T he postoperative analgesic effects of intra-articular injections of bupivacaine and/or morphine were examined prospectively in 437 patients who had total knee replacement for osteoarthritis. They were divided randomly into four groups. Group I received 10 mg of morphine (1 ml) and 9 ml of saline, group II received 10 ml of bupivacaine (2.5 mg/ml), group III received 10 ml of saline, and group IV received 10 mg of morphine (1 ml) and 9 ml of bupivacaine (2.5 mg/ml). All analgesics administered in the first 24 hours after operation were recorded. The patients rated their pain on the McGill-Melzack scale at 1, 6, 12 and 24 hours. No significant differences were found between any of the groups in the use of Demoral and/or Toradol in 24 hours, the length of stay in hospital or the pain rating at 1, 6, 12 or 24 hours. Patients in groups I and IV, whose injections included morphine, used significantly more morphine in the first 24 postoperative hours than did groups II or III. [Br] 1999;81-B:301-3. J Bone Joint Surg Received 13 May 1998; Accepted after revision 6 August 1998In 1991, Stein et al 1 studied the analgesic effects of intraarticular injections of morphine after arthroscopic knee surgery. Their findings suggest that only small amounts are required to manage pain effectively. More recently, Badner et al 2 noted that bupivacaine markedly reduced the need for postoperative analgesia and led to an increase in the range of flexion achieved after total knee replacement (TKR). We have therefore studied the analgesic effect of morphine and bupivacaine, both alone and in combination, on the control of pain after TKR. Patients and MethodsWe studied 437 consecutive patients (294 women and 143 men) who had had primary unilateral TKR for osteoarthritis and had no allergic reaction to morphine. Gastrointestinal reactions were accepted, but postoperatively, patients with these problems were given Demerol or Toradol. The patients were randomised prospectively by computer into four groups. The mean age was 71.76 years (29 to 93, SD 8.31) ( Table I). In group I there were 41 men and 68 women with a mean age of 69.5 years, in group II 36 men and 78 women of mean age 71.7 years, in group III 25 men and 72 women of mean age 72.9 years and in group IV 41 men and 76 women, with a mean age 72.3 years.We used general anaesthesia in 357 patients and spinal anaesthesia in 80. All spinal anaesthetics used 3 ml (0.5%) of bupivacaine.After skin closure, various combinations of analgesics were injected into the knee. Group I received 10 mg of morphine (1 ml) and 9 ml of saline, group II 10 ml of bupivacaine (2.5 mg/ml), group III 10 ml of saline, and group IV 10 mg of morphine (1 ml) and 9 ml of bupivacaine (2.5 mg/ml). The injections were given under doubleblind conditions. The postoperative protocol was the same in all cases. No wound evacuation drains were used. Walking began on day one. On the second day, the knees were put through a range of movement. Patients were discharged between the fourth and sixth days.We used the McGill-Mel...

The postoperative analgesic effects of intra-articular injections of bupivacaine and/or morphine were examined prospectively in 437 patients who had total knee replacement for osteoarthritis. They were divided randomly into four groups. Group I received 10 mg of morphine (1 ml) and 9 ml of saline, group II received 10 ml of bupivacaine (2.5 mg/ml), group III received 10 ml of saline, and group IV received 10 mg of morphine (1 ml) and 9 ml of bupivacaine (2.5 mg/ml). All analgesics administered in the first 24 hours after operation were recorded. The patients rated their pain on the McGill-Melzack scale at 1, 6, 12 and 24 hours. No significant differences were found between any of the groups in the use of Demoral and/or Toradol in 24 hours, the length of stay in hospital or the pain rating at 1, 6, 12 or 24 hours. Patients in groups I and IV, whose injections included morphine, used significantly more morphine in the first 24 postoperative hours than did groups II or III.

Postoperative vision loss (POVL) associated with spine surgery is a well known, albeit very rare complication. POVL incidence after spinal surgery ranges from 0.028 to 0.2%; however, due to the increase in number and duration of annual complex spinal operations, the incidence may increase. Origin and pathogenesis of POVL remain frequently unknown. A 73-year-old patient presented with lumbar disc herniation with associated neurological deficits after conservative pre-treatment at a peripheral hospital. Known comorbidities included arterial hypertension, moderate arterial sclerosis, diabetes mellitus type 2, mildly elevated blood lipids and treated prostate gland cancer. During lumbar spine surgery in modified prone position the patient presented with an acute episode of severe hypotension, which required treatment with catecholamines and Trendelenburg positioning. Three hours postoperatively, a visual loss in the right eye occurred, resulting in a complete amaurosis. Antihypertensive medication, arteriosclerosis and intraoperative hypotension are possible causes for the POVL. Intraoperative administration of catecholamines and Trendelenburg positioning for treatment of systemic hypotension might further compromise ocular perfusion. In patients with comorbidities compromising arterial blood pressure, blood circulation and microcirculation, POVL must be considered as a severe postoperative complication. It is recommended to inform patients about such complications and obtain preoperative informed consent regarding POVL. Any recent modification of antihypertensive medication must be reported and analysed for potential intraoperative hemodynamic consequences, prior to spine surgery in prone position.

Dangerous painkillers may cause serious problems for those who fall into drugs’ addictive trap, such as former NFL quarterback Brett Favre. The addictiveness of painkillers such as OxyContin and Vicodin is largely attributed to the response they trigger in proteins such as mu opioid receptors (MOPs). This receptor activates cellular signaling pathways responsible for dulling pain; however, the protein also has the ability to stimulate cellular signaling pathways that makes MOP‐based painkillers rewarding. An alternate target that alleviates pain but does not produce reward is the kappa opioid receptor (KOP). Unfortunately, many KOP agonists also activate signaling pathways that produce hallucinogenic effects. To investigate the changes that occur when KOP binds to different ligands, the Divine Savior Holy Angels SMART (Students Modeling A Research Topic) Team has used 3D printing technology to model the active site of the KOP with salvinorin A, to see how the induced fit changes the signal transduction pathways in a neuron. Manipulating receptor proteins like the KOP to inhibit pain pathways without the addictive effect of MOP‐targeting painkillers would be a breakthrough in chronic pain management. Computer‐aided drug design helps streamline the development of KOP ligands that activate this receptor in ways that result in less hallucinogenic effects. Grant Funding Source: Supported by a grant from NIH‐CTSA.

Background: A serious complication of intrathecal (IT) infusion therapy for pain management is catheter-tip-associated granuloma. Catheter-tip granulomas can lead to permanent severe neurological sequelae if not promptly detected. Case Description: We report a patient with a recurrence of a catheter-tip granuloma causing a high-grade paresis of the lower extremities and we review briefly the literature. Conclusion: Patients with IT pump therapy presenting new neurological findings need prompt imaging of the spinal axis to rule out a catheter-tip granuloma. In case of catheter-tip granuloma, early surgical decompression is important.