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The purpose of this study was to determine if implementation of an enhanced recovery pathway (ERP) for elective spine surgery reduced opioid use and pain scores in elective spine surgery. A historical cohort study of 171 patients undergoing elective spine procedures between 2017 and 2021 was performed. The primary outcomes were opioid use and average daily pain scores. A group of 92 patients received the novel ERP (2019 - 2021) in comparison to a historical control group of 79 patients without the ERP (2017 - 2019). On postoperative days 1 to 3, the ERP group received 36% (p < 0.001), 36% (p < 0.001), and 37% (p = 0.005) less milligram morphine equivalents, respectively. On postoperative days 1 to 3, the ERP group pain scores were 1.5 (p < 0.001), 1.0 (p = 0.003), and 1.1 (p = 0.004) points lower, respectively. Length of stay was similar (4.3 vs. 4.5 days, p = 0.693). Adoption of this ERP protocol was associated with clinically significant reduced opioid consumption and pain scores in elective spine surgery. (Journal of Surgical Orthopaedic Advances 33(3):162-167, 2024).

Introduction Erector spinae plane (ESP) block was first introduced for the management of thoracic pain but has become increasingly popular for the treatment of abdominal surgical pain. Previous studies have shown the ESP block can be easily adapted to abdominal procedures at the corresponding dermatome level and provide postoperative analgesia. Though the versatility, simplicity, and safety of the ESP block have been demonstrated, there is a gap in the literature regarding its comparison between thoracic and abdominal surgeries. This study aims to evaluate the efficacy of the ESP block in treating acute postoperative pain in patients undergoing thoracic and abdominal surgeries. Methods This retrospective study included 50 patients in the non-cardiac thoracic surgery group (bilateral breast mastectomy with reconstruction) and 50 patients in the abdominal surgery group (robotic or laparoscopic sleeve gastrectomy). Data was obtained via the acute pain service records at a tertiary care center from 2018 to 2022. All patients received bilateral ESP blocks, performed under ultrasound guidance. Various parameters were evaluated including oral morphine equivalents (OMEs) and visual analog scale (VAS) scores during post-anesthesia care unit (PACU), 6, 12, and 24 hours postop. The use of abortive antiemetic medications within 24 hours was also measured to evaluate the incidence of nausea and vomiting. The results were analyzed and compared. No control group is included, as all patients at our institution receive a peripheral nerve block as a part of the institution's enhanced recovery pathway (ERP). Results This retrospective study included 50 patients in the non-cardiac thoracic surgery group (bilateral breast mastectomy with reconstruction) and 50 patients in the abdominal surgery group (robotic or laparoscopic sleeve gastrectomy). Compared to the thoracic group, the abdominal group had a statistically higher VAS score in PACU with mean difference (MD) 1.3 VAS, 95% confidence interval (CI) 0.03-2.56, p-value 0.0443, statistically higher OME consumption in the PACU (difference 13.35 OME, 95% CI 4.97-21.73, p-value 0.0003), and required significantly more antiemetic pharmacotherapy (mean 1.4 antiemetics administered, 95% CI 0.84-2.04, p-value <0.0001). Despite the abdominal group having more OME utilization in the PACU, there was no difference in cumulative OME use in the first 24 hours (95% CI -9.745-24.10, p-value 0.4021). Conclusion In this study, we demonstrated that ESP blocks are an effective regional anesthesia technique to reduce postoperative pain and opioid consumption. The ESP block can serve as a useful and safe alternative to either thoracic epidural or paravertebral block techniques in thoracic and upper abdominal surgeries for perioperative pain management., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Hymes-Green et al.)

The diagnosis and management of postoperative nerve injury can be a challenging and frustrating proposition for the patient, surgeon, and anesthesia provider. Unfortunately, in many cases, the true etiology is never elucidated and the injury is ascribed to positioning or a nerve block with "expectant management" being the order of the day, which can result in persistent disability for the patient. However, there is a rare subset of disorders affecting the nervous system that can masquerade as a peripheral nerve injury that warrants further investigation of risk factors and co-morbidities when other common causes of nerve injury are ruled out. We describe a patient with rheumatoid arthritis that underwent revision hip arthroplasty and presented almost immediately in the postoperative period with what was initially diagnosed as femoral nerve palsy. Further diagnostic workup later revealed that she had suffered from postoperative inflammatory neuropathy resulting in lumbosacral plexus injury and not a discrete nerve injury. Had the true cause been identified early enough, treatment with corticosteroids could have been initiated in an attempt to mitigate and perhaps reverse the progress of the neuropathy. We present this cautionary tale to remind practitioners to continue to be vigilant and consider more esoteric and unconventional diagnoses in the workup of perioperative neuropathies., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Godlewski et al.)

Abdominal organ transplantation - and more specifically small bowel transplant - can be quite painful, generally requiring significant opioid administration with the attendant negative ramifications. We present contrasting experiences with a gentleman who underwent transplantation for Crohn's disease and his retransplantation with the addition of post-operative anterior Quadratus Lumborum (QL) block. After the index procedure, he had significant pain and discomfort. The addition of the QL block lead to substantial improvement in both subjective and objective endpoints. While each case is different, a QL block can be a useful adjunct to achieve pain control, decrease opioid requirements, and potentially facilitate early extubation., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Anaesthesiology Clinical Pharmacology.)

Historically, pregnancy in females with spinal muscular atrophy was contraindicated due to the great risk to the parturient, but with improved management and increased survival more patients are becoming pregnant. We describe the management of a pregnant patient with spinal muscular atrophy type-2, who had severe restrictive lung disease, extensive spinal fusion that precluded neuraxial anesthesia, and chronic respiratory failure on nocturnal Bilevel Positive Airway Pressure. Airway management was further complicated by limited mouth opening and cervical spine ankylosis., (Copyright © 2017 Elsevier Ltd. All rights reserved.)