Background: The authors tested the primary hypothesis that perioperative IV lidocaine administration during spine surgery (and in the postanesthesia care unit for no more than 8 h) decreases pain and/or opioid requirements in the initial 48 postoperative hours. Secondary outcomes included major complications, postoperative nausea and vomiting, duration of hospitalization, and quality of life. Methods: One hundred sixteen adults having complex spine surgery were randomly assigned to perioperative IV lidocaine (2 mg·kg −1 ·h −1 ) or placebo during surgery and in the post anesthesia care unit. Pain was evaluated with a verbal response scale. Quality of life at 1 and 3 months was assessed using the Acute Short-form (SF) 12 health survey. The authors initially evaluated multivariable bidirectional noninferiority on both outcomes; superiority on either outcome was then evaluated only if noninferiority was established. MORE than half-million spine surgeries are performed each year in the United States. Extensive spine surgery is painful, and postoperative pain is often difficult to control. Opioids-the most common analgesic approachin turn, often provoke postoperative nausea and vomiting. Patients with extensive lumbar spine surgery are prone to life-threatening complications, with incidences varying from 2.3% among patients having decompression alone to 5.6% among those having complex fusions.1 However, the overall complication incidence, including minor and major complications, is up to 16.4% (17.8% in thoracolumbar vs. 8.9% in cervical procedures).2 Therefore, functional recovery is often prolonged.2 A likely common mechanism for many adverse outcomes is the systemic inflammatory response to surgical tissue injury.Systemic lidocaine is antiinflammatory, 3 analgesic,

Background Ultrasound guidance for continuous femoral perineural catheters may be supplemented by electrical stimulation through a needle or through a stimulating catheter. We tested the primary hypothesis that ultrasound guidance alone is noninferior on both postoperative pain scores and opioid requirement and superior on at least one of the two. Secondarily, we compared all interventions on insertion time and incremental cost. Methods Patients having knee arthroplasty with femoral nerve catheters were randomly assigned to catheter insertion guided by: 1) ultrasound alone (n=147); 2) ultrasound and electrical stimulation through the needle (n=152); or, 3) ultrasound and electrical stimulation through both the needle and catheter (n=138). Noninferiority between any two interventions was defined for pain as no more than 0.5 points worse on a 0–10 Verbal Response Scale (VRS) scale and for opioid consumption as no more than 25% greater than the mean. Results The stimulating needle group was significantly noninferior to the stimulating catheter (difference (95% CI) in mean VRS pain score [stimulating needle versus stimulating catheter] of −0.16 (−0.61, 0.29), P<0.001; percent difference in mean IV morphine equivalent dose of −5% (−25%, 21%), P=0.002) and to ultrasound only (difference in mean VRS pain score of −0.28 (−0.72, 0.16), P<0.001; percent difference in mean IV morphine equivalent dose of −2% (−22%, 25%), P=0.006). In addition, the use of ultrasound alone for femoral nerve catheter insertion was faster and cheaper than the other two methods. Conclusion Ultrasound guidance alone without adding either stimulating needle or needle/catheter combination thus appears to be the best approach to femoral perineural catheters.

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