Ketamine Reduces Morphine Consumption!; Does Resident Involvement Impact Surgery?; Good News for Scoliosis Patients

Ketamine Reduces Morphine Consumption!

According to new work from California and Switzerland, supplementing morphine with ketamine may be effective at reducing pain in spine surgery. The study, “Perioperative Ketamine for Analgesia in Spine Surgery: A Meta-analysis of Randomized Controlled Trials,” was published in the March 1, 2018 edition of Spine.

Arif Pendi, M.S., co-author of the paper and with the Department of Orthopaedic Surgery at the University of California, Irvine, California, told OTW, “Clinicians at our institution want to reduce our reliance on opiates.”

“Morphine is the standard of care to manage pain postoperatively. But, morphine use is linked to too many side effects and may act as a gateway to prescription opioid abuse. When this paper was submitted for review to Spine, a physician reviewer commented that ‘we’ (i.e., spine surgeons collectively) are interested in looking into ANY ways to reduce our reliance on morphine postoperatively.”

“Meta-analysis is an ideal way to answer the fundamental research question because we have much more power (i.e., patients) than a single study and we are only including the highest quality studies (randomized controlled trials). This means that our study is amongst the highest quality of evidence.”

The authors wrote, “We conducted a comprehensive search of PubMed, the Cochrane Central Register of Controlled Trials for prospective RCTs [randomized controlled trials], Web of Science, and Scopus. Patients who received supplemental ketamine were compared with the control group in terms of postoperative morphine equivalent consumption, pain scores, and adverse events…”

“A total of 14 RCTs comprising 649 patients were selected for inclusion into the meta-analysis. Patients who were administered adjunctive ketamine exhibited less cumulative morphine equivalent consumption at 4, 8, 12, and 24 hours following spine surgery. The ketamine group also reported lower postoperative pain scores at 6, 12, and 24 hours…”

Pendi commented to OTW, “Ketamine consistently reduced morphine consumption and pain scores in the immediate postoperative period (24 hours after surgery). Notably, it did so without significantly increasing the rate of complications.”

“Most clinicians are worried about the side effects of ketamine, which results in delirium at-worst. Although we couldn’t analyze rates of delirium, many of the symptoms of delirium (e.g. hallucinations) were not significantly more common. A lot of these side effects occur when you use very high doses of ketamine.”

“However, ketamine as an additive agent means that we are suggesting adding only a small dose of ketamine to existing pain control regimens which are dominated by morphine use (intravenous patient-controlled analgesia or IV-PCA). This idea (of adding other agents in varying amounts to supplement morphine) is called multi-modal analgesia.”

“My specific advice: try ketamine. In general, I would advise considering supplemental analgesics to reduce reliance on morphine or other opiates as the primary postoperative analgesic.”

Does Resident Involvement Impact Cervical Fusion Cases?

When residents are involved in posterior cervical fusion (PCF) is there an increase in morbidity or mortality?

A new study published in the March 1, 2018 edition of Spine examines that question. The study is entitled, “The Impact of Resident Involvement in Elective Posterior Cervical Fusion.”

Samuel K. Cho, M.D. with the Department of Orthopedics at the Icahn School of Medicine at Mount Sinai in New York and co-author on the study, told OTW, “Resident and fellow training and education is a critical part of academic medicine. This is how we continue to raise up the next generation of physicians who are going to go out into our communities and serve them.”

“At the same time, our patients have entrusted their health to us for utmost care. This is this ongoing tension between the practice of medicine and training of young physicians.”

“There have been several academic papers on this topic and we and other groups have published on. We want to explore resident involvement in the context of posterior cervical fusion (PCF) which is a complex and delicate procedure.”

“Further, I wanted to generate a larger discussion around how we are training physicians and whether there are areas for improvement and continued modifications. I think we can learn from other industries such as the airline industry, for example.”

The authors wrote, “The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was examined from 2005 to 2012…A total of 448 cases were assessed in NSQIP. Less than half of these cases involved residents…”

Dr. Cho commented to OTW, “The database that we used is a national one and as such allowed for a bird’s eye view of recent trends in surgical practices of multiple institutions. The use of these types of data mitigates certain biases that may be either surgeon or institution specific or arises from a small sample size. On the other hand, we lack granularity that we love as clinicians that is specific to our specialty, spine surgery in this case.”

“In some sense the results we obtained were as expected. When residents are involved in the surgical care of performing posterior cervical fusion, it takes slightly longer and there may be concomitant increase in blood loss and perhaps even length of stay. However, we also need to keep in mind that many of these participating institutions are tertiary academic medical centers where we take on the toughest and sickest patients. Therefore, surgical care may be a bit bumpier whether residents are involved or not.”

“Be mindful of the downstream effect of resident involvement during posterior cervical fusion on the patients and actively balance physician training and patient care on an ongoing basis. Resident education and training is the sine qua non of academic medicine. We should all be continuously engaged in this endeavor to produce the best and most well-trained physicians for our communities. At the same time, we should also think of ways to improve on the process.”

Good News for Scoliosis Patients

Researchers from Washington University in St. Louis (WUSTL) have some good news for scoliosis patients who are concerned for their offspring.

The new study, “Scoliosis severity does not impact the risk of scoliosis in family members,” appears in the March 2018 edition of the Journal of Pediatric Orthopaedics B.

Matthew B. Dobbs, M.D., orthopedic surgeon at WUSTL and co-author on the study, told OTW, “This study developed after an inquisitive undergraduate student approached us about working in our musculoskeletal genetics laboratory.”

“This student, who is also a co-author of the paper, had previously had surgery for scoliosis, and was interested in knowing whether the severity of his scoliosis would influence his risk of having children with scoliosis. Engaging stakeholders in research is important, as they often direct us to the most salient questions.”

“As part of our large genetic study of scoliosis, we had collected more than 1,200 pedigrees from patients with scoliosis to evaluate. Because this study is done in the modern treatment era when bracing is standard treatment for scoliosis, we are limited by evaluating scoliosis progression in this context.”

“Overall, on a population level, individuals with surgically treated scoliosis are no more likely than those with nonsurgically treated scoliosis, of having either an affected relative or a surgically treated relative.”

“This study, along with others that have found similar results, can be reassuring to surgically treated patients who worry about the risks of their children requiring similar treatments. In our cohort, we found only <2% of our surgically treated patients had a parent or child with surgically treated scoliosis.”

“Epidemiological and genetic studies are beginning to accumulate data that suggest that the risks for scoliosis may indeed be independent from the risk for scoliosis progression. Ongoing work in our research lab and others around the country may soon identify the individual risk factors for curve progression that will allow for better prognosis and preventive treatment of scoliosis.”