Conflicts of interest: No conflicts of interest. Sources of funding: This study is supported by Health Education England and the National Institute for Health Research (HEE/ NIHR ICA Programme Clinical Lectureship, Dr Siobhan Stynes, NIHR300441). The views expressed are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care

Studies have shown significantly shorter hospital stays and earlier return to mobilization when epidural analgesia was used in lower extremity surgeries. This study quantified the effects of epidural analgesia on lower extremity kinetics and kinematics during gait. There were no significant differences found in hip, knee, or ankle joint moments or angles between baseline (no drug) and epidural trials, using two different drugs. These findings indicate that epidural analgesia does not alter normal gait in healthy subjects, suggesting that patients requiring epidural analgesia following orthopaedic surgery may also be able to participate in rehabilitation without significant epidural-related changes in gait. Epidural analgesia has been used post-operatively following chest, abdominal and lower extremity surgery, with significantly shorter hospital stay and earlier return to mobilization demonstrated. This study quantified the effects of epidural analgesia on lower extremity kinetics and kinematics during gait. Ten healthy volunteers were tested on different days with two drugs. With the catheter (L3-L4 intervertebral space) in place but prior to drug administration, gait was assessed. Testing was repeated 30 min after drug administration. Motion and ground reaction force data were recorded during walking with a four-camera video-based system (Motion Analysis Corp) and force platform (Kistler). No significant differences existed in 3-D hip, knee, or ankle joint moments or angles among baseline (no drug) and drug trials. These findings indicate that epidural analgesia does not alter normal gait in healthy subjects, suggesting that patients requiring epidural analgesia following orthopaedic surgery may also be able to participate in rehabilitation without significant epidural-related changes in gait. It is well documented that early mobilization and rehabilitation following orthopaedic surgery improve healing and shorten hospital stay. However, pain often limits full participation. Epidural analgesia appears to be an appropriate mode of pain relief that, despite somatosensory changes, may allow normal gait. Epidural analgesia in healthy volunteers does not alter lower extremity kinetics or kinematics, suggesting that it may be an effective mode of pain relief that will allow better participation in therapy following orthopaedic surgery. Funding: McCaig Professorship Program Development Fund, Wood Professorship, The Foothills Hospital Obstetric Anesthesia Research Fund, The National Science and Engineering Research Council of Canada, and The University of Calgary Biomedical Engineering Program

Use of epidural analgesia post-operatively in spinal surgery is becoming increasingly common. We have conducted a prospective study examining the side-effects associated with epidurals and the need for additional analgesia in 36 adult patients undergoing either lumbar spine decompression, lumbar spine fusion, or a combination of decompression and fusion. A mixture of bupivacaine and fentanyl was used for up to 72 hours post-operatively via an epidural catheter placed under direct vision at the time of surgery. All patients had urinary catheters inserted peri-operatively. 15 patients experienced one or more side-effects; 6 patients had a subjectively unpleasant sensory block, 3 patients developed a motor block, 4 patients had pruritus, 3 developed hypotension, and 2 had episodes of nausea or vomiting. All these features resolved upon reduction of the epidural rate or cessation of the epidural. All patients required additional oral analgesia at some point during their observation. There were no serious complications, such as infection, permanent neurological deficit, or cord compression. We conclude epidural analgesia following lumbar spine surgery is a safe practice, although the high rate of side-effects necessitates close observation by fully trained staff. It appears additional oral analgesia is required to obtain satisfactory levels of analgesia

Introduction and Aims: Speculation exists with regard to the exact mechanism of remodelling of thoracolumbar burst fractures treated non-operatively. We prospectively evaluated spinal canal remodelling in 30 patients with burst fractures by measuring the epidural pressure following ethical approval. Method: Thirty-four patients (average age 37 years) were recruited into the study. The injury followed a fall from a height in 18 patients; and 12 resulted from a road traffic accident. All patients were neurologically intact. Plain X-rays and CT scans were obtained to evaluate the injuries. The patients were treated non-operatively with orthoses. At two weeks and 12 months post-injury epidural pressures were measured in theatre. The measurements were performed in the lateral decubitis position, and a fluoroscopically guided radio-opaque catheter was positioned below the fracture site to record the epidural pressure. Results: Thirty patients were included in the study and four were excluded due to inadequate follow-up. The average progress in the Cobb’s angle at one-year follow-up was 2.690 (range 10–60). At the time of injury the mean canal compromise measured on CT scans was 43% (range 32%–83%) and at follow-up had improved to 28% (range 44%–100%). The CT volumetric measurements showed an average improvement of 10% in volume at follow-up (range 7%–16%). The average epidural pressure recorded at the time of injury was 16.65mmHg (range 2.5–30.85mmHg) and at follow-up was –5.85mmHg (range 0 to –10.17mmHg). There were no complications following epidural pressure monitoring. Conclusion: Scapinelli and Candiotti hypothesised that burst fractures remodelled secondary to respiratory oscillations transmitted to the epidural space. The raised epidural pressure (p< 0.001), by virtue of its mechanical effect, may be one of the factors responsible for the remodelling of burst fractures

Introduction: Epidural steroid injection is commonly used for treatment of sciatica. Traditionally these have been administered through a needle inserted in the posterior mid line via an interlaminar (IL) route. However, in recent years the transforaminal (TF) route of administration has become popular. Potential advantages of the TF route include greater accuracy of injection (with radiological confirmation) and placement of the needle tip closer to the point at which the nerve is compressed. Methods: Consecutive patients from the practices of 2 surgeons that use an IL technique were compared with those from the practices of 2 other surgeons that use a TF technique. Inclusion criteria were leg pain accompanied by a radiological diagnosis of nerve root compression. Both patients with disc prolapse and spinal stenosis were included. Treatment outcome was measured using the Roland-Morris (RM) Score, the Sciatica Frequency and Bothersome Index (SFBI) and the Euroqol (EQ-5D) questionnaire obtained at recruitment and three months after the epidural steroid injection. A global assessment (GA) of outcome; where patients were asked whether they were. much better,. better,. un changed or. worse after treatment; was obtained at 3 months. Patients were also asked the duration of any relief obtained. Statistical methods utilized included the two tailed t-test, the Wilcoxon Rank Sum test, Odds ratio (OR) and the Chi Squared Test. Results: 39 patients received an interlaminar epidural steroid injection and 25 received a transforaminal epidural steroid injection (total 64 patients). Follow-up was achieved for 36/39 (92.3%) and 25 (100%) patients respectively. The median pre-test RM score was 11 (range 3–11) for both groups. Post test RM score was 12(6–16) for the IL group and 3 (6–10.5) for the TF group (p=0.01). Median pre-test SFBI was 25 (0–46) and 26 (4–46) for the IL and TF groups respectively. Post test SFBI was 22 (0–46) and 18 (0–41) for the IL and TF groups respectively (p=0.003). Median pre- test EQ-5D was 0.54 for both groups (range 0.06–0.72 for the IL group and 0.08–0.72 for the TF group). Post test EQ-5D was 0.55 (0.06–1) for the IL group and 0.66 (0.06–1) (p=0.21). According to their GA, 11.1% felt much better, 33.3% felt better and 55.6% felt unchanged at 3 months in the IL group. 64% felt much better, 34% better and 12% felt unchanged in the transforaminal group. The proportion of patients having relief for 3 months or more after the injections was 3/36 (8.3%) for the IL group and 10/25 (40%) for the TF group. The transforaminal injection was 7 times more likely to result in pain relief at 3 months. (OR 7.3 95% CI 1.5 – 45.8, p=0.003). Discussion: Epidural steroid injection by the transforaminal route is more effective then by the interlaminar route in the short term relief of sciatica

The purpose of this study was the investigation and treatment of all the complications that may occur from the epidural postoperative analgesia in patients who have undergone major orthopaedic surgery. From October 1999 to April 2002, 200 patients ASA I- III, aged 45–90 (average 72) were studied. They all received postoperative epidural analgesia and were given a mixture of local anaesthetic and Opioid analgesic, more specifically Ropivacaine 2% 10 ml/h and Morphine 0, 1 ug/h via the epidural catheter by means of a stable infusion pump. The analgesic effect covers the patients for the first 2–3 postoperative days and permits earlier and pain free mobilization and physiotherapy. The analgesic result of this method was completely satisfactory with a mean of VAS 96. The most frequent side-effects were nausea and vomiting. Pruritus, mild hypotension, hypaesthesia and motor blockage were documented as well but in a very small percentage. No case of respiratory depression or medical toxicity was mentioned, neither epidural haematoma nor infection due to the placement of epidural catheter. The complications during the recovery phase were treated easily by discontinuation of the infusion or by symptomatic therapy. Epidural analgesia with a steady infusion pump is a secure method of analgesia. However it is of great importance that the patient is informed about the epidural anaesthesia and postoperative analgesia, in a such a way as to attain his/ her consent, participation and collaboration for the best therapeutic result

Background. Clinical guidelines recommend epidural steroid injection (ESI) as a treatment option for severe disc-related sciatica, but there is considerable uncertainty about its effectiveness. Currently, we know very little about factors that might be associated with good or poor outcomes from ESI. The aim of this systematic review was to synthesize and appraise the evidence investigating prognostic factors associated with outcomes following ESI for patients with imaging confirmed disc-related sciatica. Methods. The search strategy involved the electronic databases Medline, Embase, CINAHL Plus, PsycINFO and reference lists of eligible studies. Selected papers were quality appraised independently by two reviewers using the Quality in Prognosis Studies (QUIPS) tool. Between study heterogeneity precluded statistical pooling of results. Results. 2726 citations were identified; 11 studies were eligible. Overall study quality was low with all judged to have moderate or high risk of bias. Forty-five prognostic factors were identified but were measured inconsistently. The most commonly assessed prognostic factors were related to pain and function (n=7 studies), imaging features (n=6 studies), health and lifestyle (n=5 studies), patient demographics (n=4 studies) and clinical assessment findings (n=4 studies). No prognostic factor was found to be consistently associated with outcomes following ESI. Most studies found no association or results that conflicted with other studies. Conclusions. There is little, and low quality, evidence to guide practice in terms of factors that predict outcomes in patients following ESI for disc-related sciatica. The results can help inform some of the decisions about potential prognostic factors that should be assessed in future well-designed prospective cohort studies. Conflicts of interest: No conflicts of interest. Sources of funding: This study is supported by Health Education England and the National Institute for Health Research (HEE/ NIHR ICA Programme Clinical Lectureship, Dr Siobhan Stynes, NIHR300441). The views expressed are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care

Background. Evidence from recent trials has supported the efficacy of periarticular analgesic injection for pain control following total knee arthroplasty (TKA). However, no randomized controlled trial has compared the efficacy of periarticular analgesic injection with that of other regimens for simultaneous bilateral TKA. Methods. We conducted a randomized controlled trial in which patients scheduled for simultaneous bilateral TKA were randomly assigned to receive periarticular analgesic injection or epidural analgesia. In the periarticular analgesic injection group, the injection contained 7.5 mg/ml ropivacaine 40 ml, 10 mg/ml morphine hydrochloride hydrate 1.0 ml, 1.0 mg/ml epinephrine 0.6 ml, methylprednisolone 80 mg, and ketoprofen 50 mg. These agents were mixed with normal saline to a combined volume of 120 ml. The 60 ml of the cocktail was injected into each knee. In the epidural analgesia group, the catheter was placed at the L2–3 or L3–4 level, and connected to an infusion pump delivering continuous infusion (flow rate: 4 ml/h) of 100 ml of 2 mg/ml ropivacaine plus 1.0 ml of 10 mg/ml morphine hydrochloride hydrate. Surgery was managed under spinal anaesthesia. Surgical techniques and postoperative medication protocols were identical in both groups. The primary endpoint was postoperative pain at rest, quantified as the area under the curve (AUC) of the score on a visual analogue scale. Results. Seventy-one patients with 142 knees were randomly assigned to receive periarticular analgesic injection or epidural analgesia. The flow chart presented in Figure 1 outlines the trial. The periarticular analgesic injection group had a significantly lower AUC at 4–24 hour compared with the epidural analgesia group (174.9 ± 181.5 versus 360.4 ± 360.6; p = 0.0073), while no difference in the AUC was noted at 24–72 hour (1388.1 ± 727.2 versus 1467.3 ± 810.1; p = 0.67). The consumption of diclofenac sodium suppositories as rescue analgesia was significantly lower in the periarticular analgesic injection group than in the epidural analgesia group on the night of surgery (0.16 ± 0.4 versus 0.70 ± 0.9; p = 0.0013). The incidence of nausea on the night of surgery and postoperative day 1 and that of pruritus were significantly lower in the periarticular analgesic injection group than in the epidural analgesia group (7.4 % versus 45.5 %; p = 0.0031, 7.4 % versus 54.5 %; P = 0.0003, and 0 % versus 15.2 %; p = 0.014, respectively). Conclusions. Compared with epidural analgesia, periarticular analgesic injection following simultaneous bilateral TKA was associated with better postoperative pain relief and decreased opioid-related side-effects. Periarticular analgesic injection is preferable to epidural analgesia for postoperative pain relief after simultaneous bilateral TKA

Background: Traditionally, lumbar discectomy is performed under general anaesthesia because of ability to perform operations of long duration in prone position with a secure airway. Some recent reports suggest better outcomes with regional anaesthesia. Aim: The aim of this study was to compare the intra-operative and short-term post-operative outcome variables in patients undergoing primary single-level lumbar discectomy with epidural and general anaesthesia. Methods: This was a prospective randomized trial involving sixty patients over a two-year period in a tertiary hospital in India. Patients were allocated into two groups: Group A (n=30) patients received general anaesthesia and Group B (n=30) patients received epidural anaesthesia. Baseline and intra-operative haemodynamic parameters, surgical duration, surgical onset time, intra-operative blood loss, cost incurred by patient, nausea and vomiting and post-operative pain score were also recorded. Results: The groups were comparable for demographic data and baseline hemodynamic observations. Patients in the epidural anaesthesia group had significantly lower blood loss (p< 0.001), lower peak pain scores (p< 0.001), lesser surgical time (p< 0.001),and significantly reduced post-operative nausea and vomiting (p< 0.01) as compared to the general anaesthesia group. The cost incurred for epidural anaesthesia was two third of that incurred in general anaesthesia (p< 0.001). Epidural group had significantly more surgical onset time (p< 0.001). Conclusion: Lumbar discectomy can be safely performed using epidural anaesthesia. The intra-operative blood loss, surgical duration, cost incurred by the patient, postoperative nausea, vomiting and pain are significantly reduced in patients receiving epidural anaesthesia, thereby leading to a significantly higher patient satisfaction. In the present climate of NHS, where any initiative to cut down the cost of resources consumed is welcomed as long as the patient safety is not compromised, epidural anaesthetic may provide an effective alternative to general anaesthetic for lumbar discectomy

Background. Continuous epidural anesthesia or femoral nerve block has decreased postoperative pain after total knee arthroplasty to some extent. Although the established efficacy of these pain relief method, some adverse events such as hematoma or muscle weakness are still problematic. Intraoperative local infiltration of analgesia (LIA) has accepted as a promising pain control method after total knee arthroplasty. The safety and efficacy of LIA has been reported, although there are still limited evidence about the effect of LIA on quadriceps function and recovery of range of motion in early post-operative phase. The purpose of this study is to compare the quadriceps function and range of motion after TKA between the LIA with continuous epidural anesthesia and continuous epidural anesthesia alone. Methods. Thirty patients with knee osteoarthritis who underwent primary TKA were included in this study. Patients who took anticoagulants were treated continuous epidural anesthesia alone (n=11) and the other patients were treated with LIA with continuous epidural anesthesia (n=19). A single surgeon at our department performed all surgeries. Surgical procedure and rehabilitation process was identical between two groups. Before the implantation, analgesic drugs consisting of 20 ml of 0.75 % ropivacaine and 6.6 mg of dexamethasone were injected into the peri-articular tissues. In each group, fentanyl continuous epidural patient-controlled analgesia (PCA) was also used during 48-h post-operative period. Knee flexion and extension angle were evaluated before surgery, post-op day 3, 7, 10 and 14. The quadriceps function was evaluated by quadriceps peak torque at 30° and 60° flexion using VIODEX. The peak torque was recorded preoperatively, day 14 and 3 month after surgery. The difference between two groups was analyzed by Mann Whitney U-test using Prism 6, a statistical software. Results. LIA group showed better postoperative flexion angle until day 7 (Fig. 1). Then the discrepancy became smaller and came to the same degree at day14. The peak torque at 30° and 60° flex is higher in LIA group compared to epidural anesthesia alone. The LIA group showed less peak torque decrease at 2 weeks after surgery than epidural anesthesia alone group (Fig. 2, 3). No adverse events such as were observed in each group. Discussion. This paper demonstrated that LIA in addition to the continuous epidural anesthesia after TKA provides better quadriceps function and early recovery in knee range of motion. In this study we also used continuous epidural anesthesia, thus this study can not evaluate the stand alone LIA effects on quadriceps function and range of motion recovery. Furthermore the patients were not randomly assigned in this study, this might be another limitation of this study. In conclusion, LIA provide better quadriceps function and early recovery of range of motion in addition to the pain relief. To view tables/figures, please contact authors directly

Background. Clinical guidelines recommend epidural steroid injection (ESI) for severe sciatica but there is uncertainty of effectiveness. The POiSE study aims to identify factors, routinely collected in clinical practice that predict outcome in patients who have ESI. This presentation describes characteristics and early clinical outcomes of POiSE participants. Methods. Prospective cohort study in 19 NHS spinal services in England, inviting patients with sciatica listed for an ESI. Participant baseline characteristics and 6-week follow-up outcomes are presented. Outcomes include pain intensity (0–10 NRS), disability (Oswestry Disability Index 0–100) and global change in symptoms. Results. Over 24 months, 693 patients were invited to participate and 353 (51%) completed baseline questionnaires. Mean (SD) age 49.0 years (14.4), 60% female, and 46% (n=101) of those in work had certified time-off for sciatica. Mean pain intensity was 7.2 (2.0) and 6.2 (2.7) for leg and back pain respectively and mean disability (ODI) was 46.5 (18). 60% (n=210) had leg pain for >6 months. Average confidence at baseline (0 to 10) that the ESI would help symptoms was 5.7 (2.4). Of 217 patients reaching 6-week follow-up, mean leg and back pain intensity is 5.0 (2.8) and 4.9 (2.9) respectively and ODI 36.6 (20.4), with 57% reporting improvement (completely recovered/much better/better). Follow-up data collection at 6, 12 and 24-weeks post-ESI is ongoing. Conclusion. Interim analysis shows only just over half of patients are reporting improvement at 6 weeks post ESI. The POiSE cohort study will help better identify the patients with sciatica who are most likely to benefit from this treatment. Conflicts of interest. None. Sources of funding. This study is supported by Health Education England and the National Institute for Health and Care Research (HEE/ NIHR ICA Programme Clinical Lectureship, Dr Siobhan Stynes, NIHR300441). The views expressed are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care

Total arthroplasties are considered as severe and very painful operations, intra- and postoperatively. The operation is usually carried out under epidural anaesthesia via a catheter and it is logical to proceed for postoperative analgesia epidurally. In this study, two methods of epidural postoperative analgesia are compared: with infusion of a local anaesthetic alone or in combination with a small dose of opioid. Material-method: Twenty-five patients, scheduled for total hip or knee arthroplastie were studied. They were randomly allocated in two groups: in group LA they received an epidural infusion of 10 ml/h ropivacaine 0,2%, while in group OP they infused epidurally 5 ml/h of a mixture of morphine 3 ug/kg in ropivacaine 0,1%. The infusion was performed using disposable pumps. At 2–6-12–24–48 hour postoperatively, analgesia (at rest and movement, VAS 0–10), sedation (0–3) and motor blockade (Bromage 0–3) were evaluated and recorded. Additionally, side effects (pruritus, nausea-vomiting) as well as the need for rescue analgesic (paracetamol 500mg on patients demand) were recorded. Results: Demographic data of two groups were comparable. In general, postoperative analgesia was satisfactory in both groups. Pain was reported by: a) at 6 h 10% of patients in LA group (none in OP group) b) at 12 h 30% of patients in LA group and 10% in OP group c) at 24 h 10% of patients in LA group and 30% in OP group and d) at 48 h 10% of patients in LA group and 0% in OP group. The 10% of patients in OP group reported pruritus at 2 h after operation. The 10% of patients in LA group presented intence motor blockade (Bromage 3) at 12 and 24 h. in case of motor blockade the infusion was discontinued and the blockade was completely recovered after 1–2 hours. In 1 patient of LA group and 2 of OP group nausea and vomiting was observed, only at the first 2 h from the end of anaesthesia. The big percentage of patients (LA group: 12 h = 27%, 24 h = 45%• OP group: 24 h = 7%) that needed additional analgesics, is attributed to a discomfort of most patients, even under light pain. Conclusions: The epidural infusion of ropivacaine alone or in combination with low dose of morphine, can be considered effective and usefull method for postoperative analgesia in total hip or knee arthroplasties

The exact mechanism of remodelling of burst fractures is uncertain. We studied the relationship between epidural pressures and remodelling. In a prospective, ethically-approved study in 34 patients with burst fractures at the levels T12 to L4, epidural pressure was measured. Four patients were lost to follow-up. In 18 patients the fractures were due to a fall and in 12 to motor vehicle accidents. The mean age was 37 years. All patients were neurologically intact and treated non-operatively. Plain radiographs and CT scans measuring the sagittal plane deformity and mid-sagittal diameter respectively were obtained. Using a fluoroscopically-guided radio-opaque catheter placed at the normal interspace below the burst fracture, epidural pressure was measured at 2 weeks and at 12 months after the injury. The mean canal compromise shown on CT scan at the time of injury and at follow-up was 43% (32% to 83%) and 28% (44% to 100%) respectively. CT volumetric measurements showed a mean improvement of 10% at follow-up (7% to 16%). The epidural pressures recorded at the time of injury and at follow-up were 16.65 mmHg (2.5 to 30.85) and 5.85mmHg (0 to 10.17) respectively. At 1-year follow-up, the Cobbs angle had progressed by a mean of 2.69° (10° to 60°). The retropulsed burst fracture fragments cause localised constriction of the spinal cord (Venturi effect). Epidural pressure, raised to maintain a constant flow rate across this constriction, has a mechanical effect on the retropulsed fragments, thus promoting remodelling

Introduction: Postoperative overdistention of the bladder produces chronic, irreversible changes in the detrusor muscle. This study investigated whether an effective epidural, may cause postoperative overdistention of the bladder. Methods: A retrospective single surgeon/unit study of 144 male patients who had undergone spinal surgery over a two year period was undertaken. Data was collected into two groups: Patients requiring catheterisation and those that did not. All patients received a 16G epidural catheter inserted at the end of the procedure. Demographics, operation type and epidural rate were all correlated with the need for catheterization. In all cases the residual volumes were recorded. Results: Patients remained on postoperative epidural analgesia for an average of 50hours. 54 patients required urinary catheterisation. The average postoperative duration until catheterisation was 18hours, with a maximum of 33hours. The average residual volume at catheterization was 936mls, with a maximum of 2200mls. All patients were managed with intermittent catheterisation, most, (63%) requiring only a single episode before spontaneously voiding. Discussion: Although patients in the catheterised group were older, (p< 0.05), we found no other significant differences in patients that subsequently required catheterisation, when compared for operation type, or epidural infusion rates. We were therefore unable to predict which patients would require catheterisation. Questioning and bladder palpation was found to be unreliable when assessing overdistention. Our study demonstrated that patients undergoing spinal surgery using epidural analgesia should be closely monitored in order to prevent overdistention of the bladder and has led to a proactive regimen for spinal patients with epidural analgesia in our unit

Several studies have reported that remodelling of the spinal canal occurs in lumbar burst fractures following non-operative treatment. Various theories have been proposed for spinal canal remodelling, including the possible effect of the oscillatory pulsations of the subdural space, but no studies have been done to evaluate this effect. In a prospective study between September 1999 and April 2002, we evaluated 17 men and seven women, with a mean age of 35.25 years (19 to 59), who had sustained a burst fracture in the upper lumbar region. The fractures were at the L1 and L2 regions in 14 and 10 patients respectively. The epidural pressure and radiological appearances were initially evaluated approximately two weeks after injury, and again 12 months after injury. All patients were neurologically intact and treated non-operatively. CT evaluation of the initial injury showed a mean initial canal compromise of 49.81% (22.3% to 80%) as measured by mid-sagittal diameter and 13.9% (8.2% to 16.9%) as measured by volumetric assessment, with a mean epidural pressure of 14.56mmHg (2.5 to 30.38). At follow-up 12 months later, the mean epidural pressure was -4.67mmHg (−1.1 to −8.9) and the mean canal compromise as measured by the mid-sagittal diameter and volumetric measurements on CT scan were 24.56% and 8.9% respectively. Our data show that the epidural pressure was raised in acute burst fractures and reverts to normal with remodelling. We can conclude that the raised epidural pressure may be one of the mechanisms that contribute to the remodelling process

Aim. Assess efficacy of caudal epidural injection with epidurogram with validated outcome measures. Introduction. The administration of local steroids and other drugs into caudal epidural space has been well established procedure in the management of low back pain with or without leg symptoms. Various studies have been done to assess the efficacy of the different routes of administration of epidural injections. However, only a few published prospective studies have been done on performing caudal epidural injections under fluoroscopic guidance with validated outcome measures. Methods. Between 2007 and 2009, a total of 129 patients underwent caudal epidural injections under image intensifier guidance with epidurogram. The study included 69 males and 60 females ranging from 20 to 80 years of age. They were prospectively followed up using validated outcome measures at 6 weeks, 3 months, 6 months and 12 months. Results. Out of 129 patients 120 patients were followed at one year. There was statistically significant improvement in mean Low Back Outcome Score (LBOS) and Oswestry Disability Index (ODI) Scores in these patients which was maintained at the end of one year. Based on LBOS and ODI scores, 76% of patients at 6 weeks, 68% at 3 months, 55% at 6 months and 49% at 1 year had excellent and good results. Patients with less than two levels of degenerative disc disease, with predominant unilateral leg symptoms and with symptomatic duration of less than 6 months had a better outcome of results when compared with patients with predominant back symptoms, multi-level degenerative disc disease, bilateral involvement and history of previous lumbo-sacral spine surgery. Discussion and Conclusion. Our study on caudal epidural injections done under fluoroscopic guidance indicate improved and predictable outcome in addition to the patient satisfaction

Introduction. Thoracic wall surgery can cause severe pain and inhibition of coughing with effects. (1) Various local anaesthetic (LA) techniques have been tried successfully to mitigate the use of opioids alone. We believe this is the first time that a serratus plane block using an epidural catheter (SABER)has been studied in anterior spinal fusion (ASF) procedures. Our aim was to ascertain how it would affect ASF compared to gold standard posterior spinal fusion (PSF) surgery. Materials and Methods. We identified 43 patients from the years 2017 to 2019. 24 had ASF and 19 had PSF. Detailed data were collected on local anaesthetic infusion (LAI) SaBER, mean pain scores(MPS), morphine, chirocaine usage and hospital length of stay (HLOS). We divided the patients into 4 groups: Short PSF (SPSF), Long PSF (LPSF), Thoracic anterior fusion (TA) and Thoracolumbar anterior fusion (TLA) surgery. 4 patients in the SPSF and 4 in the LPSF group had LAI because they had a costoplasty. All patients in the anterior group had SaBER. Results. Mean morphine usage was higher in the ASF group. Mean LA usage was lowest in the TLA and highest in the LPSF group (see table). 12 and 24 hour MPS were lower in both anterior groups compared to posterior. Mean HLOS was similar in all groups. Conclusion. Despite painful costoplasties in the anterior group, LAI enabled lower MPS overall and similar HLOS between PSF and ASF groups. Consequently, ASF (with fewer fusion levels) can replace equivalent PSF with resultant less stiffness and increased mobility. Reduction in MPS may be further improved by investigating detailed protocols whereby boluses of LA are given in addition to LAI. This may lead to morphine sparing in the anterior group as has been seen in other studies on thoracic wall procedures. (2). For any figures or tables, please contact the authors directly