When compared with endoscopic thoracic sympathetic clipping at the T2 or T2+3 levels, endoscopic thoracic sympathetic clipping at the T3+4 level was associated with a higher satisfaction rate, a lower rate of severe compensatory sweating, and a trend toward fewer subsequent reversal procedures. Subjective reversibility of adverse effects after endoscopic thoracic sympathetic clipping was seen in approximately half of the patients who underwent endoscopic removal of surgical clips. Although yet to be supported by electrophysiologic studies, reversal of sympathetic clipping seems to provide acceptable results and should be considered in selected patients.

Introduction The epidemic of nonmedical use of prescription opioids (NMUPO) has been fueled by the availability of legitimately prescribed unconsumed opioids. The aim of this study was to better understand the contribution of prescriptions written for pediatric patients to this problem by quantifying how much opioid is dispensed and consumed to manage pain following hospital discharge, and whether leftover opioid is appropriately disposed of. Our secondary aim was to explore the association of patient factors with opioid dispensing, consumption and medication remaining upon completion of therapy. Methods Using a scripted 10-minute interview, parents of 343 pediatric inpatients (98% post-operative) treated at a university children’s hospital were questioned within 48 hours and 10–14 days after discharge to determine amount of opioid prescribed and consumed, duration of treatment, and disposition of unconsumed opioid. Multivariable linear regression was used to examine predictors of opioid prescribing, consumption, and doses remaining. Results Median number of opioid doses dispensed was 43 (IQR, 30–85 doses), and median duration of therapy was 4 days (IQR, 1–8 days). Children who underwent orthopedic or Nuss surgery consumed 25.42 [95% CI, 19.16–31.68] more doses than those who underwent other types of surgery (p < 0.001), and number of doses consumed was positively associated with higher discharge pain scores (p = 0.032). Overall 58% [95% CI, 54%–63%] of doses dispensed were not consumed, and the strongest predictor of number of doses remaining was doses dispensed (p < 0.001). Nineteen percent of families were informed how to dispose of leftover opioid, but only 4% (8/211) did so. Discussion Pediatric providers frequently prescribed more opioid than needed to treat pain. This unconsumed opioid may contribute to the epidemic of NMUPO. Our findings underscore the need for further research to develop evidence-based opioid prescribing guidelines for physicians treating acute pain in children.

Our results indicate that significant differences in the characteristics of acute spine trauma but not demographics have occurred overtime in our institution. Also, there were significant differences between our database and the NTR regarding age distribution. Our reduced in-hospital mortality rates in comparison with the provincial data reinforce the recommendations for early management of SCI patients in a spine trauma center.

Despite the shift in demographics of spinal cord injury (SCI) due to an aging population, relatively little has been reported regarding the effect of age on outcomes after SCI. This study examines the potential confounding effect of co-morbidities on the age-related differences in the hospital mortality following acute traumatic SCI. All consecutive patients with SCI who were admitted to our spine center from 1996 to 2007 were included. Co-morbidities were classified using the Charlson Co-morbidity Index (CCI), Cumulative Illness Rating Scale, and the number of ICD-9 codes. Major potential confounders included age, gender, co-morbidity, and level and severity of SCI. There were 217 males and 80 females with ages from 15 to 96 years. Most patients had an incomplete cervical SCI following falls or motor vehicle accidents. The mean in-hospital mortality rate was 5.7%. Using univariate analyses, older age, relevant pre-existing medical conditions, and motor complete SCI were major risk factors for in-hospital death after acute SCI. Among the three co-morbidity assessments, the CCI was the most reliable co-morbidity index for prediction of hospital mortality in SCI patients after controlling for age in the Cox proportional hazard modeling. In addition, the CCI appears to be a major confounder, which accounts for the majority of age-related differences in mortality following SCI. Our findings have implications for future clinical trials of therapies for adult patients with acute SCI and for management strategies of elderly individuals with SCI.

Despite the shift in demographics of spinal cord injury (SCI) due to an aging population, relatively little has been reported regarding the effect of age on outcomes after SCI. This study examines the potential confounding effect of co-morbidities on the age-related differences in the hospital mortality following acute traumatic SCI. All consecutive patients with SCI who were admitted to our spine center from 1996 to 2007 were included. Co-morbidities were classified using the Charlson Co-morbidity Index (CCI), Cumulative Illness Rating Scale, and the number of ICD-9 codes. Major potential confounders included age, gender, co-morbidity, and level and severity of SCI. There were 217 males and 80 females with ages from 15 to 96 years. Most patients had an incomplete cervical SCI following falls or motor vehicle accidents. The mean in-hospital mortality rate was 5.7%. Using univariate analyses, older age, relevant pre-existing medical conditions, and motor complete SCI were major risk factors for in-hospital death after acute SCI. Among the three co-morbidity assessments, the CCI was the most reliable co-morbidity index for prediction of hospital mortality in SCI patients after controlling for age in the Cox proportional hazard modeling. In addition, the CCI appears to be a major confounder, which accounts for the majority of age-related differences in mortality following SCI. Our findings have implications for future clinical trials of therapies for adult patients with acute SCI and for management strategies of elderly individuals with SCI.

Pain following intracranial surgery has historically been undertreated because of the concern that opioids, the analgesics most commonly used to treat moderate-to-severe pain, will interfere with the neurologic examination and adversely affect postoperative outcome. Over the past decade, accumulating evidence, primarily in adult patients, has revealed that moderate-to-severe pain is common in neurosurgical patients following surgery. Using the neurophysiology of pain as a blueprint, we have highlighted some of the drugs and drug families used in multimodal pain management. This analgesic method minimizes opioid-induced adverse side effects by maximizing pain control with smaller doses of opioids supplemented with neural blockade and nonopioid analgesics, such nonsteroidal antiinflammatory drugs, local anesthetics, corticosteroids, N-methyl-D-aspartate (NMDA) antagonists, α2 -adrenergic agonists, and/or anticonvulsants (gabapentin and pregabalin).

Open craniosynostosis repair is associated with high levels of pain and low utilization of nonopioid analgesics. Strategies to improve pain, decrease emesis and LOS include implementation of multimodal analgesia period and avoidance of enteral medications in the first 24 hours after surgery.

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