pain and shoulder

PAIN AND SHOULDER

OCTOBER 27, 2020 | 5:00–6:00 P.M. ET

KOJI AOKI

Effects of Shoulder Distraction on Canine Shoulder

Arthroscopy

Koji Aoki, Jun-Yan Sek, Fernando Freitas, Miriam Bates

Presenter: Koji Aoki, BVSc, MVS, DACVS-SA

University of Saskatchewan

Disclosure

• No conflict of interest to this study

Background

• Iatrogenic articular cartilage injury (IACI) associated with arthroscopy is common

• IACI in human literatures• 31% IACI in ankle arthroscopy

• J. Vega, 2016

• 77.6 % IACI in knee arthroscopy• J. Compton, 2020

Background

• Use of joint distractor in Vet Med• Decrease IACI and increase procedural success rate

• Canine stifle and hip

• K. Kim, 2016, J, Kim 2019

P. BOTTCHER, 2009

Leipzig Distractor

Background

• Use of joint distractor in Vet Med• Decrease IACI and increase procedural success rate

• Canine stifle and hip

• K. Kim, 2016, J, Kim 2019

• No study • Effect of shoulder joint distraction on arthroscopy

P. BOTTCHER, 2009

Leipzig Distractor

Objective

• To evaluate the effect of shoulder distraction using a Leipzig distractor on

• IACI

• Surgery time

• Visibility and palpability of intra-articular structure

Hypothesis

• Shoulder (Leipzig) distraction device would

• Decrease IACI

• Decrease surgery time

• Improve visibility and palpability of the intra-articular structures

Outline

1. Ex vivo – cadaveric study

2. Clinical case series

1. Cadaveric Study

Material and Methods

• 30 shoulder joints • From 15 large breed canine cadavers

• Body weight 20.7 kg to 42.7 kg (mean 31.3 kg)

• Euthanized unrelated to this study

• Body in -20 °C and thawed to room temperature (22 °C)


• Non-distraction group (n = 15)• Standard lateral shoulder arthroscopy

• Camera port establishment• Distal to the acromion process• 18g needle• 10 ml of saline infusion • A 2.7mm arthroscope

• An egress port • 18g needle


• Non-distraction group (n = 15)• Standard lateral shoulder arthroscopy

• Instrument port • 18g spinal needle

• 2.7 mm blunt obturator

• 3.4-mm hook tipped probe


• Distraction group (n = 15)

• Leipzig distractor placement • Prior to establishing ports

• 2.4 mm positive threaded half pin



• Leipzig distractor placement • Prior to establishing ports

• Camera and egress ports• Same as non-distraction group

• No distraction performed



• Joint distraction • Visualizing medial collateral ligament

• To prevent excessive distraction

Medial glenohumeral ligament



• Joint distraction

• Instrument port • Same as non-distraction group

• 18g spinal needle

• 2.7 mm blunt obturator

• 3.4-mm hook tipped probe


• Joint space• Measured on captured digital arthroscopic images

• Using a 3.4-mm hook tipped probe at the middle of medial glenohumeral ligament


• Visibility and palpability of intra-articular structures • Using a 3.4-mm hook tipped probe

Medial glenohumeral ligament

Medial glenohumeral ligament Subscapularis

Medial glenohumeral ligament Subscapularis Glenoid

Medial glenohumeral ligament Subscapularis Glenoid Supraglenoid Tubercle


Biceps


Biceps Caudal Humeral head


Biceps Caudal Humeral head Caudal synovial pouch

Visibility Score

Score 1 The structure is not visible

Score 2 The structure is partially visible

Score 3 The entire structure is visible

Visibility Score

Score 1 The structure is not visible

Score 2 The structure is partially visible

Score 3 The entire structure is visible

Palpability Score

Score 1 The structure is not palpable

Score 2 The structure is partially palpable OR the entire structure is palpable only with limited angle

Score 3 The entire structure is palpable without restriction in motion


• Procedural duration • From the beginning of the instrument port establishment

Needle time Probe Time Palpation Time

Total Surgery Time

Visualizing and palpating Intra-articular structures


• Assessment of IACI • Dissection and disarticulation

• Humeral head and glenoid stained with Indian black

• Measurement of IACI area and number

Humeral head Glenoid


• Dissection around pin holes• For unexpected bony lesions

Statistics

• Paired t test for normally distributed data• Mean ± SD

• Wilcoxon signed-rank tests for not normally distributed data• Median (interquartile range, IQR)

• Shapiro-Wilk test for normality

Results

Joint space

Joint space (IQR) 4 mm ( 1 mm) 8 mm (1.5 mm)

P value P = 0.01

Non-distraction Distraction

Outcome Non distraction Distraction P value

Needle time 55 (110) sec 38 (43) sec = 0.39

Probe time 215 ± 112 sec 159 ± 82 sec = 0.15


Total Surgery Time



Needle time 55 (110) sec 38 (43) sec = 0.39

Probe time 215 ± 112 sec 159 ± 82 sec = 0.15

Palpation time 138 (87) 66 (38) = 0.03*

Total surgery time 335 ± 147 sec 242 ± 88 sec = 0.01*


Total Surgery Time


IACI


IACI glenoid 3 (7.5) mm2 0 (2.3) mm2 = 0.10

IACI head 11.5 (11.8) mm2 0 (2.5) mm2 = 0.004*

IACI total number 3 (3.5) 1.5 (1) = 0.004*

IACI

Visibility and Palpability

• No significant difference for visibility or palpability scores for the intra-articular structures

• Higher visibility score of the supraglenoid tubercle in distraction group (P = 0.015)

Supraglenoid Tubercle

Results

• Leipzig distractor• 132 ± 46 seconds for placement

• No complications during the procedure

• After the procedure • No loosening of the pins

• No fracture around the pin holes

2. Clinical Case Series

Clinical Case Series

• Distracted shoulder arthroscopy in clinical cases • 9 shoulder joints with shoulder OCDs

• From 5 dogs

• Age• 8 month to 17 month year old

• Body Weight• 17 – 42 kg

• Recorded perioperative complications

• Minimal follow up of 6 weeks• At WCVM, rDVM, phone interview,

Clinical Case Series

• Results• Joint space increased with distraction

• Distraction device interfered visibility of caudal pouch (n=1/9)

• No perioperative complications associated with shoulder distraction

• No complications with follow up • Median 8 weeks (6-8 weeks)

Before distraction After

Discussion

• Distraction provided larger working joint space • Decreased IACI with distracted shoulders

• Decreased joint exploration (palpation) time

• No difference in visibility or palpability of structures• Besides supra-glenoid tubercle visibility

• Most of the structures were thoroughly visible and palpable • Without distraction

• Resulting in no significant difference between the groups

Discussion

• No obvious complications associated with the distractor• In vivo and ex vivo

• One clinical case experienced interference between the distractor and arthroscope

• Leipzig distractor needs to be placed cranio-lateral position than lateral

• OCD lesions were easy to manage in clinical cases • On subjective assessment

• No need for limb manipulation

Limitation

• Depth of the IACI not measured• Required histopathology

• Performed by a single ACVS surgeon

• Limb manipulation not performed in non-distraction group• Manipulation could improve the procedural speed

• Small sample size and no controls in the clinical case series

Conclusion

• Distractor decreased the area and incidence of IACI and shortened the arthroscopic time

• No major complications observed

Questions?

ALEXANDRA KALAMARAS

Development and Assessment of

Neuropathic Pain in Dogs after TPLO for

Cranial Cruciate Ligament Rupture

Alexandra Kalamaras, DVM, MS

ACVS 2020/2021 Webinar Series

The Ohio State University

Columbus, Ohio

Disclosure

• I hereby certify that, to the best of my knowledge, no aspect of

my current personal or professional situation might reasonably

be expected to significantly affect my views on the subject on

which I am presenting

• Funding provided by The Ohio State Canine Grant

Outline

Background

• Neuropathic Pain & Assessment

• Neuropathic Pain in Orthopedic Conditions1

Experimental Design2

Results3

Discussion

• Limitations4

Conclusions

• Clinical Relevance5

Background

Pain

• Definitions

• Pain: unpleasant sensory and emotional experience associated with actual or potential tissue damage

• Nociception: neural process of encoding noxious stimuli

• Analgesia: absence of pain in response to stimulus normally painful

• Hyperalgesia: abnormally increased sensitivity to a painful stimulus

• Allodynia: normally non-painful stimulus experienced as painful

• Hyperesthesia: non-noxious stimulus results in exaggerated and painful response

Tranquilli & Grimm 2015; Lorenz et al. 2011

Pain

Wiese & Yaksh 2015

Pain

• Nociceptive vs. Neuropathic

• Nociceptive → normal functioning somatosensory system

• Neuropathic → dysfunction somewhere along the pain pathway

• International Association for the Study of Pain (IASP)

Neuropathic Pain

• Definition in people:

• Pain that arises as direct consequence of lesion or disease

affecting the somatosensory system (Treede et al. 2008)

• Effects 1 in 10 adults over 30 (Yawn et al. 2010)

• Healthcare costs ~ $100 billion per year

• Huge impact on quality of life (IASP 2014)

• IASP Global Year Against Neuropathic Pain

Neuropathic Pain

• Underexplored in veterinary patients

• Somatosensory nervous system malfunction

• Peripheral Sensitization

• Central Sensitization

• Chronic neurologic or orthopedic injury

• Hallmarks → allodynia, hyperalgesia, and hyperesthesia

• LOWER threshold to detect a painful stimulus

Neuropathic Pain

Sensory Threshold (ST)

Minimum amount of stimulus that can be detected or is considered painful

(Kerns et al. 2019)

Mechanical ST

Strength of mechanical stimulus → conscious behavioral response

(Moore et al. 2013, Kerns et al. 2019)

Thermal ST

Hot/cold thermal stimulus →conscious behavioral response

(Freire et al. 2016, Knazovicky et al. 2016, Knazovicky et al. 2017)

Neuropathic Pain Assessment

• Von Frey Anesthesiometry (VFA)

• Quantitative evaluation of ST – evaluated in dogs

• Normal (Freire et al. 2016; Kerns et al. 2019)

• Neurologic disease (Moore et al. 2013; Song et al. 2016; Thoefner et al. 2019)

• Osteoarthritis (Freire et al. 2016; Knazovicky et al. 2016; Knozovicky et al. 2017)

Neuropathic Pain

Hyperesthesia & Hyperalgesia

Lower ST

Electronic Von Frey Device

Neuropathic Pain Assessment

• Moderate interobserver agreement (Kerns et al. 2019)

• Neurologic injury and/or disease• Higher ST - acute spinal cord injury (Moore et al. 2013)

• Differences in ST – normal vs. spinal cord injury (Song et al. 2016)

• No difference in ST – normal vs. syringomyelia (Thoefner et al. 2019)

• Osteoarthritis (OA) and degenerative joint disease (DJD)• No difference in ST - normal vs. DJD (Freire et al. 2016)

• Lower ST – osteoarthritis (Knazovicky et al. 2016)

Objectives

1. Assess ST in dogs before and after TPLO surgery in order to

evaluate for the development of neuropathic pain

2. Identify differences (if any) in ST among three different peri-

operative analgesic protocols for TPLO surgery in dogs

• Intravenous opioids

• Lumbosacral epidural

• Peripheral nerve blockade

Hypothesis

ST values 8 weeks postoperative would be lower in dogs

receiving only perioperative opioid administration, indicative of a

neuropathic pain state

Experimental Design

Study Design

• Approved by Institutional Animal Care and Use Committee

(IACUC) of The Ohio State University

• Prospective double-blinded clinical trial

• Client owned dogs with CCLR enrolled (n = 45)

• Between May 2018 and August 2019

• Procedure:

• Stifle arthroscopy

• TPLO

Patient Selection

• Preoperative diagnostics:

• Orthopedic and neurologic exams

• Orthopedic radiographs

• Complete blood count

• Serum biochemistry

• Urinalysis

Arthurs 2011

Patient Selection

Inclusion Criteria

• Diagnosed with CCLR

• Weight > 15 kg and < 60 kg

• Preoperative TPA 20º – 34º

• Temperament amenable to

handling and hospitalization

• Owner consent to 2 week and 8

week recheck visits at The OSU

Main Campus location

Exclusion Criteria

• Neurologic, systemic, or other

orthopedic disease

• Tramadol or steroids (30 days)

• Prior orthopedic surgery on

affected limb

• Conversion to arthrotomy

• Fibular fracture or implant failure

• Complication → revision surgery

Treatment Groups

• Three treatment groups (random assignment)

• Group 1 (MLK): n = 15

• Intravenous infusion of morphine, lidocaine & ketamine

• Group 2 (EPID): n = 15

• Lumbosacral ropivacaine & morphine epidural

• Group 3 (SSNB): n = 15

• Saphenous & sciatic nerve blockade with ropivacaine

Treatments

• Premedication:

• Acepromazine 0.05 mg/kg IM

• Morphine 0.2 mg/kg IM

• General anesthesia induction:

• Propofol 4 mg/kg IV to effect

• General anesthesia maintenance:

• Isoflurane in oxygen

Treatments

• Group 1 (MLK)

• Morphine 0.1 mg/kg/hr IV CRI

• Lidocaine 3 mg/kg/hr IV CRI

• After initial 2 mg/kg IV bolus

• Ketamine 0.6 mg/kg/hr IV CRI

• Medications in IV fluids

• Fluid bags labeled with patient #:

• (ex) Study Pt. #1

Treatments

• Group 2 (EPID)

• 1% ropivacaine 0.2 mg/kg

• Preservative-free morphine 0.09 mg/kg


• Every patient shaved for epidural

• Board-certified anesthesiologist

Treatments

• Group 3 (SSNB)

• 1% ropivacaine 2 mg/kg (each site)

• Ultrasound-guided nerve blocks

using a nerve stimulator:

• Saphenous nerve

• Sciatic nerve

• Board-certified anesthesiologistPortela, Verdier, & Otero 2018

Surgery


• Medial meniscal tear(s) → treated

arthroscopically

• Intact medial meniscus → left intact

• Routine TPLO surgery

• Performed by board-certified surgeon

Von Frey Anesthesiometry

• Evaluations:

• Preoperative

• 1 day, 2 weeks, & 8 weeks

postoperative

• 5 measurements from each

hind paw

• Highest and lowest discarded

• Average of middle 3 values

Moore et al. 2013

Temporospatial Gait Analysis

• Evaluations:

• Preoperative

• 1 day, 2 weeks, & 8 weeks

postoperative

• Tekscan™ Animal Walkway

System

• Data from 5 best trials

• Velocity ≥ 0.8 and ≤ 1.3 m/sec

Statistics

• Demographic data

• ANOVA models

• Categorical data

• Mixed effect models testing treatment effect on primary outcomes

• Kenward-Roger adjustment to degrees of freedom

• Control type I error rates

• Continuous data

• T-tests (2 variables) or ANOVA (> 2 variables)

• Two-sided significance of p<0.05

Results

CharacteristicTreatment 1

(n = 15) (MLK)

Treatment 2

(n = 15) (EPID)

Treatment 3

(n = 15) (SSNB)P-value

Weight (kg)

(mean SD)37.28 9.57 34.25 8.09 30.12 8.89 0.0975

Age (years)

(mean SD)4.93 2.15 5.2 2.57 5.33 3.24 0.9180

Sex

Female Intact

Female Spay

Male Neutered

Male Intact

0

7

8

0

2

5

7

1

0

8

7

0

0.5121

Surgical Limb

Left

Right

9

6

8

7

9

60.9999

Completeness of Tear

Full

Partial

11

4

9

6

13

2

0.3156

Current Bilateral CCLR

Yes

No

4

11

3

12

4

110.9999

Meniscal Status

Intact

Torn

7

8

9

6

9

60.8039

Results

• Sensory Threshold

• Lower for surgical limb

(p < 0.0001)

• No difference among

treatment groups250

300

350

400

450

500

550

Preop Postop 2 Weeks 8 Weeks

Sensory Threshold (Average)

Epidural + Other Epidural + Surgical

Saphenous Sciatic + Other Saphenous Sciatic + Surgical

MLK + Other MLK + Surgical

Results

• No difference among treatment groups

• Anesthesia duration (p = 0.8140)

• Temporospatial gait analysis

• Surgery duration not affected by surgeon (p = 0.8350)

Discussion

Discussion

Hypothesis rejected:

• No difference in ST among treatment groups

Discussion

• ST lower in surgical limb

• Expected finding

• No difference in ST among treatment groups

• Even when ST scaled to body weight

• Discussed by Moore et al. 2013

• OA associated with lower ST (Knazovicky et al. 2016)

• Current study did not evaluate severity of OA

• May have missed an essential variable with regards to ST

Limitations

• Low number of patients

• Type I error

• ST Data

• 8 weeks may not be enough time for neuropathic pain development

• No assessment of osteoarthritis (radiographically)

• Variability between surgeons or anesthesiologists

Conclusion

Conclusion

• No significant change in sensory threshold over time

• Unable to show a difference in neuropathic pain state development

• Sensory threshold values consistently lower in surgical limb

Acknowledgements

• Nina R. Kieves, DVM, DACVS-SA, DACVSMR, CCRT

• Sarah Moore, DVM, DACVIM (Neurology)

• Turi Aarnes, DVM, MS, DACVAA

• Carolina Ricco Pereira, DVM, MS, DACVAA

• Stephen C. Jones, MVB, MS, DACVS-SA

• James Howard, DVM, MS, DACVS-SA

• Juan Peng, MAS

Thank You!

References

• Aguado D, Benito J, Gomez de Segura IA (2011) Reduction of the minimum alveolar concentration of isoflurane in dogs using a constant rate of infusion of lidocaine-ketamine in combination with either morphine or fentanyl. Vet J 189, 63-66.

• Bartel AKG, Campoy L, Martin-Flores M et al. (2016) Comparison of bupivacaine and dexmedetomidine femoral and sciatic nerve blocks with bupivacaine and buprenorphine epidural injection for stifle arthroplasty in dogs. Vet AnesthAnalg 43, 435-443.

• Boscan P, Wennogle S (2016) Evaluating femoral-sciatic nerve blocks, epidural analgesia, and no use of regional analgesia in dogs undergoing tibia-plateau leveling-osteotomy. J Am Anim Hosp Assoc 52, 102-108.

• Campoy L, Martin-Flores M, Ludders JW et al. (2012) Comparison of bupivacaine femoral and sciatic nerve block versus bupivacaine and morphine epidural for stifle surgery in dogs. Vet Anaesth Analg 39, 91-98.

• Caniglia AM, Driessen B, Pureto DA et al. (2012) Intraoperative antinociception and postoperative analgesia following epidural anesthesia versus femoral and sciatic nerve blockade in dogs undergoing stifle joint surgery. J Am Vet Med Assoc 241, 1605-1612.

• Conzemius MG, Hill CM, Sammarco JL et al. (1997) Correlation between subjective and objective measures used to determine severity of postoperative pain in dogs. J Am Vet Med Assoc 210, 1619-1622.

• Drygas KA, McClure SR, Goring RL et al. (2011) Effect of cold compression therapy on postoperative pain, swelling, range of motion, and lameness after tibial plateau leveling osteotomy in dogs. J Am Vet Med Assoc 238, 1284-1291.

• Duerr FM, Martin KW, Rishniw M et al. (2014) Treatment of canine cranial cruciate ligament disease. Vet Comp OrthopTraumatol 27, 478-483.

References

• Ebner LS, Lerche P, Bednarski RM et al. (2013) Effect of dexmedetomidine, morphine-lidocaine-ketamine, and dexmedetomidine-morphine-lidocaine-ketamine constant rate infusions on the minimum alveolar concentration of isoflurane and bispectral index in dogs. Am J Vet Res 74, 963-970.

• Gurney MA, Leece EA (2014) Analgesia for pelvic limb surgery. A review of peripheral nerve blocks and the extradural technique. Vet Anaesth Analg 41, 445-458.

• Hoelzler MB, Harvey RC, Lidbetter DA et al. (2005) Comparison of perioperative analgesic protocols of dogs undergoing tibial plateau leveling osteotomy. Vet Surg 34, 337-344.

• Hofmeister EH, Chandler MJ, Read MR (2010) Effects of acepromazine, hydromorphone, or acepromazine-hydromorphone combination on the degree of sedation in clinically normal dogs. J Am Vet Med Assoc 237, 1155-1159.

• Hofmeister EH, Egger CM (2005) Evaluation of diphenhydramine as a sedative for dogs. J Am Vet Med Assoc 226, 1092-1094.

• Holton LL, Scott EM, Nolan AM et al (1998) Comparison of three methods used for assessment of pain in dogs. J Am Vet Med Assoc 212, 61-66

• Jones RS (2001) Epidural analgesia in the dog and cat. Vet J 161, 123-131.

• Knazovicky D, Helgeson ES, Case B et al. (2016) Widespread somatosensory sensitivity in naturally occurring canine model of osteoarthritis. Pain 157, 1325-1332.

• KuKanich B, Wiese AJ (2015) Opioids. Chapter in Veterinary Anesthesia and Analgesia (5th edition)

References

• Lewis KA, Bednarski RM, Aarnes TK et al. (2014) Postoperative comparison of four perioperative analgesia protocols in dogs undergoing stifle joint surgery. J Am Vet Med Assoc 244, 1041-1046.

• Lorenz M, Coates J, Kent M (2011) Pain. Chapter in Handbook of Veterinary Neurology (5th edition)

• McCally RE, Bukoski A, Branson KR et al. (2015) Comparison of short-term postoperative analgesia by epidural, femoral nerve block, or combination femoral and sciatic nerve block in dogs undergoing tibial plateau leveling osteotomy. Vet Surg 44, 983-987.

• Mich PM, Hellyer PW, Kogan L et al. (2010) Effects of a pilot training program on veterinary students’ pain knowledge, attitude, and assessment skills. J Vet Med Educ 37, 358-368.

• Muir III WW, Wiese AJ, March PA et al. (2003) Effects of morphine, lidocaine, ketamine, and morphine-lidocaine-ketamine drug combination on minimum alveolar concentration in dogs anesthetized with isoflurane. Am J Vet Res 64, 1155-1160.

• Murrell JC, Psatha EP, Scott EM et al. (2008) Application of a modified form of the Glasgow pain scale in a veterinary teaching centre in the Netherlands. Vet Rec 162, 403-408.

• Palomba N, Vettorato E, De Gennaro C et al. (2019) Peripheral nerve block versus systemic analgesia in dogs undergoing tibial plateau levelling osteotomy: Analgesic efficacy and pharmacoeconomics comparison. Vet AnaesthAnalg, 47, 119-128.

• Portela DA, Verdier N, Otero PE (2018) Regional anesthetic techniques for the pelvic limb and abdominal wall in small animals: A review of the literature and technique description. Vet J 238, 27-40.

References

• Reid J, Nolan AM, Hughes JML et al. (2007) Development of the short-form Glasgow Composite Measure Pain Scale (CMPS-SF) and derivation of an analgesic intervention score. Anim Welf 16, 97-104.

• Smith LJ, Yu JKA, Bjorling ED et al. (2001) Effects of hydromorphone or oxymorphone, with or without acepromazine, on preanesthetic sedation, physiologic values, and histamine release in dogs. J Am Vet Med Assoc 218, 1101-1105.

• Tomas A, Bledsoe D, Wall S et al. (2015) Initial evaluation of a canine stifle arthrotomy post-operative pain model. Vet J 204, 293-298.

• Tranquilli WJ, Grimm KA (2015) Introduction: Use, definitions, history, concepts, classification, and considerations for anesthesia and analgesia. Veterinary Anesthesia and Analgesia (5th edition)

• Treede RD, Jensen TS, Campbell JN (2008) Neuropathic pain: redefinition and a grading system for clinical and research purposes. Neuro 70, 1630-1635.

• Wagner MC, Hecker KG, Pang DSJ (2017) Sedation levels in dogs: a validation study. BMC Vet Res 13, 110.

• Wendlund TM, Martin KW, Duncan CG et al. (2016) Evaluation of pacing as an indicator of musculoskeletal pathology in dogs. J Vet Med Anim Health 8, 207–213.

• Wiese AJ, Yaksh TL (2015) Nociception and Pain Mechanisms. Chapter in Handbook of Veterinary Pain Management (3rd edition)

ALEXANDRA KALAMARAS

Effect of Analgesic Protocols on

Postoperative Pain in Dogs after TPLO

for Cranial Cruciate Ligament Rupture

Alexandra Kalamaras, DVM, MS

ACVS 2020/2021 Webinar Series

The Ohio State University

Columbus, Ohio

Disclosure

• I hereby certify that, to the best of my knowledge, no aspect of

my current personal or professional situation might reasonably

be expected to significantly affect my views on the subject on

which I am presenting

• Funding provided by The Ohio State Canine Grant

Outline

Background

• Pain Perception & Assessment

• TPLO Analgesia1

Experimental Design2

Results3

Discussion

• Limitations4

Conclusions

• Clinical Relevance5

Background

Pain Assessment

• Methods for assessment of post-operative pain

• Simple descriptive scales (SDS)

• Visual analog scale (VAS)

• Numerical rating scale (NRS)

• Multifactorial pain scales (MFPS)

• Behavior-based composite scales

• Colorado State University Canine Acute Pain Scale (CSU-CAPS) (Mich et al. 2010)

• Glasgow Composite Measure Pain Scale – short form (CMPS-SF) (Holton et al. 2001, Morton et al. 2005, Reid et al. 2007)

Pain Assessment









Conzemius et al. 1997

Minimal

Mild

Mild to Moderate

Reassessanalgesic plan

Moderate


Moderate toSevere

May be rigid toavoid painful

movement


Pain Score Psychological & BehavioralExample Response to Palpation Body Tension

Comments

© 2006/PW Hellyer, SR Uhrig, NG Robinson

Colorado State University

Veterinary Medical Center

Canine Acute Pain Scale

Date

Time

Tender to palpation

Warm

Tense

Rescore when awake

Supported by an Unrestricted Educational Grant from Pfizer Animal Health

1

2

3

4

0Comfortable when resting

Happy, content

Not bothering wound or surgery site

Interested in or curious about surroundings

Content to slightly unsettled or restless

Distracted easily by surroundings

Looks uncomfortable when resting

May whimper or cry and may lick or rub

wound or surgery site when unattended

Droopy ears, worried facial expression

(arched eye brows, darting eyes)

Reluctant to respond when beckoned

Not eager to interact with people or surroundings

but will look around to see what is going on

Unsettled, crying, groaning, biting or

chewing wound when unattended

Guards or protects wound or surgery site by

altering weight distribution (i.e., limping,

shifting body position)

May be unwilling to move all or part of body

Constantly groaning or screaming when

unattended

May bite or chew at wound, but unlikely to

move

Potentially unresponsive to surroundings

Difficult to distract from pain

Cries at non-painful palpation

(may be experiencing allodynia,

wind-up, or fearful that pain

could be made worse)

May react aggressively to palpation

May be subtle (shifting eyes or

increased respiratory rate) if dog

is too painful to move or is stoic

May be dramatic, such as a

sharp cry, growl, bite or bite

threat, and/or pulling away

Reacts to palpation of wound,

surgery site, or other body part

by looking around, flinching, or

whimpering

Flinches, whimpers cries, or

guards/pulls away

Nontender to palpation of

wound or surgery site, or to

palpation elsewhere

Animal is sleeping, but can be aroused - Not evaluated for pain

Animal can’t be aroused, check vital signs, assess therapy

RIGHT LEFT

Pain Assessment









Cranial Cruciate Ligament Rupture

• Spontaneous cranial cruciate

ligament (CCL) rupture

common in dogs

• Tibial plateau leveling

osteotomy (TPLO) → stabilize

stifle by altering tibial plateau

angle (TPA)

Evans & de Lahunta 2013

TPLO Perioperative Analgesia

• No gold standard perioperative

analgesic protocol

• Commonly reported options:

• Intravenous opioids

• Lumbosacral epidural analgesia

• Peripheral nerve blockade

Guedes 2011

Portela, Verdier, & Otero 2018

Perioperative Analgesia

• Peripheral nerve block vs. intravenous opioids• Peripheral nerve block superior (Palomba et al. 2019)

• Peripheral nerve block vs. epidural • Epidural – more rescue opioids, urine retention (Campoy et al. 2012)

• No difference (Caniglia et al. 2012; McCally et al. 2015; Bartel et al. 2016)

• Intravenous opioids vs. epidural• No difference (Lewis et al. 2014)

• Intravenous opioids vs. epidural vs. peripheral nerve block• No difference (Boscan & Wennogle 2016)

Objectives

1. Evaluate efficacy of three different analgesic protocols for

TPLO surgery in dogs

2. Identify superior and/or inferior protocols, if any, for immediate

postoperative pain control

3. Assess sedation levels associated with three different

analgesic protocols for TPLO surgery in dogs

Hypotheses

1. Lumbosacral epidural analgesia and saphenous/sciatic nerve

blockade would provide superior analgesia compared to

intravenous opioids (demonstrated by lower pain scores)

2. Intravenous opioids would cause more sedation than

lumbosacral epidural analgesia and saphenous/sciatic nerve

blockade (demonstrated by higher sedation scores)

Experimental Design

Study Design

• Approved by Institutional Animal Care and Use Committee

(IACUC) of The Ohio State University

• Prospective double-blinded clinical trial

• Client owned dogs with CCLR enrolled (n = 45)

• Between May 2018 and August 2019

• Procedure:


• TPLO