BACKGROUND: Hypotension remains a frequent complication of spinal anesthesia, increasing the risk of nausea and vomiting, altered mental status, and aspiration. The aim of this systematic review and meta-analysis was to determine whether 5-hydroxytryptamine3 (5-HT3) receptor antagonists, administered before the initiation of spinal anesthesia, mitigate hypotension. METHODS: After a systematic literature search in various databases, randomized placebo-controlled double-blind trials studying the preventive effect of 5-HT3 receptor antagonists were included. A random-effects model was applied, risk ratio (RR, binary variables) or weighted mean difference (continuous variables) with 95% confidence intervals (CIs) were calculated. The primary outcome was the incidence of hypotension. RESULTS: Seventeen trials (8 obstetric, 9 non-obstetric) reporting on 1604 patients were identified. Ondansetron in doses from 2 to 12 mg was studied in 12 trials. Prophylactic 5-HT3 administration significantly reduced the risk of hypotension in the combined analysis of 17 trials, RR 0.54 (95% CI 0.36–0.81, I ² = 79%). In obstetric trials, the RR was 0.52, 95% CI 0.30–0.88, I ² = 87% (number needed to treat 4). In non-obstetric studies, the 95% CIs were wide and included a clinically relevant reduction in the risk of hypotension (RR 0.50, 95% CI 0.22–1.16; I ² = 66%). Contour-enhanced funnel plots confirmed publication bias. Meta-regression showed a significant ondansetron dose response in non-obstetric patients (β = −0.355, P = .04). In the combined and in the obstetric-only analysis, the risk of bradycardia was significantly reduced as was the use of phenylephrine equivalents. CONCLUSIONS: 5-HT3 antagonists are effective in reducing the incidence of hypotension and bradycardia; the effects are moderate and are only significant in the subgroup of patients undergoing cesarean delivery. The effects in the non-obstetric population are not significant.

Intramedullary spinal cord tumors (IMSCT) comprise the least common types of spinal neoplasms; surgery is mostly conducted with intraoperative neuromonitoring (IONM). However, although IONM is widely used to prevent neurologic damage and many single-center studies have been reported, the added value, in terms of overall sensitivity and specificity, of different monitoring techniques used in IMSCT surgery remains to be clearly defined. To summarize and review the reported evidence on the use of IONM in IMSCT surgery, including our own case series (n = 75 patients). We systematically searched the literature published from January 2000 to February 2018. Articles included patients with IMSCT who underwent surgery with neuromonitoring. We estimated the sensitivity, specificity, 95% confidence interval (CI), positive likelihood ratio, and negative likelihood ratio. Of 1385 eligible articles, 31 were included in the systematic review. Fifteen of these articles were used for a meta-analysis, complemented with our own case series. All neuromonitoring modalities showed acceptable but not optimal test characteristics. For the indications used in the different studies, the motor evoked potentials approach showed the highest sensitivity (0.838; 95% CI, 0.703-0.919) and the best specificity (0.829; 95% CI, 0.668-0.921) for detecting neuronal injury. In our own case series, the extent of resection was significantly smaller in the false-positive group than in the true-negative group (P = 0.045). IONM showed high but not perfect sensitivity and specificity. IONM prevents neurologic damage but can also limit the extent of tumor resection. Prospective studies will have to define the definitive value of IONM.

BACKGROUND: Combined spinal–epidural labor analgesia has gained popularity, but it is unclear whether this technique is associated with a higher incidence of nonreassuring fetal heart rate (FHR) tracings compared with epidural analgesia. Our meta-analysis aimed at comparing the incidence of nonreassuring FHR tracings between the 2 neuraxial techniques. METHODS: Databases were searched to identify randomized controlled trials that compared the incidence of nonreassuring FHR tracings, as defined in the individual studies, after combined spinal–epidural versus epidural analgesia in laboring women. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using the random-effects model. We performed a subgroup analysis for studies using low-dose epidural bupivacaine concentrations (≤0.125%) for epidural analgesia. RESULTS: Seventeen trials including 3947 parturients were retrieved that compared the 2 neuraxial techniques. All trials used intrathecal opioids in 1 study arm. The pooled effect estimate of low- and high-dose epidural bupivacaine studies together showed a significantly increased risk of nonreassuring FHR tracings with the combined technique (RR 1.31, 95% CI 1.02–1.67, P = .03, I ² = 18%). A subgroup analysis of 10 trials using low-dose epidural bupivacaine found a RR for nonreassuring FHR tracings between combined spinal–epidural and epidural analgesia of 1.12, 95% CI 0.93–1.34, P = .18. In a sensitivity analysis of those low-dose epidural bupivacaine studies that ensured blinding of the outcome assessor, the RR was 1.41, 95% CI 0.99–2.02, P = .06. CONCLUSIONS: Combined spinal–epidural labor analgesia was associated with a higher risk of nonreassuring FHR tracings than epidural analgesia alone. In the subgroup analysis comparing combined spinal–epidural with low-dose epidural labor analgesia, the 95% CI contains a clinically significant difference between groups; moreover, the 95% CI overlaps with the 95% CI of the comparison of the combined low- and high-dose epidural techniques. Therefore, it cannot be concluded that there was no difference between combined spinal–epidural and low-dose epidural techniques.

Object: This is the first observational study to compare perioperative pain character and intensity in patients undergoing different types of elective neurosurgical procedures. Methods: A structured questionnaire was used to inquire about pain intensity, character, and management during the perioperative course, and the anticipated visual analogue scale (VAS) score in 649 patients during a 1-year period. The anticipated maximal postoperative VAS score was lower than the actual postoperative maximal VAS score and was independent of operation type and preoperative VAS score. Patients undergoing craniotomy experienced less pain than those undergoing spinal surgery. A majority of patients did not receive analgesic medication after surgery. Patients undergoing spinal surgery experienced higher preoperative VAS scores than those undergoing other neurosurgical treatments, with a shift from preoperative referred pain to postoperative local pain. After lumbar flavectomy, referred pain was greater than local pain. Patients with preoperative pain suffered significantly more postoperative pain than those without preoperative pain. In patients with postoperative surgery-related complications, VAS scores were higher than in those without complications. Conclusions: Neurosurgical procedures cause more pain than anticipated. Anticipated pain intensity is independent of the operation type and preoperative pain intensity. Postcraniotomy on-demand analgesic medication is appropriate, if the nurses on the ward react quickly. Otherwise, patient-controlled analgesia might be an option. Other neurosurgical procedures require scheduled analgesic therapies. Spinal surgery requires intensive preoperative pain treatment; a shift in pain character from preoperative referred pain to postoperative local pain is expected. Patients with referred pain after lumbar flavectomy are prone to the most intense pain. Patients with preoperative pain experience more postoperative pain than those without preoperative pain and require more intensive pain management. Increased postoperative VAS scores are associated with surgery-related complications.

Awake craniotomy patients are exposed to various stressful stimuli while their attention and vigilance is important for the success of the surgery. We describe several recent findings on the perception of awake craniotomy patients and address nonpharmacological perioperative factors that enhance the experience of awake craniotomy patients. These factors could also be applicable to other surgical patients. Proper preoperative counseling gives higher patient satisfaction and should be individually tailored to the patient. Furthermore, there is a substantial proportion of patients who have significant pain or fear during an awake craniotomy procedure. There is a possibility that this could induce post-traumatic stress disorder or related symptoms. Preoperative preparation is of utmost importance in awake craniotomy patients, and a solid doctor-patient relationship is an important condition. Nonpharmacological intraoperative management should focus on reduction of fear and pain by adaptation of the environment and careful and well considered communication.