Multimedia Fusion 2 Standard (Full CD) .rar
Savage Doherty
The group focuses on measurement and evaluation methods to facilitate the use of technologies that provide easier access to multimedia and multi-lingual information and that improve human-computer interface modalities. These technologies include recognizing and/or transforming information in speech, text, images, video, and other multimedia modalities, and the fusion of heterogeneous media content. Focus areas include speech recognition, speaker recognition, language recognition, machine translation, image processing, image understanding, video processing, visual recognition, 2-D and 3D shape analysis, image quality assessment, and interoperable digital media access.
Background: The opioid epidemic is at epic proportions currently in the United States. Exposure to opioids for surgery and subsequent postoperative pain management is a known risk factor for opioid dependence. In addition, opioids can have a negative impact on multiple aspects including clinical outcomes, length of hospital stay, and overall cost of care. Thus, the greatest effort to reduce perioperative opioid use is necessary and a multimodal pain control (MMPC) has been gaining popularity. However, its efficacy in spine surgery is not well known. We aimed to evaluate the efficacy of a MMPC protocol in patients undergoing lumbar single-level anterior lumbar interbody fusion (ALIF).
Methods: This is a retrospective comparative study. From a prospective, single-surgeon, surgical database, consecutive patients undergoing single-level ALIF with or without subsequent posterior fusion for degenerative lumbar conditions were identified before and after initiation of the MMPC protocol. The MMPC protocol consisted of a preoperative oral regimen of cyclobenzaprine (10 mg), gabapentin (600 mg), acetaminophen (1 g), and methadone (10 mg). Postoperatively they received a bilateral transverse abdominis plane block with 0.5% Ropivacaine prior to extubation. We compared in-hospital opioid consumption between the MMPC and non-MMPC cohorts as well as baseline demographic, the length of hospital stay, cost, and rate of postoperative ileus. Opioid consumption was calculated and normalized to the morphine milligram equivalents (MMEs).
Results: In total, 68 patients in the MMPC cohort and 39 in the non-MMPC cohort were identified. There was no difference in baseline demographics including sex, body mass index, smoking status, or preoperative opioid use between the two groups. Although there was no difference in the MMEs on the day of surgery (58.5 vs. 66.9, P=0.387), cumulative MMEs each day after surgery was significantly lower in the MMPC cohort, with final cumulative MMEs being reduced by 62% (120.2 vs. 314.8, P
Conclusions: The use of a MMPC protocol in patients undergoing single-level ALIF for degenerative conditions reduced opioid consumption starting on the first day after surgery, resulting in a cumulative reduction of 62%.
The United States is in the midst of an unprecedented opioid epidemic. More than 2 million people are addicted to prescription opioids (1). The rate of deaths involving opioid overdose has increased over 200% since 2000 (2). Recent studies have shown that surgery is a risk factor for developing opioid dependence (3-5). In opioid-naive patients, 3% continued to use opioids for more than 90 days after major elective surgery (3). A greater amount of initial opioid use is associated with greater risks of long-term use, misuse, and overdose (6,7).
Opioids have numerous dose-dependent adverse effects, including nausea, ileus, urinary retention, respiratory depression, hyperalgesia, and delirium, which can impair postoperative recovery. Additionally, opioids are associated with worse clinical outcomes including higher complication rate, longer hospital stay, higher costs, and need for early revision surgery (8-11). Thus, perioperative opioid use should be limited to the lowest effective dose and the shortest duration.
The multimodal pain control (MMPC) approach was developed to decrease perioperative opioid consumption (12). The principle of MMPC is to use multiple agents in a combination of both systemic and regional anesthesia in efforts to reduce overall opioid consumption. MMPC targets several different pathways and mediators involved in nociception to improve analgesic effect, reduce the doses of each agent to minimize the side-effects (12,13). MMPC has been reported to be associated with less postoperative pain and opioid consumption, shorter hospital stay, and increased patient satisfaction in other elective orthopedic procedures (14-16).
In spine surgery, several studies have examined the efficacy of MMPC. Intravenous lidocaine, ketamine, postoperative intramuscular local anesthetic infiltration, and oral pregabalin have been reported to reduce postoperative pain and opioid consumption (17-20). The number of patients undergoing spine surgery is increasing (21) and patients with spine pathology have a high incidence of preoperative opioid use, ranging from 20% to 55% (22,23). Alarmingly, as much as 38% of patients undergoing spine surgery were still on opioids one year after surgery (24). Given these reports, developing a protocol to minimize opioid consumption following elective spine surgery is of paramount importance. Here, we established the perioperative pain management protocol using MMPC approach. The purpose of this study was to evaluate the efficacy of the protocol on patients undergoing single-level anterior lumbar interbody fusions (ALIF).
This is a retrospective comparative study. A retrospective review of a prospective, single-surgeon, surgical database was utilized for consistency in surgical technique. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by institutional ethics board of University of Louisville (#18.1197) and individual consent for this retrospective analysis was waived. Consecutive patients undergoing single-level ALIF with subsequent posterior fixation/fusion for degenerative lumbar conditions were identified before and after initiation of the MMPC protocol.
The sample size calculation is based on the parameters α=0.05 (two-sided) and power: 1-β=0.8. With MMPC having a medium effect size of 0.5 on reducing postoperative opioid consumption the sample size was calculated to be 102.
We compared baseline demographic, surgical data [estimated blood loss (EBL), surgical time, level fused, and primary vs. revision], and preoperative opioid use as all of these could affect postoperative pain and opioid use. We defined revision surgery as history of spine surgery involving the same level, such as pseudoarthrosis and adjacent segment disease. As well as baseline demographic, the length of hospital stay (LOS), cost, rate of postoperative ileus were assessed.
Retroperitoneal approach was done using a left paramedian incision. The anterior rectus sheath was opened, and the rectus mobilized laterally. A retroperitoneal pocket was created bluntly to place a spinal Thompson retractor and blunt dissection carried out between the iliac vessels and psoas muscles.
Once the disc of interest was exposed, the disc was excised using a knife followed by Cobb elevator and endplate preparation tools. It was then dilated to accommodate a cage. The endplates were cleaned off all disc, and the posterior annulus was exposed. A cage was packed with an allograft and bone graft substitutes or extenders. It was impacted into the disc space with good fit and fixation. Patients were then positioned in the prone position and posterior fusion were performed in standard fashion.
The MMPC protocol consisted of a preoperative oral regimen of cyclobenzaprine (10 mg), gabapentin (600 mg), acetaminophen (1 g), and methadone (10 mg). Postoperatively patients received a bilateral transverse abdominis plane (TAP) block with 0.5% Ropivacaine prior to extubation. This regimen is based on the fact that patients undergoing combined procedure typically complain of abdominal pain as well as back pain and spasm postoperatively. Therefore, we included TAP block in addition to standard pain medications such as cyclobenzaprine, gabapentin, and acetaminophen.
Difference between groups were analyzed using Fisher exact test for categorical variables or Mann-Whitney U test for continuous variables. All statistical analyses were performed using SPSS Statistics 25 (IBM Corp., Armonk, NY, USA). A statistical significance was defined as P value
In total, 68 patients in the MMPC cohort and 39 in the non-MMPC cohort were identified. There was no difference in baseline demographics including sex, body mass index (BMI), smoking status, or preoperative opioid use between the two groups. The MMPC cohort was older (56.8 vs. 51.6 years, P=0.026). There was no difference in surgical data including operative time, EBL, number of fused levels, and rate of revision surgery (Table 1).
MMPC was initially introduced in abdominal surgery and is currently used in orthopedic and spine procedures. Although some studies have shown that MMPC reduced opioid consumption (16,25-27) other studies have not (28). A variety of agents are available for MMPC and have been studied to reduce postoperative opioid consumption. There are numerous reports detailing the efficacy of acetaminophen for postoperative pain management, showing reduced LOS, opioid consumption, and complication rate (29-31). Gabapentin also has been studied regarding its efficacy in the reduction of postoperative pain and opioid consumption (16,32,33). TAP block has been considered an effective analgesia for abdominal surgery (34,35). These studies examined the efficacy of a single modality, with each medication having a significant benefit in reducing postoperative opioid consumption. Since our patients underwent ALIF and subsequent posterior fusion surgery, our regimen included a combination of oral agents and a TAP block. In our cohort and regimen, MMPC significantly decreased in-hospital opioid consumption (62%). In our cohort and regimen, MMPC significantly decreased in-hospital opioid consumption (62%). Soffin et al. examined the efficacy of MMPC including pre-incisional TAP block, regularly scheduled non-opioid analgesics (gabapentin, acetaminophen, ketorolac) for ALIF and lateral lumbar interbody fusion (LLIF) (36), which is similar to our study. They showed median MME was 57.5. The MMEs are much lower than those of our patients, which may be due to the difference in procedure. They evaluated patients undergoing ALIF/LLIF without posterior procedures whereas our patients all underwent posterior fusion. Also, their study did not have a control group, and sample size was small (n=32). In our study, we compared opioid consumption between MMPC and non-MMPC (control group) with relatively large size. Our finding provided a concrete evidence in the efficacy of MMPC regimen including TAP block.
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