Farmacia italiana online: acquisto cialis in Italia e Roma senza ricetta.

Laspinesurgeon.com

SPINE Volume 33, Number 19, pp 2079 –20822008, Lippincott Williams & Wilkins Ketorolac and Spinal Fusion
Does the Perioperative Use of Ketorolac Really Inhibit
Spinal Fusion?
Ben B. Pradhan, MD, MSE,* Robert L. Tatsumi, MD,† Jason Gallina, MD,‡Craig A. Kuhns, MD,§ Jeffrey C. Wang, MD,¶ and Edgar G. Dawson, MD࿣ benefits of NSAIDs include reduced pain, improved post- Study Design. Retrospective review.
operative ambulation, shorter hospitalization and de- Objective. To evaluate the effect of postoperative use
creased nausea, emesis and sedation.2–4 NSAIDs have of ketorolac (Toradol) on spinal fusion in humans.
documented efficacy when administered as the sole anal- Summary of Background Data. The value of parenteral
ketorolac in postoperative analgesia has been well docu- gesic after minor surgical procedures and adjuvants to mented across surgical specialties. However, some stud- other analgesics after major surgery.5,6 Ketorolac (Tor- ies have shown that ketorolac may adversely affect osteo- adol, Roche Laboratories, Nutley, NJ), approved by the genic activity and fracture healing.
Food and Drug Administration in November 1989 for Methods. A total of 405 consecutive patients who un-
the control of postoperative pain, enhances the effect of derwent primary lumbar posterolateral intertransverseprocess fusion with pedicle screw instrumentation were narcotics, and decreases narcotic requirement.2,4,7–15 included in this retrospective study. A subtotal of 228 Empirically the authors have observed a more comfort- patients received Toradol after surgery for adjunctive an- able postoperative hospital course in spinal fusion pa- algesia. Each patient received a mandatory dose of 30 mg tients who received parenteral Ketorolac at our institu- intravenously every 6 hours for 48 hours. The same sur- tion without any attendant increase in complications.
geon performed the fusion procedure on all of these pa-tients. Historical controls included 177 patients who did NSAIDs, however, have a myriad of undesirable side not receive Toradol after surgery. The minimum fol- effects especially in the perioperative period and includes low-up period was 24 months. Nonunions were diag- gastrointestinal bleeding or ulcers, wound healing prob- nosed by analyzing sequential radiographs, flexion-ex- lems or bleeding, and renal failure.7,16–25 NSAIDs may tension radiographs, and computed tomography with also adversely affect osteogenic activity and fracture multiplanar reconstructions. The gold standard of surgi-cal exploration was performed in symptomatic patients healing.26 –29 Regarding spinal surgery, a number of with diagnostic ambiguity or nonunions diagnosed by studies have shown adverse effects on fusion rates in an- imals.30–33 This may occur through any one or all of Results. There were no smokers in the study popula-
several mechanisms.28,31,34 Glassman et al35 examined tion. Pseudarthrosis was identified in 12 of 228 patients the influence of ketorolac on spinal fusion in humans and (5.3%) who received Toradol after surgery, and in 11 of177 patients (6.2%) who did not. There was no significant concluded that this drug significantly inhibited fusion at difference detected in the nonunion rates between the doses typically used for postoperative pain control and two groups (P Ͼ 0.05, ␹2 method).
that NSAIDs should be avoided in the early postopera- Conclusion. Use of ketorolac after spinal fusion sur-
gery in humans, limited to 48 hours after surgery for The goal of this retrospective study was to determine adjunctive analgesia, has no significant effect on ultimatefusion rates.
the nonunion rate at 34 months after spine surgery in Key words: spinal fusion, pseudoarthrosis, ketorolac,
patients who were given a short-term amount of ketoro- nonsteroidal analgesics. Spine 2008;33:2079 –2082
Materials and Methods
Nonsteroidal anti-inflammatory drugs (NSAIDs) are Nonsmoking patients who underwent 1, 2, or 3 level lumbar commonly used for pain control and are the most often posterolateral intertransverse process fusion with pedicle prescribed class of medication around the world.1 The screw instrumentation and decompression by a single sur-geon (EGD) were given ketorolac intravenously as a manda-tory drug, and not as a prn (as needed) drug. Every patient From the *Risser Orthopaedic Group, Pasadena, CA; the †Pacific received the same dose and duration of the drug–30 mg Spine Specialists, Tualatin, OR; ‡New York, NY; the §University ofMissouri School of Medicine, Columbia, MO; ¶UCLA School of Med- intravenously every 6 hours for a total of 48 hours (total 240 icine, Los Angeles, CA. ࿣Edgar G. Dawson, MD, is deceased.
mg). No loading dose was given. Patient’s were contraindi- Acknowledgment date: November 25, 2007. Acceptance date: Febru- cated to have ketorolac if they had a documented allergy to NSAIDs, history of peptic ulcer disease, congestive heart The device(s)/drug(s) is/are FDA-approved or approved by correspond-ing national agency for this indication.
failure, liver disease, bleeding disorder, serum creatinine No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related Patient’s who underwent the same procedure by the senior directly or indirectly to the subject of this manuscript.
author (EGD) before November 1989 (before the introduction Address correspondence and reprint requests to Ben B. Pradhan, MD, of ketorolac) and by another surgeon (JCW) were not given MSE, Risser Orthopaedic Group, 2627 East Washington Boulevard, Pas-adena, CA 91107; E-mail: bpradhanb@hotmail.com Ketorolac after surgery. All patients were given patient con- 2080 Spine Volume 33 Number 19 2008
Table 1. Patient Demographics
Table 2. Nonunion Results
Discussion
trolled analgesia transitioned to prn acetaminophen and opioid The use of posterolateral fusion in the treatment of de- tablets. No oral NSAIDs were given after surgery.
generative, traumatic, and other unstable spinal disor- The status of the fusion was determined based on antero- ders has been one of the most popular methods in spine posterior and flexion-extension radiographs or computerizedtomography at the time of 1-year follow-up. Pseudarthrosis surgery.36 –38 Pseudarthrosis rates for posterolateral (nonunion) was defined as the absence of bridging bone for- lumbar spine fusions has been quoted to be anywhere mation without trabeculation, Ͼ2° of motion on flexion- from 3% to 35% in the literature.39–42 The addition of extension radiographs, and/or radiolucency around the instrumentation has not eliminated this problem.43–45 Various factors may contribute to pseudarthrosis which Demographic data (age, sex, height, weight), the level of may include smoking and long-term NSAID usage.
fusions, and the use of iliac crest bone graft (ICBG) were ana- Smoking has been shown to increase pseudarthrosis rates lyzed with analysis of variance (Table 1). The incidence of 2- to 5-fold.39,41,46,47 Long-term, high dose, NSAID use pseudarthrosis was evaluated by a ␹2 analysis.
after fusion surgery has been shown to adversely affectfusion rates in animals.30–33,48,49 NSAIDs are commonly used for pain control and are the Four hundred five patients underwent primary lumbar most often prescribed class of medications around the posterolateral intertransverse process fusion with pedicle world.1 Ketorolac has been used in the perioperative period screw instrumentation and decompression. Two hun- frequently and safely in many surgical procedures.12,50–55 dred twenty-eight patients received ketorolac and 177 A number of studies have specifically examined the use of patient’s did not receive this drug and these patients were ketorolac after orthopaedic and spine surgery, finding no split approximately equally between 2 surgeons, (EGD) increase in complications.2,4,8,11–14,56,57 Aubrun et al13 de- tected no difference in perioperative complications with in- There was no significant difference between the 2 travenous ketoprofen use after adult spinal fusion surgery.
groups for age, gender, height, weight, or number of Munro et al15 and Vitale et al58 found no increase in com- levels fused. There was also no significant difference de- plication rates after pediatric scoliosis fusion surgery. Le tected between the 2 groups for pseudarthrosis or any Roux and Samudrala14 arrived at similar findings after differences between the 2 surgeons. Nonunion was diag- lumbar disc surgery. Gora-Harper et al59 noted less mor- nosed in 12 of 228 (5.3%) patients who received Tor- bidity and lower cost after joint and spine procedures adol, and in 11 of 177 (6.2%) of patients who did not receive ketorolac (Table 2). When comparing the pa- The adverse effects of NSAIDs on spinal fusion seen in tients the senior surgeon (EGD) operated on, there was animal studies are likely dose and duration-depen- a higher nonunion rate when he did not use ketorolac; dent.30,60,61 The dose of ketorolac for humans in this study however, this difference was not significant under sta- was approximately 1.5 mg/kg/d for the first 48 hours only.
tistical analysis. There was a trend toward higher non- Studies involving spinal fusions in animals have dosed union rates with 3 level fusions as opposed to 1–2 NSAIDs anywhere from 3 mg/kg/d to 10 mg/kg/d for du- levels, however, there was limited data to find statisti- rations from 7 days to 12 weeks.30–33,60,62 Ho et al60 dis- covered that while 4 mg/kg/d of ketorolac given for 6 weeks A large proportion of patients in this study did not delayed endochondral ossification in rabbit ulnar fractures, receive autogenous ICBG to augment fusion. The per- a dosing schedule of 2 mg/kg/d for 6 weeks seemed to have centage of patients receiving ICBG was significantly little or no effect. The latter in fact is one of the lowest lower in the Toradol treated group than in the non- dosing schedules in the literature. Table 3 lists the break- Toradol treated group (54.8% vs. 86.4%, P Ͻ 0.05).
down of the cumulative doses of NSAIDs administered in Ketorolac and Spinal Fusion Pradhan et al 2081
Table 3. Cumulative Doses of NSAIDs on
Bone Formation

● Ketorolac is a good adjuvant with other analge- sics after major surgical procedures.
● The use of ketorolac after primary lumbar spinalfusion surgery in humans did not affect fusion rates when compared with surgical patients who did not References
1. Baum C, Kennedy DL, Forbes MB. Utilization of nonsteroidal antiinflam- matory drugs. Arthritis Rheum 1985;28:686 –92.
2. Kinsella J, Moffat AC, Patrick JA, et al. Ketorolac trometamol for postoper- d indicates days; h, hours; wk, weeks.
ative analgesia after orthopaedic surgery. Br J Anaesth 1992;69:19 –22.
3. Reuben SS, Ekman EF. The effect of cyclooxygenase-2 inhibition on analge- various studies in the literature. It is notable that in this sia and spinal fusion. J Bone Joint Surg Am 2005;87-A:536 – 42.
4. Reuben SS, Connelly NR, Lurie S, et al. Dose-response of ketorolac as an study, the ketorolac dose amounted to approximately 1.5 adjunct to patient-controlled analgesia morphine in patients after spinal fu- mg/kg/d for 2 days. It seems, however, that this dose can sion surgery. Anesth Analg 1998;87:98 –102.
still be lowered without compromising results. Reuben et 5. Souter AJ Fredman B, White PF. Controversies in the perioperative use of non-steroidal antiinflammatory drugs. Anesth Analg 1994;79:1178 –90.
al4 performed a study on the analgesic effects of ketorolac 6. Dahl JB Kehlet H. Non-steroidal anti-inflammatory drugs: rationale for use specifically after spinal fusion surgery, and concluded that in severe postoperative pain. Br J Anaesth 1991;66:703–12.
the minimum effective dose of ketorolac was 15 mg every 6 7. Gillis JC, Brogden RN. Ketorolac. A reappraisal of its pharmacodynamic and hours for 24 hours, which translates to approximately 0.4 pharmacokinetic properties and therapeutic use in pain management. Drugs1997;53:139 – 88.
mg/kg/d for a day assuming a 70 kg patient.
8. Sutters KA, Shaw BA, Gerardi JA, et al. Comparison of morphine patient- To our knowledge, there has been only one clinical controlled analgesia with and without ketorolac for postoperative analgesia study that has evaluated the effects on bone formation by in pediatric orthopedic surgery. Am J Orthop 1999;28:351–58.
9. Sevarino FB, Sinatra RS, Paige D, et al. Intravenous ketorolac as an adjunct ketorolac use during the perioperative period after spinal to patient-controlled analgesia (PCA) for management of postgynecologic fusion surgery in humans.35 The purpose of our study surgical pain. J Clin Anesth 1994;6:23–7.
was to demonstrate that limited use of ketorolac for im- 10. Picard P, Bazin JE, Conio N, et al. Ketorolac potentiates morphine in post- operative patient-controlled analgesia. Pain 1997;73:401– 6.
mediate postoperative analgesia after spinal fusion, does 11. Reuben SS, Connelly NR, Steinberg R. Ketorolac as an adjunct to patient- not necessarily lead to increased pseudarthrosis rates.
controlled morphine in postoperative spine surgery patients. Reg Anesth There are several improvements in our study method 12. Turner DM, Warson JS, Wirt TC, et al. The use of ketorolac in lumbar spine compared to Glassman et al.35 One of the major short- surgery: a cost-benefit analysis. J Spinal Disord 1995;8:206 –12.
comings in the previous study was that Toradol admin- 13. Aubrun F, Langeron O, Heitz D, et al. Randomised, placebo-controlled istration was not indiscriminate-it was given as a PRN study of the postoperative effects of ketoprofen after spinal fusion surgery.
Acta Anaesthesiol Scand 2000;44:934 –39.
medication and patients with more pain received higher 14. Le Roux PD, Samudrala S. Postoperative pain after lumbar disc surgery: a accumulated dosages of this medication. Thus, the vari- comparison between parenteral ketorolac and narcotics. Acta Neurochir able dosage amount might be a confounding factor when 15. Munro HM, Walton SR, Malviya S, et al. Low-dose ketorolac improves one is evaluating the effect of nonunion. Furthermore, in analgesia and reduces morphine requirements following posterior spinal fu- the aforementioned study, there were additional con- sion in adolescents. Can J Anaesth 2002;49:461– 66.
founding factors that could affect spinal fusion rates such 16. Saag KG, Cowdery JS. Nonsteroidal anti-inflammatory drugs. Balancing benefits and risks. Spine 1994;19:1530 – 4.
as a high population of smokers (50%) and multiple 17. Nuutinen LS, Laitinen JO, Salomaki TE, et al. A risk-benefit appraisal of surgeons performing the fusion procedures.
injectable NSAIDs in the management of postoperative pain. Drug Saf 1993; In this study, the patients who were given Toradol 18. Connelly CS, Panush RS. Should nonsteroidal anti-inflammatory drugs be after surgery were operated on by a single surgeon in a stopped before elective surgery? Arch Intern Med 1991;151:1936 – 46.
nonsmoking population. Based on the findings in this 19. Toto RD, Anderson SA, Brown-Cartwright D, et al. Effects of acute and study, and in contrast to the previous study, we conclude chronic dosing of NSAIDs in patients with renal insufficiency. Kidney Int1986;30:760 – 68.
that limited use of ketorolac for analgesia after lumbar 20. Feldman HI, Kinman JL, Berlin JA, et al. Parenteral ketorolac: the risk for spinal fusion surgery had no significant effect on fusion.
acute renal failure. Ann Intern Med 1997;126:193–9.
To minimize other complications, we suggest screening 21. Kenny GN. Potential renal, haematological and allergic adverse effects asso- ciated with nonsteroidal anti-inflammatory drugs. Drugs 1992;44:31– 6.
the patients for risk factors and to use the minimum 22. Strom BL, Berlin JA, Kinman JL, et al. Parenteral ketorolac and risk of effective dose and duration per surgeon discretion.
gastro-intestinal and operative site bleeding: a postmarketing surveillancestudy. JAMA 1996;275:376 – 82.
23. Kallis P, Tooze JA, Talbot S, et al. Preoperative aspirin decreases platelet aggregation and increases post-operative blood loss-a randomized, placebo- Key Points
controlled, double-blind clinical trial in 100 patients with chronic stableangina. Eur J Cardiothorac Surg 1994;8:404 –9.
● Ketorolac has been safely used in the periopera- 24. RuDusky BM. Severe postoperative hemorrhage attributed to single-dose tive period for many surgical procedures.
parenteral ketorolac-induced coagulopathy. Angiology 2000;51:999 –1002.
25. Haws MJ, Kucan JO, Roth AC, et al. The effects of chronic ketorolac 2082 Spine Volume 33 Number 19 2008
tromethamine (toradol) treatment on wound healing. Ann Plast Surg 1996; 45. Steinman JC, Herkowitz HN. Pseudarthrosis of the spine. Clin Orthop Relat 26. Elves MW, Bayley I, Roylance PJ. The effect of indomethacin upon experi- 46. Silcox DH, Daftari T, Boden SD. The effect of nicotine on spinal fusions.
mental fractures in the rat. Acta Orthop Scand 1982;53:35– 41.
27. Ritter MA, Gioe TJ. The effect of indomethacin on para-articular ectopic 47. Wing KJ, Fisher CG, O’Connell JX. Stopping nicotine exposure before sur- ossification following total hip arthroplasty. Clin Orthop 1982;167:113–17.
gery: the effect on spinal fusion in a rabbit model. Spine 2000;25:30 – 4.
28. Bo J, Sudmann E, Marton PF. Effect of indomethacin on fracture healing in 48. Maxy RJ Glassman SD. The effect of nonsteroidal anti-inflammatory drugs rats. Acta Orthop Scand 1976;47:588 –99.
on osteogenesis and spinal fusion. Reg Anesth Pain Med 2001;26:156 – 8.
29. Tornkvist H, Lindholm TS, Netz P, et al. Effect of ibuprofen and indometh- 49. Deguchi M, Rapoff AJ, Zdeblick TA, et al. Posterolateral fusion for acin on bone metabolism reflected in bone strength. Clin Orthop 1984;187: isthmic spondylolisthesis in adults: analysis of fusion rate and clinical results. J Spinal Disord 1998;11:459 – 64.
30. Riew KD, Long J, Rhee J, et al. Time-dependent inhibitory effects of indo- 50. Mather LE. Do the pharmacodynamics of the nonsteroidal anti- methacin on spinal fusion. J Bone Joint Surg 2003;85A:632–5.
inflammatory drugs suggest a role in the management of postoperative pain? 31. Dimar JR, Ante WA, Zhang YP, et al. The effects of nonsteroidal anti- Drugs 1992;33 (Suppl 5):1–12.
inflammatory drugs on posterior spinal fusions in the rat. Spine 1996;21: 51. Freedland SJ, Blanco-Yarosh M, Sun JC, et al. Effect of ketorolac on renal function after donor nephrectomy. Urology 2002;59:826 –30.
32. Martin GJ Jr, Boden SD, Titus L. Recombinant human bone morphogenetic 52. Waterbury L, Kunysz EA, Beuerman R. Effects of steroidal and non-steroidal protein-2 overcomes the inhibitory effect of ketorolac, a nonsteroidal anti- anti-inflammatory agents on corneal wound healing. J Ocul Pharmacol inflammatory drug (NSAID), on posterolateral lumbar intertransverse pro- cess spine fusion. Spine 1999;24:2188 –93.
53. Barton SF, Langeland FF, Snabes MC, et al. Efficacy and safety of intrave- 33. Long J, Lewis S, Kuklo T, et al. The effect of cyclooxygenase-2 inhibitors on nous parecoxib sodium in relieving acute postoperative pain following gy- spinal fusion. J Bone Joint Surg Am 2002;84A:1763– 8.
necologic laparotomy surgery. Anesthesiology 2002;97:306 –14.
34. Keller J, Bunger C, Andreassen TT, et al. Bone repair inhibited by Indometh- 54. Vetrugno M, Maino A, Quaranta GM, et al. The effect of early steroid acin. Effects on bone metabolism and strength of rabbit osteotomies. Acta treatment after PRK on clinical and refractive outcomes. Acta Ophthal Orthop Scand 1987;58:379 – 83.
35. Glassman SD, Rose SM, Dimar JR, et al. The effect of postoperative nonste- 55. Freedland SJ, Blanco-Yarosh M, Sun JC, et al. Ketorolac-based analgesia roidal anti-inflammatory drug administration on spinal fusion. Spine 1998; improves outcomes for living kidney donors. Transplantation 2002;73: 36. Stauffer RN, Coventry MB. Posterolateral lumbar spine fusion. Analysis of 56. Alexander R, El-Moalem HE, Gan TJ. Comparison of the morphine-sparing mayo clinic series. J Bone Joint Surg Am 1972;54A:1195–204.
effects of diclofenac sodium and ketorolac tromethamine after major ortho- 37. Watkins MB. Posterolateral fusion of the lumbar and lumbosacral spine.
pedic surgery. J Clin Anesth 2002;14:187–92.
J Bone Joint Surg Am 1953;35A:1014 –18.
57. Eberson CP, Pacicca DM, Ehrlich MG. The role of ketorolac in decreasing 38. Wiltse LL, Bteman JG. Experience with transverse-process fusion of the length of stay and narcotic complications in the postoperative pediatric or- lumbar spine. J Bone Joint Surg Am 1965;47A:848 –9.
thopaedic patient. J Pediatr Orthop 1999;19:688 –92.
39. Patel TC, Erulkar JS, Grauer JN, et al. Osteogenic protein-1 overcomes the 58. Vitale MG, Choe JC, Hwang MW, et al. Use of ketorolac tromethamine in inhibitory effect of nicotine on posterolateral lumbar fusion. Spine 2001;26: children undergoing scoliosis surgery. An analysis of complications. Spine J 40. Blumenthal SL, Baker J, Dossett A, et al. The role of anterior lumbar fusion 59. Gora-Harper ML, Record KE, Darkow T, et al. Opioid analgesics versus for internal disc disruption. Spine 1986;13:566 –9.
ketorolac in spine and joint procedures: impact on healthcare resources. Ann 41. Brown CW, Orme TJ, Richardson HD. The rate of pseudarthrosis (surgical Pharmacother 2001;35:1320 – 6.
nonunion) in patients who are smokers and patients who are nonsmokers: a 60. Ho ML, Chang JK, Wang GJ. Effects of ketorolac on bone repair: a radio- comparison study. Spine 1986;11:942–3.
graphic study in modeled demineralized bone matrix grafted rabbits. Phar- 42. Minamide A, Kawakami M, Hashizume H, et al. Evaluation of carriers of bone morphogenetic protein for spinal fusion. Spine 2001;26:933–9.
61. Ho ML, Chang JK, Wang GJ. Antiinflammatory drug effects on bone repair 43. DePalma AF, Rothman RH. The nature of pseudarthrosis. Clin Orthop and remodeling in rabbits. Clin Orthop Relat Res 1995:270 – 8.
62. Gerstenfeld LC, Thiede M, Seibert K, et al. Differential inhibition of fracture 44. Zdeblick TA. A prospective randomized study of lumbar fusion: preliminary healing by non-selective and cyclooxygenase-2 selective non-steroidal anti- results. Spine 1993;18:983–91.
inflammatory drugs. J Orthop Res 2003;21:670 –5.

Source: http://www.laspinesurgeon.com/sitebuildercontent/sitebuilderfiles/ketorolac.pdf

Kaken.01.10.11.pdf

M A I N P R O D U C T S P h a r m a c e u t i c a l s >> Fiblast Spray (Wound healing agent) • Consisting of Trafermin, a recombinant form of human bFGF, FiblastSpray is a new type of drug for treating bed sores and skin ulcers. • This strongly stimulates the growth of endothelial cells andfibroblasts, and accelerates wound healing by producing highly• Fiblast Spra

!framtidens l−kemedel

© Författaren och Reforminstitutet 2002Sättning: Ateljé Typsnittet L&R AB, StockholmTryck: Larserics Digital Print AB, Bromma, 2002info@reforminstitutet.nu www.reforminstitutet.nu Försäkring med valfri självrisknivå Introducera valmöjligheten att lägga livsstilsläkemedel till försäkringen Något ökade kostnader för en mer flexibel försäkring Läkemedelsförmånen bö

Copyright © 2010-2014 Pdf Pills Composition